Rational Drug Use Group Confirms Validity of Indicators of Adherence to Antiretroviral Therapy

[Coptic Waiting in Tent. Photo Credit: MSH Staff]Coptic Waiting in Tent. Photo Credit: MSH StaffOn November 4–6, 2009, in Gisenyi, Rwanda, the Initiative on Adherence to Antiretrovirals of the International Network for the Rational Use of Drugs (INRUD-IAA) hosted its third annual meeting on antiretroviral therapy (ART) adherence. Results of an INRUD-IAA research study showed that the adherence indicators chosen for study are clinically meaningful—that is, they correlate to increases in patients’ CD4 counts and weight gain. Additional research investigated the determinants of good and poor adherence in facilities in Ethiopia and Uganda.

Addressing questions about adherence to ART is particularly critical in African countries, where access to antiretrovirals has increased without the benefit of existing infrastructure or resources to measure, monitor, and improve compliance to long-term treatments.

At the meeting, participants discussed challenges in adherence to ART; reviewed the progress of interventions to improve adherence developed this year by teams in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda; and examined issues related to data analysis and reporting and to strategies for nationwide scale-up of proven interventions.

When the project started, country partners tested the feasibility and reliability of methods to collect data on treatment adherence. Based on these analyses, INRUD-IAA defined core treatment adherence indicators that can be calculated in a standardized way from data routinely available in ART clinics.

Standard Indicators and Data Sources

Percentages calculated from pharmacy records—

  • Days covered by ART dispensed over six months
  • Patients with a 30-day or more gap in medicines dispensed over six months
  • Patients attending the clinic appointment (set three months earlier) on or before the scheduled appointment day
  • Patients attending the clinic appointment (set three months earlier) within three days of the scheduled appointment day 

Percentage calculated from patient exit interviews— 

  • Patients who self-reported full adherence over the previous three days

Standardizing adherence measurement offers a systematic way to, first, assess and compare adherence across facilities and programs and, second, assess the impact of systemic interventions to improve adherence. In the four survey countries where country partners tested the data collection methodology, facilities generally maintained patients at a high level of treatment adherence. For all indicators, however, they identified some facilities that performed less well, thus providing targets for quality improvement efforts. 

Country groups in Kenya, Rwanda, Tanzania, and Uganda established their own priorities for trial interventions based on study results and on local knowledge and experience. The national teams have conducted baseline studies, finalized intervention designs, and initiated their interventions. Follow-up evaluations in the four countries are due to be completed in early 2010. Rather than undertaking a pilot intervention, Ethiopia is improving adherence in the national program through systemwide activities with U.S. Agency for International Development funding.

In addition to the November conference, INRUD-IAA has been working to publicize the importance of monitoring facilities’ performance in ART adherence among patients. For example, during the Global Health Council’s 2009 Conference in Washington, DC, INRUD-IAA presented a full panel on its adherence work. The presentations included the following:

INRUD-IAA’s partners and collaborators comprise the following:

  • INRUD groups in Ethiopia, Kenya, Tanzania, and Uganda
  • National AIDS control programs in Ethiopia, Kenya, Rwanda, Tanzania, and Uganda
  • Karolinska Institutet’s Division of International Health
  • Harvard Medical School’s Drug Policy Research Group
  • World Health Organization’s Department of Essential Medicines and Pharmaceutical Policies


INRUD-IAA is funded by the Swedish International Development Cooperation Agency.