A home visit intervention to improve medication adherence in HIV infected children in El Salvador
G.M. Maron1, L.G. Castaneda2, S.V. Ayala2, E.I. Granados2, G.A. Escobar2, P.M. Flynn1, A.H. Gaur1
1St. Jude Children's Research Hospital, Infectious Diseases, Memphis, United States, 2Hospital Nacional de Niños Benjamin Bloom, Infectious Diseases, San Salvador, El Salvador
Background: Barriers to antiretroviral medication (ARV) adherence are multifactorial and clinic-based interventions have limitations. Few community-based interventions have been tried for HIV-infected children prompting us to examine the feasibility of home-visits to understand and address the socioeconomic and psychosocial factors associated with non-adherence.
Methods: A home visit program (HVP) was designed by the national pediatric HIV carecenter in El Salvador. Children with < 95% adherence to ARVs at two consecutive clinic visits despite standard-of-care clinic-based interventions received monthly social worker led home-visits until their adherence improved. At each visit logistical, socioeconomic and psychosocial barriers to adherence were assessed and solutions identified. Caregiver feedback was obtained through an exit survey.
Results: Forty children (median age 8.5 years) qualified for the HVP and received at least two monthly visits. 66% had lost at least one parent. 89% lived in poverty; 58% in areas with difficult access to the HIV clinic. While 81% of caregivers verbalized importance of adherence to ARVs and only 25% acknowledged difficulties with adherence, half could not identify ARVs by name/color or remember their dose/frequency. 100% of caregivers feared their children would face discrimination if observed taking medicine and only 60% had revealed the child's diagnosis to other caregivers. The HVP was well accepted by caregivers: 91% felt motivated to give ARVs, 78% reported improved administration practices, and 94% verbalized wanting HVP to continue. The intervention's cost per patient was 2/3rd the annual cost of a second line regimen. Participants maintained a median adherence of 98% (range 70-100%) twelve months after the home-visits ended.
Conclusion: The HVP was well accepted, cost-effective and associated with a durable improvement in adherence to ARVs. The program provided contextual insight into the challenges to ARV adherence and an opportunity to address them. Judicious use of home visits should be added to the repertoire of adherence improvement interventions.
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