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 May 2005, Vol. 11, No. 2HIV/AIDS Since 1996, the standard treatment for HIV infection has moved from single- and double-drug therapies to therapies containing three or more anti-HIV drugs, also known as Highly Active Antiretroviral Therapy, or HAART. One of the main concerns of antiretroviral programs is to motivate clients to follow their complex drug regimen exactly as prescribed. Unless the therapy is adhered to at least 95 percent correctly, levels of HIV in the blood will rise, resulting in AIDS-related complications. To address this concern, the Population Council’s Horizons Program collaborated with the International Centre for Reproductive Health and the Coast Province General Hospital in Mombasa, Kenya, to create a manual for training health care workers in improving patient compliance with antiretroviral therapy. “This handbook is one of the first counseling training tools designed to increase adherence to HAART that has been developed in Africa,” says Horizons/Population Council researcher Avina Sarna, one of the handbook’s authors. The manual is being used in an intervention study in Kenya that is investigating ways of improving patients’ adherence to HAART. Introducing antiretrovirals to Africa Patients face significant challenges in following multi-drug antiretroviral therapies precisely. HAART is a life-long treatment. While first-line treatment regimens may be available in fixed-dose combinations where all medications are contained in one pill, second- and third-line regimens often consist of multiple medications that must be taken two to three times a day with varying dietary instructions. Antiretroviral medications also have side effects. Some of these are temporary, but others may last longer and their severity may compel a change of treatment. When patients fail to follow the regimen closely, virus becomes more prevalent in their bloodstreams, killing their CD4 immune system cells. As a result, opportunistic infections appear, and health suffers. Additionally, if proper treatment protocols are not followed, the virus can mutate into drug-resistant strains. The manual consists of four training modules for health care workers, each of which takes approximately two hours to complete. The material covered in the workbook includes information on educating the patient about HIV and the HAART regimen, including potential side effects; assessing patient adherence to the protocol; and identifying and overcoming barriers to following the regimen. The manual uses various techniques to explore these topics: brainstorming, small group discussions, PowerPoint presentations, case studies, and role-playing. The Mombasa HAART project, for which the training manual was devised, was initiated in 2003. It was designed as a learning site for similar service-delivery programs that are starting up in public-health facilities in Kenya and other African countries. The intervention compares two approaches to enhancing patient adherence to the HAART regimen. One arm of the intervention involves counseling patients, teaching them to use medication diaries and pill boxes, and encouraging them to enlist the help of sympathetic family and friends, among other strategies. The other arm uses all these approaches, but it additionally focuses on modified “directly observed therapy.” Directly observed therapy (DOT) is a treatment strategy originally developed for tuberculosis patients, who must take all their medications consistently and on time for up to nine months to rid themselves of the infection. In the standard DOT approach, health workers or community volunteers literally watch clients as they take their medication. “DOT has proven to be very effective in helping TB patients maintain their treatment schedules,” said Sarna. “One big difference between treatments for TB and HIV, though, is that antiretroviral medications for HIV/AIDS must be taken for life.” A DOT strategy for AIDS treatment is called DAART, for “directly administered antiretroviral therapy.” A DAART program includes observation of patients taking their medications, but less often than for TB. Although it is too early in the study to report findings about long-term adherence, clients in both arms who have completed four to six months of follow-up have shown weight gain and increases in the number of CD4 immune system cells that circulate in their blood. They have also experienced significant improvement in quality-of-life measures such as physical functioning, cognitive functioning, depression, and pain and energy levels. Source Outside funding The Horizons Program is implemented by the Population Council in collaboration with the International Center for Research on Women, the International HIV/AIDS Alliance, the Program for Appropriate Technology in Health, Tulane University, Family Health International, and Johns Hopkins University. See Also
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