Reader Comments

Post a new comment on this article

How to take your HIV antiretroviral medications on time without a watch in rural Uganda

Posted by plosmedicine on 30 Mar 2009 at 23:50 GMT

Author: 'David' 'Bangsberg'
Position: Dr.
Institution: San Francisco General Hospital
Additional Authors: Marissa Maier , Mbewsa Bwana , Nneka Emenyonu , Larry Pepper
Submitted Date: February 10, 2006
Published Date: February 14, 2006
This comment was originally posted as a “Reader Response” on the publication date indicated above. All Reader Responses are now available as comments.

Over 90% of the worldwide HIV infection occurs in resource-limited settings[1]. Some have suggested that individuals living in extreme poverty may have difficulties with adherence[2], including Andrew Natisios, who said Africans "don't know what western time is"[3]. 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[4-6], the question remains: how do people take medications on time without a watch?

EK is a 40 year old, HIV+ man living in rural western Uganda. He 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. EK owns a lantern, bed, sofa, 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) 4 months after developing disseminated herpes zoster and Kaposi's sarcoma with a CD4 count of 151. EK's 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, EK had 98.9% adherence by electronic monitor, and took 90% percent of prescribed doses within 10 minutes of 7:20 am and within 17 minutes of 7:20 pm. When asked how he knew when to take his dose, EK said that he knows it is time to take his medications by "listening to Radio West's 'News and Announcements' every morning and evening".

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

1. Russell S (2001) AIDS Activists in Uproar over Official's Remarks on Africa. San Francisco Chronicle.
2. Stevens W, Kaye S, Corrah T (2004) Antiretroviral therapy in Africa. Bmj 328: 280-282.
3. UNAIDS (2004) Report on the global AIDS epidemic: Executive summary. Geneva: UNAIDS.
4. 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.
5. 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.
6. 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.

Competing interests declared: Funding: NIMH 54907, NIAAA 15287, UCSF-GIVI Fogarty, and The Doris Duke Charitable Foundation.

All procedures were approved by the Mbarara University of Science and Technology Human Subjects Committee, University of California Human Subjects Committee and The Ugandan National Council of Science and Technology . There are not competing interests of any of the authors