title: Adherence to highly active antiretroviral therapy assessed by pharmacy claims predicts survival in HIV-infected South African adults.
abstract: It is unclear how adherence to highly active antiretroviral therapy (HAART) may best be monitored in large HIV programs in sub-Saharan Africa where it is being scaled up. We aimed to evaluate the association between HAART adherence, as estimated by pharmacy claims, and survival in HIV-1-infected South African adults enrolled in a private-sector AIDS management program. Of the 6288 patients who began HAART between January 1999 and August 2004, 3805 (61%) were female and 6094 (97%) were black African. HAART adherence was >or=80% for 3298 patients (52%) and 100% for 1916 patients (30%). Women were significantly more likely to have adherence>or=80% than men (54% vs 49%, P<0.001). The median (interquartile range) follow-up time was 1.8 (1.37-2.5) years. As of 1 September 2004, 222 patients had died-a crude mortality rate of 3.5%. In a multivariate Cox regression model, adherence<80% was associated with lower survival (relative hazard 3.23; 95% confidence interval: 2.37-4.39). When medication adherence was divided into 5 strata with a width of 20% each, each stratum had lower survival rates than the adjacent, higher-adherence stratum. Among other variables tested, only baseline CD4+ T-cell count was significantly associated with decreased survival in multivariate analysis (relative hazard 5.13; 95% confidence interval: 3.42-7.72, for CD4+ T-cell count<or=50 cells/microL vs >200 cells/microL). Pharmacy-based records may be a simple and effective population-level tool for monitoring adherence as HAART programs in Africa are scaled up.
authors.affiliation: Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, Baltimore, MD 21205, USA. jnachega@jhsph.edu
authors.forename: Jean B
authors.initials: JB
authors.lastname: Nachega
authors.forename: Michael
authors.initials: M
authors.lastname: Hislop
authors.forename: David W
authors.initials: DW
authors.lastname: Dowdy
authors.forename: Melanie
authors.initials: M
authors.lastname: Lo
authors.forename: Saad B
authors.initials: SB
authors.lastname: Omer
authors.forename: Leon
authors.initials: L
authors.lastname: Regensberg
authors.forename: Richard E
authors.initials: RE
authors.lastname: Chaisson
authors.forename: Gary
authors.initials: G
authors.lastname: Maartens
mesh_terms: D000328:Adult; D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count; D005260:Female; D015658:HIV Infections / Q000188:drug therapy* / Q000401:mortality*; D015497:HIV-1 / Q000235:genetics / Q000302:isolation & purification; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D010349:Patient Compliance; D010352:Patient Dropouts; D012189:Retrospective Studies; D013019:South Africa; D015996:Survival Rate; D019562:Viral Load