How to investigate Adherence to Antiretroviral Treatment ... - INRUD

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How to Investigate Adherence to Antiretroviral Treatment in Health Facilities: Adherence Indicators Field-Testing Methods Four national surveys were undertaken in Kenya, Rwanda, Uganda, and Ethiopia between October 2006 and June 2007 to investigate the feasibility and reliability of the methods for collecting the adherence indicators. The sampling strategy included 20 randomly chosen health facilities in each country with at least 100 patients on ARVs six months before the survey. Data collectors were practicing pharmacists, doctors, or senior-level medical or pharmacy students. Teams of three, four, or five data collectors surveyed a single facility in one day and entered the day’s data in the evening. In each facility, data collectors randomly sampled medical and pharmacy records and interviewed 30 patients who were leaving the clinic. Data collectors examined the pharmacy records to see how many days of medicine had been dispensed over the period and to track patients from the previous months to see when and if they showed up for their next appointment. Pill count and self-reported adherence data were included if mentioned in the records. Results More than 6,500 records showed that across facilities, the median percentage of days that patients received medicines was high—91–95 percent (table 1). On a facility level though, this measure varied from 53 to 100 percent. The median percentage of patients with gaps in treatment of 30 days or more across countries was between 2 and 18 percent, but on a facility level, the figure ranged from 0 to 60 percent. The median percentage of patients who attended their next appointment on or before the day scheduled ranged from 72 to 92 percent (table 1). However, variability across facilities was large, with the best facility achieving 100 percent on-time attendance versus only 15 percent at the worst facility. Interviewers carried out 1,631 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). 4
Chapter 1. Overview of Manual Table 1. Adherence Values across Countries and Facilities Median Percent Across All Facilities (Minimum facility percent- Maximum facility percent) Country Ethiopia Uganda Rwanda Kenya Indicator 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 percent days covered by medicine dispensed 95 (89–99) 91 (77–97) 97 (88–100) 95 (53–100) Percent of patients with ≥ 30 days gap in medicines dispensed 9 (0–33) 18 (0–42) 2 (0–12) 16 (0–60) Percent of patients attending clinic appointment as scheduled 72 (58–99) 78 (15–100) 92 (38–100) 77 (46–96) Percent of patients attending clinic within three days of appointment N/A = Data not collected 87 (72–99) 80 (20–100) 96 (67–100) N/A Usefulness of Pill Counts and Self-Report in Clinic Notes Overall, only 15 percent of 6,551 patient records included a pill count (table 4). 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 percent overall), although this measure was infrequently recorded in Rwanda (10 percent). 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 percent adherence, an “F” (fair) for 85–95 percent or a “P” (poor) for less than 85 percent. Of the 83 percent of records that included a self-report measure, 96 percent were rated “good.” Table 2. Number of Records with Pill Counts and Self Reports Ethiopia Uganda Rwanda Kenya Total Number of records examined 1,989 1,695 1,602 1,265 6,551 Percent of records with pill counts 0 9 44 12 15 Percent of records with self-reports 83 33 10 4 45 5
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Page 3 and 4: ACKNOWLEDGEMENTS This manual has be
Page 5 and 6: ACRONYMS AIDS ART ARV HIV IAA IHCAR
Page 7 and 8: CONTENTS Acknowledgements .........
Page 9 and 10: INTRODUCTION Collecting data on adh
Page 11: CHAPTER 1. OVERVIEW OF MANUAL The 2
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Page 17 and 18: Chapter 2. Core Indicators of Adher
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Page 21 and 22: CHAPTER 3. INDICATORS FOR POSSIBLE
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CHAPTER 7. TRAINING OF DATA COLLECT
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CHAPTER 8. DATA ENTRY AND DATA PROC
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