title: Reasons for Missing Antiretroviral Therapy: Results from a Multi-Country Study in Tanzania, Uganda, and Zambia.
abstract: OBJECTIVE
  To identify the reasons patients miss taking their antiretroviral therapy (ART) and the proportion who miss their ART because of symptoms; and to explore the association between symptoms and incomplete adherence.
  
  
  METHODS
  Secondary analysis of data collected during a cross-sectional study that examined ART adherence among adults from 18 purposefully selected sites in Tanzania, Uganda, and Zambia. We interviewed 250 systematically selected patients per facility (≥ 18 years) on reasons for missing ART and symptoms they had experienced (using the HIV Symptom Index). We abstracted clinical data from the patients' medical, pharmacy, and laboratory records. Incomplete adherence was defined as having missed ART for at least 48 consecutive hours during the past 3 months.
  
  
  RESULTS
  Twenty-nine percent of participants reported at least one reason for having ever missed ART (1278/4425). The most frequent reason was simply forgetting (681/1278 or 53%), followed by ART-related hunger or not having enough food (30%), and symptoms (12%). The median number of symptoms reported by participants was 4 (IQR: 2-7). Every additional symptom increased the odds of incomplete adherence by 12% (OR: 1.1, 95% CI: 1.1-1.2). Female participants and participants initiated on a regimen containing stavudine were more likely to report greater numbers of symptoms.
  
  
  CONCLUSIONS
  Symptoms were a common reason for missing ART, together with simply forgetting and food insecurity. A combination of ART regimens with fewer side effects, use of mobile phone text message reminders, and integration of food supplementation and livelihood programmes into HIV programmes, have the potential to decrease missed ART and hence to improve adherence and the outcomes of ART programmes.
authors.affiliation: London School of Hygiene and Tropical Medicine, Department of Clinical Research, London, United Kingdom.|Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium.
authors.forename: Olivier
authors.initials: O
authors.lastname: Koole
authors.affiliation: FHI 360, Social and Behavioral Health Sciences, Durham, North Carolina, United States of America.|Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America.
authors.forename: Julie A
authors.initials: JA
authors.lastname: Denison
authors.affiliation: Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium.
authors.forename: Joris
authors.initials: J
authors.lastname: Menten
authors.affiliation: FHI 360, Social and Behavioral Health Sciences, Durham, North Carolina, United States of America.|Johns Hopkins Bloomberg School of Public Health, Department of International Health, Baltimore, Maryland, United States of America.
authors.forename: Sharon
authors.initials: S
authors.lastname: Tsui
authors.affiliation: Infectious Diseases Institute, Makerere University College of Health Sciences, Kampala, Uganda.
authors.forename: Fred
authors.initials: F
authors.lastname: Wabwire-Mangen
authors.affiliation: Muhimbili University of Health and Allied Sciences, Dar es Salaam, United Republic of Tanzania.
authors.forename: Gideon
authors.initials: G
authors.lastname: Kwesigabo
authors.affiliation: Tropical Diseases Research Centre, Ndola, Zambia.
authors.forename: Modest
authors.initials: M
authors.lastname: Mulenga
authors.affiliation: Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Andrew
authors.initials: A
authors.lastname: Auld
authors.affiliation: Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Simon
authors.initials: S
authors.lastname: Agolory
authors.affiliation: FHI 360, Social and Behavioral Health Sciences, Durham, North Carolina, United States of America.
authors.forename: Ya Diul
authors.initials: YD
authors.lastname: Mukadi
authors.affiliation: FHI 360, Social and Behavioral Health Sciences, Durham, North Carolina, United States of America.
authors.forename: Eric
authors.initials: E
authors.lastname: van Praag
authors.affiliation: FHI 360, Social and Behavioral Health Sciences, Durham, North Carolina, United States of America.
authors.forename: Kwasi
authors.initials: K
authors.lastname: Torpey
authors.affiliation: Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Seymour
authors.initials: S
authors.lastname: Williams
authors.affiliation: Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Kaplan
authors.affiliation: Division of Global HIV/AIDS, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America.
authors.forename: Aaron
authors.initials: A
authors.lastname: Zee
authors.affiliation: Massachusetts General Hospital, Boston, Massachusetts, United States of America.|Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: David R
authors.initials: DR
authors.lastname: Bangsberg
authors.affiliation: Institute of Tropical Medicine, Clinical Sciences Department, Antwerp, Belgium.|Epidemiology and Social Medicine, University of Antwerp, Antwerp, Belgium.
authors.forename: Robert
authors.initials: R
authors.lastname: Colebunders
mesh_terms: D000328:Adult; D044966:Anti-Retroviral Agents / Q000627:therapeutic use*; D003430:Cross-Sectional Studies; D005260:Female; D006678:HIV / Q000472:pathogenicity*; D015658:HIV Infections / Q000188:drug therapy* / Q000523:psychology / Q000821:virology; D006801:Humans; D008297:Male; D008875:Middle Aged; D010349:Patient Compliance / Q000706:statistics & numerical data*; D013636:Tanzania; D014454:Uganda; D015024:Zambia; D016903:Drug Monitoring
chemical_list: D044966:Anti-Retroviral Agents