From Directly Observed Therapy to Accompagnateurs: Enhancing AIDS Treatment Outcomes in Haiti and in Boston
SUPPLEMENT ARTICLE
From Directly Observed Therapy to
Accompagnateurs: Enhancing AIDS Treatment
Outcomes in Haiti and in Boston
H. L. Behforouz, P. E. Farmer, and J. S. Mukherjee
Partners In Health; Division of Social Medicine and Health Inequalities and Department of Medicine, Brigham and Women’s Hospital;
and Harvard Medical School, Boston, Massachusetts
ACCESS TO ANTIRETROVIRAL THERAPY
More than 2 decades after the onset of a worldwide
pandemic, the World Health Organization (WHO) has
declared AIDS to be a global health emergency. Worldwide, 142 million people are living with HIV infection,
yet !5% of infected persons have access to antiretroviral medications, the standard of HIV/AIDS care in
the world’s wealthiest nations. In Africa, the most afflicted continent, it is estimated that well under 1% of
those infected are receiving daily combination antiretroviral therapy. Recent initiatives, such as the Global
Fund to Fight AIDS, Tuberculosis, and Malaria, aim to
Financial support: Thomas J. White, Fondation Connaissance et Liberte (Open
Society Institute, Haiti), the Brigham and Women’s Hospital, Harvard Medical
School’s Division of AIDS, the Center for AIDS Research, the Bill and Melinda
Gates Foundation, and the Global Fund to Fight AIDS, Tuberculosis, and Malaria.
Reprints or correspondence: Dr. Heidi L. Behforouz, PACT Project, Division of
Social Medicine and Health Inequalities, Brigham and Women’s Hospital, Third
Floor, One Brigham Circle, 1620 Tremont St., Boston, MA 02120
().
Clinical Infectious Diseases 2004; 38:S429–36
2004 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2004/3811S5-0010$15.00
increase access to antiretrovirals and offer hope that
these lifesaving therapies will be made available to the
underserved.
The increasing availability of these drugs, whether in
resource-poor countries or in affluent nations, raises
the question of their proper delivery and application.
Lack of infrastructure is a long-cited reason to withhold
such drugs in settings of extreme poverty. Here, we seek
to demonstrate the feasibility and efficacy of community-based HIV/AIDS prevention and care. Drawing on
our experiences with the provision of antiretrovirals
and other complex therapeutic regimens in resourcepoor settings—including rural Haiti and inner-city
Boston—we argue that variants of directly observed
therapy with highly active antiretroviral therapy (DOTHAART) will prove useful in introducing complex multidrug regimens in settings lacking requisite health care
infrastructures. Such DOT-HAART approaches are also
effective in situations in which adherence to such regimens is compromised by fragmented medical services
or social problems such as addiction.
Herein we report our efforts to improve access to
care and adherence to treatment in markedly different
Enhancing Adherence to AIDS Treatment • CID 2004:38 (Suppl 5) • S429
Like tuberculosis, human immunodeficiency virus (HIV) disease is associated with poverty and social inequalities, conditions that hamper the delivery of care. Like tuberculosis, treatment of HIV infection requires
multidrug regimens, and the causative agent acquires drug resistance, which can be transmitted to others. A
pilot project in rural Haiti introduced DOT-HAART (directly observed therapy with highly active antiretroviral
therapy) for the care of patients with advanced acquired immune deficiency syndrome. A similar DOT-HAART
effort was launched in Boston for patients with drug-resistant HIV disease who had experienced failure of
unsupervised therapy. In both settings, community health promoters or accompagnateurs provide more than
DOT: they offer psychosocial support and link patients to clinical staff and available resources. DOT-HAART
in these 2 settings presents both challenges and opportunities. These models of care can be applied to other
poverty-stricken populations in resource-poor settings.
settings and discuss the challenges posed by the expansion of
DOT-HAART, whether in rural Haiti or the urban United
States. Experience in both settings leads us to conclude that
providing comprehensive care not only supports HIV treatment
and prevention efforts but also serves to strengthen public
health infrastructures and reinforce other fundamental health
care goals. A focus on integrated AIDS prevention and care
does not siphon resources away from other health priorities,
but instead helps generate new interest in other neglected diseases. In addition, it sparks renewed investment in drug procurement and the application of developed-country diagnostics
and therapeutics in developing countries.
ADHERENCE TO COMPLEX REGIMENS
S430 • CID 2004:38 (Suppl 5) • Behforouz et al.
THE HIV EQUITY INITIATIVE: HAITI
Haiti is the poorest country in the Western Hemisphere and
one of the poorest in the world, ranking 150th of the 175
countries in the United Nations Development Programme Development Index [19]. Decades of political instability and economic crisis have contributed to increasing poverty and deteriorating health and social infrastructures; the United Nations
recently ranked Haiti the world’s ninth hungriest country [20].
Not coincidentally, Haiti bears the Western Hemisphere’s worst
AIDS epidemic: with a prevalence among adults of 15%, HIV/
AIDS has now surpassed tuberculosis as the leading cause of
death among young adults nationwide [21].
Partners In Health/Zanmi Lasante (PIH/ZL) has a long history of providing HIV and tuberculosis care through the Clinique Bon Sauveur in the village of Cange, a squatter settlement
in rural Haiti. In 1988, these organizations launched a DOT
program for tuberculosis and began to build an extensive network of community health workers. These accompagnateurs
would serve as the essential link between the patients, dispersed
throughout rural villages in mountainous central Haiti, and the
clinic-hospital complex in Cange [22]. This infrastructure developed by PIH/ZL to contend with the tuberculosis epidemic
was critical to respond to the growing HIV threat in the late
1980s.
Although enhancing access to care remains the primary challenge of AIDS treatment globally, adherence emerges as a foremost problem whenever antiretrovirals become available. The
WHO has defined adherence as “the extent to which a person’s
behavior—taking medication, following a diet, and/or executing lifestyle changes—corresponds with agreed recommendations from a health care provider” [1, p. 117]. Combination
antiretroviral therapy, remarkably efficacious when used as prescribed, may stand as the most complicated and demanding
regimen for a condition requiring continuous open-ended
treatment [2]. It is estimated that adherence levels of 195% are
required to achieve durable suppression of HIV load [3]. In
the developed-country settings in which adherence to complex
medication regimens for various diseases has been studied, adherence rates are low, even when patients are judged to comprehend the co (...truncated)
