Newsletter from the national HIV/AIDS and TB Programme, Pretoria
Number 32, 28 February 2003
Compliance – The Cornerstone of Successful Therapy
This article is the second of a series.
Examining responsibilities
The diagnosis of any disease is a traumatic experience and more so in the case of a TB, STI or HIV infection. The patient has to deal with many issues, often in the space of a short interview with the medical professional who treats such diagnoses as routine procedures. Very often the patient fails to comprehend how they could possibly be a victim of such an infection. We take the diagnosis of infectious diseases for granted, but patients view them as something somebody else acquires – not themselves. This is particularly true in the case of STIs, and definitely true in the case of HIV.
Most of these diseases, including HIV are now treatable (although treatment for all for HIV is still not available in South Africa). The responsibility for treatment lies very much in the hands of the doctor and any support staff. The medication prescribed is a decision taken by the doctor based on the patient’s condition and disease. The doctor is fully able to understand his diagnostic and treatment procedure – yet it is the patient that has to take the medication. If the patient fails to understand either the disease or the medication, a patient will often leave the surgery in a confused state especially if other concerns are not addressed either. How then can our patient be expected to comply with doctor’s instructions?
A recent study in the UK (i-Base) revealed that only 15% of patients understand what is required of them, 70% did not fully understand and a further 15% didn't understand anything at all. In South Africa, based on my own survey amongst patients on antiretroviral therapy 28% understood, 30% partly understood and 42% didn't understand anything. However, on probing the level of understanding drops significantly and less than 5% understand anything at all!! How can we expect patients to comply with treatment procedures when they do not understand their condition or their treatment?
Patients have very selective understanding and as individuals are known only to recall about 5% of an interview in the doctors surgery. By the time they reach their own surroundings the only reminder they have is what is written on the pill bottle, which is often in conflict with what they perceive as doctors instructions. Although they may attend the surgery to collect further scripts the instructions are rarely re-enforced. Patients when asked if they are taking the medication will often give an affirmative response.
Lesson 1 – Patients tell doctors what they want to hear.
Lesson 2 – Doctors believe what patients tell them
And so the foundation is established for poor compliance.
If you ask patients the times at which medication is taken then an answer nearer the truth will be heard. As soon as the word ‘about’ or ‘approximately’ appears in the sentence then you know there is highly likely to be a compliance problem.
Again it falls back to a time problem. If a health care professional is unable to dedicate time to the patient then compliance issues can never be corrected. Bansberg in the USA examined compliance issues very carefully and found that if patients were put on the spot they felt pressurised into giving certain answers. The use therefore of simple questionnaires, which the patient completes on each visit, allows the patient in their own time in the waiting area to state exactly what is happening. For the doctor it gives immediate insight into possible compliance problems. Doctors in South Africa when presented with this solution showed little enthusiasm. Do we wonder then that compliance levels are poor?
Disease Management Companies have sprung up like wild mushrooms because they have seen a weakness in the system, which they can exploit. They have made significant inroads into the private healthcare sector doing what healthcare professionals are failing to do. It all comes back to responsibility for the patient. Surely it is the responsibility of the doctor to support the patient and not pass it over to an unknown third party. Surely this is a recipe for a poor doctor /patient relationship and a spiral of poor compliance.
Some medical aids are currently allowing patients two opportunities at antiretroviral treatment. If there is failure then the patient is blamed and the benefits may be adjusted. Is this really a true assessment of the situation? Had the dialogue between patient and doctor been open and honest would such patients find themselves deprived of effective management of their condition?
Patients should never start a treatment unless they are full aware of and accept the implications of the treatment decision. Too many patients start treatment ill informed and unprepared. Patients are quite capable of accepting responsibility for compliance to their medication but it is the responsibility of the healthcare professional to ensure that the correct level of understanding and support is provided. Doctors in South Africa that have examined the compliance issue thoroughly and spend time with their patients find that in the long term their actual input into treatment declines, surgery visits are less regular and compliance is far higher. They have reversed the trend and take responsibility for their patients and allowed patients to take responsibility for themselves producing a spiral in the other direction.
For more information, contact Peter Adams at helplinedirect@worldonline.co.za
South African AIDS Conference, August 2003
The South African AIDS Conference is planned for 3-6 August 2003, to be held at the ICC in Durban. For more information on the different tracks, the sponsorship opportunities and the basic structure of the programme, please visit the website for the Conference: www.sa-aidsconference.com
World TB Day, 24 March 2003
Despite numerous efforts towards the reduction of TB in South Africa, the burden of TB continues to increase. When coupled with the added burden of HIV, we find ourselves in a situation where we currently have the highest co-incidence rate in the world. In addition to being 9th on the list of high-burden TB countries, this dual pandemic has the potential of far outstripping the HUGE social and economic losses currently borne by our country.
Given the attention to HIV/AIDS, the commitment to fighting TB at societal level is weak.
This is set against the target of reducing the incidence of TB by 50% by 2010, which was agreed to at a Conference in 2000, referred to as the Amsterdam 2000 Declaration. The South African response to achieving these targets has been detailed in the Medium-Term Development Plan (MTDP) that was published at the beginning of 2002.
After discussion with each province, it was agreed that the Department of Health should develop a three years advocacy and social mobilisation campaign in order to achieve the targets committed to by the South African government in Amsterdam 2000.
World TB Day 2003 is a perfect time to officially launch this watershed national campaign, which complements the Stop TB Partnership campaign. This launch is to take place in Port Elizabeth. The theme for World TB Day is "DOTS cured me, it can cure you too!"
The objectives to be highlighted in the campaign are:
In addition to the launch of the campaign on 24 March, this will also see the launch of a series of TB fact sheets and other materials.
For more information, please contact Mr. Phumlani Ximiya at (012) 312-0113 or ximiyap@health.gov.za
Important Dates and Meetings
24 March: World TB Day
Useful Websites
www.health.gov.za
www.aidsinfo.co.za
www.aidsdirectory.co.za
www.dpp.org.za
www.hst.org.za
www.who.int/hiv
www.saavi.org.za
www.afroaidsinfo.org
www.lovelife.org.za
www.childaidsservices.org
www.equityproject.co.za
www.learnscapes.co.za
www.hivan.org.za
www.unaids.org
www.caprisa.org
You are also encouraged to share information on other useful websites. Feedback on the Department of Health website would be especially valuable.
Compiled by Celicia M Serenata
Project Manager: HIV/AIDS
Tel: (012) 312-0128
Fax: (012) 326-2891
e-mail: serenc@health.gov.za
Red Ribbon Resource Centre
For all requests of HIV/AIDS materials (posters etc.), please contact:
Tel: (011) 880-0405
Fax: (011) 880-8552
Address List for Chief Directorate
Fax: (012) 326-2891 or (012) 323-7323
Dr. Nono Simelela
Chief Director: HIV/AIDS and TB
Tel: (012) 312-0121
simeln@health.gov.za
Collen Bonnecwe
Director: HIV/AIDS (NGOs)
Tel: (012) 312-0137
bonnec@health.gov.za
Thami Skenjana
Director: GAAP
Tel: (012) 312-0133
Fax: (012) 325-0165
Dr. Refiloe Matji
Director: TB
Tel: (012) 312-0106
Fax: (012) 326-4365
matjir@health.gov.za
Dr. Rose Mulumba
Director: HIV/AIDS and STIs
mulumr@health.gov.za
Ms. Celicia Serenata
Project Manager: HIV/AIDS
serenc@health.gov.za