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Open Access Research article

Measuring adherence to antiretroviral treatment in resource-poor settings: The clinical validity of key indicators

Dennis Ross-Degnan1*, Marsha Pierre-Jacques1, Fang Zhang1, Hailu Tadeg2, Lillian Gitau3, Joseph Ntaganira4, Robert Balikuddembe5, John Chalker6, Anita K Wagner1 and INRUD IAA7

Author Affiliations

1 Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston MA, USA

2 Management Sciences for Health, Addis Ababa, Ethiopia

3 Sustainable Health Care Foundation, Nairobi, Kenya

4 Department of Epidemiology, School of Public Health, National University of Rwanda, Kigali, Rwanda

5 Department of Clinical Pharmacology, Makerere University, Kampala, Uganda

6 Center for Pharmaceutical Management, Management Sciences for Health, Arlington VA, USA

7 International Network for the Rational Use of Drugs Initiative on Adherence to Antiretrovirals, Management Sciences for Health, Arlington, VA, USA

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BMC Health Services Research 2010, 10:42  doi:10.1186/1472-6963-10-42

Published: 19 February 2010



Access to antiretroviral therapy has dramatically expanded in Africa in recent years, but there are no validated approaches to measure treatment adherence in these settings.


In 16 health facilities, we observed a retrospective cohort of patients initiating antiretroviral therapy. We constructed eight indicators of adherence and visit attendance during the first 18 months of treatment from data in clinic and pharmacy records and attendance logs. We measured the correlation among these measures and assessed how well each predicted changes in weight and CD4 count.


We followed 488 patients; 63.5% had 100% coverage of medicines during follow-up; 2.7% experienced a 30-day gap in treatment; 72.6% self-reported perfect adherence in all clinic visits; and 19.9% missed multiple clinic visits. After six months of treatment, mean weight gain was 3.9 kg and mean increase in CD4 count was 138.1 cells/mm3.

Dispensing-based adherence, self-reported adherence, and consistent visit attendance were highly correlated. The first two types of adherence measure predicted gains in weight and CD4 count; consistent visit attendance was associated only with weight gain.


This study demonstrates that routine data in African health facilities can be used to monitor antiretroviral adherence at the patient and system level.