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[e-drug] MSF on FDCs (5)

E-DRUG: MSF on FDCs (5)

Dear e-druggers

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
South Africa

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