ASSESSING ADHERENCE TO COMBINATION ART IN AN URBAN PRIVATE HOSPITAL DR. EVELYN MBUGUA AGA KHAN UNIVERSITY HOSPITAL

ASSESSING ADHERENCE TO COMBINATION ART IN AN URBAN PRIVATE HOSPITAL DR. EVELYN MBUGUA AGA KHAN UNIVERSITY HOSPITAL

ACKNOWLEDGMENT Supervisors: Prof. Gerald Yonga, Chairman,Dept of Medicine Dr. Reena Shah, Infectious Disease specialist Dr. Nelly Kitazi, Consultant Psychiatrist Thanks to Department of Medicine Faculty

THE NUMBERS 22.4 million people said to be living with HIV infection in Sub-Saharan Africa and an estimated 2.4 million AIDSrelated deaths reported in 2008 alone(1). Combination Antiretroviral therapy has dramatically decreased morbidity and mortality since the start of the CART era in the late 90s Kenya-decreased mortality by 29% btwn 2002-2007(2). >95% adherence is required to reap these benefits of cart(3). 1.UNAIDS 2009 AIDS epidemic update 2. National AIDS Control Council/National AIDS/STI Control Program 3. Paterson DL et al. Adherence to Protease Inhibitor Therapy and Outcomes in Patients with HIV Infection. Annals of Internal Medicine. 2000:21-30.

About 2.5 million deaths are estimated to have been averted in low- and middleincome countries due to increased access to HIV treatment since 1995. UNAIDS Report

THE FACTORS Education level below university Unemployment Free treatment Severe depression Baseline CD4 count>200/ml Hospitalization >2 times, Moderate to severe side-effects 4 or more medicines On multivariate analysis two main factors were independently associated with lower levels of adherence: obtaining free treatment and severe depression Sarna et al. Adherence to antiretroviral therapy & its determinants amongst HIV patients in India. Indian Journal Of Medical Research. 2008;127:28-36.

THE STUDY Aim: To determine the influence of depression on adherence to antiretroviral (ARV) therapy among HIV-infected patients. Design: Cross-sectional survey Patients: 140 HIV-positive patients on treatment with Combination Antiretroviral Therapy selected from the out-patient department of Aga Khan University Hospital took part in the survey.

PRIMARY OBJECTIVES To determine levels of adherence to Combination Antiretroviral Therapy amongst HIV infected patients receiving treatment at Aga Khan University Hospital (Nairobi) To determine the prevalence of depression amongst these patients To determine any relationship between depression and levels of adherence

SECONDARY OBJECTIVES To determine how patients pay for their antiretroviral medication To determine levels of disclosure of HIV status to spouses To determine how these two factors may affect adherence

INCLUSION CRITERIA Age >18yrs HIV infected Has been on CART >3 months

EXCLUSION CRITERIA Patients previously diagnosed to have schizophrenia or other DSM IV diagnosis of mental illness excluding depression Active opportunistic CNS infection causing significant cognitive dysfunction as assessed by the primary investigator using the Mini Mental Score Exam Lack of informed consent

ASSESSMENT OF ADHERENCE Self-report: The Adult AIDS Clinical Trial Group follow up adherence questionnaire Pharmacy-based: Pharmacy data retrieved and used to assess adherence by calculating the medication possession ratio(mpr) : 100 x ([pills dispensed/pills prescribed per day]/number of days between refills)

CONT For patients collecting their drugs monthly, the last four refills for the contiguous preceding three months were used to calculate the medication possession ratio as shown:

DATA ANALYSIS MPR>95%- optimal adherence MPR 80-95%- sub-optimal adherence MPR <80% - poor adherence The data was analysed using SPSS and chi square was calculated for relationships between adherence and depression. Odds ratio was also calculated for the risk of depression in the non-adherent group compared to the adherent group.

PATIENT HEALTH QUESTIONNAIRE 9 Based on DSM IV criteria Validated in a study carried out in western Kenya Monahan P, Shacham E,. Validity/reliability of PHQ-9 and PHQ-2 depression scales among adults living with HIV/AIDS in western Kenya. J Gen Intern Med. 2009;24:189-97.

PHQ SCORE Frequency Percent </=4 102 72.9 5-14 32 22.9 >/=15 6 4.3 Total 140 100.0

PREVALENCE OF DEPRESSION

Although this did not reach significant levels, patients who were non-adherent were 1.3 times more likely to be depressed. On multivariate analysis there was no significant association between depression and levels of adherence. There was however a significant association between cash payment for medication and higher viral loads (p= 0.029).

STATUS DISCLOSURE DISCLOSURE OF HIV STATUS TO SPOUSE ADHERENCE BY MPR YES NO NOT APPLICABLE Total OPTIMAL ADHERENCE 47 5 12 64 SUBOPTIMAL AND 41 6 13 60 POOR ADHERENCE Total P=0.814 88 11 25 124

CONCLUSIONS 82% of the sampled patients reported >95% adherence to cart. (84% had undetectable viral loads) However only 52% of these same patients had >95% medication possession ratio. 27.2% of the sampled patients reported depressive symptoms There was no significant association between depression and adherence to antiretroviral therapy.

STUDY LIMITATIONS Cross sectional design yet adherence is dynamic over time Missing pharmacy data- drug refills in other pharmacies Sample size calculated to detect 22% difference based on previous study(4). 4. Starace F, Ammassari A, Trotta MP, Murri R, Longis PD, Izzo C, et al. Depression Is a Risk Factor for Suboptimal Adherence to Highly Active Antiretroviral Therapy. JAIDS. 2002;31:S136-9.

RECOMMENDATIONS Routine screening for depression due to high prevalence in this population and its impact on quality of life Reinforce adherence due to noted discrepancy between self-report and pharmacy-based methods Referral to institutions where ART is more subsidized for cash-paying patients who express financial constraints

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