Background: Universal access to highly active antiretroviral therapy (HAART) is still elusive in most developing nations. We asked whether peer support influenced adherence and treatment outcome and if a single viral load (VL) could define treatment failure in a resource-limited setting.
Methods: A multicenter longitudinal and cross-sectional survey of VL, CD4 T cells, and adherence in 546 patients receiving HAART for up to 228 months. VL and CD4 counts were determined using m2000 Abbott RealTime HIV-1 assay and FACS counters, respectively. Adherence was assessed based on pill count and on self-report.
Results: Of the patients, 55.8%, 22.2%, and 22% had good, fair, and poor adherence, respectively. Adherence, peer support, and regimen, but not HIV disclosure, age, or gender, independently correlated with VL and durability of treatment in a multivariate analysis (P < 0.001). Treatment failure was 35.9% using sequential VL but ranged between 27% and 35% using alternate single VL cross-sectional definitions. More patients failed stavudine (41.2%) than zidovudine (37.4%) or tenofovir (28.8%, P = 0.043) treatment arms. Peer support correlated positively with adherence (χ2, P < 0.001), with nonadherence being highest in the stavudine arm. VL before the time of regimen switch was comparable between patients switching and not switching treatment. Moreover, 36% of those switching still failed the second-line regimen.
Conclusion: Weak adherence support and inaccessible VL testing threaten to compromise the success of HAART scale-up in Kenya. To hasten antiretroviral therapy monitoring and decision making, we suggest strengthening patient-focused adherence programs, optimizing and aligning regimen to WHO standards, and a single point-of-care VL testing when multiple tests are unavailable.
*Center for Research in Therapeutic Sciences and the Institute of Healthcare Management, Strathmore University, Nairobi, Kenya;
†Kenya Medical Research Institute, Nairobi, Kenya;
‡Institute of Tropical Medicine and Infectious Diseases at JKUAT, Nairobi, Kenya;
§MCPHS University, Worcester, MA;
‖Center for Global Public Health, Tufts University School of Medicine, Boston, MA; and
¶African Centre for Clinical Trials, Nairobi, Kenya.
Correspondence to: Washingtone Ochieng, MSc, MBA, PhD, Centrer for Research in Therapeutic Sciences, Strathmore University, P.O. Box 59857-00200, Nairobi, Kenya (e-mail: firstname.lastname@example.org).
Supported by the Consortium for National Health Research (Kenya) Grant# RCDG-2012-005, with funds from the Wellcome Trust and the Department for International Development (DFID), UK (Grant ID, WT080883Kokwaro).
The authors have no conflicts of interest to disclose.
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Received August 21, 2014
Accepted January 13, 2015