Trends in Antiretroviral Drugs Prescribing at Public Health Facilities in

Ethiopia:

Compliance to Treatment GuidelinesAuthors: Hailu Tadeg and Negussu Mekonnen

Presenting Author:

Hailu Tadeg (B.Pharm, MSc, MPH)

Management Sciences for Health

Strengthening Pharmaceutical Systems (MSH/SPS)

Ethiopia

Introduction With the advent of ARV drugs, HIV/AIDS has become a treatable

chronic disease Currently, more than 4 million people are receiving ART in low-

and middle-income countries In Ethiopia, HIV was first reported in 1984 In 2008, an estimated 1.03 million people were living with HIV More than 125 000 people get newly infected every year, and an

estimated 290,000 people need ART Ethiopia started fee-based ART in 2003 and launched free ART in

January 2005 As of March 2010, 511 health facilities (142 hospitals and 369

health centers) provide ART service throughout the country Out of all ART clients, about 58% are female. In terms of drug combination, the majority of patients are on 1st

line regimen while only 1% (1,079) of patients were switched to a 2nd line regimen

Introduction (2) Given the life-long nature of ART, its costs and public health implications,

adequate monitoring of the program is essential Evidence-based treatment guidelines are increasingly used to guide clinicians’

medical care decisions The use of combination ARV medications has transformed HIV infection into a

treatable chronic infection However, the complexity of ARVs has reduced adherence and increased drug–

drug interactions and metabolic toxicities. Some ARV combinations are discouraged because of excess toxicities, regimen

complexity, or adverse drug interactions The FMOH of Ethiopia has revised the STG taking into account these

complexity of ARVs management The latest STG for ART was last revised in March 2008, launched nationally and

used to guide national trainings on ART The guideline was then distributed to prescribers and dissemination further

strengthened during supportive supervision and mentoring visits Understanding of prescribing patterns in comparison with STGs might show

changes in practice and will help in suggesting the need for early interventions

Objectives In spite of its importance the adherence of prescribers to STG for

ART has not been systematically studied in Ethiopia. The current study is conducted to fill this gap

General Objective:To investigate trends in the prescribing of antiretroviral drugs in public health facilities and the level of compliance of prescribers to ART guideline

Specific Objectives:To study trends in the patterns of choices of preferred 1st line, alternative 1st line and 2nd line regimens by prescribersTo examine the trends in the proportion of patients on D4T versus TDF based regimensTo identify differences in ARVs prescribing trends amongst regions To compare ARVs prescribing practices and trends between hospitals and health centers

Methods

Data was extracted from the monthly activity reports of ART pharmacy received in October of the years 2008, 2009 and 2010

Data on regimens was compiled by region and level of health facility

The regimens were evaluated for compliance with the recommendations of the national STG

Design Retrospective descriptive studySetting ART Pharmacies Seven regions in EthiopiaPopulation All public health facilities providing ART servicesSample Size 154 Hospitals (70 Hospitals and 84 Health Centres)Inclusion Criteria

All ART sites that had consistently reported on October of 2008, 2009, 2010.

Results

Regimen Type

Year2008 2009 2010

# % # % # %D4T/3TC/NVP 21220 41.678 22818 36.488 35185 31.196

D4T/3TC/EFV 11940 23.451 12838 20.529 18944 16.796

ZDV/3TC/NVP 9515 18.688 13174 21.066 26623 23.605

ZDV/3TC/EFV 6507 12.780 7999 12.791 15599 13.831

TDF/3TC/NVP 8 0.016 2001 3.200 4424 3.922

TDF/3TC/EFV 284 0.558 3175 5.077 8784 7.788

ABC/3TC/NVP 222 0.436 24 0.038 20 0.018

ABC/3TC/EFV 0 0.000 23 0.037 38 0.034

ABC/3TC/ZDV 0 0.00 14 0.022 308 0.273

ABC/3TC/LOP/r 14 0.027 0 0.000 31 0.027

ABC/ddI/LOP/r 5 0.010 67 0.107 220 0.195

ZDV/ddI/LOP/r 5 0.010 0 0.000 0 0.000

ZDV/3TC/LOP/r 0 0.000 57 0.091 131 0.116

D4T/3TC/LOP/r 1 0.002 0 0.000 68 0.060

TDF/3TC/LOP/r 0 0.000 121 0.193 177 0.157

TDF/3TC/ZDV 3 0.006 0 0.000 0 0.000

TDF/ddi/LOP/r 48 0.094 50 0.080 77 0.068

TDF/3TC/ABC/Lop/r 7 0.014 0 0.000 123 0.109

Others 1139 2.229 175 0.280 2034 1.803

Total 50,918 100.00 62,536 100.00 112,786 100.00

Majority of prescribed regimens are a combination of nucleoside and non-nucleoside analogues

About 98% of prescribed regimens are picked from within the STG.

More than 97% of patients are taking three antiretroviral drug combinations.

Aggregate number and percentage of patients on each regimen

Result (2)

# Patients on preferred first line regimen has increased from 32% in 2008 to 49% in 2010 while those on alternative first line regimen declined from 66% to 48%.

% of patients on regimens not recommended by the guideline increased by more than 5-fold between 2008 and 2010

Result (3)

The actual prescribing practice follows the recommended trends.

But, does this prove compliance to the STG?

Large proportion of new patients are being treated with D4T based regimen

against guidelines recommendations!

Result (4) Prescribing patterns

follows more or less similar trends

The shift from D4T-based to TDF and ZDV-based regimens is slower in AA, Amhara and Tigray

The trend in Diredawa and Harari much better than other regions

Result (5)

Although the new STG recommend TDF-based regimen as preferred first option, the proportion of patients on this regimen is still very low in both hospitals (14%) and HCs (8%)

Overall prescribing practice follows similar trends irrespective of the level of health facility

Proportion of patients on D4T-based regimens is consistently higher in HCs than Hospitals

The shift to TDF-based regimens appears to be faster in HCs

Conclusion

A significant number of patients are still on alternative first-line regimens

Large number of patients including newly enrolled ones are on D4T-based regimens signifying an important safety and adherence concerns.

Differences in prescribing practice exist between regions and between hospitals & health centres

Prescribing combination of ARVs that are not recommended by STG increased over the study period

Overall, the findings of this study indicate that compliance to ART guidelines requires significant improvement.

Therefore, additional interventions, including revision of STG, are required to improve compliance to ART guideline recommendations

Thank You!!!