Health care provider communication training in rural Tanzania empowers HIV-infected patients on antiretroviral therapy to discuss adherence problems

Abstract

Objectives: Self-reported adherence assessment in HIV-infected patients on antiretroviral therapy (ART) is challenging and may overestimate adherence. The aim of this study was to improve the ability of health care providers to elicit patients' reports of nonadherence using a "patient-centred" approach in a rural sub-Saharan African setting.

Methods: A prospective interventional cohort study of HIV-infected patients on ART for ≥ 6 months attending an HIV clinic in rural Tanzania was carried out. The intervention consisted of a 2-day workshop for health care providers on patient-centred communication and the provision of an adherence assessment checklist for use in the consultations. Patients' self-reports of nonadherence (≥ 1 missed ART dose/4 weeks), subtherapeutic plasma ART concentrations (< 2.5th percentile of published population-based pharmacokinetic models), and virological and immunological failure according to the World Health Organization definition were assessed before and after (1-3 and 6-9 months after) the intervention.

Results: Before the intervention, only 3.3% of 299 patients included in the study reported nonadherence. Subtherapeutic plasma ART drug concentrations and virological and immunological failure were recorded in 6.5%, 7.7% and 14.5% of the patients, respectively. Two months after the intervention, health care providers detected significantly more patients reporting nonadherence compared with baseline (10.7 vs. 3.3%, respectively; P < 0.001), decreasing to 5.7% after 6-9 months. A time trend towards higher drug concentrations was observed for efavirenz but not for other drugs. The virological failure rate remained unchanged whereas the immunological failure rate decreased from 14.4 to 8.7% at the last visit (P = 0.002).

Conclusions: Patient-centred communication can successfully be implemented with a simple intervention in rural Africa. It increases the likelihood of HIV-infected patients reporting problems with adherence to ART; however, sustainability remains a challenge.

Keywords: HIV; antiretroviral therapy; patient-centred communication; self-reported adherence; sub-Saharan Africa; therapeutic drug monitoring.

Figure 1

The study algorithm. V1, visit 1 (baseline visit); V2, visit 2; V3, visit 3; Questionnaire, self‐reported adherence questionnaire; TDM, therapeutic drug monitoring; days, days between the evaluation and the communication training (interquartile range); numbers represent numbers of patients.

Figure 2

Percentage of patients with self‐reported nonadherence to antiretroviral therapy (ART) assessed using the questionnaire at each study visit. The y‐axis shows the percentage of patients with self‐reported nonadherence.

Figure 3

Plasma concentration−time plots for different antiretroviral therapy (ART) drugs. (a) Plasma concentration−time plots for patients receiving 600 mg efavirenz once daily for all three study visits. (b) Plasma concentration−time plots for patients receiving 200 mg nevirapine twice daily for all three study visits. (c) Plasma concentration−time plots for patients receiving 400/100 mg lopinavir/ritonavir twice daily for all three study visits. The y‐axis has a logarithmic scale. Circles represent patient samples. The dashed line represents the 2.5th percentile concentration curve derived from published population‐based pharmacokinetic models (efavirenz 41, nevirapine 42 and lopinavir 43). Concentrations of ART drugs below the 2.5th percentile are considered subtherapeutic. Circles on the x‐axis represent patient samples with drug concentrations below the lower limit of quantification or undetectable.