The availability of health care that is free to everyone in the community greatly increases the patient’s and his family’s utilization of services. This not only enables the entire family to be engaged in their own health care but also permits close surveillance of a patient’s social contacts, who are at increased risk for HIV and TB. The comprehensive support provided to all patients, regardless of whether they are yet receiving ART, prevents the loss of HIV-positive patients to follow-up. Even if HIV-positive patients are not receiving directly observed ART or prophylactic therapy, a community health worker performs routine visits to assess the ongoing needs of the household and monitor health problems in the family.
As discussed in Section 3.3.2, adherence to antiretroviral medications is critical for optimizing the clinical outcome of patients and preventing the emergence of drug resistance; this is one reason ZL clinical staff rely on the technique of directly observed therapy of ART. Supervision of directly observed therapy takes place in the patient’s home, where accompagnateurs are responsible for administering all TB- and HIV-related medications as well as any medications for other chronic diseases, such as hypertension or psychiatric disorders. Visits by accompagnateurs take place once or twice a day, to accommodate the schedules of both the patient and accompagnateur. The performance of accompagnateurs should be assessed on a regular basis to ensure that proper directly observed therapy is taking place.
Daily visits and observation of patients taking their medicines not only ensures that patients adhere to their treatment, but also affords an opportunity for the community health worker to provide support, monitor for symptoms of adverse reactions to ART and/or HIV-related complications, answer questions about medications and their side effects, and stress secondary prevention messages. Although patients are seen monthly at a ZL health clinic, most HIV patients develop a close relationship with their accompagnateur that encompasses both a supportive friendship and a resource connecting them even more closely to their medical care.
The ZL program would not have been successful without accompagnateur-supervised directly observed therapy. Arguments have been raised in the medical, public health, and policy literature against the use of accompagnateurs and DOT, citing concerns such as the need to maintain the confidentiality of a patient’s HIV status within the community and the costs of salarying community health workers.139 To date, neither argument has proved to be an impediment for PIH’s programs.140 Stigma against infected patients has not prevented them from accepting members of their community as treatment supervisors, and accompagnateur salaries represent only a minor component of programmatic costs. In addition, the accompagnateur model generates jobs in areas where unemployment is often high. While the feasibility of providing life-long DOT has been questioned, ZL medical staff have sustained DOT for eight years with no indications to suggest that continuation of DOT will prove unacceptable or unfeasible. In fact, by preventing treatment failure that carries with it increased mortality and morbidity, the need for complicated salvage regimens, and costly inpatient care of chronic terminal cases, DOT is likely to have significant long-term benefits as well as short-term rewards.141
Patients on ART who are nonadherent should be counseled about the risk of treatment failure and the development of drug resistance. Care providers should attempt to understand and address nonadherence and noncompliance within the larger context of economic hardship in which most patients in resource-poor settings live. Home visits and careful socioeconomic assessment can often reveal the broad range of factors contributing to the patient’s nonadherence; these factors may include increased economic or nutritional hardship, the illness of a family member, medication side effects or intolerance,142 or domestic violence. In conjunction with the patient, a multidisciplinary team of health professionals, educators, and social workers should strive to identify and remediate the patient’s hardship factors and improve the patient’s ability to remain engaged in her or his health care. In the ZL program, for example, transportation stipends and free health services for any ongoing complaints help to minimize the number of missed appointments. Other forms of support include education regarding TB and HIV; social worker services; nutritional support; and housing, educational, financial, and employment assistance as necessary. Rather than considering these interventions to be enablers or incentives, patients recognize them as critical components of ZL’s comprehensive approach to addressing underlying risk factors for disease.