9.2 Guidance on operations and service delivery: adherence to ART
Consolidated ARV guidelines, June 2013
9.2.3 Monitoring adherence to ART in routine programme and care settings
Objective monitoring of adherence to ARV drugs is necessary for effective and efficient treatment planning and ongoing support. Each facility visit brings opportunity for assessing and supporting treatment adherence. Effectively monitoring adherence requires a combination of approaches based on human and financial resource capacity, acceptability to people living with HIV and to health workers and the local context.
Viral load monitoring
These guidelines recommend viral load monitoring to diagnose and confirm treatment response and failure. Although treatment failure is often caused by lapses in adherence to ART, it may also result from other factors (such as drug stock-outs, drug interactions or malabsorption). However, viral load monitoring does not provide an opportunity for care providers to monitor non-adherence in real time and prevent progression to treatment failure. Viral load monitoring must therefore be combined with other approaches to monitoring adherence.
Pharmacy refill records
Pharmacy refill records provide information on when people living with HIV pick up their ARV drugs (42,43). When people obtain pharmacy refills at irregular intervals, this may indicate non-adherence to ART; however, in many routine care settings, people may pick up their medications when receiving care irrespective of their adherence level. This behaviour could lead health care providers to overestimate adherence by solely using pharmacy refill records. A recent validation study to assess the usefulness of various adherence monitoring approaches found pharmacy records to be more reliable than self-report (44). In many settings, pharmacy refill records are already a part of national monitoring and evaluation frameworks and can also provide additional information on adherence to ART when used in combination with other tools.
Asking people living with HIV or their caregivers how many doses of medication they have missed since the last visit (or within a specified number of days in the past) can help to estimate non-adherence. However, although this method is commonly used, people may not remember missed doses accurately or may not report missed doses because they want to be perceived as being adherent and to avoid criticism. Counselling on the importance of remembering and/or documenting ARV drug doses and an environment that promotes and enables honest reporting of non-adherence are critical components of monitoring adherence to ART in routine care settings (45).
Counting the remaining pills in bottles may help to assess adherence. Pill counts usually take place at routine health care visits. However, some people may throw away tablets prior to health care visits, leading to overestimated adherence (45,46). Although unannounced visits at people’s homes could lead to more accurate estimates, this approach poses financial, logistical and ethical challenges. Counting pills also requires health care personnel to invest significant time and may not be feasible in routine care settings.