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SOUTH AFRICA: New challenge in achieving adherence

[This report does not necessarily reflect the views of the United Nations]

DURBAN, 20 May (PLUSNEWS) - South Africa's rollout of antiretroviral (ARV) drugs for people living with HIV/AIDS has presented the government with a new set of challenges.

Health authorities now face the formidable task of educating beneficiaries about the need to adhere strictly to the drug regime. If ARVs are not taken consistently, twice a day at the correct time, patients will develop resistant strains of the virus, making the medication ineffective.

The Ithemba antiretroviral outreach project of St. Mary's Hospital in Mariannhill in KwaZulu-Natal province has put in place a comprehensive compulsory ARV education course for patients before they receive ARVs.

"If we don't do it right the first time around, we will see a large number of people resistant to ARVs in a few years' time, and this country can hardly afford the first round [of free ARV treatment]," Ithemba community outreach director, Monty Thomas, told IRIN.

Patients who fail to adhere to the drug regime often do not understand the importance of never skipping a dose and always taking their medicine at the same times - in some cases patients stop taking the medication as soon as their health improves.

Ithemba has developed a five-step, five-week assessment and training plan to ensure that every patient who receives ARVs through its programme will take their pills in a responsible manner.

On enrolment, HIV patients consult with trained counsellors and undergo a medical examination, including a viral load count. Should their count be below 200, the patient is a candidate for the ARV programme, if it is above 200, the patient is referred to the primary care programme. Ithemba can accept 25 new patients per month.

The first appointment is followed by a three-day training course, which takes place over a period of three weeks, when the patient is taught about the virus. Only in the fifth week is the patient given ARVs.

By then, it is expected that they will be more aware of the impact of the drugs on the body and any possible side-effects. "Only patients with such detailed background knowledge will be responsible pill-takers. You cannot just give someone tablets and expect results," Thomas explained.

The Ithemba programme also insists that patients disclose their HIV status, arguing that it improves treatment. "There is no suitable explanation why someone has to take tablets twice a day for the rest of his life, other than being HIV-positive," said Thomas. The patient's emotional stress level is also much lower after disclosure, which has a positive effect on overall health.

Although some patients were initially offended by the programme's disclosure stipulation, almost all the project's ARV patients have had positive disclosure experiences, Thomas noted.

Ithemba's ARV treatment plan is supported by home-based care. Health workers visit patients on a regular basis to monitor drug-intake and identify psychosociological challenges to adherence. "You need to stay in constant contact with the community to make an ARV rollout work," Thomas commented.

The main obstacles to regular drug-taking identified by home-based carers were hunger, violence and poverty. To ensure that these concerns would not hamper adherence, carers help patients to access social grants.

Apart from these problems, the Ithemba project has to deal with patients from outside the programme. An HIV positive patient who has interrupted his ARV treatment will enter the clinic at least twice, either because he cannot afford to pay for the pills, or his private doctor has run out of medication.

In some cases, the patient has already developed resistance to some of the drugs, said Dr. Stephen Carpenter, who works for the Ithemba programme.

Another dilemma is that private doctors often prescribe a cheaper dual combination of ARVs to make the drugs more affordable, rather than the recommended formulation of three drugs. The cheapest dual combination costs R60 (US $9) per month but is less effective, said Carpenter. He and his team then have the difficulty of finding a different yet effective combination of drugs for the patient.

Ithemba has achieved a 95 percent success rate of patient compliance with its drug-taking rules since the ARV programme started.

The project is currently funded by the US, Britain and South Africa, and hopes to become an official rollout site of the South African government's programme in the near future. It will then receive ARVs free of charge, whereas today it has to purchase the drugs with donor money. A triple-therapy drug cocktail currently costs US $68 per patient per month.

[ENDS]