AIDS Alert International: Study in Ghana found strikingly highlevels of antiretroviral adherence
AIDS Alert International
Special Coverage of 43rd IDSA Meeting
High Levels of Medication Adherence in Resource-Poor Areas
Study in Ghana found strikingly high levels of antiretroviral adherence
A study conducted in Accra, Ghana, adds to the body of evidence that HIV patients in resource-poor areas are able to achieve high levels of medication adherence.
"Having reviewed some of the medical literature on antiretroviral adherence in developing countries in preparation for our study, I did anticipate relatively high levels of compliance to antiretrovirals among the patients at Fevers Unit, but not as high as our results showed," says Oni Blackstock, MD, an intern in primary care-social medicine residency program at Montefiore Medical Center/Albert Einstein College of Medicine in Bronx, NY.
The study, conducted at the Fevers Unit, an HIV/AIDS clinic at Korle Bu Teaching Hospital in Accra, Ghana, found that of 101 patients there was an average rate of self-reported adherence of 99.4 percent for the previous three days and of 99.1 percent for the previous two weeks.1
Backed by the Global Fund, the Ghanaian government has provided partially subsidized antiretroviral medication at three pilot sites, including the Fevers Unit, since December, 2003, Blackstock says.
"I traveled to the clinic in October, 2004, in order to get an idea of the patients’ experience with taking antiretrovirals and to ascertain whether there existed certain factors among this patient cohort that might be associated with antiretroviral adherence," Blackstock explains.
The study’s 101 subjects out of 600 on antiretrovirals were asked about adherence and other factors that might influence health behavior, including patient-doctor relationship, the patient’s attitudes, beliefs, and perceptions about HIV/AIDS or health, she says.
"Although antiretroviral adherence was ascertained by patient self-report, which tends to overestimate medication adherence, I believe these high rates reflected the dedication and commitment of the patients at Fevers Unit to play a primary role in their own health care," Blackstock says.
Several years ago when the United States and other wealthy nations began the process of funding antiretroviral therapy for resource-poor nations, many people assumed that these resource-poor areas would not be capable of handling antiretrovirals because of poor health care infrastructure, says Joyce Aba Sackey, MD, an assistant professor of medicine at Harvard Medical School in Boston, MA, and an associate professor in medicine at Beth Israel Deaconess Medical Center in Boston.
"People were very concerned about the development of resistance," Sackey says. "The concern was that in poor places people may not have resources or even the desire to take medication on a regular basis."
Some in the debate even went so far as to say that some places don’t have clocks and watches, so how would they take their medicine at the right times, Sackey recalls.
"They were completely overlooking the fact that in many places they do have clocks and watches and that in the pre-clock era people could keep time by the sun rising and setting," Sackey adds.
"Now we have a number of researchers who have looked at places where antiretroviral therapy has become available, and we have found that people are motivated to do everything they can to live," Sackey says. "When they have children relying on them, and when you make medications available that prolong their lives -- guess what? -- they want to take them."
The study’s findings mirror what recent medical literature on antiretroviral adherence in developing countries has shown, and that is that patients in resource-challenged settings tend to have higher levels of adherence than their counterparts in developed countries, Blackstock says.
"Almost all of the patients I interviewed knew when to take their medications," Blackstock says. "If they didn’t have a watch, they used other cues to remind themselves."
The initial skepticism has had the positive result of convincing providers and communities to focus on adherence strategies, including directly-observed therapy (DOT) in some locations and community outreach, Sackey notes.
Patients participating in the Fevers Unit study were a highly motivated group, Blackstock says.
"Many patients appeared flabbergasted when I asked questions about having missed doses of their medications," Blackstock says. "They were thinking it was incredulous that they would somehow forget to take potentially life-prolonging antiretrovirals that were, for so long, out of their reach."
In some ways, the patients enrolled in the study were self-selecting because these were the people who actively sought help for their illness, Blackstock adds.
The Fevers Unit in Accra, provided HIV patients with some adherence resources, Sackey says.
"One thing I was impressed about was that the hospital had trained pharmacists and pharmacy assistants to talk with patients every time they came in for prescription renewals about pharmacy side effects," Sackey says. "This was a great resource."
As soon as patients began taking antiretroviral medication, they were required to meet with a pharmacist when they picked up their refills, Blackstock explains.
"These sessions serve as an opportunity for the pharmacist and patient to discuss how the patient is coping with taking medications that must be taken on a strict schedule and can often have serious side effects," Blackstock says. "Pharmacists also use these meetings to reinforce the importance of adherence, and patients can speak in greater detail about the challenges they face living with HIV/AIDS and taking medications."
Also, the Fevers Unit patients had access to a patient-run support group called the Wisdom Association, which serves to teach others infected with HIV how to advocate for themselves, Blackstock says.
The support group assists with social needs, including finding employment or influencing healthy policy for HIV prevention and treatment, Blackstock adds.
"Counselors, mostly young adults who are not patients, provide pre-test and post-test counseling in the clinic," Blackstock says. "In addition, for those patients who meet criteria for beginning antiretrovirals, the counselors meet with them to prepare them for starting medications, discussing side effects, dose timing, adherence, etc."
Some of the challenges HIV patients faced in this region were similar to those faced in affluent countries, including factors relating to a patient’s social support system, mental health issues, such as depression, and unanticipated side effects, Sackey says.
"The things that are different in Ghana are the fact that resources in places like Ghana are quite limited," Sackey adds. "People don’t have the same kinds of third-party coverage as we do here, so they’re very dependent on governmental resources, which is why this program of national treatment was very good -- they were able to get medication for free."
From the researchers’ perspective, one of the more challenging aspects was language, Blackstock says.
"Prior to going to the Fevers Unit, I thought that most patients would speak English," Blackstock says. "What I realized is that I had spoken with middle and upper class Ghanaians who in fact speak English and led me to believe the patients at Fevers would as well."
Instead, most of the patients spoke Twi and/or Ga, Blackstock says.
"As a result, I enlisted the assistance of counselors, nurses, and nursing students to help conduct interviews in the patients’ indigenous languages," she says.
Even with translator assistance, there were language problems, Blackstock notes.
"Communicating specific ideas and thoughts were challenging and required input from several physicians and nurses to express," Blackstock says.
The lessons physicians, particularly new physicians, learn from conducting research in the developing world is invaluable, Sackey says.
"I direct an AIDS collaborative project, and as a result of this project, we’ve been able to work with residents and medical students in Ghana," Sackey says.
The take-home message is that encouraging trainees, medical students to engage in international health serves three purposes, Sackey says.
"One, it has direct help for people in resource-poor countries," Sackey says. "They learn a ton as a result of what they do, and the third thing is it’s a smart way to train physicians because the global stage is getting smaller and smaller and many are interested in international health."
Training physicians to work in resource-poor settings has the added benefit of giving them a new perspective on western medicine practice, she notes.
"We have so many diagnostic tests available here that they tend to order them regardless of cost," Sackey says. "In poor settings they rely more on physical diagnostic skills and deductive reasoning, and when they come back here they maybe are more thoughtful about using diagnostic tests."
Blackstock also learned from the experience that HIV/AIDS carries with it a burden of shame that is unprecedented in medicine.
"I cannot think of another medical condition that is so heavily stigmatized and creates obstacles in all aspects of life from forming relationships to finding a job," Blackstock says.
Reference:
- Blackstock OJ, Sackey JA, Agyei A. Antiretroviral adherence in an HIV clinic with an adherence training program in Accra, Ghana. Presented at the 43rd Annual Meeting of the Infectious Diseases Society of America, Oct. 6-9, 2005, in San Francisco, CA. Abstract: 777.
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