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Debating directly observed therapy (DOT) and ARV adherence among the urban poor
By: D. Elliott

Background: Adherence to antiretroviral therapy is one of the most powerful predictors of survival for people living with HIV/AIDS. Despite simplification of medication regimens, adherence remains sub-optimal in many North American urban settings. Inner city populations affected by homelessness, chronic illicit drug use and mental illness experience increased challenges in maintaining adequate adherence. One of the most controversial public health interventions to improve adherence among inner city populations is Directly Observed Therapy for HAART (DOT-HAART).
Methods: This paper is drawn from 16 months of ethnographic research in urban health clinics in Vancouver, Canada. Semi-structured, open-ended interviews were conducted with 50 HIV positive individuals attending DOT-HAART programs at two inner city health clinics in Vancouver, Canada. Participants were recruited from health clinics offering supportive interventions and treatment for HIV/AIDS. Clinicians and front-line health providers (n=40) were also interviewed and observed in daily clinical practice.
Results: While clinical measures tend to be favorable towards DOT-HAART, this research suggests that such measures may eclipse the unintended consequences of observed therapy. While the direct observation of ingestion is reported as important for patients who were cognitively impaired or mentally ill, other patients reported feeling a loss of autonomy and involvement in decision-making surrounding their own health-care in DOT-HAART. Some patients reported the supervision as paternalistic and excessive, leading to reticence in attendance and thereby increasing non-adherence. In this sense, DOT programs at times may work as a form of iatrogenic violence, and should raise critical concerns regarding the unanticipated outcomes of directly observed therapy.
Conclusions: The success of DOT-HAART remains uncertain and requires further investigation, especially among participants. Novel strategies that improve adherence yet respect autonomy remain an urgent need for optimal delivery of care for inner city populations.

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