Assessing and achieving readiness to initiate HIV medication

Readiness for Antiretroviral Therapy: Implications for Linking HIV-Infected Individuals to Care and Treatment

Using survey data collected immediately after referral for ART (N = 87), this study examined ART-readiness among individuals (18 years and older) attending a mobile health clinic in South Africa. Most participants reported being very ready (84%) and motivated (85%) to start ART, but only 72% were assessed as ready for ART on all measures. Treatment readiness was lower among individuals who did not think they would test HIV-positive (aOR 0.26, p < 0.05) and among individuals who reported being in good health (aOR 0.44, p < 0.1). In contrast, higher readiness was associated with better ART knowledge (aOR 4.31, p < 0.05) and knowing someone who had experienced positive health effects from ART (aOR 2.65, p < 0.05). Results indicate that post-test counselling will need to be designed to deal with surprise at HIV diagnosis, and that health messaging needs to be carefully crafted to support uptake of ART among HIV-positive but healthy individuals. Further research is needed on effective post-test counselling approaches and effective framing of health messaging to increase awareness of the multiple positive benefits of early ART initiation and corresponding readiness to engage in treatment.

Using the multiphase optimization strategy (MOST) to optimize an HIV care continuum intervention for vulnerable populations: a study protocol

BACKGROUND

More than half of persons living with HIV (PLWH) in the United States are insufficiently engaged in HIV primary care and not taking antiretroviral therapy (ART), mainly African Americans/Blacks and Hispanics. In the proposed project, a potent and innovative research methodology, the multiphase optimization strategy (MOST), will be employed to develop a highly efficacious, efficient, scalable, and cost-effective intervention to increase engagement along the HIV care continuum. Whereas randomized controlled trials are valuable for evaluating the efficacy of multi-component interventions as a package, they are not designed to evaluate which specific components contribute to efficacy. MOST, a pioneering, engineering-inspired framework, addresses this problem through highly efficient randomized experimentation to assess the performance of individual intervention components and their interactions. We propose to use MOST to engineer an intervention to increase engagement along the HIV care continuum for African American/Black and Hispanic PLWH not well engaged in care and not taking ART. Further, the intervention will be optimized for cost-effectiveness. A similar set of multi-level factors impede both HIV care and ART initiation for African American/Black and Hispanic PLWH, primary among them individual- (e.g., substance use, distrust, fear), social- (e.g., stigma), and structural-level barriers (e.g., difficulties accessing ancillary services). Guided by a multi-level social cognitive theory, and using the motivational interviewing approach, the study will evaluate five distinct culturally based intervention components (i.e., counseling sessions, pre-adherence preparation, support groups, peer mentorship, and patient navigation), each designed to address a specific barrier to HIV care and ART initiation. These components are well-grounded in the empirical literature and were found acceptable, feasible, and promising with respect to efficacy in a preliminary study.

METHODS/DESIGN

Study aims are: 1) using a highly efficient fractional factorial experimental design, identify which of five intervention components contribute meaningfully to improvement in HIV viral suppression, and secondary outcomes of ART adherence and engagement in HIV primary care; 2) identify mediators and moderators of intervention component efficacy; and 3) using a mathematical modeling approach, build the most cost-effective and efficient intervention package from the efficacious components. A heterogeneous sample of African American/Black and Hispanic PLWH (with respect to age, substance use, and sexual minority status) will be recruited with a proven hybrid sampling method using targeted sampling in community settings and peer recruitment (N = 512).

DISCUSSION

This is the first study to apply the MOST framework in the field of HIV prevention and treatment. This innovative study will produce a culturally based HIV care continuum intervention for the nation's most vulnerable PLWH, optimized for cost-effectiveness, and with exceptional levels of efficacy, efficiency, and scalability.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02801747 , Registered June 8, 2016.

Critical race theory as a tool for understanding poor engagement along the HIV care continuum among African American/Black and Hispanic persons living with HIV in the United States: a qualitative exploration

Background

African American/Black and Hispanic persons living with HIV (AABH-PLWH) in the U.S. evidence insufficient engagement in HIV care and low uptake of HIV antiretroviral therapy, leading to suboptimal clinical outcomes. The present qualitative study used critical race theory, and incorporated intersectionality theory, to understand AABH-PLWH’s perspectives on the mechanisms by which structural racism; that is, the macro-level systems that reinforce inequities among racial/ethnic groups, influence health decisions and behaviors.

Methods

Participants were adult AABH-PLWH in New York City who were not taking antiretroviral therapy nor well engaged in HIV care (N = 37). Participants were purposively sampled for maximum variation from a larger study, and engaged in semi-structured in-depth interviews that were audio-recorded and professionally transcribed verbatim. Data were analyzed using a systematic content analysis approach.

Results

We found AABH-PLWH experienced HIV care and medication decisions through a historical and cultural lens incorporating knowledge of past and present structural racism. This contextual knowledge included awareness of past maltreatment of people of color in medical research. Further, these understandings were linked to the history of HIV antiretroviral therapy itself, including awareness of the first HIV antiretroviral regimen; namely, AZT (zidovudine) mono-therapy, which was initially prescribed in unacceptably high doses, causing serious side effects, but with only modest efficacy. In this historical/cultural context, aspects of structural racism negatively influenced health care decisions and behavior in four main ways: 1) via the extent to which healthcare settings were experienced as overly institutionalized and, therefore, dehumanizing; 2) distrust of medical institutions and healthcare providers, which led AABH-PLWH to feel pressured to take HIV antiretroviral therapy when it was offered; 3) perceptions that patients are excluded from the health decision-making process; and 4) an over-emphasis on antiretroviral therapy compared to other non-HIV related priorities. We found that although participants were located at the intersection of multiple social categories (e.g., gender, social class, AABH race/ethnicity), race/ethnicity and social class were described as primary factors.

Conclusions

Critical race theory proved useful in uncovering how macro-level structural racism affects individual-level health decisions and behaviors. HIV clinical settings can counter-balance the effects of structural racism by building “structural competency,” and interventions fostering core self-determination needs including autonomy may prove culturally appropriate and beneficial for AABH-PLWH.

Development and Validation of the HIV Medication Readiness Scale

Excellent medication adherence (> 95%) is required for optimal HIV treatment success. This study aimed to develop and validate a brief scale to assess psychological readiness for successfully starting and adhering to HIV medications. HIV-positive men and women (N = 142) from an HIV outpatient clinic completed the proposed HIV Medication Readiness Scale (HMRS) prior to starting HIV medications. The 10-item HMRS demonstrated high internal consistency (alpha = .90), test-retest reliability (r = .83), and sensitivity to change following a standardized 4-session psychoeducational intervention designed to increase readiness for successful adherence. Predictive validity was supported by higher readiness scores on the day starting HIV medications, predicting higher treatment adherence at 1-month follow-up. The HMRS is a brief, easy-to-use, clinically relevant tool that can assist in identifying people living with HIV at high risk of nonadherence, who might benefit from tailored readiness counseling prior to initiating HIV medications.

Is It a Trust Issue? Factors That Influence Trust for Persons Living With HIV/AIDS

Trust in one's health care provider, trust in the health care system in general, and even trust in one's community affects engagement in HIV-related health care. This article examines the issue of trust among a random sample of HIV-infected individuals residing in Mississippi, an area hard-hit by the HIV/AIDS epidemic. Five constructs based on survey responses from these individuals were developed: (1) trust in one's provider to offer the best possible medical care, (2) trust in one's provider to protect patient privacy, (3) willingness to disclose HIV status to one's provider, (4) trust in the health care system, and (5) trust in one's community. Findings suggest that interventions to improve trust in providers to deliver the highest quality of care should be targeted to young people, African Americans, and the more highly educated. Interventions to increase trust in providers to protect privacy should focus on creating and strengthening social support groups or networks that build relationships and foster trust. Interventions aimed to increase community trust also should be targeted to young people. This information is useful to researchers, policy makers, health care providers, and organizations interested in prioritizing interventions and strategies that have the greatest potential to reduce health disparities in HIV diagnosis and treatment in the Deep South.

Behavioral intervention improves treatment outcomes among HIV-infected individuals who have delayed, declined, or discontinued antiretroviral therapy: a randomized controlled trial of a novel intervention

Nationally up to 60 % of persons living with HIV are neither taking antiretroviral therapy (ART) nor well engaged in HIV care, mainly racial/ethnic minorities. This study examined a new culturally targeted multi-component intervention to address emotional, attitudinal, and social/structural barriers to ART initiation and HIV care. Participants (N = 95) were African American/Black and Latino adults with CD4 < 500 cells/mm(3) not taking ART, randomized 1:1 to intervention or control arms, the latter receiving treatment as usual. Primary endpoints were adherence, evaluated via ART concentrations in hair samples, and HIV viral load suppression. The intervention was feasible and acceptable. Eight months post-baseline, intervention participants tended to be more likely to evidence "good" (that is, 7 days/week) adherence (60 vs. 26.7 %; p = 0.087; OR = 3.95), and had lower viral load levels than controls (t(22) = 2.29, p = 0.032; OR = 5.20), both large effect sizes. This highly promising intervention merits further study.

Rational Design and Adaptive Management of Combination Therapies for Hepatitis C Virus Infection

Recent discoveries of direct acting antivirals against Hepatitis C virus (HCV) have raised hopes of effective treatment via combination therapies. Yet rapid evolution and high diversity of HCV populations, combined with the reality of suboptimal treatment adherence, make drug resistance a clinical and public health concern. We develop a general model incorporating viral dynamics and pharmacokinetics/ pharmacodynamics to assess how suboptimal adherence affects resistance development and clinical outcomes. We derive design principles and adaptive treatment strategies, identifying a high-risk period when missing doses is particularly risky for de novo resistance, and quantifying the number of additional doses needed to compensate when doses are missed. Using data from large-scale resistance assays, we demonstrate that the risk of resistance can be reduced substantially by applying these principles to a combination therapy of daclatasvir and asunaprevir. By providing a mechanistic framework to link patient characteristics to the risk of resistance, these findings show the potential of rational treatment design.

Evolving views and practices of antiretroviral treatment prescribers in Australia

OBJECTIVE

To examine whether there have been recent changes in Australian antiretroviral treatment (ART) prescribers' perceptions and practices relating to early ART initiation, which was defined as commencing ART when a patient's CD4+ T-cell count approaches 500 cells/mm3 or immediately after a patient is diagnosed with HIV.

DESIGN, PARTICIPANTS AND SETTING

Self-completed, anonymous, cross-sectional surveys, targeting all ART prescribers in Australia, were conducted online in 2012 and 2013. The surveys included questions on prescriber factors, CD4+ T-cell count at which prescribers would most strongly recommend ART initiation, and perceived patient characteristics that could change prescribers' practices of early initiation of ART.

MAIN OUTCOME MEASURES

Proportions of ART prescribers recommending early ART initiation.

RESULTS

We analysed responses from 108 participants in 2012 and 82 participants in 2013. In both years, more male than female prescribers participated. The median age of participants was 49 years in 2012 and 50 years in 2013. In both rounds, over 60% had more than 10 years' experience in treating HIV-positive patients. More prescribers in 2013 stated that they would most strongly recommend early ART initiation compared with those in 2012 (50.0% [95% CI, 38.7%-61.3%] v 26.9% [95% CI, 18.8%-36.2%]; P=0.001). The prescribers' primary concern was more about individual patient than public health benefit. Out of 824 patients for whom ART was initiated, as reported by prescribers in 2013, only 108 (13.1% [95% CI, 10.9%-15.6%]) were given ART primarily to prevent onward HIV transmission. The number of patients for whom ART was initiated was significantly associated with prescribers' HIV caseload even after adjusting for prescriber type (adjusted odds ratio, 1.73 [95% CI, 1.47-2.03]; P<0.001); of the 37 who had initiated ART for 10 or more patients, 29 had a high HIV caseload. In 2013, 60 prescribers (73.2% [95% CI, 62.2%-82.4%]) reported that they routinely recommended ART to treatment-naive, asymptomatic patients with a CD4+ T-cell count of 350-500 cells/mm3.

CONCLUSION

Our findings show increasing acceptance of and support for early ART initiation primarily as treatment and not as prevention.

'Not Until I'm Absolutely Half-Dead and Have To:' Accounting for Non-Use of Antiretroviral Therapy in Semi-Structured Interviews with People Living with HIV in Australia

Current debates regarding the use of antiretroviral therapy (ART) to promote both individual- and population-level health benefits underscore the importance of understanding why a subpopulation of people with diagnosed HIV and access to treatment choose not to use it. Semi-structured interviews were conducted between 2012 and 2014 with 27 people living with HIV in Australia who were not using ART at the time of interview. Analytic triangulation permitted an appreciation of not only the varied personal reasons for non-use of treatment, but also underlying views on HIV treatment, and the ideal conditions imagined necessary for treatment initiation. Policy goals to increase the number of people with HIV using ART must recognize the diverse explanations for non-use of ART, which include concerns about the various impacts of committing to lifelong pharmaceutical treatment use. Our research identified distinctive subgroups among people who are not using antiretroviral therapy, with a range of individual and social needs that may affect treatment decisions. These findings challenge assumptions about treatment non-use in resource-rich settings, revealing persistent consumer fears about the potent and unknown effects of HIV medications that deserve greater recognition in policy debate on treatment uptake.

Factors affecting antiretroviral therapy adherence among HIV-positive pregnant and postpartum women: an adapted systematic review

Summary

Adherence to antiretroviral therapy (ART) is crucial for effective treatment, but can be quite complex. Non-adherence can adversely affect treatment outcomes. Although many studies have been done on adherence in the general population, few have included HIV-positive pregnant and postpartum women in resource-constrained settings. This review assessed the evidence on adherence among these groups of women. A systematic search of databases was completed between June and July 2011. Both qualitative and quantitative studies were included. Eighteen studies from a total of 6622 satisfied the inclusion criteria that included inter alia facilitators and barriers to adherence. This review highlighted that there is still no consensus on the definition and measurement of adherence; also multiple factors can affect a woman's ability to adhere to ART. Some of the barriers and facilitators identified were similar in both the type of study (qualitative and quantitative) and among the various countries. Findings indicated that the few studies in this population are conducted primarily in resource-rich settings. Such paucity of information warrants urgent attention; thus targeted research is needed to provide insight on adherence within this population.

Diversity of patient preparation activities before initiation of antiretroviral therapy in Cape Town, South Africa

OBJECTIVE

To investigate patient education and counseling activities prior to the initiation of antiretroviral therapy (ART) at public sector services across Cape Town, South Africa.

METHODS

Key informant interviews and programme reviews were conducted with government bodies and non-governmental organisations involved in patient preparation activities.

RESULTS

All 11 organisations in Cape Town involved in training and managing personnel to prepare patients for ART during 2010 participated. Each organisation reported a different approach to patient preparation within public sector clinics and in each aspect of patient preparation activities. The number of patient education sessions ranged from 3 to 7, and the delays to ART initiation introduced by patient preparation ranged from 3 to 6 weeks. Different patient education materials (pamphlets, posters and flipcharts) were used by various programmes, and all programmes reported that shortages in materials meant that patient preparation often took place without any educational materials. Each programme also reported attention to mental illness and alcohol/substance use disorders, but none employed formal screening tools consistently, and the handling of patients with potential mental health- or substance-related problems varied.

CONCLUSION

Approaches to prepare patients before ART initiation are wide ranging in one part of South Africa. Their relative value requires investigation, as there is little evidence for the impact of varying approaches. Moreover, the risks associated with delayed ART initiation may outweigh any benefits of patient education before the start of treatment.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

A new taxonomy for describing and defining adherence to medications

Interest in patient adherence has increased in recent years, with a growing literature that shows the pervasiveness of poor adherence to appropriately prescribed medications. However, four decades of adherence research has not resulted in uniformity in the terminology used to describe deviations from prescribed therapies. The aim of this review was to propose a new taxonomy, in which adherence to medications is conceptualized, based on behavioural and pharmacological science, and which will support quantifiable parameters. A systematic literature review was performed using MEDLINE, EMBASE, CINAHL, the Cochrane Library and PsycINFO from database inception to 1 April 2009. The objective was to identify the different conceptual approaches to adherence research. Definitions were analyzed according to time and methodological perspectives. A taxonomic approach was subsequently derived, evaluated and discussed with international experts. More than 10 different terms describing medication-taking behaviour were identified through the literature review, often with differing meanings. The conceptual foundation for a new, transparent taxonomy relies on three elements, which make a clear distinction between processes that describe actions through established routines ('Adherence to medications', 'Management of adherence') and the discipline that studies those processes ('Adherence-related sciences'). 'Adherence to medications' is the process by which patients take their medication as prescribed, further divided into three quantifiable phases: 'Initiation', 'Implementation' and 'Discontinuation'. In response to the proliferation of ambiguous or unquantifiable terms in the literature on medication adherence, this research has resulted in a new conceptual foundation for a transparent taxonomy. The terms and definitions are focused on promoting consistency and quantification in terminology and methods to aid in the conduct, analysis and interpretation of scientific studies of medication adherence.

Readiness in HIV Treatment Adherence: A Matter of Confidence. An Exploratory Study

Adherence to treatment is recognized as the essence of a successful HIV combination therapy. Optimal adherence implies a readiness to begin the treatment on the part of the patient. A better understanding of the "readiness phenomenon" will become an asset for optimizing HIV treatment. However, few studies have focused on understanding the process underlying the choice to adhere. The aim of this study is to understand the readiness process that leads to adhering to the HIV treatment, from both patient and professional perspectives. Twenty-seven in-depth interviews, with a qualitative exploratory design, were the source of our data. Participants were recruited in two hospitals in Paris. Throughout the data-collection process, analysed data were supplied to all participants and the research team, thus allowing for shared constructions. Four themes, interrelated with a constitutive pattern, emerged from the data we collected. Being ready to begin and adhere to treatment is a matter of confidence in oneself, as well as in relatives, in the treatment and in the health professional team. These themes are not constant and unvarying; instead, they constitute a picture moving across time and life events. Results of this study show that adherence that goes beyond "complying with" the medical instructions, but depends on how much of an active role the patient plays in the choice to adhere.

The influence of traditional medicine and religion on discontinuation of ART in an urban informal settlement in Nairobi, Kenya

OBJECTIVE

The objective of this study was to explore the influence of traditional medicine and religion on discontinuation of antiretroviral therapy (ART) in one of Africa's largest informal urban settlement, Kibera, in Nairobi, Kenya.

METHODS

Semi-structured face-to-face interviews were conducted with 20 patients discontinuing the African Medical and Research Foundation (AMREF) ART program in Kibera due to issues related to traditional medicine and religion.

RESULTS

Traditional medicine and religion remain important in many people's lives after ART initiation, but these issues are rarely addressed in a positive way during ART counseling. Many patients found traditional medicine and their religious beliefs to be in conflict with clinic treatment advice. Patients described a decisional process, prior to the actual drop-out from the ART program that involved a trigger event, usually a specific religious event, or a meeting with someone using traditional medicine that influenced them to take the decision to stop ART.

CONCLUSION

Discontinuation of ART could be reduced if ART providers acknowledged and addressed the importance of religious issues and traditional medicine in the lives of patients, especially in similar resource-poor settings. Telling patients not to mix ART and traditional medicine appeared counter-productive in this setting. Introducing an open discussion around religious beliefs and the pros and cons of traditional medicine as part of standard counseling, may prevent drop-out from ART when side effects or opportunistic infections occur.

Factors influencing adherence to antiretroviral treatment in Asian developing countries: a systematic review

OBJECTIVE

To systematically review the literature of factors affecting adherence to Antiretroviral treatment (ART) in Asian developing countries.

METHODS

Database searches in Medline/Ovid, Cochrane library, CINAHL, Scopus and PsychINFO for studies published between 1996 and December 2010. The reference lists of included papers were also checked, with citation searching on key papers.

RESULTS

A total of 437 studies were identified, and 18 articles met the inclusion criteria and were extracted and critically appraised, representing in 12 quantitative, four qualitative and two mixed-method studies. Twenty-two individual themes, including financial difficulties, side effects, access, stigma and discrimination, simply forgetting and being too busy, impeded adherence to ART, and 11 themes, including family support, self-efficacy and desire to live longer, facilitated adherence.

CONCLUSION

Adherence to ART varies between individuals and over time. We need to redress impeding factors while promoting factors that reinforce adherence through financial support, better accessible points for medicine refills, consulting doctors for help with side effects, social support and trusting relationships with care providers.

Development of an easy to use tool to assess HIV treatment readiness in adolescent clinical care settings

Optimal management of HIV disease requires high levels of lifelong adherence once a patient initiates highly active antiretroviral therapy (HAART). Because suboptimal adherence to HAART is associated with adverse consequences, many providers are hesitant to prescribe HAART for patients whom they perceive as not being ready to initiate treatment. Accurately predicting HIV treatment readiness is challenging. Despite the importance of this construct, few reliable and valid instruments to assess HIV treatment readiness have been developed; none of these have been validated with adolescents and young adults, who comprise an increasing proportion of new HIV cases diagnosed. As a first step to achieve this goal, we developed the HIV Treatment-Readiness Measure (HTRM) for administration by way of audio computer-assisted self-interview (ACASI) and conducted a study to examine its internal consistency, test-retest reliability, acceptability, and preliminary factor structure. We recruited 201 adolescents and young adults living with HIV from 15 adolescent medicine clinics that were part of the Adolescent Trials Network for HIV Interventions. Youth completed the initial assessment and two weeks later the retest assessment. The refined HTRM had high internal consistency (α = 0.84). Test-retest reliability using both sum scores and mean scores were high. The HTRM was also highly acceptable and feasible to use in routine clinical practice. In exploratory factor analysis we found that a five-factor solution was the best fit; each of the subscales (Disclosure, Psychosocial Issues, Connection with Care, HIV Medication Beliefs, and Alcohol and Drugs) had good to acceptable alphas and eigenvalues greater than 2.0. Our findings support conducting a future study to examine the tool's predictive validity.

Strategies to improve HIV treatment adherence in developed countries: clinical management at the individual level

REMARKABLE ADVANCES IN THE TREATMENT OF HUMAN IMMUNODEFICIENCY VIRUS (HIV) DISEASE HAVE BEEN BLUNTED BY WIDESPREAD SUBOPTIMAL ADHERENCE (IE, NONADHERENCE), WHICH HAS EMERGED AS A MAJOR BARRIER TO ACHIEVING THE PRIMARY GOAL OF ANTIRETROVIRAL (ARV) THERAPY: suppression of HIV viral load. Nonsuppressed HIV viral load is associated with drug resistance, increased morbidity and mortality, and a higher risk of person-to-person HIV transmission. For HIV-infected individuals who are failing HIV treatment due to nonadherence, becoming adherent is a life-saving behavior change. However, overcoming nonadherence is one of the most daunting challenges in the successful management of HIV disease. The purpose of this paper is to provide clinicians with a better understanding of nonadherence to ARV treatment and to review the various factors that have been associated with either adherence or nonadherence. Strategies are presented that may help the nonadherent individual become ready to take HIV medications as prescribed.

Readiness: the state of the science (or the lack thereof)

HIV treatment guidelines state that patients' readiness should be assessed before initiating highly active antiretroviral therapy (HAART) to assure adherence. None of the guidelines provide a way to measure readiness. Therefore, this article sought to review the literature on readiness to determine if there was a viable predictor of adherence. Twenty-seven articles were reviewed. Nine described studies that examined the relationship between a measure of readiness and HAART adherence. No readiness measure demonstrated clinical utility as a predictor of adherence. Study flaws included small sample sizes (only one study >100 patients), short follow-up periods (all ≤1 year and six were ≤5 months, four ≤1 month), measures of readiness that related poorly to adherence, and inconsistent adherence measures (eight different measures were used by the researchers). Neither the guidelines nor the literature will help clinicians judge who should initiate HAART and who should delay treatment.

Can herpes simplex virus type 2 suppression slow HIV disease progression: a study protocol for the VALacyclovir In Delaying Antiretroviral Treatment Entry (VALIDATE) trial

BACKGROUND

Although highly active antiretroviral therapy (HAART) has dramatically decreased HIV-related morbidity and mortality, the associated costs, toxicities, and resistance risks make the potential delay of HAART initiation an attractive goal. Suppression of herpes simplex virus type 2 (HSV-2) may be a novel strategy for achieving this goal because HSV-2 is associated with clinically significant increases in HIV viral load, the primary driver of HIV disease progression.

METHODS/DESIGN

The VALacyclovir In Delaying Antiretroviral Treatment Entry (VALIDATE) trial is a multicentre, randomized, fully blinded, clinical trial of twice daily valacyclovir 500 mg versus placebo for delaying the need for initiating HAART among HIV-1, HSV-2 co-infected HAART-naïve adults. 480 participants from Canada, Brazil and Argentina will undergo quarterly clinical follow-up until reaching the composite primary endpoint of having a CD4+ T-cell count ≤ 350 cells/mm(3) or initiation of HAART for any reason, whichever occurs first. The primary analysis will use a proportional hazards model, stratified by site, to estimate the relative risk of progression to this endpoint associated with valacyclovir. Secondary analyses will compare the rates of change in CD4 count, median log10 HIV viral load, drug-related adverse events, frequency of HSV reactivations, rate of acyclovir-resistant HSV, and quality of life between study arms.

DISCUSSION

Although HIV treatment guidelines continue to evolve, with some authorities recommending earlier HAART among asymptomatic individuals, the potential delay of HAART remains a clinically relevant goal for many. If shown to be of benefit, implementation of the VALIDATE intervention will require careful consideration of both individual patient-level and public health implications.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN66756285. ClinicalTrials.gov NCT00860977.

Secondary care doctors' perception of appropriate prescribing

RATIONALE, AIM AND OBJECTIVE

As the prescribing of drugs in secondary care is known to influence prescribing in primary care and because an understanding of prescribers' reasoning is essential for evaluating prescribing appropriateness, the aim of this study was to investigate secondary care doctors' views of appropriate prescribing, using qualitative individual interviews.

METHOD

Qualitative, semi-structured individual interviews were conducted with 15 hospital doctors working in different medical specialities. The interviews, covering the doctors' views of the meaning of 'appropriate' prescribing, were audiotaped and analysed from an interpretivist perspective.

RESULTS

Three different main themes were identified in the analysis of how the doctors perceived appropriate prescribing: 'individualization of treatment', 'cost' and 'time'. Most importantly, treatment should be adjusted to the individual patient, although cost should also be justified. Ongoing medication reviews should be carried out, to adjust to changes in patient-related factors over time.

CONCLUSIONS

The hospital doctors brought up continuous review as a necessary part of appropriate prescribing. Thus, from the prescribers' point of view, this time perspective should be explicitly incorporated in definitions of appropriate prescribing, in addition to individualization of treatment and cost considerations.

From consultation-liaison psychiatry to integrated care for multiple and complex needs

The aim of the present study was to review the ways in which contemporary medicine addresses physical/psychiatric multimorbidity, to review the underlying concepts and methodologies used, and to propose a novel approach that may help consultation-liaison psychiatry (CLP) position itself better in the health-care field. A Medline search of the terms 'consultation-liaison psychiatry', 'integrated care', 'quality assurance' and 'qualitative methodology', was complemented by study of the literature on complexity theory and by discussions with colleagues in both the health science and sociology fields. There is a growing realization that presentation with multimorbidity of both physical and psychiatric disorders is the norm. Other health-care disciplines have responded quickly to meeting the multiple and complex needs of such patients, attracting funding to an extent that CLP has been unable to achieve. Uncritical application, however, of integrated care technology based on evidence from randomized controlled trials has produced disappointing results. There is a growing realization that such quantitative methods need to be complemented by in-depth exploration using non-traditional methods including qualitative ones, and drawing on complexity theory. The Cochrane Collaboration is exploring this. As CLP and other medical and health-care disciplines face the challenge of patients with multimorbidity, they need to find acceptable answers to the question of what works for whom in what context for patients with multiple and complex needs. CLP can contribute its rich experience in the qualitative approaches that will be needed in research addressing this question, but needs help from other disciplines to refine its techniques so that its contributions are considered valid. The context for implementing effective interventions derived from such studies will in future be that of transdisciplinary teams whose mode of working is empirically based and transparent. CLP is well placed by dint of its psychodynamic and systems theory roots to provide leadership in this transformation in health-care delivery.

A structural equation modeling approach to the concepts of adherence and readiness in antiretroviral treatment

OBJECTIVE

The objective of this secondary analysis of data from a cross-sectional, nation-wide survey, was to test a hypothesized model with two latent concepts (readiness and adherence), based on the theory of trigger events. A secondary objective was to compare this model with two simpler models, without the concept of readiness.

METHODS

Data consisted of a consecutive sample of 828 HIV patients > or = 18 years on antiretroviral treatment at 30 out of 32 HIV Clinics in Sweden (response rate 97.5%). Structural equation modeling (SEM) was used to test the models against the empirical data. Chi2 test was used to compare fit between models.

RESULTS

The hypothesized model, with two latent concepts (readiness and adherence), fitted the data best (chi(2)=223.508, d.f.=129, p-value<0.0001, GFI=0.970, CFI=0.913, RMSEA=0.030), and significantly better than the models with adherence as the only latent concept.

CONCLUSION

Although the SEM technique could not rule out that other models might also fit the data equally well, the hypothesized model, where readiness and adherence were two separate latent concepts, fitted data the best. This supports readiness as a distinct factor that influences adherence and hence treatment outcome. Increased attention should therefore be attached to interventions that focus on the individual' readiness for behavioural change, i.e. factors amendable to change and that can be addressed by the patients themselves.

PRACTICE IMPLICATIONS

Based on these results it seems necessary to shift focus from adherence to readiness, especially in conditions where treatment can be postponed such as antiretroviral treatment.

Adherence to treatment in Swedish HIV-infected patients

OBJECTIVES

The objectives were to assess the prevalence of adherence to antiretroviral treatment in Swedish human immunodeficiency virus (HIV)-infected patients and to evaluate factors associated with adherence.

METHODS

All HIV-treated patients, who attended one of 30 (of a total of 32) Swedish infectious diseases clinics, during 7 months, were asked to complete an anonymous questionnaire containing the 9-item Morisky Medication Adherence Scale (MMAS) and questions about other factors potentially affecting adherence. The summary score of MMAS ranges from 1 to 13, where 13 indicates perfect adherence; patients scoring 11 or above (corresponding to 95% adherence level) were classified as 'adherent'.

RESULTS AND DISCUSSION

In total 946 patients participated (response rate 97.5%). The proportion of patients who reported not missing a dose during the day prior to the completion of the questionnaire was 97% and the proportion classified as 'adherent' was 63%. 'Adherent' patients were more likely to have a good relationship with their health care professionals (P < 0.05) and not have problems with drugs or alcohol (P < 0.01). Being older (P < 0.01) and having a shorter time on current treatment (P < 0.01) and on treatment in total (P < 0.05) were factors also associated with good adherence.

CONCLUSION

Factors modifiable for interventions by health care professionals are patient-provider relationship, drug or alcohol problems and patients with long treatment periods.