Antiretroviral Adherence in Rural Zambia: The First Year of Treatment Availability

Abstract

We conducted a retrospective chart review of antiretroviral therapy (ART) clinic patients treated during the first 12 months after clinics opened in rural Zambia and assessed adherence based on clinic attendance, patient report, and staff assessment. We identified 255 eligible patients (mean age, 39.7 years; 44.3% male; 56.5% married; and 45.5% with only primary school education). Twenty percent had partners known to be HIV positive. Twenty percent were widowed. Thirty-seven percent had disclosed their HIV status to their spouse. Disclosure was less likely among women (27.5% versus 49.6%, P = 0.0005); 36.5% had "clinic buddies" to provide adherence support. Adherence rates were good for 59.2%. Disclosure of HIV status to ones' spouse (P = 0.047), knowing spouses' HIV status (P = 0.02), and having a clinic buddy (P = 0.01) were associated with good adherence. Social support is a key patient-level resource impacting ART adherence in rural Zambia. Limited spousal disclosure affects women more than men. Clinic buddies are associated with better adherence.

Neuropsychiatric and Socioeconomic Status Impact Antiretroviral Adherence and Mortality in Rural Zambia

“…5,[27][28][29] The overall mortality rate in this prospective study corresponded to the mortality plus default rate identified in an earlier retrospective cohort study conducted in the region and suggests that most of the patients thought to be defaulters in the retrospective assessment probably died. 19 Tracking of patients who are lost to follow-up from ARV clinics is challenging and yet understanding the reasons for defaulting and the longterm outcomes of defaulters are critical. In one South African study, among patients who failed to attend the clinic, followup assessments indicated that transportation costs and user fees were the primary barrier to clinic attendance and that loss to follow-up was associated with a high mortality rate.…”

“…The three rural HIV clinics involved in this work have been described elsewhere. 19 Before the opening of these clinics, ARV treatment was not available in these clinical catchment areas. Even people with resources for purchasing medications had to travel into urban centers to do so.…”

“…This abstraction method has been previously shown to have an inter-rater reliability of > 0.8 for all nonlinear variables. 19 The clinic intake data also included a single question regarding peripheral neuropathy symptoms ("Do you experience tingling, burning, or numbness in your feet or hands? "), which has been shown to have 95.7% sensitivity, 80.0% specificity, 88.2% positive predictive value, and 92.3% negative predictive value in the Zambian population for identifying HIV patients with peripheral neuropathy.…”

“…The demographic profile of the study population is very similar to that of the overall adult population accessing care in the study clinics. 19 Almost 40% of patients ( N = 193) had not completed primary school, 41.5% ( N = 206) came from homes where the head of the household was a subsistence farmer, and 50% resided in a mud brick hut with thatched roof and dirt floor.…”

“…In our retrospective chart review completed 1 year before this study's enrollment commenced, 36.5% of HIV patients had a buddy and having a clinic buddy was found to be associated with better adherence. 19 These findings were disseminated to the clinic staff that then began to encourage clinic attendees to bring a clinic buddy to their visits. Over the intervening year, the proportion of patients with clinic buddies increased from 36% to 51%.…”