UN Integrated Regional Information Networks - October 16, 2007

According to the survey, conducted by the Boston University School of Public Health and published in the October edition of the Public Library of Science Journal, "loss to follow-up" - patients who missed clinic visits and failed to pick up their medication, followed by death - were the two main reasons for patients being lost from the system.

"Better tracing procedures, better understanding of loss to follow-up and earlier initiation of ART [antiretroviral therapy] to reduce mortality are needed if [patient] retention is to be improved," the study's authors recommended after reviewing 32 publications reporting on over 74,000 patients in 13 sub-Saharan African countries.

In one Ugandan programme, patient retention dropped to just 46 percent at the two-year mark, while an ART programme in Malawi managed to retain 86 percent.

The authors noted that the average of 60 percent retention after two years was "an extraordinary accomplishment" in resource-poor settings, considering that adherence to medication for chronic illnesses averaged just 50 percent in developed countries.

Barriers to retention

According to James Kamau, coordinator of the Kenya Treatment Access Movement, the problems affecting that country's ARV programme ranged from financial to social. "Investment in healthcare systems across much of Africa is insufficient," he told IRIN/PlusNews. "There needs to be more social workers to reach people, even those who live in rural areas."

He pointed out that many people stopped taking the medication because widespread poverty and food shortages meant they could not afford the quantity of food needed to consume with the drugs.

"Distance from health centres, transport costs, shortages of trained health professionals, irregular supply of drugs, poor monitoring systems - these are all issues," Kamau added. "Cost is also a barrier; even though the ARVs are free, people don't have the money to treat their opportunistic infections."

He said stigma and discrimination against HIV-positive people, even by health professionals, also hindered patients from adhering to their drug regimens and seeking follow-up care.

Previous studies have shown that good adherence and outcomes from ART were possible in poor rural African settings, provided healthcare systems modified their interventions to take into account social and economic barriers.

The Boston University study suggested looking to the more successful ART programmes for ideas on how to improve those performing less well.

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