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PEPFAR Implementation: Progress and Promise
effects may be experienced with ART, which of those side effects may be self-limited, and which dictate prompt discontinuation of ART (Nachega et al., 2006). Overall, this approach appears to be working well, but is difficult to accomplish in instances in which access to ART is limited to centers at considerable distances from where patients live.
Following diagnosis, evaluation, and readiness training, the patient begins ART, usually involving one of the three-drug, first-line regimens recommended by WHO (Gilks et al., 2006). None of the WHO-recommended first-line regimens for adults require refrigeration, and all are now produced in generic form by one or more pharmaceutical companies (FDA, 2006). Although the ART guidelines in all the focus countries are based on the ARV regimens recommended by WHO, other three-drug regimens may be used at the discretion of the supervising physician in some tertiary treatment sites.
Follow-up of Patients Receiving ART
Follow-up is arranged at intervals recommended by WHO and is often reinforced by providing ARVs sufficient to last until the next essential follow-up visit. Most programs visited by the Committee use additional techniques to support adherence during the first few weeks of ART. In some sites, weekly visits to patients’ dwellings by an outreach worker are arranged for 4 to 6 weeks after initiation of treatment. In other cases, assigned “buddies,” who have received adherence training along with the patients, provide similar support. Although not universal, such techniques for enhancing adherence are employed in the majority of treatment sites. At follow-up visits, the patient is asked about side effects and difficulties with adherence. Continued close adherence to the prescribed regimen is emphasized by the health care worker. If stated adherence is good but improved strength and well-being have not been achieved, potential underlying problems (for example, inadequate caloric intake or concomitant tuberculosis infection, both discussed below) are investigated, and appropriate adjuvant therapy, insofar as possible, is arranged.
Adherence to Therapy
Based on limited observational studies, short-term adherence to ARV regimens in the focus countries appears to be as good as or better than that observed earlier in Western Europe and North America (Farmer et al., 2001; Mills et al., 2006; Nachega et al., 2006; Stringer et al., 2006). As PEPFAR progresses with rapid scale-up and outreach to previously