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Indian Journal of Community Medicine

Adherence to antiretroviral therapy: Challenges and possible solutions in Indian context

Author(s): Garg Suneela, Kaur Ravneet

Vol. 32, No. 3 (2007-07 - 2007-09)

LETTER TO EDITOR

Year : 2007 | Volume : 32 | Issue : 3 | Page : 234-235

Adherence to antiretroviral therapy: Challenges and possible solutions in Indian context

Garg Suneela, Kaur Ravneet
Department of Community Medicine, Maulana Azad Medical College, New Delhi, India
Date of Submission 06-Mar-2007
Date of Acceptance 10-Aug-2007

Correspondence Address:
Garg Suneela
Department of Community Medicine, Maulana Azad Medical College, New Delhi
India

Source of Support: None, Conflict of Interest: None
How to cite this article:
Garg S, Kaur R. Adherence to antiretroviral therapy: Challenges and possible solutions in Indian context. Indian J Community Med 2007;32:234-5
How to cite this URL:
Garg S, Kaur R. Adherence to antiretroviral therapy: Challenges and possible solutions in Indian context. Indian J Community Med [serial online] 2007 [cited 2007 Nov 30];32:234-5. Available from: http://www.ijcm.org.in/text.asp?2007/32/3/234/36846

Sir,

Human immunodeficiency virus (HIV) / acquired immunodeficiency syndrome (AIDS) has brought about an epidemic that poses a unique challenge to public health planners and program developers. However, with the advent of antiretroviral therapy (ART), dramatic decrease in mortality among HIV-infected people has been reported. Unfortunately, non-adherence remains a formidable barrier in the management of HIV, resulting in development of resistance and drug failure. In case of ART, at least 95% adherence to medications is required for sustained response.[1] Adherence is a public health concern and is a complex dynamic behavior influenced by characteristics of the patient (literacy, income, alcohol or drug use); patient-provider relationship; degree of social support, social stability; and other psycho-social factors.[2]

Levels of non-adherence vary from 10%-33% as documented in various studies.[1], [3], In India, currently only 10% of those living with HIV/ AIDS are getting free ART. The decision makers are facing difficulties in making rational decisions since adherence to ART in a resource-constrained country like India poses special challenges. The amount of GDP or health-care budget that would be required to meet the needs of those who may benefit from the therapy is of prime concern. Furthermore, many ethical issues confront us - for example, when sufficient resources are not available for all to benefit from ART, would it be acceptable for some to benefit; how should such selection be made? Another matter of importance is whether concerns about viral resistance induced by poor adherence to complex regimens can justify refusal to prescribe ART to those who request them.[4]

Adherence assessment is another issue of concern since it is an important component of monitoring HIV ART. In the Indian context, electronic devices like medical event monitoring system (MEMS) are not available. Laboratory facilities to monitor CD 4 / CD 8 counts and viral loads are also lacking in a large number of Indian settings. For monitoring of adherence, health-care providers have to depend on less reliable methods like interviews, self-reports or pharmacy records, etc. Use of other electronic devices like beepers, alarms and electronic pagers linked to internet to enhance adherence is practically not possible in India.

For addressing the issue of adherence, comprehensive range of factors is the target for most effective interventions. Most of these interventions are complex and may include provision of information counseling, reminders, reinforcement, self-monitoring, family therapy or additional supervision or attention. It is necessary to strengthen the material and psycho-social support services in a continuum of care, right from home to tertiary care setting, through public-private partnership and strengthening of the ICTCs (Integrated Counseling and Testing Centers). Rapid advances in biomedical science, such as pharmaceutical developments, must be integrated with advances in behavioral science to further the understanding of medication adherence. Despite some attention to adherence in recent years, much more remains to be done to better understand and promote adherence to ART through effective interventions.[2]

References

1. Horizons/ Population Council, International Centre for Reproductive Health and Coast Province General Hospital, Mombosa-Kenya. Adherence to Antiretroviral Therapy in Adults: A Guide for Trainers. Population Council: Nairobi; 2004. p. 6-18.
2. Ickovics JR, Meade CS. Adherence to Antiretroviral therapy among patients with HIV: A critical link between behavioral and biomedical sciences. J Acquir Immune Defic Syndr 2002;31:S98-102. [PUBMED] [FULLTEXT]
3. Wanchu A, Kaur R, Bambrey P, Singh S. Adherence to generic reverse transcriptase inhibitor based antiretroviral medication at a tertiary centre in North India. AIDS Behav 2007;11:99-102.
4. NACO. Guidelines on rational use of antiretroviral drugs. Ministry of Health and Family Welfare. 18-23.

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