hiv / aids is a chronic infectious disease causing profound immunosuppression in form of decrease in cd4 cell count .
introduction of antiretroviral therapy ( art ) has improved the cd4 count and transformed the disease from a fatal to manageable disease . major problem with art in resource - limited settings
is the emergence of drug - resistant viral strains due to poor drug adherence and the spread of these resistant viral strains in the population .
a very high levels of drug adherence ( > 95% ) are required for increasing the long - term effectiveness of art and to prevent the emergence of resistant viral strains .
the goal of national art program in india is also to attain > 95% individual drug adherence rate .
but adherence to art is difficult , and suboptimal art regimens may result in rapid development of drug resistance .
the definition of adherence has been also expanded that include retention in care , which includes attending regular follow - up visits . since the inception of national art program in 2004
, naco has reported 7% loss to follow - up cases and 3% patients who had missed treatment at some point of time .
optimizing adherence and minimizing loss to follow - up are two major challenges for the art roll - out program in india .
it is evident that adherence to treatment and follow- up are dependent on patients own will and health - seeking behavior which needs to be studied within their own sociocultural context . since a large number of patients
are on art in india , whose disease will progress if adherence is suboptimal , research is urgently needed to determine patient - level barriers to these issues . to study the level of drug adherence in patients accessing art through the national program and factor influencing drug adherence .
a hospital - based cross - sectional exploratory study was carried out in art center of sir sunder lal hospital , banaras hindu university , varanasi , india .
the study was approved by the ethics committee of the institute of medical sciences bhu .
hiv positive patients enrolled in the art center and started on art , were included in the study after informed consent .
subjects were started on art as per naco guidelines , that is , cd4 count < 200/l or stage 4 disease .
they were given 1 month therapy and followed - up every month for 6 months .
patients were asked to bring back the remaining pills in the pill box at every visit which was counted by the counselor . at every visit ,
drug adherence was estimated by patients self - reporting , pill count , and by using visual analogue scale ( vas ) .
statistical software spss for windows ( version 15.0 ) was used for data management and analysis .
statistical software spss for windows ( version 15.0 ) was used for data management and analysis .
during this period , 102 newly diagnosed hiv positive patients enrolled in the art center , and only 79 patients were started on art .
a total of 95% cases were in the age group of 20 - 49 years .
females ( mean age : 33.75 years ) were younger than males ( mean age : 34.09 ) [ table 1 ] .
majority of patients ( 60.8% ) did not know any factor which increases the drug compliance .
increase awareness ( 11.7% ) , come 2 day before for taking drug ( 13.7% ) , taking drug at fixed time ( 9.8% ) are important factor which increases the drug compliance .
twenty - eight patients missed the dose in 1 follow - up , nine patients missed in 2 follow - up , eight patients missed in 3 follow - up .
three patients lost follow - up in 2 follow - up , three patients further lost follow - up in 3 follow - up [ table 2 ] . running out of pills ( 40.0% ) , side effect ( 15.5% ) , and family problem ( 13.3% ) , poor transport facility for taking drug ( 8.9% ) , and forgetfulness ( 11.1% )
a total of 19% patients ( 15 ) in first follow - up did not know that missing the dose make treatment ineffective , but this % decreases with follow up ( 2 : 2.6% , 3 : 1.4% ) .
patients lost the follow - up were not included in this analysis . in female patients , drug adherence ( 69% ) was initially less than male patients ( 76% ) but latter on female patients ( 96.3% ) had better adherence than males ( 95.2% ) .
drug adherence was initially poor in joint family ( 71% vs. 82% ) but after follow  up , it becomes better than nuclear family ( 96.3% vs. 93.3% ) .
distribution of cases by age and sex number of missed dose in last 7 days causes of those patients who missed the dose ( open question )
nonadherence is associated with increased rate of hospitalization and longer hospital stays . in this study , concerns related to maintenance of optimal adherence to art among hiv - infected patients receiving free art . for hiv - infected patients treated with art , adherence to art is a significant determinant of survival .
adherence is second only to the cd4 cell count as a predictor of progression to aids and death . for most of the hiv patients
> 95% adherence is necessary to achieve complete and durable viral suppression . keeping these issues in mind ,
the present study include the level of drug adherence and the various factors affecting the drug adherence to art among hiv - infected patients receiving free art . after starting the art ,
a total of 28 patients ( 35.4% ) missed at least one dose of art in last 7 days during first follow - up . during second
follow - up , 11.4% missed the dose and three patients ( 3.8% ) lost the follow - up . in third follow - up , 10.2% patient missed the dose and further three patients lost the follow - up [ table 2 ] .
thus , we can say drug adherence increases with subsequent follow - up but 3 - 4 patients ( 3.8%-5.06% ) regularly lost follow - up due to some reason .
opposite to our study , some study showed that rates of adherence are known to decline over time .
this might be due to proper counseling of the patients . for assessing the cause of missed dose [ table 3 ] , patient missed the dose due to running out of pills ( 40.0% ) , side effect ( 15.5% ) , family problem ( 13.3% ) , and poor transport facility for taking drug ( 8.9% ) , forgetfulness ( 11.1% ) , economic problem ( 6.7% ) , and ignorance ( 4.4% ) .
drug adherence by vas was > 95% in first follow - up ( 73.4% ) second follow - up 92.2% , third follow - up 93.2% .
drug adherence < 70% was noted in four patients ( 5.1% ) in first follow - up which become two patients ( 2.6% ) in 2 follow - up . in third follow - up
these findings are also similar to result of some other studies . along with that , in our study the adherence rate is better than some older studies . a total of 81.0% patients know that missing the dose leads to treatment ineffective in first follow - up , but this decreases with subsequent follow - up , ( 2 : 2.6% , 3 : 1.4% ) patients lost follow - up was not in clucked . in present study ,
female patients drug adherence > 95% were initially lower ( 69.0% ) than male patient but in subsequent follow - up female patients show better adherence than males ( 96.3% vs. 95.2% ) .
drug adherence ( > 95% ) was initially better in nuclear family ( 82.6% ) than joint family ( 71.0% ) but latter on drug adherence ( > 95% ) become better in joint family ( 96.3% ) than nuclear family ( 93.3% ) .
this improvement in adherence is most probably due to social support by family members after proper counseling .
an another study has also showed that an educational intervention along with proper counseling improves adherence to antiretroviral regimens and health status .
this study suggest that in resource - limiting countries , proper counseling and close monitoring of the patients can help in increasing drug adherence and decreasing loss of follow - up , which may have a great role in preventing the drug resistance and art response .
 background : majority of hiv / aids patients who are on highly active anti retroviral therapy ( haart ) , are not aware about drug adherence and its importance which is the most important factor for drug adherence.objectives:to study the level of drug adherence in patients accessing antiretroviral therapy ( art ) through the national program and factor influencing drug adherence.materials and methods : in present study , we enrolled 102 newly diagnosed patients , among them in 79 patients , art was started . 
 to study the drug adherence a pretested , semistructured questionnaire was formed and patients were followed up for 6 months of the study . 
 pretest and posttest counseling was done to all such patients.results:a total of 28 patients missed the dose in 1st follow - up , nine patients missed in 2nd follow - up , eight patients missed in 3rd follow - up . 
 three patients lost follow - up in 2nd follow - up , three patients further lost follow - up in 3rd follow - up . running out of pills ( 40.0% ) , side effect ( 15.5% ) , and family problem ( 13.3% ) , poor transport facility for taking drug ( 8.9% ) and forgetfulness ( 11.1% ) 
 are five major causes related to miss dose . in females patients , drug adherence ( 69% ) 
 was initially less than male patients ( 76% ) but latter on female patients ( 96.3% ) had better adherence than males ( 95.2%).conclusion : this study suggest that drug adherence can be increased by proper counseling and close monitoring of the patients which may have a great role in preventing the drug resistance and art response . 
INTRODUCTION
MATERIALS AND METHODS
Statistical analysis
RESULTS
DISCUSSION
CONCLUSION