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Correspondence

How to Take HIV Antiretroviral Medications on Time without a Watch in Rural Uganda

  • Marissa Maier,

    Affiliation: University of California San Francisco, San Francisco, California, United States of America

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  • Mwebesa Bwana,

    Affiliation: Mbarara University of Science and Technology, Mbarara, Uganda

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  • Nneka Emenyonu,

    Affiliation: University of California San Francisco, San Francisco, California, United States of America

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  • Larry Pepper,

    Affiliation: Mbarara University of Science and Technology, Mbarara, Uganda

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  • David R Bangsberg mail

    David R. Bangsberg (E-mail: db@epi-center.ucsf.edu)

    Affiliation: University of California San Francisco, San Francisco, California, United States of America

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  • Published: March 28, 2006
  • DOI: 10.1371/journal.pmed.0030161

Castro has advocated that adherence to HIV antiretroviral therapy should be understood within a patient's clinical and social context [1]. Over 90% of worldwide HIV infection occurs in resource-limited settings [2]. Some have suggested that individuals living in extreme poverty may have difficulties with adherence to medication [3], including Andrew Natisios, who said Africans “don't know what Western time is” [4]. While recent reports suggest that adherence to HIV antiretroviral therapy in resource-limited settings may be as good as or better than resource-rich settings [5–7], the question remains: how do people take medications on time without a watch?

In rural western Uganda, there is, for example, a 40-year-old man who is HIV-positive, has no education, and works as a farmer. He lives with his brother, sister-in-law, and three nieces in a three-room, mud-walled house without electricity. He owns a lantern, a bed, a sofa, a bike, and a radio, but does not own a watch. He was diagnosed with HIV in April 2005 and started generic D4T/3TC/NVP (Triomune) four months after developing disseminated herpes zoster and Kaposi sarcoma with a CD4 count of 151. His adherence was measured with an electronic medication monitor that records a date-time stamp in flash memory each time the pill container is opened. Over the 89 days of monitored treatment, he had 98.9% adherence by electronic monitor and took 90% of prescribed doses within ten minutes of 7:20 a.m. and within 17 minutes of 7:20 p.m. When asked how he knew when to take his dose, he said that he knows it is time to take his medications by “listening to Radio West's ‘News and Announcements’ every morning and evening.”

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Electronic medication monitor adherence record of time of bottle openings for morning and evening doses

doi:10.1371/journal.pmed.0030161.g001
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Patient with his radio

doi:10.1371/journal.pmed.0030161.g002

While population levels of adherence will likely drop as treatment access expands and people begin to experience toxicities of long-term therapy, he is an example of how patients can have precise, if not perfect, adherence with creative solutions in a resource-limited setting.

References

  1. 1. Castro A (2005) Adherence to antiretroviral therapy: Merging the clinical and social course of AIDS. PLoS Med 2: e338. doi: 10.1371/journal.pmed.0020338.
  2. 2. Russell S (2001 June 8) AIDS activists in uproar over official's remarks on Africa. San Francisco Chronicle; Sect A: 5. Available: http://www.sfgate.com/cgi-bin/article.cg​i?f=/c/a/2001/06/08/MN164875.DTL. Accessed 7 February 2006 .
  3. 3. Stevens W, Kaye S, Corrah T (2004) Antiretroviral therapy in Africa. BMJ 328: 280–282.
  4. 4. Joint United Nations Programme on HIV/AIDS [UNAIDS] (2004) Report on the global AIDS epidemic: Executive summary. Geneva: UNAIDS. Available: http://www.unaids.org/bangkok2004/GAR200​4_html/ExecSummary_en/ExecSumm_00_en.htm. Accessed 7 February 2006 .
  5. 5. Oyugi JH, Byakika-Tusiime J, Charlebois ED, Kityo C, Mugerwa R, et al. (2004) Multiple validated measures of adherence indicate high levels of adherence to generic HIV antiretroviral therapy in a resource-limited setting. J Acquir Immune Defic Syndr 36: 1100–1102.
  6. 6. Orrell C, Bangsberg D, Badri M, Wood R (2003) Adherence is not a barrier to delivery of HIV antiretroviral therapy in resource-poor countries. AIDS 17: 1369–1375.
  7. 7. Laurent C, Kouanfack C, Koulla-Shiro S, Nkoue N, Bourgeois A, et al. (2004) Effectiveness and safety of a generic fixed-dose combination of nevirapine, stavudine, and lamivudine in HIV-1-infected adults in Cameroon: Open-label multicentre trial. Lancet 364: 29–34.