SIDA Project on ARV Adherence
The Swedish International Development Cooperation Agency (SIDA) awarded a five-year grant to
Management Sciences for Health (MSH) and the International Network for the Rational Use of Drugs (INRUD)
in 2006 for enhancing adherence to antiretrovirals (ARVs) in five East African countries (Ethiopia, Kenya,
Rwanda, Tanzania and Uganda). The DPRG is a partner in the project.
The five-year initiative is intended to:
- Develop and validate a set of indicators that can be used to monitor adherence to antiretroviral medicine therapy in existing ARV programs.
- Investigate adherence rates for different programs and different types of individuals in two countries.
- Pilot model adherence interventions at individual and programmatic levels in two target countries and measure effects.
- Establish activities/processes required for national programs and scale up successful interventions as national policy in the two target countries.
- Disseminate successful approaches for developing national programs to the other three regional project countries and facilitate implementation.
INRUD/Boston, led by Dennis Ross-Degnan, and funded by the Swedish International Development
Cooperation Agency (SIDA), is providing technical support to the project. Activities in 2006 and 2007 have
included development and pilot-testing of a candidate set of indicators that can be used to monitor
adherence in ARV programs in primary care settings; validation of the adherence indicators; and qualitative
assessments of determinants of adherence. During the remainder of 2007 and beyond, INRUD and the CCPP will
participate the design of pilot interventions to improve adherence in the five participating African countries.
Quality of Care Monitoring at HIV/AIDS Clinics
The National AIDS Control Programs in the five focus countries have expressed a need for a tool
to help monitor quality of care for clinics giving ART. The adherence measures we are developing will be
part of this tool. Through leveraged funding from USAID through MSH’s RPM Plus Program, and with country
input, Catherine Vialle-Valentin of the DPRG has developed the first draft of a Quality of Care Monitoring
tool and circulated it to the five countries for refinement. At the annual project meeting in October
2007, the tool will be further refined with quality-of-care indicators being prioritized and next steps
determined, including need for further development, field testing, and finalization.
BU Adherence Research Projects: China, Kazakhstan, Zambia
Adherence for Life (AFL) is a three phase study combining qualitative methods (Phase I) and
quantitative methods (Phases II/III) to measure adherence using multiple methods, identify factors that
affect adherence, and assess the effectiveness of a novel intervention designed to improve adherence among
Chinese HIV-positive patients in Dali, Yunnan Province. Led by Lora Sabin, the project is a collaborative
effort among researchers at the BU-CIHD, Ditan Hospital (Beijing), Horizon Research Group (Beijing), and
the Dali Second People’s Hospital (Dali), and is funded by USAID. Phase I commenced in September of 2005,
with data collection completed in early spring 2006. Between June and November 2006, a total of 80 patients
were enrolled in Phase II, which involves monthly passive data collection regarding adherence and quarterly
(baseline, Month 3, Month 6) surveys relating to economic status, behaviors, and quality of life. In Phase
III, which began in January 2007 for the earliest patients, participants were randomized into control or
intervention groups as they reached 6 months of longitudinal data collection. In addition to the base study,
the WHO has provided funding for a drug resistance component which focuses on measuring drug resistance
among AFL patients at baseline and 12 months.
By the end of June 2007, 65 patients had completed Phase II. Preliminary analysis of the Phase
II data had been conducted with the results presented at the International Adherence Conference in New
Jersey in March. They indicated that self-report vastly overstated adherence compared to electronic drug
monitoring (EDM). EDM data was also strongly correlated with changes in CD4 count between baseline and 6
months, whereas there was no correlation with self-reported data, suggesting that the most reliable measure
of adherence in this population is EDM.
Brenda Waning of Boston University is working in Temritau, Kazakhstan, where the HIV epidemic is
most concentrated, to evaluate and improve uptake and adherence to ART among a population that is
predominantly comprised of intravenous drug users (IVDU). Evaluations and qualitative research were
conducted to better understand barriers to uptake and adherence to ART in this population. Evaluations
were conducted in the form of key informant interviews and facility-based evaluations, including medical
record review. The community-based qualitative research involved free list interviews and key informant
interviews of community members to better understand community perceptions of ART services. Results of
the evaluations and research are currently being reviewed to identify interventions to introduce at
government (policy), facility and community levels to promote uptake and adherence of ART services.
This work is closely linked with the work of Abt Associates who are leading the effort to integrate ART
services into other points of health care delivery on the CAPACITY project (see below).
In November of 2006, Dr. Laura Murray of Boston University (BU) in collaboration with local
implementing partners of Zambia Exclusive Breastfeeding Study (ZEBS) and with the support of the Centers
for Disease Control (CDC) conducted a qualitative assessment on adherence to ARVs. This qualitative
assessment had three overall aims: 1) To provide information on the barriers to acceptance and adherence
to ART adherence in order to help local HIV care programs to better address these issues; 2) To provide
suggestions from the local people regarding HIV care programming; and 3) To provide preliminary data
to develop quantitative instruments to measure the extent of these problems and the impact of HIV care
programs. Two qualitative methods were used in this study: Free Listing and Key Informant Interviews.
Forty-five individuals were interviewed using Free Listing, and 33 Key Informants were interviewed.
Results show that some of the barriers identified by this study are consistent with factors cited in
the existing adherence literature from both developed and developing nations such as side effects,
hunger and stigma. Other major themes included unfamiliarity with the implications of having a chronic
disease, the complicated effect of ART on interpersonal relationships, particularly between husbands
and wives, the presence of depression and hopelessness, and lack of accurate information. These data
will be used for to develop or adapt a quantitative assessment tool that can assess the prevalence
of the barriers to acceptance and adherence to ART. Phase III will use the quantitative instrument
to evaluate overall HIV care program impact.