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HIV-Positive People in Africa More Likely to Adhere to Antiretroviral Treatment Than HIV-Positive People in North America, Study Finds

August 9, 2006

HIV-positive people in sub-Saharan Africa are more likely to adhere to their antiretroviral treatment regimens than are HIV-positive people in North America, according to a study published in the Aug. 9 edition of the Journal of the American Medical Association, the Los Angeles Times reports. Edward Mills, executive director of the Centre for International Health and Human Rights Studies in Toronto, and colleagues examined 31 studies from North America involving 17,573 HIV-positive people receiving antiretroviral drugs and 27 studies from 12 countries in sub-Saharan Africa involving 12,116 HIV-positive people receiving antiretrovirals (Cline, Los Angeles Times, 8/9). To show trends among the general population, researchers selected study sources that represented mixed populations in Africa and North America. Studies examining specific groups -- such as men only, people without permanent shelter or illicit drug users -- were excluded (Mills et al., JAMA, 8/9). According to the study, 77% of people taking antiretrovirals in sub-Saharan Africa adhered to the regimen, compared with 55% of people receiving antiretroviral treatment in North America (Los Angeles Times, 8/9). In addition, the study finds that low-income individuals in North America had a low adherence rates and also faced a number of obstacles to treatment compliance -- including poor patient-physician relationships, untreated depression and illicit drug use (Howard Price, Washington Times, 8/9).

Implications, Reaction
The study does not examine why antiretroviral therapy adherence among HIV-positive people in North America and sub-Saharan Africa differs, but according to Mills, there are a several hypotheses, the CP/Globe and Mail reports. "The [hypothesis] that seems to make the most sense to us is that people (in North America) have been taking the drugs for a long time, there are side effects related to them and sometimes they are not seeing the immediate benefits as much anymore," he said, adding, "Whereas in Africa, they're only able to access antiretroviral drugs when they get to a certain disease state (moving into AIDS), on average. A possible explanation is they're seeing the immediate benefit for themselves of taking the drugs." In addition, Louise Binder, chair of the Canadian Treatment Action Council, said many people also might not adhere to antiretroviral therapy because of "pill fatigue," or because of the numbers of pills they must take daily (Ubelacker, CP/Globe and Mail, 8/9) . The findings of the study indicate that "favorable levels of adherence, much of which was assessed via patient self-report, can be achieved in sub-Saharan African settings and that adherence remains a concern in North America," the authors write (JAMA, 8/9). "The myth of poor adherence in Africa, previously used as a rationale to delay or deny the expansion of treatment programs ... has firmly been debunked by this study," Ann-Louise Colgan of Africa Action, a Washington, D.C.- based organization focused on African issues, said (Los Angeles Times, 8/9). David Bangsberg, a study author and epidemiologist at the University of California-San Francisco, said he hopes that multinational antiretroviral programs will recognize that patients in sub-Saharan Africa "are doing extraordinarily well in taking their meds." He also said it is important "to focus on what we can do to sustain this level of adherence and also to make sure that issues around drug supply and drug distribution become the first point of concern" (Gale, Reuters Health, 8/8).

PRI's "The World" -- a production of BBC World Service, PRI and WGBH Boston -- on Tuesday included an interview with Bangsberg (Mullins, "The World," PRI, 8/8). The complete segment is available online in Windows Media.

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