Adherence to care is influenced by a wide range of factors. Mentioned above include drug toxicity, stigma and drug interactions but at varying degrees. However, proper evaluation and adequate pre-treatment preparation are keys to successful adherence among HIV positive clients. These are practices in our HIV program in Nigeria. However, community engagement has been shown to significantly help in this direction. Community engagement provides various platforms for engaging HIV positive persons that would ensure their commitment to care. For example Case Management team system allows for one-on-one interaction between a newly diagnosed HIV positive person with an older HIV case already in care for peer support and adherence to care. Treatment buddy system through mutual linking of two same HIV positive persons for mutual support. This system is easily developed from the pool of Mother-to-Mother Support Groups. Mentor Mother system provides avenue for one-on-one and in-depth counseling that ensure adherence and retention in care. These are sustainable systems within any society, whether developed and developing.

One of the most important area in addressing issues pertaining to adherence is the use of multidisciplinary approach in therapeutics; involving doctors, nurses, pharmacists etc. Patients must be fully counselled on issues related to ARVs, ADRs in particular. Even otherwise deemed minor ADRs do effects patient quality of life, which can be either prevented or handled safely. In my opinion therapeutic adherence is the key in the management of any chronic illness and HIV/AIDS is not different from any other chronic disease. Therefore ADR and its managment, avoidance and managment of drug, food and other interactions can significantly impact the out come of ARV program.

You might look at the direct observation literature which has been applied to TB and I believe AIDS but I am not sure.

I think the socio economic conditions are key components of the therapeutic approach.

Multi-disciplinary approach along with decentralized and community participation may play important role in the field of AIDS.

i think the economic factor is so important in adherence treatment for more info you can visit the web site of GHESKIO they are dealing a study about adherence and the economic factor in adolescent.

Thank you very much for your answers. the strategies applied in my country has a lot of weakness. I would like your opinion to propose effective methods correlating to my country.

Cajouste I don't find the study about adherence and the economic factor in adolescent on the web site of GHESKIO. Can you send to me the link please?

Yanick, I don't know which system is in place in your country. Can you cite such and it would be possible to exam them ? Only then can remedial measures be preferred.

I would like to express my appreciation to the views of the writers on this issue and I would like to say some thing on it but mainly based on my first hand experience rather than the multitude of literature already said on the matter including those already being implemented . I hope it brings a different perspective to the discussion.

The issue of adherence to HIV care and treatment must be approached based on the different contexts of our clients' life style as well as the back grounds of individual client vis-a-' vis the level of readiness to assume personal responsibility to enroll into chronic care and to endure the required constancy of behavior and action. But another important issue to consider is the question how the community in which clients live during their period of care perceive not only the status of a person with a chronic illness but also the different therapeutic and care related provided to these people. Some communities take those care and treatment intervention assistance and the accompanying counselling for granted and they may not feel that they should also put some effort to help the process. Other cultures take external assistance very seriously and the overall adherence to care and treatment effort of an institution could be rewarded by better retention in care. These factors mentioned above might be influenced by awareness creation and other intervention measures but to do this there is a very core requirement where all the services, gap identification and coordination activities to fill the gaps originates and this is a care and treatment facility. These facilities where care and treatment of HIV/AIDS services are provided are the places where preliminary measures of maximizing adherence are supposed to be carried out.

To prepare patients for care and treatment counseling about the importance of adherence both to care and treatment is very vital and this should be done in a very confidential and respectful manner. For this facilities should have a separate place to give counseling services on adherence other risk reduction and disclosure related education on an individual level at first and at a group level as required. The same facility is necessary also at the ART pharmacy where information about compliance, side effects and other issues should be discussed. Sadly most facilities I mentored over the past three years lack these facilities and the the counseling process about adherence to care and treatment is very poor. There for in areas with similar context it be very deceiving to attribute certain things as barriers or facilitators of adherence.

Thank you

Hi. I have read some of the answers - quite comprehensive. For patients who have to take lifelong therapy it must be daunting. We therfore have to firstly ensure that the drugs given are simplified and that means more research into better drugs taken fewer times in a day and will less side effect profiles. Patinet education and their families is crucial to ensure that patients carry on taking the drugs even if they feel well to maintain viral suppression avoid drug resistance later on. I think clinicians and healthcare providers should measure adherence in their individual and patient populations and that patients are communicated to appropriately in terms of how they are doing. There are different ways mentioned in literature on how to measure adherence in patients. Those are some of the few strategies. Thanks

Dear Yanick Simon. I had developed an online tool for the self-assessment of adherence to treatment – iCEATvih – that is available through a website www.ceat-vih.info. The website is compatible with Mobile devices. The iCEATvih measures global adherence behavior to ARV and five domains that explain individual differences in adherence to HIV medication. The iCEATvih is available in 4 language versions (i.e., English, Spanish, Portuguese and Brazilian Portuguese), and can be used directed by patients for self-monitoring, and/or health care professionals for follow up. The profile obtained is graphically shown and can be sent to a personal email account. The assessment indicate the global level of adherence and 5 elements related to adherence behavior – Compliance, Antecedents of non-adherence behaviors, Doctor-patient Communications, Personal beliefs, expectancies about the treatment, Treatment satisfaction. All these elements may be addressed by personalized counseling in an intervention. Recently published systematic review has described good measurement properties of the CEAT-VIH in several countries (Reference: Remor, E. (2013). Systematic review of the psychometric properties of the questionnaire to evaluate the adherence to HIV therapy (CEAT-VIH). The Patient: Patient–Centered Outcomes Research, 6 (2), 61-73. doi: 10.1007/s40271-013-0009-0). If you need additional information contact me at the email [email protected]

M-Health approaches certainly present a still untapped opportunity for sending out patient reminders, health messages, and rescheduling of appointments. Adherence is a complex issue. Simplification of treatment (Treatment 2.0) certainly has a key role. But so do health systems, policy, socio-economic and personal factors.

In our project in central Kenya, we have successfully implemented a missed appointment system centered around a missed appointment register that is duly filled after the clinic. Missed appointments are called the next day for rescheduling. If they do not return within two weeks physical defaulter tracing through trained community health volunteers is done. With roll-out of electronic health records, the missed appointment register is soon to become electronic and we are looking at using this interface to send out defaulter tracing lists to smart-phones/ tablets in the custody of the community health workers. Our observation is that most patients are reachable through phone calls - the only caveat is to ensure that accurate phone numbers are captured during patient registration.

Check this link for more on M-health for treatment adherence: http://www.weltel.org/weltel_randomised

I really appreciate your answer. Thank you very much. Eduardo I'll contact you soon to have more information.