From access to adherence - World Health Organization

1 From access to adherence : the challenges of antiretroviral treatment Studies from Botswana, Tanzania and Uganda 2006 Anita Hardon university of Amsterdam Sheila Davey Writer/Editor Trudie Gerrits university of Amsterdam Catherine Hodgkin Royal Tropical Institute, Amsterdam Henry Irunde Principal Investigator, Tanzania Joyce Kgatlwane Principal Investigator, Botswana John Kinsman university of Amsterdam Alice Nakiyemba Principal Investigator, Uganda Richard Laing World Health Organization World Health Organization 2006 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization , 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.)

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4 The named authors alone are responsible for the views expressed in this publication. Printed in France European Community This document has been produced with the financial assistance of the European Community. The views expressed herein are those of the authors and can therefore in no way be taken to reflect the official opinion of the European Community. WHO Library Cataloguing in Publication Data From access to adherence : the challenges of antiretroviral treatment : studies from Botswana, Tanzania and Uganda 2006 / Anita Hardon .. [et al.]. therapy, Highly active. infections drug therapy. immunodeficiency syndrome drug therapy. compliance. Republic of Tanzania.

5 , Anita. Health Organization . ISBN 92 4 156328 1 (NLM classification: WC ) ISBN 978 92 4 156328 4 iii Contents Acknowledgements vAcronyms and abbreviations viiForeword ix1. On hunger, transport costs and waiting time: a synthesis of challenges to ARV adherence in three African countries 12. Overview of antiretroviral therapy, adherence and drug resistance 233. From training to action: the process of engaging Health professionals in operational research on adherence to antiretroviral therapy 354. There s hope early observations of ARV treatment roll out in South Africa 63 COUNTRY STUDIES Botswana Factors that facilitate or constrain adherence to ARV therapy among adults at four public Health facilities in Botswana: a pre intervention study 83 Tanzania A study on antiretroviral adherence in Tanzania: a pre intervention perspective, 2005 169 Uganda Factors that facilitate or constrain adherence to ARV therapy among adults in Uganda: a pre intervention study 249 iv v Acknowledgments There have been many people involved in the production of this book.

6 A number of people have been acknowledged by country report authors in the individual chapters. We would also like to acknowledge the teachers at the Promoting Rational Drug Use in the Community course, held in Pretoria. In particular, thanks are due to Rob and Beverley Summers, Ane Haaland and Andrew Chetley. Monica Zweygarth played a critical role in establishing the course web page, and in developing the data processing and analysis tool. A number of people from the university of Amsterdam provided support for the country groups. Josien de Klerk and John Kinsman, together with Trudie Gerrits and her administrative staff, arranged workshops in Bagamoyo and Jinja, and field visits by the students to support the country groups in Uganda, Tanzania and Botswana.

7 The editing of the country reports, and the final documents was undertaken by Sheila Davey and Kathleen Hurst. We are grateful to Monique Renevier who undertook the layout of this document so promptly. Clive Ondari, Hans Hogerzeil and Howard Zucker reviewed the publication and provided useful comments. We thank the various funders who contributed resources that made this work possible. An overview of financial contributions is given in Chapter 3. In the final analysis, however, we wish to especially acknowledge the many country respondents, who shared their lives, their ideas, their concerns and suggestions with us. These were busy people, working as Health care workers or as carers, or patients struggling with a very demanding disease.

8 Their willingness to provide their time and insights to us was invaluable and we are very grateful to all of them. vi vii Acronyms and abbreviations ACHAP African Comprehensive AIDS Partnership (Botswana) ACP AIDS Control Programme (Uganda) ADR Adverse drug reaction AIDS Acquired Immune Deficiency Syndrome AMREF African Medical and Research Foundation ART Antiretroviral therapy ARVs Antiretroviral medicines BHP Botswana Harvard Partnership BOTUSA Botswana USA project CSO Central Statistical Office (Botswana) CTC Care and Treatment Clinics (ART clinics) EDM Electronic drug monitoring FGD Focus Group Discussion Global Fund Global Fund to Fight AIDS, Tuberculosis and Malaria GoT Government of Tanzania HIV Human Immunodeficiency Virus IDCC Infectious Disease Control Centre IEC Information, education and communication INRUD International Network for Rational Use of Drugs JCRC Joint Clinical Research Centre (Uganda) JRRH Jinja Regional Referral Hospital (Uganda) KIT Royal Tropical Institute (Amsterdam, the Netherlands) KITSO Knowledge, information and technology shall overcome (HIV and AIDS) MDH Muhimbili university College of Health Sciences (MUCHS)

9 , Dar es Salaam City Council and Harvard School of Public Health MEDUNSA Medical university of South Africa MNH Muhimbili National Hospital, Dar es Salaam, Tanzania MoH Ministry of Health viiiMSD Medical Stores Department MSF M decins Sans Fronti res MUCHS Muhimbili university College of Health Sciences, Dar es Salaam, Tanzania NACA National AIDS Coordinating Agency (Botswana) NACP National AIDS Coordinating Programme (Tanzania) NGO Nongovernmental Organization NIMR National Institute of Medical Research (Tanzania) NTC Nile Treatment Centre (Uganda) PASADA Pastoral Activities and Services for AIDS in Dar es Salaam Archdiocese, Tanzania PEPFAR (United States) President s Emergency Plan for AIDS Relief PLWHIV People living with HIV pMTCT Prevention of Mother to Child Transmission Portakabin Prefabricated building used in treatment centres PRDUC Promoting Rational Drug Use in the Community SIDA Swedish International Development Agency SOP Standard Operating Procedures SSI Semi structured Interview STG Standard Treatment Guidelines TASO The AIDS Support Organisation (Uganda)

10 TFDA Tanzania Food and Drugs Authority UAC Uganda AIDS Commission UDSM university of Dar es Salaam UDVL Undetectable viral load UNAIDS United Nations Joint Programme on AIDS VCT Voluntary counselling and testing for HIV WHO World Health Organization ix Foreword The devastating impact of AIDS in the World especially in sub Saharan Africa has led to an unprecedented global effort to ensure access to antiretroviral (ARV) medicines to treat the disease in every country where HIV is a threat. While the World Health Organization (WHO) goal of ensuring access to antiretroviral treatment (ART) for 3 million people by end 2005 was not achieved, an estimated million people who would not otherwise have been treated now have access to ART.