Adherence to Highly Active Antiretroviral Therapy Assessed by Pharmacy Claims Predicts Survival in HIV-Infected South African Adults

It is not clear how adherence to highly active antiretroviral therapy (HAART) may best be monitored in large HIV programs in sub-Saharan Africa where it is being scaled up, wrote the authors of the current study. They sought to evaluate the association between adherence to HAART, as estimated by pharmacy claims, and survival in HIV-1-infected adults enrolled in a private-sector AIDS program in South Africa.

Of the 6,288 patients initiated on HAART between January 1999 and August 2004, 61 percent (3,805) were female and 97 percent (6,094) were black African. Of patients, 52 percent (3,298) had HAART adherence of >=80 percent, and 30 percent (1,916) had 100 percent adherence. Women were significantly more likely than men to have adherence of >=80 percent (54 percent vs. 49 percent, P<0.001). Median (interquartile range) follow-up time was 1.8 (1.37-2.5) years.

As of Sept. 1, 2004, 222 patients had died -- a crude mortality rate of 3.5 percent. Using a multivariate Cox regression model, the researchers found adherence of <80 percent was associated with lower survival (relative hazard 3.23; 95 percent confidence interval (CI): 2.37-4.39). After dividing medication adherence into 5 strata, each with a width of 20 percent, each stratum had lower survival rates than the adjacent, higher-adherence stratum. Of all the variables tested, only baseline CD4+ T-cell count was significantly associated with decreased survival in multivariate analysis (relative hazard 5.13; 95 percent CI: 3.42-7.72, for CD4+ T-cell count <=50 cells/[mu]L vs. >200 cells/[mu]L).

"Pharmacy-based records may be a simple and effective population-level tool for monitoring adherence as HAART programs in Africa are scaled up," the authors concluded.

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