September 3, 2003
Evidence is emerging that HIV-positive people in Africa follow their antiretroviral drug regimens more closely than HIV-positive people in the United States, the New York Times reports. Studies in Botswana, Uganda, Senegal and South Africa have found that on average, AIDS patients there take about 90% of the pills in their antiretroviral drug regimens, compared with 70% among patients in the United States. Some doctors, politicians and pharmaceutical executives have argued that it is unsafe to send antiretroviral drugs to Africa for fear that poor adherence to drug regimens will speed the mutation of HIV and the spread of drug-resistant HIV strains throughout the world. Although drug-resistant strains are inevitable, they are more likely to occur and to be passed on if patients skip doses of medication, according to doctors. Most African patients are "zealous" about adhering to their drug regimens and are more truthful than their U.S. counterparts when estimating their adherence to a drug regimen, Dr. David Bangsberg, a professor of medicine at the University of California-San Francisco, said. On average, U.S. patients tell their doctors that they are doing 20% better in adhering to their regimen than they actually are. However, a study of 29 Ugandan HIV-positive people found that while the patients estimated that they were taking 93% of their pills, in reality they were taking 91% of the pills.
Reasons for Adherence
Adherence to drug regimens in Africa has become easier with the introduction of a generic three-drug regimen that can be taken in as few as two pills a day. Such pills are not yet available in the United States due to patent problems -- no one company holds the patents on three medications that are "ideal" for a three-drug regimen, according to the Times. In addition, HIV-positive people in Africa are "highly motivated" to adhere to regimens because they have seen friends or family members die, several doctors in Africa said, according to the Times. In Botswana, which has the world's highest HIV prevalence, pill counts on 400 of the 10,000 people participating in a national antiretroviral drug program found that 85% were adhering 100% to their drug regimen, according to Dr. Ernest Darkoh, manager of the national program. However, other programs in Africa have not been as successful. In Nigeria, the most populous country in Africa, a program aimed at providing drugs for 15,000 HIV-positive people "has been hampered by bureaucracy, corruption and a scarcity of laboratories," according to the Times. Dr. Ernest Ekong, an AIDS specialist at the Military Reference Hospital in Lagos, said that adherence has been "no problem" so far, but he added that some patients have shared pills, cut back on the number of pills taken or resold the drugs. Although no formal study has been conducted, Nigerian doctors have reported that some patients who were adhering to their drug regimens were not benefiting from the drugs, leading them to believe that drug-resistant HIV strains had developed in other patients and had been passed on.
In a recent study of a pilot antiretroviral drug program in Khayelitsha, South Africa, run by Doctors Without Borders, patient pill counts found that after six months on a drug regimen, 96% of patients were still taking 95% of their pills. Blood testing, a more accurate measure of drug adherence, found that after six months, 91% of patients had low levels of virus in their bloodstream, and after 18 months, 83% of the patients had low viral load counts. However, the organization has strict requirements to enter the program -- patients must give up alcohol and drugs; complete three months of taking a simple antibiotic; be on time for four consecutive appointments; reveal their HIV status to their families; and have a "buddy" who attends counseling, monitors their adherence and reports any problems to health care workers, according to the Times (McNeil, New York Times, 9/3).
Reprinted with permission from kaisernetwork.org. You can view the entire Kaiser Daily HIV/AIDS Report, search the archives, or sign up for email delivery at www.kaisernetwork.org/dailyreports/hiv. The Kaiser Daily HIV/AIDS Report is published for kaisernetwork.org, a free service of the Kaiser Family Foundation, by The Advisory Board Company. © 2003 by The Advisory Board Company and Kaiser Family Foundation. All rights reserved.