Care seeking behaviors and factors for adherence among HIV patients in four Mexican hospitals

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Care seeking behaviors and factors for adherence
among HIV patients in four Mexican hospitals

• Lisa DeMaria, Sergio Bautista-Arredondo, Veronika
  Wirtz
• Session WEAB03 - Adherence and Medicines (ARVs)
  Management
• XVII International Conference on HIV/AIDS
• 6 August 2008

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Scaling up ART care in Mexico in a multi-system
context

• 8 years since the Mexican governments commitment
  to Universal Access to antiretrovirals.
• Providing ARV coverage is carried out in a
  multi-system context
• Public health system Secretaría de Salud (SSA)
  National Institutes of Health (INSalud)
• Social security system IMSS, ISSSTE, Pemex
• Private sector health care private practice
  physicians, hospitals, insurance.
• Little known about PLWHA history of diagnosis and
  care, adherence, and patterns in seeking care in
  a context of multiple systems-- which are crucial
  to ensure quality of care and adherence.

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Objectives

• Investigate self-reported care seeking behaviors
  and adherence within the context of Universal
  Access.
• Identify how patients access care and patterns of
  care seeking, including use of private sector and
  out-of-pocket expenditures.
• Analyze factors that affect adherence, in the
  context of receiving care at public sector
  institutions.

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Methodology and Sample

• Exploratory study
• Patient interviews (2005)
• 189 HIV patients
• Convenience sample
• 4 Hospitals in and around Mexico City
• 2 tertiary care hospitals
• 1 social security hospital
• 1 public health hospital (SSA)
• Pre-coded questionnaire covering socio-economic
  status, health and HIV history, health
  expenditures, care received, disease history,
  quality of life and adherence.

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Description of the Sample
Values are means . SD
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Experience with HAART

• Nearly all currently receiving HAART (98)
• They are new to ARV therapy
• 65 lt1 year on therapy
• 25 1-5 years
• 10 gt5 years
• Feel that treatment is working (94)
• 64 feel better
• 51 are symptom free
• 29 have gained weight
• 31 dont tire as easily
• They know what they are taking (94)
• 24 report that treatment is complicated.

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Care seeking among institutions

• INSalud patients access care from more
  institutions
• Seek care at the institutions because they are
  referred there or because of the perceived
  quality of care.
• A minority supplement with private sector care
  (lt17)
• All seek ARVs at primary institution.

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1 to 2 Institutions
Patterns of care seeking
gt 3 Institutions
Intra- institucional (50)
Intra- institutional 43
gt 1 INSalud (81)
gt 1 INSalud (18)
First institution
gt 1 INSalud (61)
Inter- institucional (19)
Inter- Institutional (57)
Private Sector (75)
Private sector (12)
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Median out-of-pocket expenditures (previous 2
months)
82 report out of pocket expenditures for care in
previous 6 months
All values expressed in Mexican pesos. SD in
brackets.
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Adherence

• Half reported skipping at least one day of
  treatment at one time (49)
• Seeking care at a greater number of institutions
  (gt3) appears to be associated with non-adherence
• Most common reason for missing a dose is being
  out of the house or forgetting (54)
• 25 Sick / Side effects
• 11.25 Couldnt get meds/stockouts
• 11.25 Own decision

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Multivariate analysis for Adherence
0 No Adherence, 1 Adherence Number of
observations 130 Probgt chi2
0.0063 Reference groups time ARV 0 6 mo, no
education or elementary school, 1 institution,
time receiving attention 0-6 mo
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Conclusions

• Inter-institutional referrals are frequent -- 45
  referred and should be handled carefully.
• Private institutions play a minor role as care
  providers for PLWHA.
• Adherence needs to be reinforced in the first
  year and among patients seeking care from
  multiple institutions
• Out-of-pocket expenditures indicate insufficient
  coverage of additional services required for care
  of PLWHA.

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http//www.insp.mx ldemaria_at_insp.mx sbautista_at_insp
.mx vwirtz_at_insp.mx We would like to thank
UCMexus for funding this study and Yared Santa
Ana for her assistance with the data analysis.