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Adherence and Retention in HIV Care

Nursing Care for HIV - Adherence for Nurses

Authors: Catherine Orrell, MBChB, MSc, MMed (Clin Pharmacol); Carmen J. Portillo, RN, PhD, FAAN
Editor In Chief: Stacie Stender, MSN, MSc ID, FNP (More Info)

Last Reviewed: July 8, 2016 (What's New)

Credit Information

inPractice® Africa’s Continuing Education Unit (CEU) provider, the South African Medical Association, offers physicians 3 CPD points on a 70% pass rate for completing this individual module. Nonphysicians who successfully complete the module will receive a participation certificate. To learn more on CPD credits and participation certificates, click here.

Introduction: What Is Adherence?

  • Adherence to antiretroviral therapy (ART) is a major determinant of successful HIV treatment (Management Guidelines)[Thompson 2012]
  • In South Africa, an understanding of ART adherence has evolved over time and with increasing programmatic experience
    • Initially, adherence meant simply “taking all your tablets every day at the correct time”
    • As ART programmes grew larger and clinics became increasingly busy, the importance of retention in care, another aspects of adherence, became apparent. Adherence is now defined as having 3 distinct components[Vrijens 2012]:
      1. Initiation: starting of ART after HIV-positive diagnosis
      2. Implementation: taking all of the treatment doses as prescribed every day
      3. Persistence: Also called retention in care; describes the proportion of patients who remain in care at the clinic without interruption of treatment
          • Perfect pill taking when in care is of limited importance if a patient is out of care for long periods of time
          • In South Africa, only 55% of people commencing ART are retained in care at 8 years, representing a loss of approximately 5% of treated patients per year[Orrell 2011]
  • Patients who are 100% adherent (or close to it) should achieve complete viral suppression (Figure)

Figure 1. Virologic suppression and risk of viral resistance as a function of adherence.

  • On the other hand, patients who rarely take their treatment do not receive the benefits of therapy but are also at low risk of drug resistance because their virus is not exposed to therapy enough to drive the selection of drug-resistant mutations
  • Unfortunately, adherence in many patients lies somewhere in between these 2 extremes—that is, patients miss enough antiretroviral medication (through isolated missed doses or gaps in treatment) to allow the virus to develop resistance over time but they do not take enough to ensure continuing viral suppression

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