Long-term adherence to antiretroviral treatment and program drop-out in a high-risk urban setting in sub-Saharan Africa: a prospective cohort study.
BACKGROUND
Seventy percent of urban populations in sub-Saharan Africa live in slums. Sustaining HIV patients in these high-risk and highly mobile settings is a major future challenge. This study seeks to assess program retention and to find determinants for low adherence to antiretroviral treatment (ART) and drop-out from an established HIV/ART program in Kibera, Nairobi, one of Africa's largest informal urban settlements.


RESULTS
A prospective open cohort study of 800 patients was performed at the African Medical Research Foundation (AMREF) clinic in the Kibera slum. Adherence to ART and drop-out from the ART program were independent outcomes. Two different adherence measures were used: (1) "dose adherence" (the proportion of a prescribed dose taken over the past 4 days) and (2) "adherence index" (based on three adherence questions covering dosing, timing and special instructions). Drop-out from the program was calculated based on clinic appointment dates and number of prescribed doses, and a patient was defined as being lost to follow-up if over 90 days had expired since the last prescribed dose. More than one third of patients were non-adherent when all three aspects of adherence--dosing, timing and special instructions--were taken into account. Multivariate logistic regression revealed that not disclosing HIV status, having a low level of education, living below the poverty limit (US$ 2/day) and not having a treatment buddy were significant predictors for non-adherence. Additionally, one quarter of patients dropped out for more than 90 days after the last prescribed ART dose. Not having a treatment buddy was associated with increased risk for drop-out (hazard ratio 1.4, 95% CI = 1.0-1.9).


CONCLUSIONS
These findings point to the dilemma of trying to sustain a growing number of people on life-long ART in conditions where prevailing stigma, poverty and food shortages threatens the long-term success of HIV treatment.
Division of Global Health, IHCAR, Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden. christianunge@gmail.com
Christian
C
Unge
Björn
B
Södergård
Gaetano
G
Marrone
Anna
A
Thorson
Abigael
A
Lukhwaro
Jane
J
Carter
Festus
F
Ilako
Anna Mia
AM
Ekström
D017954:Africa South of the Sahara; D019380:Anti-HIV Agents / Q000627:therapeutic use*; D015658:HIV Infections / Q000188:drug therapy*; D006801:Humans; D016015:Logistic Models; D010349:Patient Compliance; D011446:Prospective Studies; D012307:Risk Factors; D014504:Urban Health
D019380:Anti-HIV Agents