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DURHAM, N.C. – HIV-infected patients in the African country
of Tanzania were more likely to stop taking their medications
and to fail treatment if they had to pay for the drugs
themselves.

According the results of a new study conducted by Tanzanian
physicians and Duke University Medical Center researchers,
HIV-infected patients who openly discussed their illness were
also more likely to fare better.

"Our findings suggest that efforts to provide free
medication to HIV-infected patients and to promote social
coping may increase the chances that patients will continue
taking their medications and therefore have stronger immune
systems and live longer," said Habib Ramadhani, M.D., physician
at the Kilimanjaro Christian Medical Centre and lead author of
a paper appearing early online in the journal Clinical
Infectious Diseases. Infectious disease specialists from Duke
collaborate with the Kilimanjaro medical center physicians at a
clinic in Moshi, Tanzania.

The findings of this and other studies in sub-Saharan
African countries should help policy makers and physicians
figure out how best to direct and manage the increase in the
amount of powerful HIV-fighting drugs that are flowing into the
continent, the researchers said. This group of drugs, known
generally as anti-retroviral therapy, can suppress the levels
of virus in the blood to almost non-detectable levels and
prolong life.

In order to better understand the barriers that may keep
patients in such economically challenged countries from
successfully fighting the disease, the researchers studied 150
HIV-infected patients seen at the Moshi clinic, paying
particular attention to how well patients were adhering to
their medication regimens and how successfully the levels of
virus in the blood was responding to the therapy.

About one in six of the patients reported not taking their
medications according to schedule, and the patients more likely
to have stopped complying were those who had spent a larger
proportion of their time on treatment paying for the
antiretroviral medicines themselves. These patients typically
used their scant resources on other necessities, such as food
and shelter, rather than the medicines, researchers said.

They also found that about one in three patients had
increases in the level of virus in the blood consistent with
treatment failure, and not surprisingly, the patients who were
not taking their drugs were more likely to have treatment
failure.

"Another quite interesting finding was that being public
about their HIV status was associated with suppression of
virus," Ramadhani said. "There still is a substantial stigma
associated with HIV in Africa. It is likely that individuals
infected with HIV who discussed their disease with friends or
family members are likely living in supportive environments
that promote adherence."

The researchers also found that the farther away patients
were from the clinic, the less likely they would take their
drugs as instructed.

"This study has identified critical factors that affect the
success of antiretroviral therapy programs in Africa, and we
believe that these findings should be incorporated by policy
makers into practice," said Duke's John Crump, M.B., Ch.B, who
specializes in infectious diseases and international health and
is a senior member of the research team. "These drugs, which
are known to work, should be free and readily available.

"Structural barriers to care, such as the distance to
clinics and especially the burden of patients paying for their
medication, must be removed," Crump continued. "Social coping,
including the disclosure of HIV status to people to family and
friends leads to better adherence to medication and lower rates
of treatment failure."

According to Michael H., Merson. M.D., director of the
Duke Global Health
Institute, "This study nicely illustrates some of the
factors that need to be considered in reducing the health
disparities between the haves and have nots throughout the
world, and the value of exploring ways to eliminate them
through a multidisciplinary lens. Reducing costs, increasing
access and lessening stigma are all necessary for providing
good AIDS treatment."

The study was funded by the Duke Center for AIDS Research,
which is sponsored by the National Institutes of Health.