Transcript context

Experience under the TAP:
Determinants and experience
with adherence in Burkina Faso
Hospital and Community Sites
in Burkina Faso
Pascal NIAMBA, Cecile BELOUME
OUTLINE
1. Context
2. Methods
–
–
–
–
Study design
Population and sample
Data collection
Data analysis
3. Results
4. Discussion and conclusion
Burkina Faso
•
•
•
•
•
274 200 km²
12 802 282 inhabitants (2005)
< 15 years: 55%
Women :52%
PNB 268 USD
128022
82
-46 % of the population is
below the poverty line
-IDH=0,303 en 2000
Situation Analysis
• Epidemiological Data:
– Sentinel site surveillance (2004):
• Prevalence rate 2.4%.
• Urban sites: 3.4%
• Rural areas: 1.5%
– Estimates for 2005 (UNAIDS)
• Adults living with HIV/AIDS: 135 120
• HIV/AIDS prevalence rates in adults
(15- 49): 2%
HIV patient care in Sub-Saharan Africa
« the big picture »
• Dramatic price reductions + new
programs → rapid expansion of ARV
programs
• 500 000 people are receiving ARV
(UNAIDS “3x5”)
• Scale-up is accelerating in most countries
on the African continent
PLWHIV under ART
end of 2004 to T1-2006
12000
10000
8000
9538
8136
6000
4000
2000
3867
0
Fin 2004
Fin 2005
T1-2006
Number of PLWHIV under ART
HIV patient care in Sub-Saharan Africa
« the big picture »
Adherence to treatment will become a
challenge
• Adherence determines treatment efficacy
• Initial pilot studies → high levels of
adherence
• In our initial studies → adherence
appears to be inadequate in some sites
• Few studies on determinants of adherence
in Sub-Saharan Africa
Background study
46/73 patients (63%) non-adherent
to ARV therapy in a community-based cohort in Burkina Faso
• The majority on triple therapy
• 84% on first HAART regimen
• 75% on HAART > 6 months
Side effects
Not enough food to
accompany medications
Running out of medication
Circumstantial constraints
Number of responses
19
Depression
15
13
10
Forgetting
Medication-related reasons *
9
6 4
6
3
Falling asleep
Other §
•Traoré AA, N.V., Fakoya A, McCarrick P, Dhaliwal M, Tiendrébéogo I, Ilboudo A, Barriers to adherence to ARV therapy in a community-based
cohort in Burkina Faso. The XV International AIDS Conference, 2004. Abstract number: WePeB582
Study aim
– Describe the prevalence of adherence
– Identify potential determinants of
adherence
Methods
Methods (1)
• Study design: cross-sectional study
• Population: patients >6 months ARV in
hospitals and CBO
• Sample: n=270 (94 men; 176 women)
• Recruitment sites
– In Ouagadougou: 1 Hospital and 2 CBO
• Data collection: Face-to-face interviews with a
close-ended questionnaire + chart review
Methods (2)
• Measuring adherence:
• Patients were considered adherent if they
answered “YES” to the following questions
– “Always” took their ART
– Took all pills yesterday, the day before
yesterday and during the whole week
– Followed the treatment schedule
yesterday, the day before yesterday and
during the whole week
– AND missed < 1 dose in the month
“Individual” factors
• Socio-economic
– Revenue
– Education
– Occupation
– Household attributes
• Demographics
– Age
– Gender
– Marital status
• Knowledge of treatment
Relational factors
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•
•
•
Having a regular partner
Number of children
Number of people you provide for
Serostatus notification
–To partner
–To surroundings
Treatment regimen
• Pill burden (number of pills/day)
• Complexity of schedule (food restrictions)
• Months on treatment
• Side effects
Treatment regimen: Setting
• Clinical management
• Community setting
• Hospital setting
• Time/distance to appointment
Results
Percent (%)
Adherence
in hospital vs CBO
80
70
60
50
40
30
20
10
0
* p=0.082
57,5
43,8
Burkina Faso
• Overall, adherence is inadequate: Only 58.5%
(158/270) of patients had complete adherence.
Hospitals (64.6%) > CBOs (50.0%) p<0.017
CBOs
Hospitals
Adherence is related to clinical outcome
Weight loss
% Pts with Weight loss
25
p≤0.001
21,4
20
15
10
4,6
5
0
adherent
non adherent
% Pts with OI
Adherence is related to clinical outcome
Patients with OI
8
7
p=0.034
7,3
6
5
4
3
2
2
1
0
adherent
non adherent
Individual factors associated
with adherence:
• Muslim religion, but confounded ??
• Shaped relationship between adherence
and income?
Facilitating factors and adherence
Relational Characteristics
Facilitating Factors
N(%)
p
Relational Characteristics
Number of children
0
1
2-3
>= 4
Number of people you provide for
0
1-2
3-4
5-6
>= 7
Having a regular partner
No
Yes
31/66
44/73
50/74
33/55
(47.0)
(60.3)
(67.6)
(60.0)
0.099
38/64
27/52
30/47
27/44
33/60
(59.4)
(51.9)
(63.8)
(61.4)
(55.0)
0.750
27/58 (46.6)
131/212 (61.8)
0.037
Having children
is associated
with better
adherence
Having a
regular sex
partner is
associated
with a better
adherence
Facilitating factors and adherence:
Influence of the treatment regimen
Facilitating Factors - Treatment regimen and therapeutic history
Type of treatment
IN, IN, INN
IN, IN, IP
IN, IN, IN
Length of treatment (months)
1-6
7-12
13-18
19-24
> = 25
119/195 (61.0)
32/61
(52.5)
2/3
(66.7)
0.405
26/34
57/95
28/51
20/31
23/55
0.021
(76.5)
(60.0)
(54.9)
(64.5)
(41.8)
Preventive behavior and adherence
Only 58%(123/212)
used condoms with
regular partner at last
intercourse
Preventive Behavior
Condom use with regular partner
No
Yes
Status disclosure to partner
No
Yes
54/89 (60.7)
77/123 (62.6)
0.776
58/92 (63.0)
73/120 (60.8)
0.743
Only 56%(120/212)
notified partner about
their serostatus
Concluding remarks
• Adherence and preventive behaviours are
inadequate
• No clear association between individual
factors and adherence
• Decreasing adherence over time:
– second year of treatment “high risk” for nonadherence
• Implications for antiretroviral resistance
• Need for prospective studies of
adherence to treatment AND prevention
Acknowledgements