4 ESSENTIAL MEDICINES MONITOR Issue 1 (2009) he 2004 International Conference on Improving Use of Medicines highlighted the urgent need to develop strategies to improve adherence to antiretroviral treatment (ART) (www.icium.org). Accepted wisdom is that if the ART adherence rate is less than 90–95%, treatment can fail, and the virus may become resistant. 1,2 A review of adherence studies for chronic illnesses found that achieving adherence rates above 80% is diicult, even in resource-rich countries. 3 herefore, the ability to accurately monitor adherence rates for ART and immediately address problems is crucial. Although many countries are scaling-up ART programmes, no one has developed any practical approaches to monitor treatment adherence programatically. The International Network for the Rational Use of Drugs Initiative on Adherence to Antiretroviral herapy (INRUD–IAA) is taking on the challenge. INRUD, comprising 25 member groups, was established in 1989 to design, test and disseminate efective strategies to improve the way medicines are prescribed, dispensed and used, especially in resource-poor countries. In 2006, national AIDS control programmes and INRUD groups carried out surveys in Ethiopia, Kenya, Rwanda, Uganda and the United Republic of Tanzania to assess how ART programmes were tracking patient adherence and treatment defaulting. Findings showed that programmes deined treatment adherence and patient defaulting diferently – the surveys identified 14 different definitions of defaulting, ranging from missing an appointment by one day to six months. As a result, reliable comparisons were impossible. Yet, although data collection and measurement were haphazard, clinics and pharmacies were recording much useful information. Developing indicators through collaboration Representatives from the INRUD groups and AIDS control programmes that had coordinated the survey and technical staf from Management Sciences for Health, WHO’s Department of Technical Cooperation for Essential Drugs and Traditional Medicine, the Karolinska Institutet, and Harvard Medical School gathered in Entebbe in April 2006 to discuss the survey indings. he participants agreed on the need to standardize deinitions of adherence and defaulting and define practical measurement methods. Standard indicators could help identify patients at risk, monitor facility and programme performance, and track changes. A measurement methodology would need to be practical, afordable and reproducible in any setting and provide reliable results. Participants drated core indicators to measure treatment adherence and defaulting. hey also suggested complementary indicators to address causes of good and bad adherence. he set of core indicators and their data sources are:  Self-reported doses of antiretroviral (ARV) medicine missed over a recent period (interviews or clinical records).  Number of days that ARV medicines were dispensed over the last six months or a year (pharmacy records).  Patient attendance at appointments and the number of Editor’s note: Adherence to antiretrovirals is critical for long- term efective therapy with irst-line medicines. This important study describes how groups from the International Network for the Rational Use of Drugs in East Africa developed and tested simple facility-based indicators to measure adherence. The report below demonstrates that such measurements can be reliably performed, meaning that adherence deined in diferent ways can be routinely reported. This work also demonstrates the value of operational field research carried out by national researchers and health workers within a network. Developing standard methods to monitor adherence to antiretroviral medicines and treatment defaulting in resource-poor settings The International Network for the Rational Use of Drugs Initiative on Adherence to Antiretroviral Therapy = John Chalker, Tenaw Andualem, Hailu Tadeg, Lillian Gitau, Joseph Ntaganira, Celestino Obua, Paul Waako T RATIONAL USE