Adherence to antiretroviral therapy in a home-based AIDS care programme in rural Uganda

Background: Poverty and limited health services in rural Africa present barriers to adherence to antiretroviral therapy that necessitate innovative options other than facility-based methods for delivery and monitoring of such therapy. We assessed adherence to antiretroviral therapy in a cohort of HIV-infected people in a home-based AIDS care programme that provides the therapy and other AIDS care, prevention, and support services in rural Uganda. Methods: HIV-infected individuals with advanced HIV disease or a CD4-cell count of less than 250 cells per μL were eligible for antiretroviral therapy. Adherence interventions included group education, personal adherence plans developed with trained counsellors, a medicine companion, and weekly home delivery of antiretroviral therapy by trained lay field officers. We analysed factors associated with pill count adherence (PCA) of less than 95%, medication possession ratio (MPR) of less than 95%, and HIV viral load of 1000 copies per mL or more at 6 months (second quarter) and 12 months (fourth quarter) of follow-up. Findings: 987 adults who had received no previous antiretroviral therapy (median CD4-cell count 124 cells per μL, median viral load 217 000 copies per mL) were enrolled between July, 2003, and May, 2004. PCA of less than 95% was calculated for 0·7-2·6% of participants in any quarter and MPR of less than 95% for 3·3-11·1%. Viral load was below 1000 copies per mL for 894 (98%) of 913 participants in the second quarter and for 860 (96%) of 894 of participants in the fourth quarter. In separate multivariate models, viral load of at least 1000 copies per mL was associated with both PCA below 95% (second quarter odds ratio 10·6 [95% CI 2·45-45·7]; fourth quarter 14·5 [2·51-83·6]) and MPR less than 95% (second quarter 9·44 [3·40-26·2]; fourth quarter 10·5 [4·22-25·9]). Interpretation: Good adherence and response to antiretroviral therapy can be achieved in a home-based AIDS care programme in a resource-limited rural African setting. Health-care systems must continue to implement, evaluate, and modify interventions to overcome barriers to comprehensive AIDS care programmes, especially the barriers to adherence with antiretroviral therapy. © 2006 Elsevier Ltd. All rights reserved.