Adherence by Africans to antiretroviral regimens

More HIV-infected Sub-Saharan Africans took their anti-HIV medications as directed than HIV-infected N. Americans did, according to the largest and most extensive review of adherence studies to date.

The review was directed by researchers from the Centre for International Health and Human Rights Studies and the University of California, San Francisco.

"This review contradicts a historical anticipation of poor adherence by Africans to antiretroviral regimens that was offered as a rationale to delay providing these therapies. If one had considered adherence simply on the basis of evidence, Sub-Saharan Africans would have had access to these life-saving therapies earlier," said study lead author Edward Mills, PhD, MSc, director of the Centre for International Health and Human Rights Studies.

The review, published in the August 9 issue of the Journal of the American Medical Association, looked at data from 31 studies from North America involving 17,573 HIV-infected patients and 27 studies from Sub-Saharan African involving 12,116 HIV-infected patients. Findings showed that 59 percent of North Americans took their medications as directed, while 77 percent of Sub-Saharan Africans adhered to their antiretroviral regimens.

"Thinking that poverty was a risk factor for non-adherence was a mistake. Not all poverty is the same; poverty in resource-limited settings presents a different set of challenges than poverty in the U.S. Missed doses among the poor in resource-limited settings is less about neglected doses due to complex behavioral and social problems and is more about structural barriers to reliable medication access," said study senior author David R. Bangsberg, MD, MPH, UCSF associate professor of medicine and director of the UCSF Epidemiology and Prevention Interventions Center at San Francisco General Hospital Medical Center.

While these high levels of adherence in resource-limited settings are reassuring, the authors call for programs to monitor and sustain this level of adherence.

"Adherence in Africa will decline as benefits of treatment plateau and long-term side effects accumulate and when people no longer see AIDS as a terminal disease. The challenge will be to detect and intervene on these declines prior to rising population levels of resistance," said Bangsberg.

The review notes the World Health Organization's intent to increase access to antiretrovirals in Sub-Saharan Africa and its estimates of the proportion of HIV/AIDS patients urgently needing therapy. The estimates range from 56 percent in Botswana and Uganda to 3.2 percent in Tanzania and the Democratic Republic of Congo.

"When we talk about AIDS in Africa, it is usually in broad terms--'millions of people infected' etc. In making policy, we must always be mindful that we are talking about someone's mother, daughter, brother, sister, father or son. Policymakers make decisions that have life and death consequences and those decisions should be based on evidence, not conjecture," said Mills.