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Why Measure Patient ART Adherence at Facility Level?

International Network for the Rational Use of Drugs Initiative on Adherence to Antiretrovirals (INRUD-IAA). Measuring Adherence Using Paper-Based Facility Records: Methods of the INRUD Initiative for Improving Antiretroviral Adherence in Africa ICIUM 2011 John Chalker, MSH -UK.

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Why Measure Patient ART Adherence at Facility Level?

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  1. International Network for the Rational Use of DrugsInitiative on Adherence to Antiretrovirals(INRUD-IAA) Measuring Adherence Using Paper-Based Facility Records: Methods of the INRUD Initiative for Improving Antiretroviral Adherence in Africa ICIUM 2011 John Chalker, MSH -UK

  2. Why Measure Patient ART Adherence at Facility Level? • Need standardized adherence measures to: • Assess facility/program performance over time • Compare facilities, programs • Identify poorly performing facilities • Evaluate interventions • Build evidence about successful interventions • BUT are indicators measured with routine data in real-life facilities feasible, reliable, and valid?

  3. Teams from INRUD and national AIDS control programs 5 East African countries in Feb/Mar 2006 USAID funding What information is recorded routinely that can be easily retrieved? What indicators are currently utilized? What are their precise definitions? What are their values? East African Survey: Current Facility Adherence Measurement Practices

  4. Potential Availability of Data for Adherence Monitoring 48 Facilities Reporting Availability of Data by Type, %

  5. Appointments % of patients attending on or before the day scheduled % of patients attending within 3 days of the day scheduled Dispensing % days covered by ART dispensed over 6 months % of pts with a gap in medicines dispensed of 30 or more days over the last 6 months Self-reported adherence % patients who self-report full adherence over the last three days Candidate Adherence Measures

  6. Four surveys of 20 facilities each Kenya (Oct 2006), Rwanda (Nov 2006), Uganda (Mar 2007) and Ethiopia (June 2007) In each facility aimed for At least 100 patient records to review Days covered by dispensed medicine Attendance at appointment 30 exit interviews for patient self-report Indicator Feasibility and Reliability Surveys

  7. Sampling ART Patients

  8. Patient level: % of Days Covered by Dispensed Drugs

  9. Facility-level Indicators: % of Days Covered by Dispensed Drugs

  10. Does adherence predict clinical changes in newly treated patients Weight gain and CD4 counts Ethiopia, Kenya, Rwanda, Uganda 4 varied health facilities per country 30 patients per facility, with 10 beginning ART in each of three periods: 7-13 months ago: 14-19 months ago: and 20-25 months ago Validation of Adherence Indicators Using Routine Data in Real-world Programs

  11. Validation: Weight Gain at 9 Months by % of Days Covered with ART

  12. Validation: Adjusted CD4 Gain at 4-9 Months by Days Covered with ART

  13. Self-report in medical record shows promise If routine recording with standardized question Not good for evaluating interventions Patients with less than full self-reported adherence should be sent for intensive counseling Dispensing coverage from routine data Validated against change in weight and CD4 gain Useful for monitoring intervention impacts BUT measured over longer term (over 6 months) Implications (1)

  14. Appointment Book to manage HIV/AIDS Good for rationing clinic workload Way of immediately knowing non-attendance Easy way to check facility performance Also way of improving adherence Facilities can contact patients or community organization after missed appointment Tracking missed appointments could be basic monitoring method for adherence performance Implications (2)

  15. INRUD-IAA Trial Interventions to Improve ART Adherence • Trial interventions in four countries • Kenya, Rwanda, Tanzania and Uganda • In all 4 countries most facilities did not have functioning appointment system • All interventions introduce appointment books • Appointment system accepted and appreciated • Results reported in other ICIUM presentations

  16. Routine data can be used to measure adherence in most real world facilities Survey methods and tools available http://www.inrud.org/ARV-Adherence-Project/Adherence-Survey-Tools-and-Manual.cfm Regular monitoring of appointments is possible and highly desirable HIV/AIDS and other chronic diseases Works with paper records, but electronic records would be even better!! Summary

  17. Acknowledgements: INRUD IAA • Staff at the National AIDS Control Programs • Local INRUD groups, and local MSH offices in Ethiopia, Kenya, Rwanda, Tanzania, Uganda • Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, USA • Division of Global Health IHCAR, the KarolinskaInstitutet, Stockholm, Sweden; • Center for Pharmaceutical Management, MSH • Department of Essential Medicines and Pharmaceutical Policies, WHO

  18. Acknowledgements • This work was made possible through a grant provided by the Swedish International Development Cooperation Agency • Additional funding for specific tasks • The World Health Organization • Rational Pharmaceutical Management Plus Program: funded by the U.S. Agency for International Development

  19. Publications • Chalker J, Andualem T, Minzi O, Ntaganira J, Ojoo A, Waako P, Ross-Degnan D. Monitoring Adherence and Defaulting for Antiretroviral Therapy in 5 East African Countries: An Urgent Need for Standards; Journal of the International Association of Physicians in AIDS Care, 2008, 7 (4): 193-199 • Chalker J. Wagner A, Tomson G, Laing R, Johnson K, Wahlstrom R, and Ross-Degnan D, on behalf of INRUD-IAA.Urgent need for coordination in adopting standardized antiretroviral adherence performance indicators. Journal of Acquired Immune Deficiency Syndromes2010.53(2):159-161 • Chalker J, Andualem T, Gitau L, Ntaganira J, Obua C, Tadeg H, Waako P, Ross-Degnan D. Measuring adherence to antiretroviral treatment in resource-poor settings: The feasibility of collecting routine data for key indicators. BMC Health Services Research2010 10:43. http://www.biomedcentral.com/1472-6963/10/43 • Ross-Degnan D, Pierre-Jacques M, Zhang F, Tadeg H, Gitau L, Ntaganira J, Balikuddembe R, Chalker J, Wagner A. Measuring adherence to antiretroviral treatment in resource-poor settings: The clinical validity of key indicators. BMC Health Services Research2010 10:42. http://www.biomedcentral.com/1472-6963/10/42 • Gusdal AK, Obua C, Andualem T, Wahlström R, Chalker J, Fochsen G, on behalf of the INRUD-IAA project. Peer Counselor’s role in supporting patients’ adherence to ART in Ethiopia and Uganda. AIDS Care, June 2011 23:6, 657-662 Gusdal AK, Obua C, Andualem T, Wahlström R, Tomson G, Peterson S, Ekström AM, Thorson A, Chalker J, Fochsen G, on behalf of the INRUD-IAA project. Voices on adherence to ART in Ethiopia and Uganda: A matter of choice or simply not an option?AIDS Care, 2009, 21 (11):1381 – 1387, • Gusdal AK, Obua C, Andualem T, Wahlström R, Tomson G, Peterson S, Ekström AM, Thorson A, Chalker J, Fochsen G, on behalf of the INRUD-IAA project. Voices on adherence to ART in Ethiopia and Uganda: A matter of choice or simply not an option? AIDS Care, 2009, 21 (11):1381 – 1387, •  Obua C, Gusdal A, Waako P, Chalker J, Tomson G, Wahlström R, and The INRUD-IAA Team. Multiple ART Programs Create a Dilemma for Providers to Monitor ARV Adherence in Uganda. The Open AIDS Journal, 2011, 5, 17-24.

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