Improving treatment adherence in hard to reach populations: it CAN be done

Whilst there has been great progress in rolling out access to antiretroviral treatment (ART), there are also many challenges in ensuring that patients adhere to treatment, especially those living in complex social situations. Here at the 19th International AIDS Conference in Washington, DC, today, a press conference held by Médecins Sans Frontières (MSF) drew attention to a range of initiatives for traditionally hard to reach populations – including mobile populations and adolescents living with HIV – whose success confirms that tailoring programmes for specific groups and populations can result in higher levels of retention and adherence than other ‘easier to reach’ groups. 

Closer to home’ and ‘Providing antiretroviral therapy for mobile populations’ are reports describing MSF-associated programmes in four countries: Malawi; Democratic Republic of the Congo; Mozambique; and South Africa. In each there were specific challenges in ART delivery, requiring initiatives to maximise access. In Musina, South Africa for example, rural workers are highly mobile, moving out of an area up to five times a year, especially when work is unavailable. This is usually to neighbouring Zimbabwe, and in a project supported by MSF, a range of options are available to ensure treatment adherence, such as a ‘safe travel pack’ containing three months of ART and a ‘transfer letter’ to be taken to receiving ART sites if treatment is sought. Evaluation of the project confirms that only 17% of patients never return – and overall retention is 93% at 6 months, and 90% at 12 months – outcomes that are better than general populations. Tambu Matambo, Medical Coordinator for MSF in Medina, South Africa, said “it is possible to provide HIV treatment to migrants if you tailor the programme to their specific needs.”

Another difficult-to-reach group are adolescents living with HIV. Dr Mary Nyathi, Consultant Paediatrician at Mpilo Hospital in Zimbabwe, described a package of activities such as life skills support and income generating activities for adolescents. This includes Teen Club, initiated by the adolescents themselves, counsellors not only providing information around sexual and reproductive health, but also being on constant ‘call’ if support is required urgently (this includes home visits). In addition, health care workers are trained in supporting adolescents, and all this serves to maximise “adolescent customer service.” Much of the programme is shaped by adolescents’ stated needs, and this approach is certainly effective – after 2 years, retention is as high as 85%. For Nyathi, this is a direct result of “adolescents are training us to manage their care”. 

Another example, specifically of a community-led initiative in Mozambique – where the health system is seriously understaffed and congested – was described by Dr Tom DeCroo, MSF Tete Project, Mozambique. Here, there is a ‘community ART group’, where communities form groups to take turns visiting clinics for check ups, and collecting ART refills for the rest of the group. Retention among the 5229 members of the 1000 groups is 97%, and when this approach was expanded to include 312 children, no child was lost to follow up, and the attrition rate was four times lower than the global average. 

What is key in these three examples is that initiatives are tailored to meet local needs. There is decentralisation, away from the clinical setting to the community, and the positive results achieved from these projects confirm that this model would be beneficial to other countries. As the HIV sector continues to strive for universal access to treatment by 2015, responding to those affected by HIV is bound to facilitate this goal, and prove it is possible to attain treatment efficacy in the most complex of social situations.

Ian Hodgson - CNS