Adherence and Support
Access alone does not ensure that women will adhere to treatment. “The regimens are often complicated, can require dietary restrictions and may lead to adverse effects,” such as changes in body fat that can negatively impact body image (Mills et al., 2006: 2; Holstad et al., 2006).
A systematic review of 84 studies examining barriers to treatment adherence found “fear of disclosure, forgetfulness, a lack of understanding of treatment benefits, complicated regimens, and being away from medications were consistent barriers to adherence in developed and developing nations. More common to developing settings were issues of access, including financial constraints and a disruption in access to medications” (Mills et al., 2006: 18).
There Are Gender Differences in Treatment Adherence
Men and women have similar adherence rates, and women are able to follow complicated regimens as well as men. But there are gender differences in predictors of adherence. Women may need family support, including redistribution of household responsibilities, to enable them to adhere to treatment. Even if drugs are free or subsidized, women may not be able to afford the time or money required to travel to a clinic. Women may also have difficulty navigating treatment when it conflicts with other activities for survival. One South African sex worker points out the struggles she faces: “If you don’t pay off the police, they take you to jail…you can’t take antiretroviral drugs or any medication you need” (Arnott and Crago, 2009: 10).
It is also critical for treatment programs to assess not just how many people who need treatment gain access to treatment but who gains access, how, and if it is accompanied by care and support. Does the program address adherence? Do patients receive adherence support? Do patients receive good quality counseling? Are patients satisfied with their quality of care? Have patients received proper information on medications and dosage? (Gruskin et al., 2007c). Adherence is defined as “taking medication as prescribed, and therefore issues such as pharmacy stock-outs are out of the patient’s control” (Bangsberg, 2008). Programs should also promote treatment literacy so that all people know that AIDS cannot be cured but that ARV treatment can prolong life, with improved quality of life (UNAIDS, 2005). For those on ARV therapy, treatment literacy is vital to understanding the importance of adherence.
Improving Treatment Adherence Requires Counseling, Empowerment to Overcome Barriers
While there is little data demonstrating what works specifically for women in improving treatment adherence, there are some interventions that have been shown to work for both men and women such as provision of counseling, including treatment support and literacy. A meta-analysis of 19 randomized controlled trials including 1,839 patients found that patients given one-on-one counseling by health providers, with a median of two sessions lasting 60 minutes each, resulted in patients being more than one and a half times more likely to achieve 95% adherence, compared to controls (Simoni et al., 2006 cited in Vergidis et al., 2009). An observation study of low-literacy and low-income patients in 2005 in Mozambique also found improved adherence among patients who received counseling from health care providers (Magnano San Lio et al., 2009). Counseling support by HIV-positive peers has been found to also be effective in improving treatment adherence in Thailand, through a model developed by the Thai Network of People With HIV/AIDS (TNP+), and in Haiti, Rwanda and Lesotho, supported by Partners in Health’s “accompaniment” model, which includes daily home visits by community health workers, free clinic visits, nutritional support, transportation to clinics and preferential hiring of HIV-positive people (Ford et al., 2009a; Mukherjee et al., 2008b). [See also Chapter 11G. Strengthening the Enabling Environment: Promoting Women’s Leadership]
Pill counts and pillbox organizers are low-technology empowerment tools that can increase adherence (Jean Jacques et al., 2008). Data obtained from an observational cohort of 245 people living with HIV from 1996 to 2000 in the United States showed that pillbox organizers were estimated to improve adherence by 4.1 to 4.5% and was associated with a decrease in viral load of .34-.37 log10 copies/mL and a 14.2% to 15.7% higher probability of achieving a viral load of greater than 400 copies/mL, with statistically significant effects. “Pillbox organizers should be a standard intervention to improve adherence to antiretroviral therapy” (Peterson et al., 2007).
Mobile phones are promising tool that may facilitate adherence. In a study in Kenya of 322 ARV patients, of whom 81% owned a mobile phone, found that nearly 88% of those who owned a mobile phone said they would be comfortable receiving reminders and assistance with side effects by phone (Lester et al., 2008).
These practices and tools are useful for both men and women, however further research is needed regarding the best ways to overcome a number of treatment adherence barriers specific to women such as fear of disclosure, stigma, violence, body image issues related to fat redistribution (a side effect of some medications), among others.