Over 30% of patients receiving antiretroviral treatment at three private clinics in Mumbai were found to have virologic failure, and nearly a quarter reported an adherence rate below 95% (the level needed for long-term viral suppression), according to findings from a US – Indian study published in the May 1 edition of Clinical Infectious Diseases.
Inability to pay for medication was strongly associated with poorer adherence, and participants in the study reported spending a median of 60% of monthly income on treatment - a median of $44 a month. The findings highlight the difficulties faced by patients where second-line therapy is completely unaffordable unless funded by government.
The relationship between adherence, viral load and other factors was studied in 279 adult patients of three private antiretroviral treatment clinics in Mumbai. Treatment in the private sector remains the only way many Indians can obtain antiretroviral treatment despite a government-funded programme now being rolled out through public hospitals.
The study found overall adherence of 73%, with adherence increased by social support and by understanding of the treatment and the medical system. Inability to pay consistently for medication reduced adherence. Viral suppression correlated with both adherence and appropriateness of regimen.
Standard questionnaires were used to assess adherence, adverse effects, social support, alternative treatments, concurrent medical problems, counselling, satisfaction with care received, health beliefs, quality of life, substance use, and socioeconomic situation. For each patient, the treating physician provided a clinical history. Viral loads were assessed for 200 participants.
The typical patient was an employed married man educated to secondary school level who has disclosed to family and friends. A total of 86% purchased antiretrovirals at the clinic, usually monthly. Median travel time to the clinic was 45 minutes; 13% travelled for over five hours.
A fifth of the patients received mono- or duo-therapy. More than 90% of those on triple therapy were prescribed WHO-recommended non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. Protease inhibitor (PI)-based combinations were uncommon (under 7%), probably because of their higher cost.
73% were adherent, defined as having taken at least 95% of their doses during the last four days. 16% reported taking 70-90%, with 10% managing less than 70% adherence. Reasons for missing doses were: running out (cited by 26%), absence from home (15%), feeling unwell (12%), forgot (9%), and too busy (8%).
Perhaps owing to greater familiarity with the health system, elderly patients and those with other medical conditions reported higher adherence, as did those enjoying family support and reminders and those on triple therapy. Incomplete understanding of how to take antiretrovirals, recent pain and side-effects reduced adherence. Travel time to clinic, substance use, and clinical history showed no association with adherence.
64% of those tested had viral load below 400 copies/ml, with adherent patients three times more likely to show viral suppression. A total of 75% of those on a WHO-approved NNRTI regimen achieved this, in comparison with only a third of those on NRTI duo-therapy and 45% of those whose triple therapy included a boosted PI.
The authors did not investigate reasons for inappropriate regimens, but suggest that inadequate practitioner knowledge or attempts to render treatment affordable to less affluent patients may be responsible. Affordability is a major problem: the median monthly treatment cost of US$44 represented 60% of median income. Over a third of patients economised on food to pay medical bills, more than three-quarters took loans, and almost 40% sold possessions.
Variation in performance between the three clinics was striking, though unexplained: 79% of the patients of one clinic achieved viral suppression, while another managed this for only 46%. Judging by the reasons patients gave for missing doses, and that one third felt that antiretrovirals could be discontinued when symptoms disappear, with 40% unaware that missed doses permit viral rebound, some clinicians leave patients ignorant of what is at stake; perhaps some lack adequate understanding themselves.
Half of adherent patients and three-quarters of non-adherent patients were unaware that their side-effects were antiretroviral-related, and some patients did not know they had HIV, suggesting that communication from clinics is generally suboptimal.
Although free treatment at Indian government clinics or via NGOs is becoming available, for many less-affluent AIDS patients consistent adherence is unattainable due to the need to pay private providers for expensive medications. Inappropriate use of antiretroviral therapy by under-regulated practitioners, inadequate compliance advice, and private patients who are unable to fund a continuous supply of medication could undermine the effectiveness of country-level responses to HIV/AIDS by speeding resistance to the more affordable antiretrovirals.
Reference
Shah B et al. Adherence to antiretroviral therapy and virologic suppression among HIV-infected persons receiving care in private clinics in Mumbai, India. Clin Inf Dis 44: 1235-1244, 2007.