E-DRUG: MSF on FDCs (5)
In response to Marta Darder's and others e-mails, I guess I'm interested
in why adherence rates in South Africa seem to be so much better than the
international rates. Most reports from around the world show rates of
adequate adherence at around 50% of patients, except in South Africa where
they are very much better than that (Marta quotes a rate of nearly 90% in
her e-mail). Have we found the the key to improving adherence - if so
lets identify it and implement in other settings. Or, is some other
dynamic having an effect? My gut tells me it is the latter.
Marta mentions patient understanding and education as the priority in the
Khayelitsha project. Why does that work there when the published
literature shows only a marginal benefit elsewhere in the world?
It is not as though many (or perhaps even all) of the adherence mechanisms
being proposed and used have not been studied before. An extensive body
of published work shows that these interventions at best work only poorly.
I have just recently read the paper in The Annals of Pharmacotherapy
2003;37:775-81 "Factors Affecting Patient Adherence to Highly Active
Antiretroviral Therapy" (Escobar and others) and amongst a long list of
factors tested for, they found only patient level of education, employment
status, emotional situation and substance abuse as being important
factors, but not patient knowledge of their disease and various other
factors which we would, intuitively, think to be important. I know this is
one paper but there are many more that make this point ... I don't want to
flood this list with references! (Interestingly the number of tablets and
complexity of regimen were *not* found to be important, although the
general literature is quite mixed on this).
So my point is, we are working hard on ensuring adherence at the moment -
are our results generalisable to larger scale roll outs and, what is it
that actually gets us to achieve these phenomenal adherence rates?
I am please that MSF (as reported by Marta) have changed their protocol
for inclusion of patients for ARV in Khayeltsha, the last protocol that I
looked at (admittedly it was nearly 2 years ago now) had something about
adequate nutritional statuse being a requirement for getting the ARVS.
Dr David Green
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