Adherence better in Africa than in North America, meta-analysis shows

The belief that sub-Saharan Africans will not comply with antiretroviral treatment regimes is false and should not be a reason for delaying access to treatment according to a ground-breaking study published in the Journal of the American Medical Association (JAMA) this week.

The study, the first of its kind, was a meta-analysis of 27 studies in sub-Saharan African countries (Nigeria, South Africa, Senegal, Cameroon, Uganda, Botswana, Malawi, Rwanda, Burkina Faso, Mali, Cote D’Ivoire, Tanzania and the Democratic Republic of the Congo) and 31 North American (three from Canada, the rest from the United States) measuring the levels of adherence to antiretroviral therapy (ART) regimes by people with HIV.

Contrary to expectations, the analysis found a higher level of adherence to antiretroviral regimes in the Africans studied (77%) than that among North American participants (55%).

Although only 10% of the world lives in sub-Saharan Africa, the region carries the bulk of the world’s HIV/AIDS burden. Seventy-nine percent of the world’s AIDS deaths occur in sub-Saharan countries while 70% of women with HIV live in sub-Saharan Africa and 92% of the world’s orphans live in that region.

Yet, antiretroviral treatment is still failing to reach the majority of people living with HIV in sub-Saharan Africa. The World Health Organization’s (WHO)‘3 by 5’ (three million people receiving anti-retroviral therapy by the end of 2005) programme failed to meet its targets, leaving two thirds of the world’s people with HIV untreated.

In June 2005, the WHO estimated that of people in urgent need of antiretroviral treatment in sub-Saharan Africa the percentage actually getting any treatment were: 56% in Botswana, 10% in Burkina Faso, 15.8% in Cameroon, 5.4% in Cote D’Ivoire, 3.2% in the Democratic Republic of Congo, 13.6% in Malawi, 8% in Nigeria, 26.5% in Rwanda, 12.5% in South Africa, 3.2% in Tanzania and 56% in Uganda.

It has been suggested that one reason for such failure is a difficulty with achieving adherence to antiretroviral therapy regimes. However, Mills et al, a collaborative international team supported by a grant from the Ontario HIV treatment network, point out that this study reveals that the belief poor adherence is an issue in sub-Saharan Africa is not justified.

"This suggests that concerns about suboptimal adherence are not supported by the data and such concerns should not contribute to delayed access to treatment", say the authors.

"The consistent difference of ART adherence in North America and Africa raises the question as to why early opinions may have underestimated adherence among Africans. This sentiment was expressed at high levels of international agency decision making.”

The better adherence levels among sub-Saharan Africans on antiretroviral treatment may be influenced by some of the studies being done at a stage when people on treatment were experiencing dramatic increases in health status and before they develop long-term adverse effects of therapy. The North American treatment regimes were likely to be more complex, another factor that could have lowered adherence rates.

Another interesting point raised by this study is the effect of poverty on the ability to adhere to HIV regimes. In the North American studies, poverty lowered adherence rates. But the authors say this does not mean that poverty in itself led to poor adherence, saying the barriers to adherence among impoverished North Americans “appear, however, to be due to poor patient–clinician relationships, untreated depression, substance abuse and other factors common among poor individuals in the North American setting rather than poverty itself.”

In sub-Saharan Africa the barriers to adherence were quite different. The main ones were cost, not disclosing HIV status to a loved one or fear of being stigmatized, alcohol abuse and difficulty with following complex regimes.

Stigmatisation was identified as a factor that needs to be addressed. “Encouraging voluntary HIV status disclosure in a community with access to ART may result in improved uptake of voluntary counseling and testing, help decrease the stigma and improve adherence.”