In the eye of the provider: Directly observed HIV therapy

Dallas, Texas: Given its success as a model for effective TB maintenance treatment, Direct Observed Therapy (DOT) has become a more common practice within the HIV field, particularly where HAART is taken by people who may experience difficulty with adherence.

DOT programmes involve ‘direct observance’ by health care workers of treatment consumption by patients. They evolved as a key component of TB care both because they ensure that individuals themselves gain full benefit from their treatment course, and as a public health response to the problem of TB drug resistance. Antibiotics given to treat TB are very vulnerable to resistance if not taken as prescribed, and of course the same is true of HIV therapy.

Researchers from Johns Hopkins University have reported findings from a DOT-HAART pilot conducted with 31 people in a methadone maintenance programme. All had been in the programme for at least thirty days, and were starting or changing a HAART regimen.

In this modified DOT programme HAART doses were administered and taken under observation, with evening doses and doses taken on methadone take-home days taken at home, unobserved. Health care workers asked patients about their adherence with each DOT dose, and three day emergency supplies of HAART were supplied to assist participants to maintain adherence where required.

Naturally, this approach is not a panacea. Thirteen people discontinued the programme; seven because they defaulted from the methadone programme, three for HAART side-effects, two for poor adherence, and one for ‘personal reasons’. However, those who were able to remain on treatment did benefit. After eight weeks, 76% of participants had viral load below 500 copies, and the median CD4 increase was 70 cells.

Practice guidelines from the British HIV Association and Medical Society for Study of Venereal Diseases on supporting antiretroviral adherence are open for consultation here on aidsmap.com.