The use of “treatment partners” boosts the
chances of achieving an early undetectable viral load, investigators in Nigeria
report in the online edition of the Journal
of Acquired Immune Deficiency Syndromes.
However, the virologic benefits of
treatment partners were not sustained in the long term, and the use of partners
had no effect on CD4 cell gains or mortality risk.
Adherence is a major factor contributing to
the success of antiretroviral therapy. The best outcomes are seen in people
who take all or nearly all of their doses correctly. In contrast, poor
adherence is associated with a failure to suppress viral load and the emergence
of drug-resistant strains of HIV.
Many people, including individuals in
resource-limited settings, achieve and sustain impressive levels of adherence.
However, there is an ongoing need to develop new resources to support
One possible strategy is the use of
treatment partners. This involves the selection of a family member, friend or
neighbour, by a person who is starting HIV therapy, as a treatment partner.
Treatment partners support adherence by
observing the person taking their HIV treatment, assist in the reporting and
management of side-effects and also provide reminders about clinic appointments
and pharmacy refills.
In a small, unrandomised study, investigators
in Jos, Nigeria, found treatment partners beneficial. The same team of
researchers wanted to evaluate their use in a larger, randomised study. Their
aim was to see if the use of patient-selected treatment partners affected
patient outcomes, including adherence, the chances of achieving an undetectable
viral load, increases in CD4 cell count and rates of serious illness and death.
They therefore designed a study involving
499 adults who were starting HIV therapy for the first time. The participants were
recruited between 2006 and 2007 and were randomised into two arms.
All the participants received information about
adherence from a trained counsellor and a pharmacist. Individuals who did not
have an undetectable viral load six months after starting therapy received
further adherence counselling. This package of adherence counselling was the
standard of care.
Half the people in the study were randomised to
receive a treatment partner. The participant was allowed to select his or her
treatment partner, who could be a spouse, other family member, friend or neighbour.
Outcomes were monitored at weeks twelve, 24
Similar proportions of people in the two
study arms experienced a 1 log reduction in viral load after twelve weeks of
therapy (78% treatment-partners arm vs 76% standard of care).
By week 24, people with treatment
partners were significantly more likely to have an undetectable viral load (62
vs 50%; OR = 1.58; 95% CI, 1.11-2.26; p < 0.05).
Virologic outcomes at week 48 continued to
favour the use of treatment partners. Almost two-thirds (64%) of people
with treatment partners had an undetectable viral load at this time point
compared to 56% of those who received the standard of care. However, this
difference was not significant (OR = 1.44; 95% CI, 0.99-2.09).
“Nondurability of initial virologic
benefit in treatment-partnered patients may be related to the fact that all
patients who were viremic at week 24 received focused adherence retraining,
regardless of study arm,” suggest the authors. “In addition, it is possible
that some treatment-partner fatigue occurred, and enthusiasm for intervening in
another individual’s ART waned over time.”
Increases in CD4 cell count were similar
between the two groups, as was the mortality rate (11 vs 6%).
Living near the clinic (less than 20km vs
over 100km) was associated with better levels of adherence and improved
“Use of patient-selected treatment
partners…had no durable impact on viral suppression, CD4 replenishment, or
mortality,” conclude the investigators. “The relationship between
residence-to-clinic distance and patient outcomes requires further exploration
because it may have implications for the ongoing scale-up of ART in