How to investigate levels of Adherence to antiretroviral ... - INRUD

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Chapter 1 Overview of manual Interviewers carried out 1631 interviews in the four countries, averaging 20 per facility. All self-reported adherence rates from current patients were very high across the four countries; for full self-reported adherence across health facilities, no median percentage was less than 96.6 (Table 1). Indicator Table 1. Adherence values across countries and facilities Median percentage across all facilities (Minimum facility percentage - Maximum facility percentage) Country Ethiopia Uganda Rwanda Kenya Attendance, dispensing, and gap (N = 1,989) (N =1,695) (N =1,602) (N = 1,265) Exit interviews (N = 565) (N = 408) (N = 285) (N = 373) Full self-reported adherence in last 3 days from exit interview 96.6 (90–100) 96.7 (63–100) 100 (60–100) 96.6 (80–100) Average percentage of days covered by medicine dispensed 95 (89–99) 91 (77–97) 97 (88–100) 95 (53–100) Percentage of patients with ≥ 30 days gap in medicines dispensed 9 (0–33) 18 (0–42) 2 (0–12) 16 (0–60) Percentage of patients attending clinic appointment as scheduled Percentage of patients attending clinic within three days of appointment N/A = Data not collected 72 (58–99) 87 (72–99) 78 (15–100) 80 (20–100) 92 (38–100) 96 (67–100) 77 (46–96) N/A Usefulness of pill counts and self-report in clinic notes Overall, only 15% of 6551 patient records included a pill count (Table 2). Therefore, calculating adherence measures based on pill counts in medical and pharmacy records does not appear to be widely applicable. More records included a self-report adherence measure (45% overall), although this measure was infrequently recorded in Rwanda (10%). However, the methods used to derive these self-report measures varied, which makes comparisons problematic. In Ethiopia, for example, the method of recording self-reported adherence was to use a ‚G‛ (good) to indicate better than 95% adherence, an ‚F‛ (fair) for 85–95% or a ‚P‛ (poor) for less than 85%. Of the 83% of records that included a self-report measure, 96% were rated ‚good.‛ 7
How to Investigate Adherence to Antiretroviral Treatment: An Indicator-Based Approach Table 2. Number of records with pill counts and self reports Ethiopia Uganda Rwanda Kenya Total Number of records examined 1989 1695 1602 1265 6551 Percentage of records with pill counts 0 9 44 12 15 Percentage of records with self-reports 83 33 10 4 45 Conclusion from feasibility tests The INRUD-IAA field tests examined four categories of indicators for adherence to ARV medicines and treatment defaulting: 1. Self-reported adherence from exit interviews. 2. Days supplied by medicine. 3. Patient attendance. 4. Pill counts and self-reports in clinic records. The first three methods offer feasible approaches to standardizing measures of adherence and defaulting in low-resource settings. Pill counts are used too infrequently; whereas, selfreports in clinic records appear more promising. However, the consistency of the datagathering methods needs to be assessed. The four field tests provide strong evidence that adherence targets can be met in resourcepoor settings. However, in all countries, some facilities had low values, particularly for dispensing-based adherence and patient attendance. Managers should examine the causes of poor performance in these facilities and work with them to make improvements. Facilities that are doing well can also share lessons on how to achieve exceptional performance. Only by monitoring adherence and defaulting can we know where, and what kind of. interventions are needed. 8
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6 CHAPTER 6 --- Planning and field
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A.3 APPENDIX 3 --- Training slides
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