October 29, 2010
There has been an irresistable urge for people -- doctors, public health officers, politicians, journalists, the usual pundits -- to compare adherence to HIV treatment in resource-rich vs. resource-limited setting.
I suspect this is because the whole issue got off to a famously bad start in 2001, when then-head of the U.S. Agency for International Development (USAID) Andrew Natsios said in an interview with the Boston Globe that Africans:
... don't know what Western time is. You have to take these (AIDS) drugs a certain number of hours each day, or they don't work. Many people in Africa have never seen a clock or a watch their entire lives. And if you say, one o'clock in the afternoon, they do not know what you are talking about. They know morning, they know noon, they know evening, they know the darkness at night.
The reality, of course, is that patients in Africa and other resource-limited settings have been just as adherent to HIV treatment as people in developed countries.
But are they more adherent?
But I don't buy it -- never have.
In fact, in his otherwise inspiring talks on how to bring lifesaving health care to poor countries, my doppelganger Paul Farmer has a small section I absolutely hate. (Am I allowed to criticize Paul Farmer? Sure -- he knows it.) It's where he compares adherence rates for Haitians in his community-based programs to that of patients discharged from the inpatient medical service at Grady Memorial Hospital in Atlanta.
Not surprisingly, the Haitians do better. But that's not really a fair comparison, because in Haiti the people on treatment are actively seeking care, while with these particular patients at Grady, they are actively running away from it until they get so sick they need to be hospitalized.
At the great risk of oversimplifying the issue -- and acknowledging up front that I do my work exclusively here in the USA (but in a setting with a very broad range of patients) -- here's my take:
So the next time you hear someone make a broad generalization about adherence being better in City A vs B, or Country X vs Y, remind them that people are people -- and adherence to HIV therapy is likely to be the same everywhere.
That is, excellent until proven otherwise.
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.