1. Experience under the TAP: Determinants and experience with adherence in Burkina Faso Hospital and Community Sites in Burkina Faso Pascal NIAMBA, Cecile BELOUME

2. OUTLINE 1.Context 2.Methods –Study design –Population and sample –Data collection –Data analysis 3.Results 4.Discussion and conclusion

3. Burkina Faso 274 200 km² 12 802 282 inhabitants (2005) < 15 years: 55% Women :52% PNB 268 USD 128022 82 -46 % of the population is below the poverty line -IDH=0,303 en 2000

4. Situation Analysis Epidemiological Data: –Sentinel site surveillance (2004): Prevalence rate 2.4%. Urban sites: 3.4% Rural areas: 1.5% –Estimates for 2005 (UNAIDS) Adults living with HIV/AIDS: 135 120 HIV/AIDS prevalence rates in adults (15- 49): 2%

5. HIV patient care in Sub-Saharan Africa « the big picture » Dramatic price reductions + new programs → rapid expansion of ARV programs 500 000 people are receiving ARV (UNAIDS “3x5”) Scale-up is accelerating in most countries on the African continent

6. PLWHIV under ART end of 2004 to T1-2006

7. HIV patient care in Sub-Saharan Africa « the big picture » Adherence to treatment will become a challenge Adherence determines treatment efficacy Initial pilot studies → high levels of adherence In our initial studies → adherence appears to be inadequate in some sites Few studies on determinants of adherence in Sub-Saharan Africa

8. Background study 46/73 patients (63%) non-adherent to ARV therapy in a community-based cohort in Burkina Faso The majority on triple therapy 84% on first HAART regimen 75% on HAART > 6 months Traoré AA, N.V., Fakoya A, McCarrick P, Dhaliwal M, Tiendrébéogo I, Ilboudo A, Barriers to adherence to ARV therapy in a community-based cohort in Burkina Faso. The XV International AIDS Conference, 2004. Abstract number: WePeB582 19 15 13 10 9 6 4 3 6 Number of responses Not enough food to accompany medications Running out of medication Circumstantial constraints Depression Forgetting Medication-related Falling asleep Other § Side effects reasons *

9. Study aim –Describe the prevalence of adherence –Identify potential determinants of adherence

11. Methods (1) Study design: cross-sectional study Population: patients >6 months ARV in hospitals and CBO Sample: n=270 (94 men; 176 women) Recruitment sites –In Ouagadougou: 1 Hospital and 2 CBO Data collection: Face-to-face interviews with a close-ended questionnaire + chart review

12. Methods (2) Measuring adherence: Patients were considered adherent if they answered “YES” to the following questions –“Always” took their ART –Took all pills yesterday, the day before yesterday and during the whole week –Followed the treatment schedule yesterday, the day before yesterday and during the whole week –AND missed < 1 dose in the month

13. “Individual” factors Socio-economic –Revenue –Education –Occupation –Household attributes Demographics –Age –Gender –Marital status Knowledge of treatment

14. Relational factors Having a regular partner Number of children Number of people you provide for Serostatus notification –To partner –To surroundings

15. Treatment regimen Pill burden (number of pills/day) Complexity of schedule (food restrictions) Months on treatment Side effects

16. Treatment regimen: Setting Clinical management Community setting Hospital setting Time/distance to appointment

18. 43,8 * p=0.082 57,5 0 10 20 30 40 50 60 70 80 Percent (%) Burkina Faso CBOs Hospitals Adherence in hospital vs CBO Overall, adherence is inadequate: Only 58.5% (158/270) of patients had complete adherence. Hospitals (64.6%) > CBOs (50.0%) p<0.017

19. Adherence is related to clinical outcome Weight loss p≤0.001

20. Adherence is related to clinical outcome Patients with OI p=0.034

21. Muslim religion, but confounded ?? Shaped relationship between adherence and income? Individual factors associated with adherence:

22. Facilitating factors and adherence Relational Characteristics Having children is associated with better adherence Having a regular sex partner is associated with a better adherence

23. Facilitating factors and adherence: Influence of the treatment regimen

24. Preventive behavior and adherence Only 58%(123/212) used condoms with regular partner at last intercourse Only 56%(120/212) notified partner about their serostatus

25. Concluding remarks Adherence and preventive behaviours are inadequate No clear association between individual factors and adherence Decreasing adherence over time: –second year of treatment “high risk” for non- adherence Implications for antiretroviral resistance Need for prospective studies of adherence to treatment AND prevention