title: Implementation and Operational Research: Correlates of Adherence and Treatment Failure Among Kenyan Patients on Long-term Highly Active Antiretroviral Therapy.
abstract: BACKGROUND
  Universal access to highly active antiretroviral therapy (HAART) is still elusive in most developing nations. We asked whether peer support influenced adherence and treatment outcome and if a single viral load (VL) could define treatment failure in a resource-limited setting.
  
  
  METHODS
  A multicenter longitudinal and cross-sectional survey of VL, CD4 T cells, and adherence in 546 patients receiving HAART for up to 228 months. VL and CD4 counts were determined using m2000 Abbott RealTime HIV-1 assay and FACS counters, respectively. Adherence was assessed based on pill count and on self-report.
  
  
  RESULTS
  Of the patients, 55.8%, 22.2%, and 22% had good, fair, and poor adherence, respectively. Adherence, peer support, and regimen, but not HIV disclosure, age, or gender, independently correlated with VL and durability of treatment in a multivariate analysis (P < 0.001). Treatment failure was 35.9% using sequential VL but ranged between 27% and 35% using alternate single VL cross-sectional definitions. More patients failed stavudine (41.2%) than zidovudine (37.4%) or tenofovir (28.8%, P = 0.043) treatment arms. Peer support correlated positively with adherence (χ(2), P < 0.001), with nonadherence being highest in the stavudine arm. VL before the time of regimen switch was comparable between patients switching and not switching treatment. Moreover, 36% of those switching still failed the second-line regimen.
  
  
  CONCLUSIONS
  Weak adherence support and inaccessible VL testing threaten to compromise the success of HAART scale-up in Kenya. To hasten antiretroviral therapy monitoring and decision making, we suggest strengthening patient-focused adherence programs, optimizing and aligning regimen to WHO standards, and a single point-of-care VL testing when multiple tests are unavailable.
authors.affiliation: *Center for Research in Therapeutic Sciences and the Institute of Healthcare Management, Strathmore University, Nairobi, Kenya; †Kenya Medical Research Institute, Nairobi, Kenya; ‡Institute of Tropical Medicine and Infectious Diseases at JKUAT, Nairobi, Kenya; §MCPHS University, Worcester, MA; ‖Center for Global Public Health, Tufts University School of Medicine, Boston, MA; and ¶African Centre for Clinical Trials, Nairobi, Kenya.
authors.forename: Washingtone
authors.initials: W
authors.lastname: Ochieng
authors.forename: Rose C
authors.initials: RC
authors.lastname: Kitawi
authors.forename: Timothy J
authors.initials: TJ
authors.lastname: Nzomo
authors.forename: Ruth S
authors.initials: RS
authors.lastname: Mwatelah
authors.forename: Maureen J
authors.initials: MJ
authors.lastname: Kimulwo
authors.forename: Dorothy J
authors.initials: DJ
authors.lastname: Ochieng
authors.forename: Joyceline
authors.initials: J
authors.lastname: Kinyua
authors.forename: Nancy
authors.initials: N
authors.lastname: Lagat
authors.forename: Kevin O
authors.initials: KO
authors.lastname: Onyango
authors.forename: Raphael M
authors.initials: RM
authors.lastname: Lwembe
authors.forename: Mkaya
authors.initials: M
authors.lastname: Mwamburi
authors.forename: Bernhards R
authors.initials: BR
authors.lastname: Ogutu
authors.forename: Florence A
authors.initials: FA
authors.lastname: Oloo
authors.forename: Rashid
authors.initials: R
authors.lastname: Aman
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D023241:Antiretroviral Therapy, Highly Active / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D003430:Cross-Sectional Studies; D016903:Drug Monitoring; D005260:Female; D015658:HIV Infections / Q000175:diagnosis* / Q000188:drug therapy*; D006297:Health Services Accessibility; D006801:Humans; D007630:Kenya; D008137:Longitudinal Studies; D008297:Male; D055118:Medication Adherence; D008875:Middle Aged; D017211:Treatment Failure; D019562:Viral Load; D055815:Young Adult
chemical_list: D044966:Anti-Retroviral Agents