Trends in Antiretroviral Drugs Prescribing at Public Health Facilities in Ethiopia:

1. Trends in Antiretroviral Drugs Prescribing at Public Health Facilities in Ethiopia: Compliance to Treatment Guidelines Authors: Hailu Tadeg and Negussu Mekonnen Presenting Author: Hailu Tadeg (B.Pharm, MSc, MPH) Management Sciences for Health Strengthening Pharmaceutical Systems (MSH/SPS) Ethiopia

2. 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

3. 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

4. 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 prescribers • To examine the trends in the proportion of patients on D4T versus TDF based regimens • To identify differences in ARVs prescribing trends amongst regions • To compare ARVs prescribing practices and trends between hospitals and health centers

5. 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

6. Aggregate number and percentage of patients on each regimen Results • 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.

7. 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

8. Result (3) • Large proportion of new patients are being treated with D4T based regimen • against guidelines recommendations! • The actual prescribing practice follows the recommended trends. • But, does this prove compliance to the STG?

9. 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

10. Result (5) • 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 • 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%)

11. 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

12. Thank You!!!