ARV Adherence Project

The INRUD Initiative on Adherence to Antiretrovirals (INRUD-IAA)

Launched in September 2006, the INRUD-IAA initiative is funded by the Swedish International Development Cooperation Agency. The objectives of the five-year initiative are to—
  • Develop and validate a set of indicators that can be used to monitor adherence to ART
  • Investigate adherence rates and determinants for these rates for ART programs and individuals in two target countries
  • Pilot interventions to improve adherence in individual patients and in programs in two countries
  • Establish the process needed for national AIDS control programs to scale-up successful interventions as part of national policy in the two countries
  • Work with the other three countries in the region to develop national adherence policies and implement interventions to improve adherence

INRUD-IAA Partners and Collaborators

  • INRUD groups in Ethiopia, Kenya,Rwanda, Tanzania, and Uganda
  • National AIDS control programs inEthiopia, Kenya, Rwanda, Tanzania, andUganda
  • Karolinska Institutet’s Division of International Health
  • Harvard Medical School’s Drug Policy Research Group
  • World Health Organization’s Departments of Medicine Policy and Standards and Technical Cooperation for Essential Drugand Traditional Medicine

Consensus on Standard Indicators to Measure Adherence

During the first year, research teams in Ethiopia, Kenya, Rwanda, and Uganda tested the feasibility and reliability of a method to collect adherence data. INRUD-IAA is developing a manual with supporting forms and instructions that describes the recommended indicators, data collection methodology, and analyses. The World Health Organization will also publish this adherence indicator package. At a meeting in Arusha, Tanzania in October 2007, partners and stakeholders agreed on a standard set of indicators to measure adherence and defaulting. A validity study showed that the adherence indicators correlated to increases in patients’ CD4 counts and weight gain.

 Standard Indicators and Data Sources

From pharmacy records-
  • Median percentage days covered by ART dispensed over six months
  • Percentage of patients with a 30 or more day gap in medicines dispensed over six months
  • Percentage of patients attending the clinic appointment set three months earlier on or before the scheduled appointment day
  • Percentage of patients attending the clinic appointment set three months earlier within three days of the scheduled appointment day
From patient exit interviews-
  • Percentage of patients who self-reported full adherence over the previous three days

At the Arusha meeting, presenters from Uganda and Ethiopia shared the results of their investigation of factors that help determine adherence. According to interviews with patients, ART clinic staff, and peer counselors, major impediments to treatment adherence include long waiting hours due to inefficient patient flow and insufficiently funded outreach services—although staff and patients in many facilities expressed satisfaction with community-linked peer counselors. Patients felt that support from the family was the single most important factor related to good adherence, while staff and peer counselors felt that lack of money for food, transportation, and charges for laboratory tests and medicines for opportunistic infection greatly distressed patients and represented the most important barriers to adherence.

Country Plans to Improve Treatment Adherence

Meeting participants also developed plans for testing interventions to improve adherence at the individual and program levels, based on what made sense for their own countries. Countries will test the interventions over the next twelve months and scale-up successful efforts the following year. Plans include—
  • Introducing a performance-based financing project, which would measure an adherence indicator at facilities where the service providers would receive a monetary incentive and compare them to those facilities where providers did not receive an incentive.
  • Strengthening the facility’s link with the community to be able to contact the patient quickly if they failed to appear for an appointment. The plan’s activities include introducing a patient tracking system to recognize when patients do not appear and mapping patients’ homes and their link with community support systems.
  • Strengthening the adherence component of providing home-based AIDS care. Activities will include training providers on adherence counseling and improving communication between facilities and community contacts using wireless telephone technology.
  • Scheduling patient appointments for specific times rather than requiring patients to come first thing in the morning and join a queue to wait.
  • Spreading patient appointments over several days each week rather than limiting appointments to only one or two days.
  • Developing standard operating procedures for adherence counseling and monitoring, combined with related training with supervision and mentoring system.
  • Supplying pill boxes to help patients keep track of their medicine.