Patient-centred approaches to ARV therapy adherence
The issue of how to ensure that antiretroviral therapy is taken regularly and appropriately has generated considerable discussion and controversy. Some even suggest that the use of antiretroviral therapy in poor countries will only lead to the widespread development of resistance.
They advocate either that resources are not put into making the drugs available or that they are only administered under strictly controlled conditions, such as in the presence of medical staff (along the lines of the DOTS model for TB, although the comparison is complicated by the greater frequency of dosing of antiretroviral therapy and the fact that it is life-long rather than of a limited duration).
However, in Khayelitsha, an approach centred on educating patients and empowering them to be actively involved in the treatment programme has yielded very positive results.
This begins with the careful selection of a regimen that is easy to take - for example a combination of nevirapine and co-formulated AZT/3TC, which amounts to two pills twice a day - and setting the health care facilities within easy reach of the patients (for example, at primary health care level). Once patients begin therapy (after an educational process), a tripartite programme supports adherence:
- Individual support is available in the form of trained counsellors available during clinic hours to answer questions, and, more informally, through "treatment assistants," a household member or neighbour whom each candidate for therapy is requested to identify who can provide support on adherence;
- Peer support comes in the form of support groups run solely for patients on antiretroviral therapy, and which serve both as valuable spaces for patients to discuss barriers to adherence with others sharing similar experiences and as a forum for ongoing education;
- Educational materials are provided to help patients fully appreciate the risks and benefits of antiretroviral therapy, and understand the importance of adherence.
Research is ongoing to quantify the levels of adherence, but the dramatic improvements in the surrogate markers of changes in viral load and CD4 T cell counts strongly suggest that adherence is good.