Adherence to antiretroviral treatment (ART) in a
Mexican prison: can directly observed therapy (DOT) be a realistic option?
F. Badial-Hernandez1, A. Gonzalez-Rodriguez1, M.I. Villarreal-Hernandez2, J. Sierra-Madero3
1Programa de VIH Sida de la Ciudad de Mexico, Mexico, Mexico, 2Subsecretaría del Sistema Penitenciario de la Ciudad de México, Mexico, Mexico, 3Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, Mexico, Mexico
Issues: In Mexico City, prison
inmates living with HIV who wish to disclose their status are sent to a prison
where a new model of HIV care has been implemented since January, 2009. This
model comprises care offered inside the prison - as
opposed to periodically sending them to an HIV clinic outside the prison - by a
general practitioner, assisted by an HIV expert, and a psychologist. Still,
treatment adherence remains difficult to achieve.
Description: Among 113 inmates with
HIV seen in 2009, 33 who were already receiving ART in January were followed throughout
the year. They were required to obtain their antiretroviral medication at a
“pill window” on a daily basis. Treatment
adherence was assessed through recording viral load changes and attendance to the
pill window. Directly Observed Therapy (DOT) was implemented for three
patients. Barriers to adherence were detected on personal interviews.
Lessons learned: Difficulties to expand DOT such as the
impossibility to supervise evening doses and the non-acceptance of the program
by some inmates were found. Mistrust in the treatment was a significant barrier
to adherence for some patients. However, the implementation of HIV-specific
medical and psychological care and counseling inside the prison was crucial in
bringing the percentage of patients obtaining at least 95% of their doses from 42%
to 76%. Also, the number of patients with undetectable viral load among the 33
patients increased from 10 to 26.
Next steps: DOT seems difficult to apply in this particular
setting. New strategies to continue improving treatment adherence will be
implemented: educational sessions, support groups and closer follow-up of
patients. Sensitization and training on HIV care will be offered to the
prison's medical staff. We strongly believe that HIV-specific care should
continue to be offered inside the prison. This presentation will deal with
controversies on adherence programs in prisons.
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