Adherence to antiretroviral therapy in young children in Cape Town, South Africa, measured by medication return and caregiver self-report: a prospective cohort study.
BACKGROUND
Antiretroviral therapy (ART) dramatically improves outcomes for children in Africa; however excellent adherence is required for treatment success. This study describes the utility of different measures of adherence in detecting lapses in infants and young children in Cape Town, South Africa.


METHODS
In a prospective cohort of 122 HIV-infected children commenced on ART, adherence was measured monthly during the first year of treatment by medication return (MR) for both syrups and tablets/capsules. A questionnaire was administered to caregivers after 3 months of treatment to assess experience with giving medication and self-reported adherence. Viral and immune response to treatment were assessed at the end of one year and associations with measured adherence determined.


RESULTS
Medication was returned for 115/122 (94%) children with median age (IQR) of 37 (16-61) months. Ninety-one (79%) children achieved annual average MR adherence > or = 90%. This was an important covariate associated with viral suppression after adjustment for disease severity (OR = 5.5 [95%CI: 0.8-35.6], p = 0.075), however was not associated with immunological response to ART. By 3 months on ART, 13 (10%) children had deceased and 11 (10%) were lost to follow-up. Questionnaires were completed by 87/98 (90%) of caregivers of those who remained in care. Sensitivity of poor reported adherence (missing > or = 1 dose in the previous 3 days) for MR adherence <90% was only 31.8% (95% CI: 10.7%-53.0%). Caregivers of 33/87 (38.4%) children reported difficulties with giving medication, most commonly poor palatability (21.8%). Independent socio-demographic predictors of MR adherence > or = 90% were secondary education of caregivers (OR = 4.49; 95%CI: 1.10-18.24) and access to water and electricity (OR = 2.65; 95%CI: 0.93-7.55). Taking ritonavir was negatively associated with MR adherence > or = 90% (OR = 0.37; 95%CI: 0.13-1.02).


CONCLUSIONS
Excellent adherence to ART is possible in African infants and young children and the relatively simple low technology measure of adherence by MR strongly predicts viral response. Better socio-economic status and more palatable regimens are associated with better adherence.
Davies
Mary-Ann
MA
Red Cross War Memorial Children's Hospital and the School of Child and Adolescent Health, University of Cape Town, Cape Town, The Republic of South Africa. Mary-Ann.Davies@uct.ac.za
Boulle
Andrew
A
Fakir
Tanzeem
T
Nuttall
James
J
Eley
Brian
B
D023241:Antiretroviral Therapy, Highly Active; D018791:CD4 Lymphocyte Count / Q000706:statistics & numerical data; D017028:Caregivers; D002675:Child, Preschool; D015331:Cohort Studies; D003625:Data Collection / Q000379:methods; D005260:Female; D005500:Follow-Up Studies; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D007223:Infant; D008297:Male; D010349:Patient Compliance / Q000706:statistics & numerical data*; D011446:Prospective Studies; D012923:Social Class; D013019:South Africa; D011795:Surveys and Questionnaires; D016896:Treatment Outcome; D019562:Viral Load
Pediatr Infect Dis J. 2000 Dec;19(12):1148-53
11144374
S Afr Med J. 2004 Aug;94(8):643-6
15352588
AIDS. 2006 Nov 28;20(18):2315-9
17117017
Ann Intern Med. 2001 May 15;134(10):968-77
11352698
HIV Med. 2002 Jul;3(3):215-26
12139662
Pediatrics. 2002 Apr;109(4):e61
11927734
Pediatr Infect Dis J. 1999 Aug;18(8):682-9
10462336
AIDS. 2004 Jun;18 Suppl 3:S27-31
15322481
Ann Intern Med. 2000 Jul 4;133(1):21-30
10877736
Curr HIV/AIDS Rep. 2005 Nov;2(4):171-6
16343374
PLoS Med. 2006 Nov;3(11):e438
17121449
Int J Antimicrob Agents. 2000 Nov;16(3):371-2
11091067
JAMA. 2006 Aug 9;296(6):679-90
16896111
AIDS. 2006 Oct 3;20(15):1955-60
16988517
S Afr Med J. 2006 Sep;96(9 Pt 2):988-93
17077930
Clin Infect Dis. 2007 May 1;44(9):1245-8
17407046
BMC Pediatr. 2007 Mar 17;7:13
17367540
Pediatr Infect Dis J. 2001 Dec;20(12):1174-6
11740328
BMJ. 2001 Jan 27;322(7280):226-31
11159626
Ann Trop Paediatr. 2007 Mar;27(1):1-10
17469726
J Acquir Immune Defic Syndr. 2005 Dec 1;40(4):498-500
16280708
J Acquir Immune Defic Syndr. 2003 Jun 1;33(2):211-8
12794557
AIDS Behav. 2006 Jul;10(4 Suppl):S85-93
16791525
Ann Trop Paediatr. 2007 Jun;27(2):123-31
17565809
AIDS. 2004 Sep 24;18(14):1905-13
15353976
Pediatr Infect Dis J. 2003 Jan;22(1):56-62
12544410
AIDS. 2003 Jun 13;17(9):1369-75
12799558
J Acquir Immune Defic Syndr. 2006 Dec 1;43(4):418-25
17099313
Clin Child Fam Psychol Rev. 2003 Mar;6(1):17-30
12659449