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Long-Term Adherence to Antiretroviral Treatment and Program Drop-Out in a High-Risk Urban Setting in Sub-Saharan Africa: A Prospective Cohort Study

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  • Christian Unge
  • Björn Södergård
  • Gaetano Marrone
  • Anna Thorson
  • Abigael Lukhwaro
  • Jane Carter
  • Festus Ilako
  • Anna Mia Ekström

Abstract

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. Methods and Findings: 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). Conclusion: 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.

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  • Christian Unge & Björn Södergård & Gaetano Marrone & Anna Thorson & Abigael Lukhwaro & Jane Carter & Festus Ilako & Anna Mia Ekström, 2010. "Long-Term Adherence to Antiretroviral Treatment and Program Drop-Out in a High-Risk Urban Setting in Sub-Saharan Africa: A Prospective Cohort Study," PLOS ONE, Public Library of Science, vol. 5(10), pages 1-12, October.
    • Handle: RePEc:plo:pone00:0013613
    DOI: 10.1371/journal.pone.0013613
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    References listed on IDEAS

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    1. Muhamadi, Lubega & Nsabagasani, Xavier & Tumwesigye, Mbona Nazarius & Wabwire-Mangen, Fred & Ekström, Anna-Mia & Peterson, Stefan & Pariyo, George, 2010. "Inadequate pre-antiretroviral care, stock-out of antiretroviral drugs and stigma: Policy challenges/bottlenecks to the new WHO recommendations for earlier initiation of antiretroviral therapy (CDÂ," Health Policy, Elsevier, vol. 97(2-3), pages 187-194, October.
    2. Norma C Ware & John Idoko & Sylvia Kaaya & Irene Andia Biraro & Monique A Wyatt & Oche Agbaji & Guerino Chalamilla & David R Bangsberg, 2009. "Explaining Adherence Success in Sub-Saharan Africa: An Ethnographic Study," PLOS Medicine, Public Library of Science, vol. 6(1), pages 1-7, January.
    3. Martin W G Brinkhof & Mar Pujades-Rodriguez & Matthias Egger, 2009. "Mortality of Patients Lost to Follow-Up in Antiretroviral Treatment Programmes in Resource-Limited Settings: Systematic Review and Meta-Analysis," PLOS ONE, Public Library of Science, vol. 4(6), pages 1-9, June.
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