Validating five questions of antiretroviral non-adherence in a decentralized
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Validating five questions of antiretroviral non-adherence in a decentralized public-sector antiretroviral treatment program in rural South Africa Krisda Chaiyachati 1-3 , Lisa R Hirschhorn 4,5 , , Frank Tanser2, Marie-Louise Newell 2,6 , Till Bärnighausen 2,3

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Validating five questions of antiretroviral non adherence in a decentralized

Validating five questions of antiretroviral non-adherence in a decentralized

public-sector antiretroviral treatment program in rural South Africa

Krisda Chaiyachati1-3, Lisa R Hirschhorn4,5, , Frank Tanser2, Marie-Louise Newell2,6, Till Bärnighausen2,3

1Yale Primary Care Internal Medicine Residency Program, New Haven and Waterbury, Connecticut; 2Africa Centre for Health and Population Studies, University of KwaZulu-Natal, South Africa;

3Department of Global Health and Population, Harvard School of Public Health, Boston, Massachusetts; 4Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts;

5John Snow Institute, Research and Training, Boston, Massachusetts; 6Centre for Paediatric Epidemiology and Biostatistics, UCL Institute of Child Health, London, UK

Background

Methods

Results

Summary

  • Five assessments of ART adherence administered were:

    • 7-day recall of missed doses

    • 7-day recall of late doses (missed by >2 hours)

    • A six-level Likert scale of adherence (“excellent” to “very poor”)

    • 30-day visual analogue scale (VAS, proportion of pills missed)

    • Question on the last dose missed within seven discrete time periods.

  • Questions were validated in their performance to detect treatment failure at 6 months:

    • Immunologic failure: CD4 <100 cells/mm3 after 6 months (+/- 45 days) of ART

    • OR

    • Virologic failure: VL >400 copies/ml after previously undetectable VL or VL >10,000 copies/ml after 6 months (+/- 45 days) of ART

  • Sensitivities and specificities in predicting treatment failure at 6 months were calculated.

  • Further analyses of performance:

    • At 3 months and beyond 6 months

    • Combining immunologic or virologic failure as a possible outcome

    • Combinations of highly sensitive (screen) then highly specific (confirm) questions

    • Stratification by sex, age (> or < 35 years), and education level (> or < secondary education)

  • Medication adherence is important for treatment success, especially for chronic conditions like HIV

  • Instruments to measure ART adherence identify patients needing treatment support, preventing treatment failure and the development of resistance

  • Simple questions are often used to measure ART adherence in sub-Saharan Africa (SSA)

  • Self-reported adherence tools have rarely been independently validated

  • The Likert item screened immunologic or virologic failures best, but with poor specificity

  • Altering the time of follow-up, combining outcomes or questions, and stratification did not significantly improve the performance of adherence questions

Limitations

  • Cross-sectional approach

  • Alternative reasons for treatment failure:

    • Primary and secondary HIV resistance

    • Malabsorption or vomiting

    • Drug interactions, especially tuberculosis or traditional medication

  • Lag time between adherence and treatment response

Objective

  • Validate the performance of five commonly used ART adherence questions against a gold standard of treatment failure

Enrollment

  • Inclusion: ART experienced >2 weeks, viral load (VL) or CD4 count within 6 weeks of enrolment, and age > 18 years

  • Excluded: Pregnant individuals or anticipated ART discontinuation within 6 months

Conclusions

  • No single question or combination of questions had sensitivity and specificity appropriate for screening purposes and resource allocation, respectively

  • Valid tools for measuring adherence are urgently needed in SSA to identify patients for treatment support and those at risk of treatment failure

  • These lessons can extend to the management of non-communicable diseases

Setting

  • A public sector, decentralized ART program in rural KwaZulu-Natal, South Africa between 2007-08

Citation

Chaiyachati K, Hirschhorn LR, Tanser F, Newell ML, Bärnighausen T. Validating five questions of antiretroviral nonadherence in a public-sector treatment program in rural South Africa. AIDS Patient Care STDS. 2011 Mar; 25(3): 163-70.


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