1. Improving Adherence to Anti Retroviral Treatment in Children in Resource-Limited Settings
Blasco P1, Breitenecker F1, Fontaine C1, Seangkla P2, Ruthaiwat J2.
1 : Medecins Sans Frontières France, Surin.
2 : Surin Provincial Hospital (Thailand)

2. ABSTRACT

3. BACKGROUND
The ability of HIV-infected children to adhere to anti-retroviral treatment (ART) is essential to delay resistance and to ensure lifelong effective treatment. But giving ART to children is challenging, especially in resource-limited settings. There are a lack of caregivers for orphaned children; a lack of pediatric treatment formulations; and privacy issues when medications must be taken at school. Interventions to enhance adherence is therefore essential for treatment outcomes.

4. SETTING
A collaborative project between the Provincial Hospital of Surin (Thailand) and Medecins Sans Frontières France was launched in June 2001, with the objective of providing ART to children.
As of September 2003, 77 children had started ART.

5. Caracteristics of the children having started ART
Started ART as of Sept 2003 77
Male
47%
Mean age
6,5 years (1,8 – 11,5)
ART administered
2 NRTI + Nevirapine
70%
2 NRTI + Ritonavir
21%
2 NRTI + Efavirenz 9%

6. STUDY AIMS Describe the adherence interventions
To measure the adherence to ART in children.

7. ADHERENCE INTERVENTIONS (1)
1) A systematic home visit done before starting ART to identify a care giver;
2) Education sessions provided by a trained nurse to children and caregivers (parents or relatives). Prior to the start of ART, a group session (5-6 children and their caregivers) is initiated and followed by an individual session one week later. The commitment for long-term treatment is discussed.
3) On the day when ART is prescribed, the educator explains how to take the drugs using an individualised daily schedule and instructions in case of side effects.

8. ADHERENCE INTERVENTIONS (2)
4) At each follow up visit, adherence is evaluated by self-report. The educator also tries to identify potential factors leading to non-adherence and accordingly discusses adapted solutions.
5) Group talks between caregivers and children under ART to discuss barriers to adherence and side effects.
6) Educational games
7) A hotline to answer questions.
8) Home visits done at the beginning of the ART and when the regimen is changed.

9. Adherence is evaluated by self-report at a follow-up visit

10. Educational game

11. METHOD to MEASURE ADHERENCE
Adherence reported by the caregiver measured by the % of doses missed during the last 3 days. [mean over 3 months at the beginning (M1-3) and at 12 months treatment (M11-13)].
66/77 children reached 1-3 months of treatment and therefore were included in the study.

12. MEASURE OF ADHERENCE 1-3 months of ART (n=66) 12 months (n=47*)
1-3 months
of ART
(n=66)
12 months
(n=47*)
Adherence >95%
45 (68,1%)
43 (91,5%)
Adherence 80-95%
7 (10,6%)
3 (6,3%)
Adherence <80%
14 (21,3%)
1 (2,2%)
* : Among the 66 children who have been their adherence measured at 1-3 month only 47 have been assessed at M12 (13 didn’t reached 12 months treatment, 4 died and 2 stop their treatment).

13. CONCLUSION
Adherence problems in our HIV-infected children population treated with Antiretroviral occur more commonly at the beginning of the treatment.
Regular assessment of adherence, especially at the beginning of the treatment, allows the prompt identification and planned intervention for non-adherent children on ART.