Fear that antiretroviral therapy will increase the appetite for food where none is available is the most significant obstacle to treatment adherence, according to Rwandan people with HIV questioned in a survey published in the October 24th edition of the journal AIDS.
The survey was designed to identify barriers to adherence among patients who had recently begun treatment through Projet San Francisco, a clinic in Kigali. The clinic has previously reported very good adherence rates, with all patients reviewed in 2005 reporting adherence rates of at least 95%.
A questionnaire was administered to 71 patients attending the clinic, using both structured and open-ended questions. The questionaire asked participants about their understanding of antiretroviral therapy, about sexual behaviour since starting treatment and about obstacles to adherence.
In response to an open-ended question about obstacles to adherence (actual wording not reported by the authors), three-quarters of participants said that the biggest obstacle was the fear that they would develop too much of an appetite as a result of taking the drugs, but would not be able to afford enough to eat. Fifty-six per cent brought up this concern in response to an open-ended question without prompting, the authors reported. This fear was cited despite the fact that 87% had reported regaining the ability to work at home or in a job. The next most common obstacle to adherence – disruption of work and everyday life – was cited by 29%.
“This study identified a unique and potentially major obstacle to adherence,” the authors say. “As a low body mass is associated with poor clinical outcomes even after ART initiation, nutritional supplementation as an adjunct to ART may improve both adherence and prognosis.”
Data on the effects of nutritional supplementation on ART response are limited. A randomised study carried out in Zambia, reported this summer at the Sixteenth International AIDS Conference in Toronto, showed that although individual and household food supplementation improved adherence, it could not be shown to improve treatment outcomes after 12 months of antiretroviral therapy.
Effects on behaviour and knowledge
The Rwanda study found no increase in risky sexual behaviour after starting treatment, in agreement with Ugandan findings presented earlier this year. Twenty-six per cent reported more frequent condom use, and only 3% reported less frequent condom use.
The study also found very good levels of knowledge among participants about ART, with more than 90% of patients indicating that they knew antiretrovirals needed to be taken for life, that they raised the CD4 cell count and that medications should never be missed.
AU JT et al. Access to adequate nutrition is a major potential obstacle to antiretroviral adherence among HIV-infected individuals in Rwanda. AIDS 20 (16): 2116-2118, 2006.