Secret History: Return of the Black Death Channel 4, 7-8pm In 1348 the Black Death swept through London, killing people within days of the appearance of their first symptoms. Exactly how many died, and why, has long been a mystery. This Secret History documentary follows experts as they pick through the evidence and reveal why the plague killed on such a scale. And they ask, what might be coming next?

Medscape

Introduction Many resource-poor countries with HIV epidemics are scaling up antiretroviral therapy (ART) By December 2005, an estimated 13 million people from low-and middle-income countries had been placed on treatment; 810 000 of these were in sub-Saharan Africa (1) Treatment outcomes reported from various clinics in sub-Saharan Africa, Haiti, Asia and South America have been good, comparable with those observed in countries with higher incomes (2-7) Patient outcomes are usually categorized as patients alive and on treatment, stopped treatment, transferred to another facility, dead or "lost to follow-up" Depending on the facility, patients are classified as lost to follow-up if they have missed two or more consecutive clinic appointments (2) or have not been seen for at least 2 or 3 months (4-6) The proportion of patients lost to follow-up differs between clinics, ranging from 5% in programmes supported by Medecins Sans Frontieres (5) to 25% in western Kenya (4) In 18 ART-delivery programmes in Africa, Asia and South America, 15% of 4810 patients were lost to follow-up in the first year of ART, with the average being 12% in programmes with active follow-up and 19% in those with no active follow-up (7) To our knowledge, there ate no published data from resource-poor countries on the true outcome status of these patients Malawi--a small resource-poor country in southern Africa--has been engaged in ART scale-up for nearly 3 years By 31 March 2006, 46 702 patients had ever started receiving ART in 66 facilities in the public sector; of these, 33 891 (73%) were registered as alive, 5131 (11%) were dead, 4226 (9%) were lost to follow-up, 3140 (7%) had transferred to another facility and 314 (1%) had stopped therapy (8) We hypothesized that many patients lost to follow-up may have died, and therefore conducted a study in northern Malawi to investigate this problem Methods Details on the delivery and monitoring of ART in Malawi have been described previously (9) When patients start ART, their details are entered on master cards and an ART register Patients attend the ART clinic each month, at which time their outcome status is entered on the master card and they are given another month's supply of ART drugs if a patient is not seen in the clinic for three consecutive months, the patient is registered as a "defaulter" (an abbreviated term for "lost to follow-up") on the master card and also on the register Four public-sector ART facilities in the northern region of Malawi were selected for the study These included one central hospital and three peripheral hospitals (two district hospitals and one mission hospital) Provision of free ART was initiated at the central and mission hospitals in July 2004, and at the two district hospitals in January and June 2005 respectively For the period between the date when each facility started to provide free ART and 31 March 2006, we identified all patients indicated on the master cards and registers as a defaulter Using contact details, ART facility staff visited the patients' homes to try to ascertain their true outcome status If patients were traced to the home, they were asked whether they were still taking ART and if not, why they had stopped If the patient had died, the relatives were asked when the patient had died If the patient had moved away, relatives or friends were asked when they had moved Ethical approval for the study was granted by the Malawi National Health Sciences Research Committee Informed consent was obtained from patients being interviewed, and staff took care not to disclose that the patient was receiving ART when interviewing relatives or friends in the event of the patient's death or transfer Data were collected, on Structured forms, and analysis was carried out using Epi Info version 60 Patients from the central and the peripheral hospitals were compared: the [chi square] test with relative risks (RR) and 95% confidence intervals (CI) were used for characteristics and outcomes, and the student's t-test was used for time periods between start of ART, default and patient tracing, with differences at the level Of 0 …

True Outcomes for Patients on Antiretroviral Therapy Who Are "Lost to Follow-Up" in Malawi/Veritables Issues Du Traitement Antiretroviral Pour Les Patients Consideres Comme « Perdus De Vue » Au Malawi/Evolucion Real De Los Pacientes Sometidos a Terapia Antirretroviral Y Perdidos En El Seguimiento En Malawi

Objective The rapid scale up of antiretroviral treatment (ART) in sub-Saharan Africa (SSA) has resulted in an increased focus on patient adherence. Non-adherence can lead to drug-resistant HIV caused by failure to achieve maximal viral suppression. Optimal treatment requires the identification of patients at high risk of suboptimal adherence and targeted interventions. The aim of this review was to identify and summarise determinants of adherence to ART among HIV-positive adults. Design Systematic review of adherence to ART in SSA from January 2002 to October 2014. Methods A systematic search was performed in 6 databases (PubMed, Cochrane Library, EMBASE, Web of Science, Popline, Global Health Library) for qualitative and quantitative articles. Risk of bias was assessed. A meta-analysis was conducted for pooled estimates of effect size on adherence determinants. Results Of the 4052 articles screened, 146 were included for final analysis, reporting on determinants of 161 922 HIV patients with an average adherence score of 72.9%. Main determinants of non-adherence were use of alcohol, male gender, use of traditional/herbal medicine, dissatisfaction with healthcare facility and healthcare workers, depression, discrimination and stigmatisation, and poor social support. Promoters of adherence included counselling and education interventions, memory aids, and active disclosure among people living with HIV. Determinants of health status had conflicting influence on adherence. Conclusions The sociodemographic, psychosocial, health status, treatment-related and intervention-related determinants are interlinked and contribute to optimal adherence. Clinics providing ART in SSA should therefore design targeted interventions addressing these determinants to optimise health outcomes.

https://gh.bmj.com/content/bmjgh/1/4/e000125.full.pdf

Determinants of adherence to antiretroviral therapy among HIV-positive adults in sub-Saharan Africa: a systematic review

Adherence to antiretroviral therapy (ART) is critical for reducing HIV/AIDS morbidity and mortality. Food insecurity (FI) is emerging as an important barrier to adherence to care and treatment recommendations for people living with HIV (PLHIV), but this relationship has not been comprehensively examined. Therefore, we reviewed the literature to explore how FI may impact ART adherence, retention in medical care, and adherence to health care recommendations among PLHIV. We found data to support FI as a critical barrier to adherence to ART and to other health care recommendations among HIV-infected adults, HIV-infected pregnant women and their HIV-exposed infants, and child and adolescent populations of PLHIV. Associations between FI and ART non-adherence were seen in qualitative and quantitative studies. We identified a number of mechanisms to explain how food insecurity and ART non-adherence may be causally linked, including the exacerbation of hunger or ART side effects in the absence of adequate food and competing resource demands. Interventions that address FI may improve adherence to care and treatment recommendations for PLHIV.

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A review of the role of food insecurity in adherence to care and treatment among adult and pediatric populations living with HIV and AIDS

We assessed the effectiveness of the treatment supporter initiative as an intervention in improving clinic attendance for antiretroviral (ARV) drug refills and adherence to antiretroviral therapy (ART) in a cohort of HIV-infected adults. This two-arm randomized controlled trial was undertaken at an HIV clinic in a district hospital in Uganda. A total of 174 adult patients on ART were randomized 1:1 to a standard adherence intervention package plus a treatment supporter intervention (TS arm) or to a standard adherence intervention package (non-TS arm) alone. Clinic attendance for refills and adherence measurements using monthly clinic-based pill counts were monitored for both arms for 28 weeks. Baseline characteristics were similar for both arms. There was a non-significant difference in mean adherence between the TS and non-TS groups at end of follow-up [99.1% (95% CI: 98.3-99.9% vs. 96.3% (95% CI: 94.2-98.3%), P > 0.05]. TS participants had more than four times the odds of achieving optimal adherence (≥95%) [Odds ratio (OR) = 4.51, 95% CI: 1.22-16.62, exact P = 0.027]. TS participants were also more likely to be on time for their clinic appointments: 91.6 vs. 90.1% for TS and non-TS, respectively (OR = 1.19, 95% CI: 0.74-1.91, P > 0.05). Use of patient-selected treatment supporters may be an effective intervention to improve ARV treatment outcomes in resource-constrained settings.

Improving Clinic Attendance and Adherence to Antiretroviral Therapy Through a Treatment Supporter Intervention in Uganda: A Randomized Controlled Trial

The anti-retroviral (ARV) treatment programme in Nigeria is delivered through selected teaching and mission hospitals at a free/subsidized rate. The government aims to scale up ARV treatment in the country. However, non-adherence to ARV medication can lead to viral resistance, treatment failure, toxicities and waste of financial resources. This study examined the factors responsible for non-adherence to free/subsidized ARV treatment in south-east Nigeria. The study was cross-sectional and descriptive. Information was collected from 174 patients selected by simple random sampling from the register of all patients who had been on anti-retroviral therapy (ART) for at least 12 months at the beginning of the study period. Patients were identified during their clinic visits. Information on their socio-demographic profile, ARV treatment and determinants of non-adherence to ARV treatment was obtained from those who gave consent, using pre-tested interviewer-administered questionnaires. All patients clearly understood the need to take ARV drugs throughout their lives, and what the costs entailed. They understood the need for periodic testing, the probability that complications would develop, cost of transportation to treatment site and the daily treatment regimen. Seventy-five per cent of respondents were not adhering fully to their drug regimen; the mean number of days that respondents had been off drugs was 3.57 days the preceding month. Reasons for non-adherence included: physical discomfort (side effects); non-availability of drugs at treatment site; forgetting to carry drugs during the day; fear of social rejection; treatment being a reminder of HIV status; and selling of own drugs to those unable to enrol in the projects. Being female, under 35 years, single, and having higher educational status were significantly associated with non-adherence. It is important that policy makers and programme managers address the factors responsible for non-adherence when scaling up subsidized ARV treatment in Nigeria and other parts of sub-Saharan Africa.

/pdf/determinants-of-non-adherence-to-subsidized-anti-retroviral-329qe24jk6.pdf

A C Onoka

Papers

Determinants of non-adherence to subsidized anti-retroviral treatment in southeast Nigeria.