Rates of self-reported adherence were relatively high and were influenced by multiple child and family characteristics. These findings identify targets for adherence interventions and highlight the importance of evaluating and supporting the family environment to optimize adherence.

BackgroundSubstantial resources and patient commitment are required to successfully scale-up antiretroviral therapy (ART) and provide appropriate HIV management in resource-limited settings. We used pharmacy refill records to evaluate risk factors for loss to follow-up (LTFU) and non-adherence to ART in a large treatment cohort in Nigeria.Methods and FindingsWe reviewed clinic records of adult patients initiating ART between March 2005 and July 2006 at five health facilities. Patients were classified as LTFU if they did not return >60 days from their expected visit. Pharmacy refill rates were calculated and used to assess non-adherence. We identified risk factors associated with LTFU and non-adherence using Cox and Generalized Estimating Equation (GEE) regressions, respectively. Of 5,760 patients initiating ART, 26% were LTFU. Female gender (p<0.001), post-secondary education (p = 0.03), and initiating treatment with zidovudine-containing (p = 0.004) or tenofovir-containing (p = 0.05) regimens were associated with decreased risk of LTFU, while patients with only primary education (p = 0.02) and those with baseline CD4 counts (cell/ml3) >350 and <100 were at a higher risk of LTFU compared to patients with baseline CD4 counts of 100–200. The adjusted GEE analysis showed that patients aged <35 years (p = 0.005), who traveled for >2 hours to the clinic (p = 0.03), had total ART duration of >6 months (p<0.001), and CD4 counts >200 at ART initiation were at a higher risk of non-adherence. Patients who disclosed their HIV status to spouse/family (p = 0.01) and were treated with tenofovir-containing regimens (p≤0.001) were more likely to be adherent.ConclusionsThese findings formed the basis for implementing multiple pre-treatment visit preparation that promote disclosure and active community outreaching to support retention and adherence. Expansion of treatment access points of care to communities to diminish travel time may have a positive impact on adherence.

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The authors sought to assess the utility of the electronic Medication Event Monitoring System (MEMS) in monitoring adherence to highly active antiretroviral therapy (HAART) in HIV-infected children and to compare this with other methods of adherence assessment. Twenty-six perinatally HIV-infected children being treated with three or more antiretroviral medications and their caregivers were enrolled and prospectively followed-up for 6 months. Adherence was assessed using MEMS monitoring of one antiretroviral, pharmacy refill records of all antiretrovirals, a caregiver self-report interview, a physician/nurse questionnaire, and appointment-keeping behavior. Viral loads measured at the end of the 6-month period were compared with the various adherence assessment methods. Adherence rates for the MEMS-monitored medication ranged from 12.7% to 97.9% (median = 81.4%), and 11 of the participants (42%) had less than 80% adherence using this method. A MEMS adherence rate greater than 80% was associated with viral load below the threshold of detection 6 months after enrollment (p <.001). Although not as robust, pharmacy refill rates for all antiretroviral medications were also associated with virologic response. The highest specificity was attained when both MEMS and pharmacy refill were used in combination. Physician assessment of adherence rate as well as appointment-keeping behavior was associated with virologic response, whereas caregiver self-report was not.