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Since 1996, the standard treatment for HIVinfection has moved from single- and dou-ble-drug therapies to therapies containingthree or more anti-HIV drugs, also knownas Highly Active Antiretroviral Therapy, orHAART. One of the main concerns of anti-retroviral programs is to motivate clients tofollow their complex drug regimen exactlyas prescribed. Unless the therapy isadhered to at least 95 percent correctly, lev-els of HIV in the blood will rise, resulting inAIDS-related complications.

To address this concern, the Population Council’sHorizons Program collaborated with theInternational Centre for Reproductive Health and

the Coast Province General Hospital in Mombasa, Kenya,to create a manual for training health care workers inimproving patient compliance with antiretroviral therapy.“This handbook is one of the first counseling training toolsdesigned to increase adherence to HAART that has beendeveloped in Africa,” says Horizons/Population Councilresearcher Avina Sarna, one of the handbook’s authors. Themanual is being used in an intervention study in Kenyathat is investigating ways of improving patients’ adherenceto HAART.

Introducing antiretrovirals to AfricaAlthough 70 percent of individuals worldwide who areinfected with HIV live in sub-Saharan Africa, antiretroviraltreatment programs have only recently arrived there, andmost are still on a small scale. Scarce financial resourcesand poor infrastructure have prevented broader introduc-tion of HAART. But as the cost of the drugs drops, policy-

makers, public health officials, and international donors arelaunching new initiatives to bring antiretroviral treatmentto more Africans living with HIV/AIDS.

Patients face significant challenges in following multi-drug antiretroviral therapies precisely. HAART is a life-longtreatment. While first-line treatment regimens may beavailable in fixed-dose combinations where all medicationsare contained in one pill, second- and third-line regimensoften consist of multiple medications that must be takentwo to three times a day with varying dietary instructions.Antiretroviral medications also have side effects. Some ofthese are temporary, but others may last longer and theirseverity may compel a change of treatment. When patientsfail to follow the regimen closely, virus becomes moreprevalent in their bloodstreams, killing their CD4 immunesystem cells. As a result, opportunistic infections appear,and health suffers. Additionally, if proper treatment proto-cols are not followed, the virus can mutate into drug-resist-ant strains.

The manual consists of four training modules forhealth care workers, each of which takes approximately twohours to complete. The material covered in the workbookincludes information on educating the patient about HIVand the HAART regimen, including potential side effects;assessing patient adherence to the protocol; and identifyingand overcoming barriers to following the regimen. Themanual uses various techniques to explore these topics:brainstorming, small group discussions, PowerPoint presen-tations, case studies, and role-playing.

The Mombasa HAART project, for which the train-ing manual was devised, was initiated in 2003. It wasdesigned as a learning site for similar service-delivery pro-grams that are starting up in public-health facilities inKenya and other African countries. The intervention com-pares two approaches to enhancing patient adherence tothe HAART regimen. One arm of the interventioninvolves counseling patients, teaching them to use medica-

GUIDE FOR IMPROVING ADHERENCE TO DRUG THERAPIES

tion diaries and pill boxes, and encouraging them toenlist the help of sympathetic family and friends,among other strategies. The other arm uses all theseapproaches, but it additionally focuses on modified“directly observed therapy.”

Directly observed therapy (DOT) is a treatmentstrategy originally developed for tuberculosis patients,who must take all their medications consistently andon time for up to nine months to rid themselves of theinfection. In the standard DOT approach, healthworkers or community volunteers literally watchclients as they take their medication.

“DOT has proven to be very effective in helpingTB patients maintain their treatment schedules,” saidSarna. “One big difference between treatments for TBand HIV, though, is that antiretroviral medications forHIV/AIDS must be taken for life.”

A DOT strategy for AIDS treatment is calledDAART, for “directly administered antiretroviral thera-py.” A DAART program includes observation ofpatients taking their medications, but less often thanfor TB.

Although it is too early in the study to reportfindings about long-term adherence, clients in botharms who have completed four to six months of fol-low-up have shown weight gain and increases in thenumber of CD4 immune system cells that circulate intheir blood. They have also experienced significantimprovement in quality-of-life measures such as physi-cal functioning, cognitive functioning, depression, andpain and energy levels.

Source

Horizons/Population Council, International Centre forReproductive Health, and Coast Province General Hospital,Mombasa-Kenya. 2004. Adherence to AntiretroviralTherapy in Adults: A Guide for Trainers. Nairobi:Population Council. (www.popcouncil.org/pdfs/horizons/mombasaarvtrainingguide.pdf)

Outside funding

United States Agency for International Development

The Horizons Program is implemented by the PopulationCouncil in collaboration with the International Center forResearch on Women, the International HIV/AIDS Alliance, theProgram for Appropriate Technology in Health, TulaneUniversity, Family Health International, and Johns HopkinsUniversity.

© 2007 The Population Council, Inc. www.popcouncil.org

CONTACT PUBINFO@POPCOUNCIL.ORG OR CALL +1-202-237-9400

FOR MORE INFORMATION ABOUT THE POPULATION COUNCIL’S HIV AND AIDS PROGRAM,VISIT WWW.POPCOUNCIL.ORG/HIVAIDS

Reprinted from Population Briefs, May 2005www.popcouncil.org/publications/popbriefs/

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This work was funded by the generous support of the American peoplethrough the United States Agency for International Development (USAID).The opinions expressed herein are those of the authors and do not necessarilyreflect the views of USAID.