Home-based AIDS care program achieves good adherence and response to antiretroviral therapy (ART) in rural Uganda

A home-based care programme that uses weekly visits and medicines supporters in Uganda has shown some of the highest rates of viral load suppression and medication adherence reported anywhere in the world, according to a report published as an early online article in The Lancet.

People with HIV must take antiretroviral therapy (ART) every day in order to achieve and maintain viral suppression, and must make frequent and regular clinic visits in order to collect medication in most settings. But in many African countries patients are constrained by transport costs and poverty from clinic attendance, as well as by the distances they must often travel. These obstacles have serious implications for patient adherence.

Innovative strategies to sustain good adherence to ART in resource-limited settings have been lacking. This has been addressed by a team of investigators from Uganda and the United States. The innovation is a home-based AIDS care programme in poor rural Uganda.

The study took place in two poor rural settings in Tororo and Busia Districts in eastern Uganda. The home-based AIDS care program began in May 2003. The study participants were clients of the AIDS Support Organization (TASO).

The criteria for ART were a CD4 cell count below 250 cells/mm³, WHO stage 3 or 4 disease, or a history of recurrent herpes zoster. Patients received ART, cotrimoxazole (CTX) prophylaxis, and treatment for tuberculosis (TB). There were no routine clinic visits after enrolment.

Trained and experienced counsellors made home visits at enrolment, one month after enrolment, and then quarterly for routine data collection and to provide adherence support. A home visit was made before starting treatment.

The home visit was to:

• (1) educate the client, the spouse, and a medicine companion; the latter was a family member or neighbour who agreed to observe the patient taking at least one dose of ART daily, and
• (2) formulate an individual adherence plan, a prerequisite for starting ART.

Baseline and quarterly viral load and CD4 cell counts were measured; blood was taken from home and transported to the CDC laboratory.

Medication in pill boxes were delivered weekly by a team of trained field officers on motorcycles. The officers elicited information about symptoms of possible illness or drug toxicity and self-reported adherence to ART. A system for monitoring adherence was set up.

Adherence was assessed either as pill count adherence (PCA) which was the number of pills actually taken as a percentage of the number of pills delivered, or a medication possession ratio (MPR) which provided an estimate of the proportion of time during an interval that each client had ART available. Pill count adherence was monitored by asking participants to retain any missed doses in their pill boxes, and pill boxes were checked on a weekly basis when medicines were re-stocked by the home visitors.

Remarkably, out of > 3,200,000 pills dispensed, more than 99 % were not returned and so presumably taken. The majority (> 97 %) of clients had PCA > 95 % and MPR > 95 % and 98% had viral loads below 1,000 copies/ml during the fourth quarter of follow-up.

Daily events as reminders, support from the medicine companion, weekly visits by field officers, and support from the counsellors were most frequently reported as factors which sustained good adherence.

Viral loads of at least 1,000 copies/ml was associated with poor adherence mostly caused by forgetfulness and not being at home during delivery of medication. Another risk factor for viral load above 1,000/ml copies after 36 weeks on treatment was a baseline viral load of 100,000 copies/ml and CD4 cell count 3.

Medicine companions were able to observe pill-taking on seven or more occasions during the previous week for 73% to 83% of participants, and only four per cent had no pill taking observed by a medicines companion during the previous week.

Thus, a home-based AIDS care program in a poor rural setting in Uganda achieved a good adherence and response to ART.

“We were able to demonstrate retention in care at a proportion that would have been unthinkable a few years ago,” the authors note.

Another successful home-based programme in St. Francis St. Raphael Nsambya Hospital in Kampala has been on-going for several years as part of normal healthcare to thousands of PLWA.

The study by Paul Weidle and colleagues from the US Centers for Disease Control Uganda programme provides the proof of concept for a home-based AIDS care programme for delivering healthcare to PLWA. The authors suggest that programmes which can address the transportation constraints of many HIV-positive people will be necessary in order to scale up antiretroviral therapy. Home delivery might be more feasible on a monthly or quarterly basis, they suggest, after an initial phase of weekly visits in order to address adherence and toxicity issues.