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SETTINGS AND PROBLEM

EVALUATION OF ANTIRETROVIRAL THERAPY FOLLOWED BY AN EDUCATIONAL INTERVENTION TO INCREASE APPROPRIATE USE IN ZIMBABWE. SETTINGS AND PROBLEM. Zimbabwe - one of the world’s highest HIV infection rate. Late 1990s: Antiretroviral Therapy (ARVT) used in private sector with varying standards.

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SETTINGS AND PROBLEM

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  1. EVALUATION OF ANTIRETROVIRAL THERAPY FOLLOWED BY AN EDUCATIONAL INTERVENTION TO INCREASE APPROPRIATE USE IN ZIMBABWE

  2. SETTINGS AND PROBLEM • Zimbabwe - one of the world’s highest HIV infection rate. • Late 1990s: Antiretroviral Therapy (ARVT) used in private sector with varying standards. • ARVT = narrow therapeutic index • Potential problems: • Sub-therapeutic effects, viral resistance  treatment failure, • Length of desired outcomes in individual patient is reduced • Efficacy of ARVs within the population is reduced • Unnecessary toxicity, • Wastage of limited financial resources • Disadvantage to surviving family members

  3. OBJECTIVES • Examine standards of ARVT in the private health sector by investigating: • initiation, • monitoring and evaluation of ARVT, • relevant patient outcomes • To design and pilot-test an educational intervention promoting the rational use of ARVs by increasing the physician’s knowledge on rational use of ARVs

  4. METHODS Setting: Private health sector physicians in urban centers in Zimbabwe. Study 1: • Design: Retrospective medical record review. • Individual patient data were collected on: • patients’ assessment prior to starting ART; • prescribing patterns; • monitoring for efficacy/safety; and • clinical/virological outcomes. Study 2: • Design: Educational intervention with pre- and post intervention assessment (MCQs) • Intervention: Academic detailing combined with distribution of concise printed materials

  5. CLINICAL EVALUATION BEFORE STARTING ARVT Important observations: • Only 18% patients received full clinical evaluation as recommended by current clinical guidelines • 41% had no records of any clinical examination • Complete laboratory examinations incl. CD4, TLC, VL, LFT, FBC was performed in only 2 patients (6%)

  6. INITIAL & CURRENT ARVT

  7. PRESCRIBING OF ARVs • Incorrect dose of ARVs in total of 15 patients (38%), • AZT (67% of effective dose prescribed ), 7 pts. • underdosing of SQV (22% of effective dose prescribed); 2pt. • Double dose of DDI • Interactions: • co-administration of Indinavir and Rifampicin • Irrational first-line therapy i.e. • Didanosine + hydroxyurea combination • Irrational sequencing i.e. • Patients were frequently switched from triple to dual then monotherapy • DDI+ HYU was the current therapy for 7 pts. (18%)

  8. CLINICAL & IMMUNOLOGICAL OUTCOMES Important observations: • Desired outcomes were found in pts. on triple ARV regimens; 16 patients (41%) • undetectable VL, • high CD4 and • clinically well) • Dual or monotherapy often resulted in poor outcomes in majority of pts 23 (59%) • High viral load, • CD4 count <350cells/mm3 • Clinically unwell with OIs

  9. EDUCATIONAL INTERVENTION • Structured academic detailing was developed delivering key messages regarding: • Choices for ARVT and potential drug interactions • Monitoring adherence and side effects, When to change therapy • Use of hydroxyurea in ARVT • Use of antiretrovirals for PMTCT • Single face-to-face academic detailing session were delivered to 15 physicians and lasted approx. 30 to 90 min. • Printed educational material were handed out to re-inforce key messages • Average 27% increase in knowledge of physicians measured by pre - and post assessment. • Highest increases were found in knowledge on drug interactions and adverse effects of ARVT.

  10. SUMMARY & RECOMMENDATIONS • Irrational choices for ARVT, poor monitoring and evaluation resulted in poor outcomes. • High cost of the therapy + poorly informed physicians/patients = irrational choices. • Comprehensive training of prescribers is needed to achieve: • maximum possible benefits • minimising of risks from ARVT and • getting the best value (cost-effectiveness). • Trained pharmacists providing locally developed and focused information can be valuable resource in prescriber’s education. • Reduction in prices of ARVs and necessary tests in private sector is needed to increase affordability and rational use.

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