1. Poor adherence to antiretroviral therapy (ART) is a major obstacle to successful
treatment outcomes. There is evidence that telephone support improves adherence
in several medical areas. In developing countries mobile phones are widely used and
are emerging as a new tool in health care communication. The registry of medica-
tion dispensed is an indirect method to assess adherence with acceptable sensitivity
and specificity.
To evaluate the efficacy of an adherence strategy based on a computer alarm system
and telephone support interventions.
Design: This is a retrospective intervention comparative cohort study.
The comparator referred to is year 2006. In 2007 a newly installed computer alert
system began to identify any delay of ART dispensing. Adherence strategies of telepho-
ne support were applied. Results for 2007, 2008 and 2009 were compared respect 2006.
The rates of dispensed ART were compared as indirect indicators of adherence.
Setting: This study was done at a private specialized medical center in Buenos Aires
City and affiliates in the provinces were interdisciplinary HIV/AIDS attention is provided.
Study population: The whole population in follow up was retrospectively studied
from 2006 to 2009. At baseline, year 2006, there were 3,319 patients being followed
up, mean age (SD) 37.0 (11.5) years, male 67.8%, ART 75.5%. In 2007 3,430 patients
37.3 (11.3) years, male 66.9%, ART 77.5%, in 2008 4,040 patients 37.7(11.2) years,
male 67.7%, 76.5% on ART and in 2009 there were 4,584 patients, 38.4 (11.4) years,
male 67.5%, ART 77.2%.
TABLE 1. Medical Monitoring Population: 2006 to 2009.
a Year 2006: Baseline comparator
b Year 2007: Start of the warning computer system and telephone
support adherence to ART
Intervention: A computer program was designed to alert health staff about a delay
in patient’s visit for medication dispense for the following period. Psychologists,
social workers and peer support were trained to contact those patients.
Outcome Measure: To assess efficacy of intervention in yearly rate of pharmacy dis-
pensing vhith respect baseline.
FLOW CHART OF THE INTERVENTION
The rate of medication dispensing visit showed a statistically significant increase with
respect to baseline in 2007 (81.4%; 95% CI: 80.97-81.88; p = 0.001), 2008 (81.0%; 95%
CI: 80.52 - 81.37; p = 0.004), 2009 (83.2%; 95% CI: 82.85-83.60, p < 0.001) and 2010
(88.9%; 95% CI: 88.33-89.40, p < 0.0001).
The rate of viral load < 50 copies/mL lab results showed a statistically significant in-
crease with respect to the baseline. The rate of CD4 T-cell count remained stable or
slightly increased with no statistical significance.
Table 2. HAART pick up rates, rates of studies VL <50 copies / mL and median CD4 cell count
a 2006: Baseline (reference comparator)
b 2007: Start of the warning computer system and telephone support adherence to ART
Figure 1. HAART pick up rates of pharmacy vs. Baseline (2006)
Pick up rates of ART from the pharmacy showed a statistically significant increase compa-
red to baseline (2006)
Figure 2. Percentage of studies with VL <50 copies / mL
The proportions of studies with VL <50 copies / mL had a statistically significant increase
compared to baseline
1. Key Lessons
Our findings show that centralized data of pharmacy dispensing, with a computer
alarm for any delay and telephone support improves long-term adherence to ART
and clinical outcomes.
2. Implications for implementing policies and programs to improve the use of medicines,
immediately and in the longer term
This work was selected as the best experience in the “PAHO competition Successful Expe-
riences in Management of Adherence to Antiretroviral Therapy in Latin America”
http://new.paho.org/hq/index.php?option=com_content&task=view&id=5581&Itemid=4003
Health policies that centralize computerized data and encourage the training of per-
sonnel may promote the replication of these interventions tailored to each culture.
This experience requires the work of members of different areas, which involves the
development of teamwork skills. Supervision, coordination and training of the execu-
tors are necessary for this intervention in order to avoid losing the essence of "health
intervention" to prevent becoming a purely administrative task without efficacy.
Mobile telephones are widespread, even in the poorest countries in the world. This
gives health workers the opportunity to communicate with patients and thus through
this way also strengthen adherence to treatment.
3. Specific studies should be included in a future research agenda in the field
Randomized controlled trials (RCT) are needed. Systematic reviews and meta-analysis
allow health care professionals make decisions based on evidence.
While interventions to improve adherence are described and analyzed often in detail,
the quality of care provided to the control group receives much lower attention (ie,
what is usually called standard care or usual care). On the other hand, standard care
practices for adherence to ART can vary considerably in different centers, which means
that evaluation and report is essential for the interpretation and comparison of the
effects of an intervention under research.
Funding sources: Helios Salud S.A.
Kasparas, Gustavo Guillermo (1); Iannella, María del Carmen (2);Bugarin, Gabriela (1); Miro, Roxana (1); Belforte, Marcela (1); Visciglio, Hugo (3); Bologna, Rosa (1); Cassetti, Isabel (1)
Organization(s): 1: Helios Salud, Argentina; 2: Universidad de Buenos Aires; 3: Infhos. Contact e-mail: kasparas@fibertel.com.ar
OBJECTIVES
RESULTS (I)
METHODS (I)
METHODS (II)
RESULTS (III)
RESULTS (IV)
POLICY IMPLICATION & CONCLUSION
53.6
59.6
62.7
69.3
50.00
55.00
60.00
65.00
70.00
75.00
200820072006
%
p = 0.001
p < 0.001
p < 0.001
2009 Year
Year
HAART pick up,
% (95% CI)
VL <50 copies / mL,%,
(95% CI)
CD4 cells / mL, median
(IQR)
2006a
78.1
(77.58 - 78.59)
53.7
(52.25 - 54.99)
436
(292-615)
2007b
81.4
(80.97 - 81.888)
59.6
(58.24 - 60.88)
422
(285-593)
2008
81.0
(80.52 - 81.37)
62.7
(61.52 - 63.95)
447
(306-616)
2009
83.2
(82.85 - 83.60)
69.3
(68.17 70.36)
476
(327-651)
RESULTS (II)
COMPUTER ALERT SYSTEM AND TELEPHONE SUPPORT
TO IMPROVE ANTIRETROVIRAL THERAPY ADHERENCE
INTRODUCTION
2006a
3,319
37.0
(SD11.5)
73.2
26.8
67.2
2007b
3,430
37.3
(SD11.3)
75.5
24.5
66.9
2008
4,040
37.7
(SD11.2)
76.5
23.5
67.7
2009
4,584
38.4
(SD11.4)
77.2
22.8
67.5
N° of Patients
Age, mean years
With ART,%
Without ART,%
Men,%
Pick up ART:
Case solvedTelephone Adherence Support
Social
Problem
Psychological
problem
Medical
Problem
Psychiatrist
Psychologist
Infectious
disease
physician
Social
worker
Computer alert /
Inclusion in the monitoring list
35 days of the last
pick up from ART
78.1
75.00
2006 2007 2008 2009 2010
(First four months)
80.00
85.00
90.00
95.00%
95%Cl
81.4 81.0
p < 0.001
p < 0.001
p = 0.001 p = 0.004 83.2
88.9
Year