Patient- and provider-reported adherence: toward a clinically useful approach to measuring antiretroviral adherence

Factors impacting medication adherence in a birth cohort at higher risk for Hepatitis C infection

Due to the high prevalence of Hepatitis C virus (HCV) infection among individuals born between 1945 and 1965, in 2012 the Centers for Disease Control and Prevention began recommending HCV screening for this birth cohort. As adherence to HCV treatment is essential for sustained virologic response, identifying factors influencing medication adherence is important. The validated Adherence to Refills and Medications Scale (ARMS) is used to study recent medication adherence in those with chronic disease. This cross-sectional pilot study assesses factors associated with reduced adherence, indicated by higher ARMS scores, among individuals in this birth cohort. To elucidate factors associated with medication adherence, measured by the ARMS score, among a birth cohort at higher risk for HCV to guide future treatment and improve adherence. Patients born between 1945 and 1965, accessing care at an academic family medicine clinic, were recruited between April and June 2019. Demographics, prior HCV diagnosis, HCV risk factors (prior imprisonment, tattoos, and intravenous drug use), depression assessment (Patient Health Questionnaire-9), adverse childhood experiences (ACEs), and ARMS scores were collected. Mean ARMS scores were compared using t tests and analysis of variance (α = 0.05), while multiple variable models were performed using linear regression. Women comprised 58% of participants (n = 76), 52% reported depression and 37% 4 or more ACEs. The mean ARMS score was 16.3 (SD = 3.43) and 10% reported prior diagnosis of HCV. In the final multiple variable model, ARMS scores were 2.3 points higher in those with mild depression (95% CI: 0.63, 4.04), 2.0 in those with at least 4 ACEs (95% CI: 0.55, 3.49), and 1.8 in those with tattoos (95% CI: 0.30, 3.28). ACEs and food insecurity were identified as confounding variables in those with moderate to severe depression. This study found medication adherence was related to depression, ACEs, tattoos, and food insecurity among patients in this birth cohort at higher risk for HCV.

Discordance between hemodialysis patients' reports and their physicians' estimates of adherence to dietary restrictions in Japan

INTRODUCTION

This study examined the discordance between hemodialysis patients' reports and their physicians' estimates of dietary restriction adherence and related factors in Japan.

METHODS

In a cross-sectional survey of 6,644 outpatients, physicians who estimated higher and lower adherence than their patients' self-reported were categorized as overestimation and underestimation in terms of discordance, respectively. Possible factors included clinical indicators, patient characteristics related to negative stereotypes, and health beliefs related to statistical discrimination.

RESULTS

The concordance rate was .069 based on the weighted kappa coefficient. The coefficients of acceptable serum potassium, prevalence of diabetes, and self-efficacy on overestimates were .663 , -.126, and -.132, respectively. The coefficients of these factors on underestimates were -.589, .338, and .145, respectively. All these coefficients were significant.

CONCLUSIONS

The discordance may be high and is related to physicians' clinical data reliance, negative stereotypes about patient characteristics, and a lack of understanding of patients' health beliefs.

Apathy is Associated with Critical Psychological Determinants of Medication Adherence in HIV Disease

Apathy is common in HIV, separable from depression, and has been associated with non-adherence to antiretroviral therapy (ART). We examined the associations between apathy and critical psychological determinants of ART adherence, as per the information-motivation-behavioral model, in 85 persons living with HIV. Apathy was measured using a composite of the apathy subscale of the Frontal Systems Behavioral Scale and the vigor-activation scale of the Profile of Mood States. Independent of major depressive disorder, apathy was related at small-to-medium effect sizes with motivation to adhere and self-efficacy for health-related decision-making and medication management, but not with HIV knowledge or medication management skills. These findings suggest that apathy plays a unique role in several critical health adherence determinants and support the importance of assessment and management of apathy to maximize health outcomes among individuals with HIV disease.

Treatment Adherence in Patients with Lung Cancer from Prospects of Patients and Physicians

Purpose:

Adherence to treatment can be defined as the degree to which a patient’s behavior is consonant with medical or health advice he or she receive as part of his treatment regimen. The aim of this study was: 1) to measure the rate of treatment adherence to among patients with lung cancer from the prospect of both patients and physicians, 2) to measure the degree of concordance between the two prospect, and 3) to identify factors related to adherence for both prospect (patients and physicians).

Materials and Methods:

A total of 250 patients were included in this study. Information about socio-economic characteristics, depressive and anxiety symptoms (Hospital Anxiety and Depression scale), nicotine dependence (Fagerstrom scale), barriers to accessing care, and the level of treatment adherence was collected through interview. Physicians were enquired about disease and treatment variables as well as patients’ level of adherence.

Results:

From the patient perspective, only 1.2% of patients displayed poor adherence; whereas the corresponding percentage among physicians was 12.4%. The concordance between the two was low: 0.244. The correlation of measurements made on the same individual was found to be equal to 0.14. Barriers to accessing medication (O.R.=2.82, 95% C.I.: 1.01-8.09) was the only risk factor when adherence was self-rated; barriers to accessing medication (O.R.=2.45, 95% C.I.: 1.03-5.86), education equal to 12 years (O.R.=0.33, 95% C.I.: 0.13-0.82) or higher than 12 years (O.R.=0.28, 95% C.I.: 0.08-0.96), nicotine dependence (O.R.=1.41, 95% C.I. 1.17-1.69) and HADS anxiety score (O.R.=1.15, 95% C.I. 1.03-1.30) were the predictors in physicians’ rating.

Conclusions:

Differences in rating adherence may underpin communication gaps between patients and physicians. Systemic determinants of poor adherence should not be overlooked. A concerted effort by researchers, physicians and policy makers in defining as well as communicating adherence, while removing its barriers should be made.

Men's beliefs about treatment for erectile dysfunction-what influences treatment use? A systematic review

Successful treatment of erectile dysfunction (ED) is associated with improvements in quality of life; however, treatment utilisation is sub-optimal. The aim of this systematic review was to identify the rates of ED treatment utilisation and the barriers and enablers men experience when using treatment. We searched: MEDLINE^®, Embase, the Cochrane library; AMED; HMIC; HTA; CINAHL; PsychARTICLES; PsychINFO up to August 2018. Data on rates of treatment utilisation and barriers and enablers of utilisation were extracted and summarised. Fifty studies were included. Discontinuation rates ranged from 4.4 to 76% for phosphodiesterase type 5 inhibitors, 18.6 to 79.9% for intracavernosal injections, and 32 to 69.2% for urethral suppositories. In relation to those with a penile prosthesis, 30% discontinued having sex due to, e.g. device complications, lack of partner or a loss of sexual interest. Most research included in the current review examined barriers to treatment utilisation and therefore focussed on reasons for discontinuing treatment. However, a small number explored factors that men found helpful with regards to treatment utilisation. The most prevalent barriers to utilisation were treatment ineffectiveness, side effects, the quality of men's intimate relationships and treatment costs. With regards to treatment enablers, the most salient finding was that men who reported side effects to a healthcare professionals (HCPs) were significantly less likely to discontinue treatment. There were limitations in methodology in that the studies did not use validated measures of treatment utilisation or barriers and enablers and no study used psychological theory to inform the examination of factors that influenced treatment utilisation. This review identifies a number of influential factors relating to ED treatment utilisation and highlights the importance of men's beliefs with regards to ED and its treatment. Beliefs are potentially modifiable and therefore the findings of this review highlight important considerations for HCPs with regards to supporting men to make better use of treatment.

Characteristics Associated With Clinically Important Treatment Responses in Women Undergoing Nonsurgical Therapy for Fecal Incontinence

OBJECTIVE

To identify baseline clinical and demographic characteristics associated with clinically important treatment responses in a randomized trial of nonsurgical therapies for fecal incontinence (FI).

METHODS

Women (N = 296) with FI were randomized to loperamide or placebo- and manometry-assisted biofeedback exercises or educational pamphlet in a 2 × 2 factorial design. Treatment response was defined in 3 ways from baseline to 24 weeks: minimal clinically important difference (MID) of -5 points in St. Mark's score, ≥50% reduction in FI episodes, and combined St. Mark's MID and ≥50% reduction FI episodes. Multivariable logistic regression models included baseline characteristics and treatment groups with and without controlling for drug and exercise adherence.

RESULTS

Treatment response defined by St. Mark's MID was associated with higher symptom severity (adjusted odds ratio [aOR] 1.20, 95% confidence interval [CI] 1.11-1.28) and being overweight vs normal/underweight (aOR 2.15, 95% CI 1.07-4.34); these predictors remained controlling for adherence. Fifty percent reduction in FI episodes was associated with the combined loperamide/biofeedback group compared with placebo/pamphlet (aOR 4.04, 95% CI 1.36-11.98), St. Mark's score in the placebo/pamphlet group (aOR 1.29, 95% CI 1.01-1.65), FI subtype of urge vs urge plus passive FI (aOR 2.39, 95% CI 1.09-5.25), and passive vs urge plus passive FI (aOR 3.26, 95% CI 1.48-7.17). Controlling for adherence, associations remained, except St. Mark's score.

DISCUSSION

Higher severity of FI symptoms, being overweight, drug adherence, FI subtype, and combined biofeedback and medication treatment were associated with clinically important treatment responses. This information may assist in counseling patients, regarding efficacy and expectations of nonsurgical treatments of FI.

Controlling faecal incontinence in women by performing anal exercises with biofeedback or loperamide: a randomised clinical trial

BACKGROUND

Well designed, large comparative effectiveness trials assessing the efficacy of primary interventions for faecal incontinence are few in number. The objectives of this study were to compare different combinations of anorectal manometry-assisted biofeedback, loperamide, education, and oral placebo.

METHODS

In this randomised factorial trial, participants were recruited from eight clinical sites in the USA. Women with at least one episode of faecal incontinence per month in the past 3 months were randomly assigned 0·5:1:1:1 to one of four groups: oral placebo plus education only, placebo plus anorectal manometry-assisted biofeedback, loperamide plus education only, and loperamide plus anorectal manometry-assisted biofeedback. Participants received 2 mg per day of loperamide or oral placebo with the option of dose escalation or reduction. Women assigned to biofeedback received six visits, including strength and sensory biofeedback training. All participants received a standardised faecal incontinence patient education pamphlet and were followed for 24 weeks after starting treatment. The primary endpoint was change in St Mark's (Vaizey) faecal incontinence severity score between baseline and 24 weeks, analysed by intention-to-treat using general linear mixed modelling. Investigators, interviewers, and outcome evaluators were masked to biofeedback assignment. Participants and all study staff other than the research pharmacist were masked to medication assignment. Randomisation took place within the electronic data capture system, was stratified by site using randomly permuted blocks (block size 7), and the sizes of the blocks and the allocation sequence were known only to the data coordinating centre. This trial is registered with ClinicalTrials.gov, number NCT02008565.

FINDINGS

Between April 1, 2014, and Sept 30, 2015, 377 women were enrolled, of whom 300 were randomly assigned to placebo plus education (n=42), placebo plus biofeedback (n=84), loperamide plus education (n=88), and the combined intervention of loperamide plus biofeedback (n=86). At 24 weeks, there were no differences between loperamide versus placebo (model estimated score change -1·5 points, 95% CI -3·4 to 0·4, p=0·12), biofeedback versus education (-0·7 points, -2·6 to 1·2, p=0·47), and loperamide and biofeedback versus placebo and biofeedback (-1·9 points, -4·1 to 0·3, p=0·092) or versus loperamide plus education (-1·1 points, -3·4 to 1·1, p=0·33). Constipation was the most common grade 3 or higher adverse event and was reported by two (2%) of 86 participants in the loperamide and biofeedback group and two (2%) of 88 in the loperamide plus education group. The percentage of participants with any serious adverse events did not differ between the treatment groups. Only one serious adverse event was considered related to treatment (small bowel obstruction in the placebo and biofeedback group).

INTERPRETATION

In women with normal stool consistency and faecal incontinence bothersome enough to seek treatment, we were unable to find evidence against the null hypotheses that loperamide is equivalent to placebo, that anal exercises with biofeedback is equivalent to an educational pamphlet, and that loperamide and biofeedback are equivalent to oral placebo and biofeedback or loperamide plus an educational pamphlet. Because these are common first-line treatments for faecal incontinence, clinicians could consider combining loperamide, anal manometry-assisted biofeedback, and a standard educational pamphlet, but this is likely to result in only negligible improvement over individual therapies and patients should be counselled regarding possible constipation.

FUNDING

Eunice Kennedy Shriver National Institute of Child Health and Human Development and the National Institutes of Health Office of Research on Women's Health.

Factors affecting adherence to antiepileptic medications among Sudanese individuals with epilepsy: A cross-sectional survey

Background:

Nonadherence to medication is widespread in epilepsy and other chronic diseases. Studies reporting adherence to antiepileptic medications are very limited in African countries. Adherence reports from low income African countries are few in contrast to multiple studies from high-income countries. Therefore, the aim of this study is to measure the level of adherence to antiepileptic medication in Sudanese population.

Methods:

A descriptive cross-sectional study of 96 individuals with epilepsy recruited from neurology outpatient clinics in three tertiary centers in Sudan. Data were collected by using a structured questionnaire containing Morisky Medication Adherence Scale-4 (MMAS-4) and Belief about Medication Questionnaire and analyzed by statistical package of social sciences.

Results:

About 35% of patients were estimated to be nonadherent. Most of the patients (93%) acknowledged their need for antiepileptic drugs. However, 35% had high concern score. Adherence is affected by attitude toward antiepileptic drugs (AEDs) and presence of side effects to AEDs. The relation between side effects and adherence was significant (P value 0.000). Furthermore, there was a statistically insignificant relation between the number of drugs used and adherence (P value 0.002). There was a significant relation between adherence, necessity mean score, concern mean score, and necessity concern differential P value 0.000 for all.

Conclusion:

Nonadherence to antiepileptic medication was reported in almost in one third of individuals in this cohort. There were statistically significant associations between nonadherence and both side effects and number of medications used in the treatment of epilepsy. Therefore, family physician should always check compliance with antiepileptic medication. Patient's education about adherence to medication through family physician may in part decrease the recurrence of epileptic seizures. Further research is needed to explore ways to increase adherence with AEDs in a low resource country like Sudan.

Adherence assessment practices in haemodialysis settings: A qualitative exploration of nurses and pharmacists' perspectives

AIMS AND OBJECTIVES

To explore clinician assessment of patient adherence and identify strategies to improve adherence assessment practices in haemodialysis settings.

BACKGROUND

Patients with chronic kidney disease undergoing haemodialysis are typically prescribed complex regimens; as such, they are at high risk of medication nonadherence. Current clinical practices focus on prescribing medications; however, little attention is paid to measuring and ensuring patient adherence to their prescribed treatments.

DESIGN

A qualitative study.

METHODS

Semi-structured individual interviews were conducted in November and December 2016, with 12 nurses and 6 pharmacists, working in Australian haemodialysis settings. The study was conducted and reported in accordance with COREQ guidelines.

RESULTS

Participants were 25-60 years old and had 1-27 years of experience in dialysis. Seven themes related to assessing adherence were identified: prioritisation of resources, interplay between workload and available time, awareness of formalised adherence measures and training deficits, concerns about practicality/suitability of adherence measures, communication of assessment services, patient participation and trust. Three themes related to strategies for improving adherence assessment practices were identified: formalisation of adherence assessment process, integration of assessment processes and tools into routine, and use of multidisciplinary support to assess and promote adherence.

CONCLUSIONS

Current adherence assessment practices could be improved through formalisation and integration of the assessment process into dialysis unit policy/procedures. Additionally, as barriers to assessing adherence were identified at organisational, professional and patient levels, there is a need to address barriers from each level in order to improve adherence assessment practices in haemodialysis settings.

RELEVANCE TO CLINICAL PRACTICE

This qualitative study highlights the challenges and practical ways by which adherence assessment practices could be improved in haemodialysis settings. This would encourage renal clinicians to actively participate in adherence assessment and promotion activities to ensure patients benefit from their therapies.

Use of a Self-Report Medication Adherence Scale for Measuring Adherence to Antiretroviral Therapy in Patients With HIV/AIDS

BACKGROUND AND PURPOSE

This study examined the psychometric properties of a 9-item Morisky Medication Adherence Scale (MMAS-9) adapted specifically for patients with HIV/AIDS.

METHODS

We used data from two randomized controlled trials investigating telephone-delivered interventions for improving adherence to antiretroviral therapy to assess reliability (Cronbach's α and Pearson's product correlation) and validity (convergent and concurrent) of the MMAS-9.

RESULTS

The internal consistency (Cronbach's α) of the MMAS-9 was .66 (study 1) and .69 (study 2); 3-month test-retest reliability (Pearson's correlation) ranged from .50 to .74. Validity was supported by associations with electronic event monitored adherence, social support, depressive symptoms, self-efficacy, stigma, regimen complexity, and impact of side effects in the hypothesized direction.

CONCLUSIONS

The adapted MMAS-9 demonstrated good convergent validity but somewhat lower internal consistency reliability than other reports.

Rationale, design, and methodology of a trial evaluating three models of care for HCV treatment among injection drug users on opioid agonist therapy

BACKGROUND

People who inject drugs (PWID) constitute 60% of the approximately 5 million people in the U.S. infected with hepatitis C virus (HCV). Treatment of PWID is complex due to addiction, mental illness, poverty, homelessness, lack of positive social support, poor adherence-related skills, low motivation and knowledge, and poor access to and trust in the health care system. New direct-acting antiviral medications are available for HCV with high cure rates and few side effects. The life expectancy and economic benefits of new HCV treatments will not be realized unless we determine optimal models of care for the majority of HCV-infected patients. The purpose of this study is to evaluate the effectiveness of directly observed therapy and group treatment compared with self-administered individual treatment in a large, urban opioid agonist therapy clinic setting in the Bronx, New York.

METHODS/DESIGN

In this randomized controlled trial 150 PWID with chronic HCV were recruited from opioid agonist treatment (OAT) clinics and randomized to one of three models of onsite HCV treatment in OAT: 1) modified directly observed therapy; 2) group treatment; or 3) control - self-administered individual treatment. Participants were age 18 or older, HCV genotype 1, English or Spanish speaking, treatment naïve (or treatment experienced after 12/3/14), willing to receive HCV treatment onsite, receiving methadone or buprenorphine at the medication window at least once per week, and able to provide informed consent. Outcomes of interest include adherence (as measured by self-report and electronic blister packs), HCV treatment completion, sustained virologic response, drug resistance, and cost-effectiveness.

DISCUSSION

This paper describes the design and rationale of a randomized controlled trial comparing three models of care for HCV therapy delivered in an opioid agonist treatment program. Our trial will be critical to rigorously identify models of care that result in high adherence and cure rates. Use of blister pack technology will help us determine the role of adherence in successful cure of HCV. Moreover, the trial methodology outlined here can serve as a template for the development of future programs and studies among HCV-infected drug users receiving opioid agonist therapy, as well as the cost-effectiveness of such programs.

TRIAL REGISTRATION

This trial was registered with ClinicalTrials.gov ( NCT01857245 ). Trial registration was obtained prospectively on May 20th, 2013.

Adherence and virologic outcomes among treatment-naïve veteran patients with human immunodeficiency virus type 1 infection

Many studies have estimated the association between the adherence to antiretroviral therapies and human immunodeficiency virus (HIV) patients' virologic/immunologic outcomes. However, evidence is lacking on the causal effect of adherence on the outcomes. The goal of this study is to understand whether near perfect adherence is necessary to achieve optimal virologic outcome and also to investigate the effect of initial adherence to antiretroviral therapies on initial viral suppression by different regimens. A cohort study was conducted on HIV veterans initiating antiretroviral therapies in 1999 to 2015. The primary outcome was the first viral suppression occurred within 30 to 60 days since the index date. Multiple imputation was used to impute the missing value of virologic outcomes. The inverse probability of treatment weighting (IPTW) method was applied to estimate the viral suppression rate at each specific adherence category for each regimen category. Marginal structural models with IPTW were used to estimate the risk of viral suppression in lower-adherence categories in comparison to near-perfect adherence level ≥95%. Data showed that lower adherence caused lower viral suppression rate, with the association differentiated by the regimen. Patients on integrase strand transfer had the highest viral suppression rate, with patients on protease inhibitors having the lowest rate. Regardless of regimens, the viral suppression rate among patients at initial adherence of 75 to <95% was not statistically different from patients at adherence of ≥95%; however, the differences might be clinically significant.

Accuracy of a screening tool for medication adherence: A systematic review and meta-analysis of the Morisky Medication Adherence Scale-8

Background

This systematic review examined the reliability and validity of the Morisky Medication Adherence Scale-8 (MMAS-8), which has been widely used to assess patient medication adherence in clinical research and medical practice.

Methods

Of 418 studies identified through searching 4 electronic databases, we finally analyzed 28 studies meeting the selection criteria of this study regarding the reliability and validity of MMAS-8 including sensitivity and specificity. Meta-analysis for Cronbach’s α, intraclass correlation coefficient (ICC), sensitivity and specificity to detect a patient with nonadherence to medication were performed. The pooled estimates for Cronbach’s α and ICC were calculated using the random-effects weighted T transformation. A bivariate random-effects model was used to estimate pooled sensitivity and specificity.

Findings

The pooled Cronbach's α estimate for type 2 diabetes group in 7 studies and osteoporosis group in 3 studies were 0.67 (95% Confidence Interval(CI), 0.65 to 0.69) and 0.77 (95% CI, 0.72 to 0.83), respectively. With regard to test-retest, the pooled ICC for type 2 diabetes group in 3 studies and osteoporosis group in 2 studies were 0.81 (95% CI, 0.75 to 0.85) and 0.80 (95% CI, 0.74 to 0.85). For a cut-off value of 6, the pooled sensitivity and specificity in 12 studies were 0.43 (95% CI, 0.33 to 0.53) and 0.73 (95% CI, 0.68 to 0.78), respectively.

Conclusions

The MMAS-8 had acceptable internal consistency and reproducibility in a few diseases like type 2 diabetes. Using the cut-off value of 6, criterion validity was not enough good to validly screen a patient with nonadherence to medication. However, this study did not calculated a pooled estimate for criterion validity using the higher values than 6 as a cut-off value since most of included individual studies did not report criterion validity based on those values.

Health Technology-Enabled Interventions for Adherence Support and Retention in Care Among US HIV-Infected Adolescents and Young Adults: An Integrative Review

The objective of this integrative review was to describe current US trends for health technology-enabled adherence interventions among behaviorally HIV-infected youth (ages 13-29 years), and present the feasibility and efficacy of identified interventions. A comprehensive search was executed across five electronic databases (January 2005-March 2016). Of the 1911 identified studies, nine met the inclusion criteria of quantitative or mixed methods design, technology-enabled adherence and or retention intervention for US HIV-infected youth. The majority were small pilots. Intervention dose varied between studies applying similar technology platforms with more than half not informed by a theoretical framework. Retention in care was not a reported outcome, and operationalization of adherence was heterogeneous across studies. Despite these limitations, synthesized findings from this review demonstrate feasibility of computer-based interventions, and initial efficacy of SMS texting for adherence support among HIV-infected youth. Moving forward, there is a pressing need for the expansion of this evidence base.

Association Between Adherence to Pharmacotherapy and Outcomes in Type 2 Diabetes: A Meta-analysis

OBJECTIVE

A previous study suggests an association between poor medication adherence and excess mortality in chronic disease. The purpose of this study was to assess the association between medication adherence and risk of cardiovascular disease (CVD), all-cause mortality, and hospitalization in type 2 diabetes.

RESEARCH DESIGN AND METHODS

We conducted an electronic search on many electronic databases from inception to 27 April 2016. We selected randomized controlled trials and case-control and cohort studies reporting on CVD, all-cause mortality, or hospitalization outcomes by adherence in adults with type 2 diabetes. Two reviewers independently screened for eligible studies and extracted outcome data. Pooled relative risks (RRs) were calculated using a random-effects meta-analysis; risk of bias in each of the included studies was assessed using the GRADE approach.

RESULTS

Eight observational studies were included (n = 318,125). The mean rate of poor adherence was 37.8% (95% CI 37.6-38.0). Adjusted estimates were provided by five studies only. The RRs of good (≥80%) versus poor adherence to medication were 0.72 (95% CI 0.62-0.82, I² = 0%, three studies) for all-cause mortality and 0.90 (0.87-0.94, I² = 63%, seven studies) for hospitalization. No evidence of small study bias was observed. Only one study reported CVD outcomes by adherence.

CONCLUSIONS

We identified no trials reporting on outcomes by adherence, suggesting a systematic failure to include this information. Pooled estimates from available observational studies suggest that good medication adherence is associated with reduced risk of all-cause mortality and hospitalization in people with type 2 diabetes, although bias cannot be excluded as an explanation for these findings.

Adherence to On-Time ART Drug Pick-Up and Its Association with CD4 Changes and Clinical Outcomes Amongst HIV Infected Adults on First-Line Antiretroviral Therapy in Nigerian Hospitals

Medication adherence is a major determinant of antiretroviral treatment (ART) success. Promptness in medication refill pick-ups may give an indication of medication adherence. This study determined medication refill adherence among HIV positive patients on ART and its association with treatment outcomes in HIV treatment centers in Nigeria. This retrospective multi-center cohort study involved a review of ART refill records for 3534 HIV-positive patients aged 18-60 years who initiated first-line ART between January 2008 and December 2009 and were on therapy for ≥18 months after ART initiation. Drug refill records of these patients for 10 consecutive refill visits after ART initiation were analyzed. The first ten consecutive refill appointment-keeping rates after ART initiation ranged from 64.3 % to 76.1 % which decreased with successive visits. Altogether, 743 (21.1 %) patients were deemed adherent, meaning they picked up their drugs within 7 days of the drug refill appointment date on at least nine out of ten refill visits. The adherent group of patients had a mean CD4 cells increase of 206 ± 6.1 cells/dl after 12 months of ART compared to 186 ± 7.1 cells/dl reported among the nonadherent group (p = 0.0145). The proportion of patients in the adherent category who showed no OIs after 12 months on ART (81 %) was significantly higher when compared to the proportion in the non-adherent category (23.5 %), (p = 0.008). The multivariate analysis showed that the odds of being adherent was 2-3 times more in patients who had a baseline CD4 count of less than 200 cells/dl compared to those with a baseline CD4 of >350 cells/dl. (AOR 2.43, 95 % CI 1.62-3.66). In addition, for patients with baseline CD4 cell count of 201-350 cells/dl, the odds of being adherent was found to be 1.9 compared to those with baseline CD4 of greater than 350 cells/dl (AOR 1.93, 95 % CI 1.27-2.94). Pharmacy refill data can serve as an adherence measure. Adherence to on-time drug pickup on ≥90 % of refill appointments was associated with a better CD4 count response and a reduction in the presence of opportunistic infections in ART patients after 12 months of treatment.

Factors associated with medication adherence in patients with human immunodeficiency virus in South Korea

This study aimed to identify the factors associated with medication adherence in human immunodeficiency virus (HIV) patients in South Korea. A cross-sectional study was conducted from six hospitals participating in the Nationwide Specialized Counseling Program for HIV infected patients from 22 February to 10 May 2010. A total of 300 HIV patients have completed a self-administered questionnaire. Among 300 patients, 230 patients had above 95% medication adherence. Binary logistic regression analysis revealed that having medical insurance (p = .003) and a good relationship with the medical team (p = .046) were the main factors affecting medication adherence in HIV patients. In conclusion, medical insurance through the National Health Insurance Service and a good relationship between HIV infected patients and physicians are the main influencing factors that impact medication adherence in countries with low economic barriers to treatment.

Highly specific reasons for nonadherence to antiretroviral therapy: results from the German adherence study

BACKGROUND

Reasons for and frequency of nonadherence to antiretroviral therapy (ART) may have changed due to pharmacological improvements. In addition, the importance of known non-pharmacologic reasons for nonadherence is unclear.

METHODS

We performed a cross-sectional, noninterventional, multicenter study to identify current reasons for nonadherence. Patients were categorized by physicians into the following adherence groups: good, unstable, or poor adherence. Co-variables of interest included age, sex, time since HIV diagnosis, ART duration, current ART regimen, HIV transmission route, comorbidity, HIV-1 RNA viral load (VL), and CD4 cell count. Patients self-reported the number of missed doses and provided their specific reasons for nonadherent behavior. Statistical analyses were performed using Fisher's extended exact test, Kruskal-Wallis test, and logistic regression models.

RESULTS

Our study assessed 215 participants with good (n=162), unstable (n=36), and poor adherence (n=17). Compared to patients with good adherence, patients with unstable and poor adherence reported more often to have missed at least one dose during the last week (good 11% vs unstable 47% vs poor 63%, p<0.001). Physicians' adherence assessment was concordant with patients' self-reports of missed doses during the last week (no vs one or more) in 81% cases. Similarly, we found a strong association of physicians' assessment with viral suppression. Logistic regression analysis showed that "reduced adherence" - defined as unstable or poor - was significantly associated with patients <30 years old, intravenous drug use, history of acquired immune deficiency syndrome (AIDS), and psychiatric disorders (p<0.05). Univariate analyses showed that specific reasons, such as questioning the efficacy/dosing of ART, HIV stigma, interactive toxicity beliefs regarding alcohol and/or party drugs, and dissatisfaction with regimen complexity, correlated with unstable or poor adherence (p<0.05).

CONCLUSION

Identification of factors associated with poor adherence helps in identifying patients with a higher risk for nonadherence. Reasons for nonadherence should be directly addressed in every patient, because they are common and constitute possible adherence intervention points.

Coronary Artery Bypass Graft Versus Percutaneous Coronary Intervention

Background:

Multiple studies have compared coronary artery bypass graft (CABG) with percutaneous coronary interventions (PCI) for coronary revascularization. There is considerable evidence that adherence to medical therapy can affect the outcomes of therapeutic interventions. However, the long-term influence of compliance with recommended medical therapy on the comparative outcomes of CABG versus PCI remains to be defined.

Methods:

All non–ST-segment–elevation myocardial infarction patients undergoing coronary revascularization in an 8-hospital network were followed for up to 8 years to determine medication history and major adverse cardiac events: all-cause mortality, nonfatal myocardial infarction, and reintervention. All mortalities were checked against the Social Security Death Index. Survival curves were derived with Kaplan-Meier methods; hazard ratios were calculated with the Cox proportional hazard model; and propensity score matching was used to account for differences in patient selection.

Results:

Among the 973 CABG and 2255 PCI patients, Kaplan-Meier major adverse cardiac event–free survival curves demonstrated a significant benefit for antiplatelet, lipid-lowering, and β-blocker therapy in both the CABG and PCI groups ( P =0.001 for all 3 medications). Cox regression identified compliance with optimal medical therapy as a more powerful predictor of major adverse cardiac event–free survival than choice of therapy (hazard ratio for noncompliance=2.79; 95% confidence limits, 2.19–3.54; P <0.001; hazard ratio for PCI versus CABG=1.68, 95% confidence limits, 138–2.04; P <0.001). In propensity-matched patients, CABG outcomes were superior to PCI outcomes in patients nonadherent to optimal medical therapy ( P =0.001) but were not different in patients adherent to optimal medical therapy ( P =0.574).

Conclusions:

Regardless of coronary revascularization strategy, medication adherence has a dramatic effect on long-term outcome. Among comparable patients who adhere to optimal medical therapy, outcomes of PCI and CABG may not differ; however, among nonadherent patients, CABG affords better major adverse cardiac event–free survival. Therefore, patient compliance with medical therapy may inform clinical decision making and should be incorporated into all future comparative studies of comparative coronary revascularization strategies.

Effects of Quality of Life and Coping on Depression among Adults Living with HIV/AIDS

This prospective study examined the effect of maladaptive coping strategies and psychological quality of life (QOL) on depression at two time points in a diverse sample of persons living with HIV/AIDS ( N = 85). The use of maladaptive coping strategies to deal with the stress of living with HIV/AIDS, particularly engaging in various kinds of avoidant behaviors, was significantly associated with greater depression at baseline and increased depression at three months. QOL was the single most important predictor of depression. In an effort to develop effective clinical methods aimed at decreasing depression among adults living with HIV, future studies need to focus on improving quality of life and increasing adaptive coping strategies associated with the stress of living with HIV/AIDS.

Which adherence measure - self-report, clinician recorded or pharmacy refill - is best able to predict detectable viral load in a public ART programme without routine plasma viral load monitoring?

OBJECTIVE

Combination antiretroviral therapy (cART) suppresses viral replication to an undetectable level if a sufficiently high level of adherence is achieved. We investigated which adherence measurement best distinguishes between patients with and without detectable viral load in a public ART programme without routine plasma viral load monitoring.

METHOD

We randomly selected 870 patients who started cART between May 2009 and April 2012 in 10 healthcare facilities in Addis Ababa, Ethiopia. Six hundred and sixty-four (76.3%) patients who were retained in HIV care and were receiving cART for at least 6 months were included and 642 had their plasma HIV-1 RNA concentration measured. Patients' adherence to cART was assessed according to self-report, clinician recorded and pharmacy refill measures. Multivariate logistic regression model was fitted to identify the predictors of detectable viremia. Model accuracy was evaluated by computing the area under the receiver operating characteristic (ROC) curve.

RESULT

A total of 9.2% and 5.5% of the 642 patients had a detectable viral load of ≥40 and ≥400 RNA copies/ml, respectively. In the multivariate analyses, younger age, lower CD4 cell count at cART initiation, being illiterate and widowed, and each of the adherence measures were significantly and independently predictive of having ≥400 RNA copies/ml. The ROC curve showed that these variables altogether had a likelihood of more than 80% to distinguish patients with a plasma viral load of ≥400 RNA copies/ml from those without.

CONCLUSION

Adherence to cART was remarkably high. Self-report, clinician recorded and pharmacy refill non-adherence were all significantly predictive of detectable viremia. The choice for one of these methods to detect non-adherence and predict a detectable viral load can therefore be based on what is most practical in a particular setting.

Tenofovir exposure alters associations of serum bicarbonate with chronic kidney disease risk in HIV-infected veterans

OBJECTIVE

Among HIV-infected persons, tenofovir disoproxil fumarate (TDF) use is associated with higher risk of developing chronic kidney disease (CKD). Because lower serum bicarbonate concentrations may precede CKD onset, this study investigated the associations between TDF use and bicarbonate concentrations, and between bicarbonate with CKD risk among TDF users and nonusers.

METHODS

Retrospective cohort study of 16,070 HIV-infected US veterans who initiated antiretroviral therapy between 1997-2011. The association between TDF use with longitudinal bicarbonate concentrations and associations between bicarbonate with incident CKD stratified by TDF use (never, initial, and later user) were evaluated.

RESULTS

Compared with TDF users, never users had faster declines in bicarbonate concentrations: change in bicarbonate -0.11 mmol/l per year (95% confidence interval -0.16, -0.05), compared with -0.04 mmol/l per year (-0.06, 0.05) in initial users and -0.02 mmol/l per year (-0.05, 0.01) in later users. Low baseline bicarbonate (<22 mmol/l) was significantly associated with CKD risk among TDF never users (1.80; 1.21, 2.68), but not among TDF users (0.98; 0.69, 1.38). Similarly, declining bicarbonate concentrations were associated with higher CKD risk among never users (hazard ratio 1.67 per mmol/l; 1.34, 2.08), but not among TDF users (1.09; 0.98, 1.22). Interactions were highly significant for both analyses (P value = 0.001).

CONCLUSION

Despite associations with nephrotoxicity, TDF use was associated with higher serum bicarbonate concentrations longitudinally. Additionally, TDF use obscured the strong associations of bicarbonate with CKD risk in HIV-infected persons. Therefore, the role of bicarbonate concentrations as a tool to monitor kidney health in HIV-infected persons may be limited in the setting of TDF use.

Number of Drinks to "Feel a Buzz" by HIV Status and Viral Load in Men

The impact of HIV and its treatment on the effects of alcohol remain unclear. Blood alcohol concentrations have been noted to be higher in HIV infected individuals prior to antiretroviral initiation. Our goal was to compare number of drinks to "feel a buzz or high" among HIV infected and uninfected men, stratified by viral load (VL) suppression. Data includes 1478 HIV infected and 1170 uninfected men in the veterans aging cohort study who endorsed current drinking. Mean (SD) number of drinks to feel a buzz was 3.1 (1.7) overall. In multivariable analyses, HIV infected men reported a lower mean number of drinks to feel a buzz compared to uninfected men (coef = -14 for VL < 500; -34 for VL ≥ 500; p ≤ .05). Men with HIV, especially those with a detectable VL, reported fewer drinks to feel a buzz. Future research on the relationship between alcohol and HIV should consider the role of VL suppression.

Physician reported adherence to immunosuppressants in renal transplant patients: Prevalence, agreement, and correlates

OBJECTIVE

Adherence to immunosuppressants (IS) is crucial to prevent allograft rejection. Even though there is evidence that non-adherence to IS among kidney transplant recipients is common, it is rarely routinely assessed in clinical practice. Especially, little is known about how physicians estimate patients' adherence to IS medication.

METHODS

In a single center, cross-sectional study adult patients at least 1 year after kidney transplantation were asked to complete measures of adherence (BAASIS©, Transplant Effect Questionnaire) and of general psychopathology (anxiety, depression, perceived social support). Also the physicians were asked to estimate their patients' adherence. Medical data (time since transplantation, treatment for rejection, IS serum trough levels and target levels) were taken from the patients' charts.

RESULTS

Physicians rated 22 of 238 (9.2%) patients as non-adherent. Physicians' estimations of non-adherence were lower compared to the results of the self-ratings and biopsy-proven rejections. No association was found between physicians' estimates and the variability of IS through levels. Significantly more women and patients who reported that their native language was not German were rated as non-adherent by the physicians. Also, physician-rated non-adherent patients reported significantly higher depression and anxiety scores as well as less social support compared to adherent patients.

CONCLUSION

Our results suggest that physicians tend to underestimate patient non-adherence to IS medication. They appear to use observable cues such as sex, language skills, and elevated anxiety and depression scores in particular, to make inferences about an individual patient's adherence. Underestimation of medication non-adherence may impede physicians' ability to provide high quality care.

Controlling anal incontinence in women by performing anal exercises with biofeedback or loperamide (CAPABLe) trial: Design and methods

The goals of this trial are to determine the efficacy and safety of two treatments for women experiencing fecal incontinence. First, we aim to compare the use of loperamide to placebo and second, to compare the use of anal sphincter exercises with biofeedback to usual care. The primary outcome is the change from baseline in the St. Mark's (Vaizey) Score 24weeks after treatment initiation. As a Pelvic Floor Disorders Network (PFDN) trial, subjects are enrolling from eight PFDN clinical centers across the United States. A centralized data coordinating center supervises data collection and analysis. These two first-line treatments for fecal incontinence are being investigated simultaneously using a two-by-two randomized factorial design: a medication intervention (loperamide versus placebo) and a pelvic floor strength and sensory training intervention (anal sphincter exercises with manometry-assisted biofeedback versus usual care using an educational pamphlet). Interventionists providing the anal sphincter exercise training with biofeedback have received standardized training and assessment. Symptom severity, diary, standardized anorectal manometry and health-related quality of life outcomes are assessed using validated instruments administered by researchers masked to randomized interventions. Cost effectiveness analyses will be performed using prospectively collected data on care costs and resource utilization. This article describes the rationale and design of this randomized trial, focusing on specific research concepts of interest to researchers in the field of female pelvic floor disorders and all other providers who care for patients with fecal incontinence.

Medication adherence in type 2 diabetes patients in Nigeria

BACKGROUND

Medication adherence is a major universal factor influencing patient health outcomes, particularly in chronic diseases such as diabetes. Poor adherence to antidiabetes medication can cause therapeutic failure, leading to manifestation of diabetes-related complications, such as retinopathy, neuropathy, nephropathy, etc., reduced quality of life, and increased healthcare costs. To forestall these, likely predictors of medication nonadherence should be assessed and addressed appropriately. The purpose of this work was therefore to assess medication adherence among type 2 diabetes patients and to identify patient characteristics and probable factors associated with nonadherence.

SUBJECTS AND METHODS

A descriptive, cross-sectional research design was used. The study was conducted on 360 ambulatory type 2 diabetes patients attending an endocrinology clinic between June 2012 and February 2013. The eight-item Modified Morisky Adherence Scale was used to assess medication adherence; sociodemographic information and respondents' opinion on the possible barrier(s) to medication adherence were also obtained. Data were analyzed using SPSS version 14.0 software (SPSS, Inc., Chicago, IL).

RESULTS

Of the 303 patients included in the final analysis, 19.8% of respondents were judged to be highly adherent. Medium and low adherers were 30.0% and 50.2%, respectively. The median adherence score was 5.75 (interquartile range, 4.5-7.0). Adherence to medication correlated with low literacy level (P=0.008), forgetfulness (P=0.009), high cost of medication (P=0.014), limited access to care (P=0.001), complexity of regimen (P=0.001), poor patient-provider communication (P=0.000), lack of trust in the provider (P=0.046), and depression (P=0.031). No statistically significant relationship was found between patients' characteristics and medication adherence.

CONCLUSIONS

Medication adherence was generally poor among the cohorts studied.

Depression and adherence to antiretroviral therapy in low-, middle- and high-income countries: a systematic review and meta-analysis

We investigated the associations between depressive symptoms and adherence to antiretroviral therapy (ART) among people living with HIV (PLHIV). We searched the PubMed, EMBASE and Cochrane CENTRAL databases for studies that reported an association between depression and adherence to ART as a primary or secondary outcome. We used a random-effect model to pool the risk estimates from the individual studies. The odds ratio (OR) with their 95 % CIs were used as summary estimates. Of 2861 citations, 111 studies that recruited 42,366 PLHIV met our inclusion criteria. When reported, the rate of PLHIV with depressive symptoms ranged from 12.8 to 78 % and the proportion of PLHIV who achieved good adherence (≥ 80 %) ranged from 20 to 98 %. There were no significant differences in rate of depressive symptoms in PLHIV by country income group; however, the proportion of PLHIV who achieved good adherence was significantly higher in lower-income countries (as defined in the 2012 World Bank Country Income Groups) (pooled rate=86 %) compared to higher-income countries (pooled rate=67.5 %; p< .05). We found that the likelihood of achieving good ART adherence was 42 % lower among those with depressive symptoms compared to those without (pooled OR=0.58, 95 % CI 0.55 to 0.62). The relationship between depressive symptoms and adherence to ART was consistent across the country's income group, study design and adherence rates. We found that the magnitude of the association significantly decreases with more recent publications and increasing study sample size. The higher the prevalence of depressive symptoms of PLHIV recruited in the studies, the lower the likelihood of achieving good adherence to ART. In conclusion, the likelihood of achieving good adherence was lower among those with depressive symptoms compared to those without.

[The lack of adherence to antiosteoporotic drugs: crossing methods, the key to adherence measurement?]

OBJECTIVE

To use two different techniques to assess adherence of patients treated with antiosteoporotic drug.

METHODS

This monocentric transversal study was performed on a 6 months period, on patients of a single French pharmacy treated with antiosteoporotic drugs. Adherence was assessed crossing 2 techniques (patient autoquestionnaire and medication possession ratio measurement). Statistical analysis consisted in a description of the population study and a multivariate logistic regression to identify the factors associated with a lack of observance.

RESULTS

Using the two techniques, the lack of adherence was estimated to be between 14 and 55%. Adherence was better in patients who were given dietetic advice or information about the usefulness of physical activity and worse in patients who reached menopause less than 23 years ago.

CONCLUSION

A better identification of patients with a lack of observance is possible by crossing several techniques to assess adherence of the patient to his antiosteoporotic drug.

Rationale and design of a randomized controlled trial of varenicline directly observed therapy delivered in methadone clinics

Background

Tobacco cessation medication adherence is one of the few factors shown to improve smoking cessation rates among methadone-maintained smokers, but interventions to improve adherence to smoking cessation medications have not yet been tested among methadone treatment patients. Methadone clinic-based, directly observed therapy (DOT) programs for HIV and tuberculosis improve adherence and clinical outcomes, but have not been evaluated for smoking cessation. We describe a randomized controlled trial to evaluate whether a methadone clinic-based, directly observed varenicline therapy program increases adherence and tobacco abstinence among opioid-dependent drug users receiving methadone treatment.

Methods/Design

We plan to enroll 100 methadone-maintained smokers and randomize them to directly observed varenicline dispensed with daily methadone doses or treatment as usual (self-administered varenicline) for 12 weeks. Our outcome measures are: 1) pill count adherence and 2) carbon monoxide-verified tobacco abstinence. We will assess differences in adherence and abstinence between the two treatment arms using repeated measures models.

Discussion

This trial will allow for rigorous evaluation of the efficacy of methadone clinic-based, directly observed varenicline for improving adherence and smoking cessation outcomes. This detailed description of trial methodology can serve as a template for the development of future DOT programs and can guide protocols for studies among opioid-dependent smokers receiving methadone treatment.

Trial Registration

clinicaltrials.gov NCT01378858

Adherence in psychiatry

The word 'adherence' refers to the provision of consistent support (eg. for a political party or religion) or the act of holding particular elements together (eg. in constructing a building). In the medical context, adherence refers to the extent to which patients take their medications as prescribed. While the terminology related to medical adherence has changed significantly over the past two millennia, the core issue has not. Most recently, the term 'adherence' has replaced the term 'compliance', although it still jostles with 'concordance' in a growing literature which focuses now, as always, on one key question: why do so many people seek treatment for illness but then decide not to take their prescribed medication? This is an important question, both in terms of public health and societal cost: in the US, up to 50% of patients do not take their prescribed medications, resulting in additional healthcare costs of $290 billion per year. The greatest cost of non-adherence, however, relates to prolonged illness, increased rates of relapse and reduced wellness.

A chronic kidney disease risk score to determine tenofovir safety in a prospective cohort of HIV-positive male veterans

OBJECTIVE

Tenofovir disoproxil fumarate is a widely used antiretroviral for HIV infection that has been associated with an increased risk of chronic kidney disease (CKD). Our objective was to derive a scoring system to predict 5-year risk of developing CKD in HIV-infected individuals and to estimate difference in risk associated with tenofovir use.

DESIGN

We evaluated time to first occurrence of CKD (estimated glomerular filtration rate <60 ml/min per 1.73 m(2)) in 21 590 HIV-infected men from the Veterans Health Administration initiating antiretroviral therapy from 1997 to 2010.

METHODS

We developed a point-based score using multivariable Cox regression models. Median follow-up was 6.3 years, during which 2059 CKD events occurred.

RESULTS

Dominant contributors to the CKD risk score were traditional kidney risk factors (age, glucose, SBP, hypertension, triglycerides, proteinuria); CD4(+) cell count was also a component, but not HIV RNA. The overall 5-year event rate was 7.7% in tenofovir users and 3.8% in nonusers [overall adjusted hazard ratio 2.0, 95% confidence interval (CI) 1.8-2.2]. There was a progressive increase in 5-year CKD risk, ranging from less than 1% (zero points) to 16% (≥9 points) in nonusers of tenofovir, and from 1.4 to 21.4% among tenofovir users. The estimated number-needed-to-harm (NNH) for tenofovir use ranged from 108 for those with zero points to 20 for persons with at least nine points. Among tenofovir users with at least 1 year exposure, NNH ranged from 68 (zero points) to five (≥9 points).

CONCLUSION

The CKD risk score can be used to predict an HIV-infected individual's absolute risk of developing CKD over 5 years and may facilitate clinical decision-making around tenofovir use.

Chronic myeloid leukemia patients' adherence to peroral tyrosine kinase inhibitors compared with adherence as estimated by their physicians

PURPOSE

To evaluate chronic myeloid leukemia (CML) patients' adherence to peroral tyrosine kinase inhibitors in Finland and to compare this with adherence as estimated by their physicians. Other aspects studied included how patients' knowledge of the disease and its treatment influence adherence.

MATERIALS AND METHODS

A total of 120 CML patients were contacted between June 2012 and September 2013 in eight secondary or tertiary care hospitals in Finland. Of these, 86 participated in the study. This covers approximately 20% of all Finnish CML patients. The mean age was 57.8 years and 52% were male. Of the patients, 79.1% were using imatinib, 10.5% dasatinib, and 10.5% nilotinib. The patient-reported adherence (experienced adherence) was evaluated using the eight-item Morisky Medication Adherence Scale (MMAS). In addition, the treating physicians were asked to give their subjective opinion on their patients' adherence (observed adherence). The experienced adherence was compared with the observed adherence using a three-level rating system (high, medium, low). All patients were personally interviewed and their demographic data collected. The statistical analysis of the data was based on descriptive statistics presented as frequencies, percentages, means, and medians. The kappa coefficient was calculated between the patient's and the doctor's assessment of adherence.

RESULTS

A total of 23% (20/86) of the patients were fully adherent according to the MMAS, while physicians evaluated 94% (80/86) of the patients as fully adherent. The physicians' estimate was too optimistic in 73% of cases. The discrepancy was confirmed by a kappa value of -0.004. The patients' knowledge of the disease and its treatment was poor in all adherence levels.

CONCLUSION

The patient-reported adherence to tyrosine kinase inhibitor treatments in Finland was found to be the same as that found in the majority of previous studies. However, there seems to be a very weak agreement between the patient's and the physician's assessment of adherence. This study suggests that physicians overestimate the adherence of CML patients and base their assessment primarily on the clinical treatment response.

Type 2 translational research for CKD

Strategies to effectively treat people with CKD have been identified by conventional clinical research. Despite this evidence, awareness, screening, detection, diagnosis, risk factor control, treatment, and outcomes remain substandard. Translating clinical evidence into actionable measures that reduce the burden of CKD is a pressing need. Expansion from a "bench-to-bedside" paradigm (conventional type 1 translation) to research that encompasses "clinic and community" is the core concept of type 2 translation. Specifically, this is the discipline of identifying factors and using strategies that lead to adoption, maintenance, and sustainability of science-based interventions in practice. This review identifies key elements of type 2 translational research and highlights the current scope of this type of research for CKD. For type 2 translation to achieve the goals of providing high-quality care and better health outcomes, key facilitators (e.g., theory-based frameworks, adaptable interventions, and inclusion of sustainability and evaluation metrics) and essential elements (e.g., multidisciplinary team care, health information technology, and stakeholder engagement) must be integrated. The National Institute of Diabetes and Digestive and Kidney Diseases recently funded five proposals that aim to improve outcomes for people with CKD, focusing on diverse components of the healthcare continuum: patient safety and transitions; delivery of high-quality, evidence-based CKD care; and elimination of disparities. The need for type 2 translational research in CKD is urgent because of preventable human suffering and unsustainable costs of providing care. Focus on the theory, framework, and approaches we have suggested may help us meet that challenge.

[Anticancer drug adherence]

A large number of anticancer drugs have been introduced during the two last decades with significant impact for survival, making cancer a chronic disease in a growing number of indications. However, these drugs are costly, induce adverse effects and their efficacy frequently depends on the dose. For all these reasons, adherence in cancer therapy is critical for an optimal benefit-risk ratio. Patient adherence remains virtually unexplored in many cancers, such as malignant blood diseases. When measured, adherence is poor, especially when the drug is administered as oral and prolonged therapy (hormonotherapy in breast cancer, imatinib). Physician nonadherence represents another form of drug misadministration; poorly documented, its mechanism remains obscure. Adherence may be measured by a panel of methods, each of them displaying limits and pitfalls, suggesting that several complementary methods should be used in the context of prospective studies. Risk factors are age, socio-educative profile, disease stage and physician profile. This review emphasizes some methods to prevent nonadherence. Finally, this review argues for prospective studies, which should integrate a social pharmacology approach, including medicine, psycho-sociology and economics.

Adherence to Antiretroviral Therapy and Its Effect on Survival of HIV-Infected Individuals in Jharkhand, India

Introduction

Research in India has extensively examined the factors associated with non-adherence to antiretroviral therapy (ART) with limited focus on examining the relationship between adherence to ART regimen and survival status of HIV infected patients. This study examines the effect of optimal adherence to ART on survival status of HIV infected patients attending ART centers in Jharkhand, India.

Materials and Methods

Data from a cohort of 239 HIV infected individuals who were initiated ART in 2007 were compiled from medical records retrospectively for 36 months. Socio-demographic characteristics, CD4 T cell count, presence of opportunistic infections at the time of ART initiation and ART regimen intake and survival status was collected periodically. Optimal adherence was assessed using pill count methods; patients who took <95% of the specified regimens were identified as non-adherent. Cox-proportional hazard model was used to determine the relative hazards of mortality.

Results

More than three-fourths of the patients were male, on an average 34 year old and median CD4 T cell count was 118 cells/cmm at the time of ART registration. About 57% of the patients registered for ART were found to be adherent to ART. A total of 104 patients died in 358.5 patient-years of observation resulting in a mortality rate of 29 per 100 patient-years (95% confidence interval (CI): 23.9–35.2) and median survival time of 6.5 months (CI: 2.7–10.9). The mortality rate was higher among patients who were non-adherent to ART (64.5, CI: 50.5–82.4) than who were adherent (15.4, CI: 11.3–21.0). The risk of mortality was fourfold higher among individuals who were non-adherent to ART than who were adherent (Adjusted hazard ratio: 3.9, CI: 2.6–6.0).

Conclusion

Adherence to ART is associated with a higher chance of survival of HIV infected patients, ascertaining the need for interventions to improve the ART adherence and early initiation of ART.

HIV seroprevalence, associated risk behavior, and alcohol use among male Rwanda Defense Forces military personnel

A cross-sectional study was conducted among active-duty male soldiers, aged ≥21 years, in the Rwanda Defense Forces (RDF) and included an anonymous behavioral survey and HIV rapid testing to determine risk factors associated with HIV seroprevalence. Overall prevalence was 2.6 % (95 % CI: 1.84-3.66); personnel who were divorced, separated or widowed, served ≥6 years, never deployed, uncircumcised, reported STI symptoms, had ≥6 lifetime sex partners, or screened positive for harmful alcohol use (via Alcohol Use Disorders Identification Test) had higher HIV prevalence. Ever being divorced, separated or widowed (OR = 29.8; 95 % CI: 5.5-159.9), and STI symptoms (OR = 3.4; 95 % CI: 1.5-7.6) were significantly associated with infection, after multivariable adjustment, while circumcision was protective (OR = 0.4; 95 % CI: 0.2-0.9). Despite mobility and other factors that uniquely influence HIV transmission in militaries, RDF prevalence was similar to the general population. A reason for this finding may be conservative sexual behavior combined with effective leadership-supported prevention programs. Data suggest a concentrated rather than generalized epidemic, with targets identified for intervention.

Patient adherence to antiviral treatment for chronic hepatitis B and C: a systematic review

INTRODUCTION

Poor adherence to treatment for various chronic diseases is a frequent phenomenon. Current guidelines for the treatment of chronic hepatitis B (HBV) and hepatitis C (HCV) recommend optimal adherence, since it has been suggested that poor adherence is associated with an increased risk of virological failure. We aimed to give an overview of studies exploring adherence to combination treatment (PEG-interferon plus ribavirin) for HCV and nucleos(t)ide analogues for HBV. Material and methods. A systematic review was conducted using the databases PubMed, Embase, Cochrane Library and Web of Knowledge. Search terms included "adherence" or "compliance" combined with "hepatitis B", "hepatitis C" or "viral hepatitis".

RESULTS

The final selection included 19 studies (13 HCV, 6 HBV). Large differences in patient numbers and adherence assessment methods were found between the various studies. For HCV mean adherence varied from 27 to 97%, whereas the proportion of patients with ≥ 80% adherence varied from 27 to 96%. Mean adherence reported in HBV studies ranged from 81 to 99%, with 66 to 92% of patients being 100% adherent. For both HCV and HBV studies, the highest adherence rates were reported in studies using self-report whereas lower adherence rates were reported in studies using pharmacy claims. Poor adherence to treatment was associated with an increased risk of virological failure.

CONCLUSION

Non-adherence to treatment in chronic viral hepatitis is not a frequent phenomenon. However, given the increased risk of virological failure in poorly adherent patients, clinicians should routinely address adherence issues in all patients treated for chronic viral hepatitis.

Ethanol concentration-dependent alterations in gene expression during acute binge drinking in the HIV-1 transgenic rat

BACKGROUND

Binge drinking of high ethanol (EtOH) concentration beverages is common among young adults and can be a risk factor for exposure to sexually transmitted diseases, including HIV-1. We used a novel noninfectious HIV-1 transgenic (HIV-1Tg) rat model that mimics HIV-1 patients in terms of altered immune responses and deficits in cognitive learning and memory to investigate EtOH concentration-dependent effects on 48 alcohol-modulated genes during binge EtOH administration.

METHODS

HIV-1Tg and control F344 rats were administered water, 8% EtOH, or 52% EtOH by gavage (i.g.) for 3 days (2.0 g/kg/d). Two hours after final treatment, blood, liver, and spleen were collected from each animal. Serum blood EtOH concentration (BEC) was measured, and gene expression in the liver and spleen was determined using a specifically designed PCR array.

RESULTS

The BEC was significantly higher in the 52% EtOH-treated HIV-1Tg rats compared with the 8% EtOH group; however, the BEC was higher in the 8% EtOH-treated control rats compared with the 52% EtOH group. There was no change in expression of the EtOH metabolism-related genes, Adh1, Adh4, and Cyp2e1, in either the 8 or 52% EtOH-treated HIV-1Tg rats, whereas expression of those genes was significantly higher in the liver of the 52% EtOH control rats, but not in the 8% EtOH group. In the HIV-1Tg rats, expression of the GABAA , metabotropic glutamate, and dopamine neurotransmitter receptor genes was significantly increased in the spleen of the 52% EtOH group, but not in the 8% EtOH group, whereas no change was observed in those genes in either of the control groups.

CONCLUSIONS

Our data indicate that, in the presence of HIV-1 infection, EtOH concentration-dependent binge drinking can have significantly different molecular effects.

Evaluation of the single-item self-rating adherence scale for use in routine clinical care of people living with HIV

The self-rating scale item (SRSI) is a single-item self-report adherence measure that uses adjectives in a 5-point Likert scale, from "very poor" to "excellent," to describe medication adherence over the past 4 weeks. This study investigated the SRSI in 2,399 HIV-infected patients in routine care at two outpatient primary HIV clinics. Correlations between the SRSI and four commonly used adherence items ranged from 0.37 to 0.64. Correlations of adherence barriers, such as depression and substance use, were comparable across all adherence items. General estimating equations suggested the SRSI is as good as or better than other adherence items (p's <0.001 vs. <0.001-0.99) at predicting adherence-related clinical outcomes, such as HIV viral load and CD4(+) cell count. These results and the SRSI's low patient burden suggest its routine use could be helpful for assessing adherence in clinical care and should be more widespread, particularly where more complex instruments may be impractical.

Comparing adherence to two different HIV antiretroviral regimens: an instrumental variable analysis

The objective of this observational cohort study was to compare adherence to protease inhibitor (PI)-based regimens or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. HIV-seropositive, antiretroviral-naïve patients initiating therapy between 1998 and 2006 were identified using Veterans Health Administration databases. First-year adherence ratios were calculated as proportion of days covered (PDC). Multivariable regressions were run with an indicator for PDC >95, 90, 85, and 80 % as the dependent variable and an indicator for a PI-based regimen as the key independent variable. We controlled for residual unmeasured confounding by indication using an instrumental variable technique, using the physician's prescribing preference as the instrument. Out of 929 veterans on PI-based and 747 on NNRTI-based regimens, only 19.7 % of PI patients had PDC >80 %, compared to 35.1 % of NNRTI patients. In multivariable analysis, starting a PI regimen was significantly associated with poor adherence for all 4 adherence thresholds using conventional regressions and instrumental variable methods.

Adherence to tuberculosis therapy among patients receiving home-based directly observed treatment: evidence from the United Republic of Tanzania

BACKGROUND

Non-adherence to tuberculosis (TB) treatment is the leading contributor to the selection of drug-resistant strains of Mycobacterium tuberculosis and subsequent treatment failure. Tanzania introduced a TB Patient Centred Treatment (PCT) approach which gives new TB patients the choice between home-based treatment supervised by a treatment supporter of their own choice, and health facility-based treatment observed by a medical professional. The aim of this study was to assess the extent and determinants of adherence to anti-TB therapy in patients opting for home-based treatment under the novel PCT approach.

METHODS

In this cross-sectional study, the primary outcome was the percentage of patients adherent to TB therapy as detected by the presence of isoniazid in urine (IsoScreen assay). The primary analysis followed a non-inferiority approach in which adherence could not be lower than 75%. Logistic regression was used to examine the influence of potentially predictive factors.

RESULTS

A total of 651 new TB patients were included. Of these, 645 (99.1%) provided urine for testing and 617 patients (95.7%; 90%CI 94.3-96.9) showed a positive result. This result was statistically non-inferior to the postulated adherence level of 75% (p<0.001).

CONCLUSIONS

Adherence to TB therapy under home-based Directly Observed Treatment can be ensured in programmatic settings. A reliable supply of medication and the careful selection of treatment supporters, who preferably live very close to the patient, are crucial success factors. Finally, we recommend a cohort study to assess the rate of adherence throughout the full course of TB treatment.

Physician recommendation and patient adherence for colorectal cancer screening

BACKGROUND

Physician recommendation is one of the strongest, most consistent predictors of colorectal cancer (CRC) screening. Little is known regarding characteristics associated with patient adherence to physician recommendations in community and academic based primary care settings.

METHODS

Data were analyzed from 975 patients, aged ≥50 years, recruited from 25 primary care practices in New Jersey. Chi-square and generalized estimate equation analyses determined independent correlates of receipt of and adherence to physician recommendation for CRC.

RESULTS

Patients reported high screening rates for CRC (59%). More than three fourths of patients reported either screening or having received a screening recommendation (82%). Men (P = .0425), nonsmokers (P = .0029), and patients who were highly educated (P = .0311) were more likely to receive a CRC screening recommendation. Patients more adhere to CRC screening recommendations were older adults (P < .0001), nonsmokers (P = .0005), those who were more highly educated (P = .0365), Hispanics (P = .0325), and those who were married (P < .0001).

CONCLUSIONS

Community and academic primary care clinicians appropriately recommended screening to high-risk patients with familial risk factors. However, they less frequently recommended screening to others (ie, women and smokers) also likely to benefit. To further increase CRC screening, clinicians must systematically recommend screening to all patients who may benefit.

Non-compliance with digoxin in patients with heart failure and/or atrial fibrillation: a systematic review and meta-analysis of observational studies

BACKGROUND

Digoxin is highly potent and efficacious for treatment of heart failure (HF) and/or atrial fibrillation (AF) yet compliance is often poor.

AIMS

To examine prevalence rates of non-compliance with digoxin; variations between clinical settings, types of non-compliance and methods of detection; and potential factors influencing non-compliance with digoxin.

METHODS

This was a systematic review and meta-analysis of prospective observational studies of non-compliance with digoxin in patients with HF and/or AF, published in English. The studies were identified through these bibliographic databases: MEDLINE, EMBASE, CINAHL, IPA and Cochrane CENTRAL. Subgroup analysis examined the influence of clinical settings, types of non-compliance and methods of detection.

RESULTS

Ten studies met the inclusion criteria, comprising 1841 patients with HF and/or AF. The corresponding prevalence rates of non-compliance for outpatients, after hospital discharge and inpatients were 43.1% (interquartile range [IQR] 29-48%), 25% (95% confidence interval [CI] 12-37%) and 4.5%, respectively. In patients with HF and AF co-morbidities, the prevalence rate of non-compliance with digoxin was 38.7% (IQR 27-46%); the corresponding prevalence rates of overdosing and underdosing were 33.04% (IQR 22-49%) and 33.8% (95% CI 25-42%), respectively. Rates varied depending on the methods of detecting non-compliance. Regularity of prescribed dose, diuretic use, coronary artery bypass, implantable cardioverter-defibrillator, number of office visits and pill boxes demonstrated strong associations with non-compliance with digoxin.

CONCLUSIONS

Non-compliance with digoxin is prevalent among patients with HF and/or AF. A better understanding of the factors influencing compliance and improved intervention strategies are necessary to increase digoxin compliance.

A mobile phone text message program to measure oral antibiotic use and provide feedback on adherence to patients discharged from the emergency department

OBJECTIVES

Nonadherence to prescribed medications impairs therapeutic benefits. The authors measured the ability of an automated text messaging (short message service [SMS]) system to improve adherence to postdischarge antibiotic prescriptions.

METHODS

This was a randomized controlled trial in an urban emergency department (ED) with an annual census of 65,000. A convenience sample of adult patients being discharged with a prescription for oral antibiotics was enrolled. Participants received either a daily SMS query about prescription pickup, and then dosage taken, with educational feedback based on their responses (intervention), or the usual printed discharge instructions (control). A standardized phone follow-up interview was used on the day after the intended completion date to determine antibiotic adherence: 1) the participant filled prescription within 24 hours of discharge and 2) no antibiotic pills were left on the day after intended completion of prescription.

RESULTS

Of the 200 patients who agreed to participate, follow-up was completed in 144 (72%). From the 144, 26% (95% confidence interval [CI] = 19% to 34%) failed to fill their discharge prescriptions during the first 24 hours, and 37% (95% CI = 29% to 45%) had pills left over, resulting in 49% (95% CI = 40% to 57%) nonadherent patients. There were no differences in adherence between intervention participants and controls (57% vs. 45%; p = 0.1). African American race, greater than twice-daily dosing, and self-identifying as expecting to have difficulty filling or taking antibiotics at baseline were associated with nonadherence.

CONCLUSIONS

Almost one-half (49%) of our patients do not adhere to antibiotic prescriptions after ED discharge. Future work should improve the design and deployment of SMS interventions to optimize their effect on improving adherence to medication after ED discharge.

Association of tenofovir exposure with kidney disease risk in HIV infection

OBJECTIVE

Despite widespread HAART use, HIV disease remains associated with increased risk of kidney disease. Whether tenofovir use is associated with higher risk of kidney disease is controversial.

DESIGN

We evaluated the association of cumulative and ever exposure to tenofovir on kidney outcomes in 10,841 HIV-infected patients from the Veterans Health Administration who initiated antiretroviral therapy from 1997 to 2007.

METHODS

Cox proportional hazards and marginal structural models evaluated associations between tenofovir and time to first occurrence of proteinuria (two consecutive urine dipstick measurements ≥30 mg/dl), rapid decline in kidney function (≥3 ml/min per 1.73 m annual decline), and chronic kidney disease (CKD; estimated glomerular filtration rate <60 ml/min per 1.73 m).

RESULTS

Median follow-up ranged from 3.9 years (proteinuria) to 5.5 years (CKD), during which 3400 proteinuria, 3078 rapid decline, and 533 CKD events occurred. After multivariable adjustment, each year of exposure to tenofovir was associated with 34% increased risk of proteinuria [95% confidence interval (CI) 25-45, P < 0.0001], 11% increased risk of rapid decline (3-18, P = 0.0033), and 33% increased risk of CKD (18-51, P < 0.0001). Preexisting renal risk factors did not appear to worsen the effects of tenofovir. Other antiretroviral drugs showed weaker or inconsistent associations with kidney disease events. Among those who discontinued tenofovir use, risk of kidney disease events did not appear to decrease during follow-up.

CONCLUSION

Tenofovir exposure was independently associated with increased risk for three types of kidney disease events, and did not appear to be reversible. Because subtle kidney function decline affects long-term morbidity and mortality, the balance between efficacy and probable adverse effects requires further study.

Plasma drug level validates self-reported adherence but predicts limited specificity for nonadherence to antiretroviral therapy

Introduction. Adherence to antiretroviral therapy (ART) in low-income countries is mainly assessed by self-reported adherence (S-RA) without drug level determination. Nonadherence is an important factor in the emergence of resistance to ART, presenting a need for drug level determination. Objective. We set out to establish the relationship between plasma stavudine levels and S-RA and validate S-RA against the actual plasma drug concentrations. Methods. A cross-sectional investigation involving 234 patients in Uganda. Stavudine plasma levels were determined using high-performance liquid chromatography. We compared categories of plasma levels of stavudine with S-RA using multivariable logistic regression models. Results. Overall, 194/234 patients had S-RA ≥ 95% (good adherence) and 166/234 had stavudine plasma concentrations ≥ 36 nmol/L (therapeuticconcentration). Patients with good S-RA were eight times more likely to have stavudine levels within therapeutic concentration (Adjusted Odds Ratio: 7.7, 95% Confidence Interval: 3.5–7.0). However, of the 194 patients with good S-RA, 21.7% had below therapeutic concentrations. S-RA had high sensitivity for adherence (91.6%), but limited specificity for intrinsic poor adherence (38.2%). Conclusions. S-RA is a good tool for assessing adherence, but has low specificity in detecting nonadherence, which has implications for emergence of resistance.

Control of medical comorbidities in individuals with HIV

BACKGROUND

With improved combination antiretroviral therapy-related survival, diabetes and hypertension increasingly contribute to morbidity and mortality among individuals with HIV. However, there is limited data on diabetes and blood pressure control in this population. We examined whether virologic control is associated with control of diabetes and hypertension.

METHODS

We examined HIV viral load, hemoglobin A1c (HbA1c), and blood pressure measurements from 70 diabetics and 291 hypertensives in the Johns Hopkins HIV Clinical Cohort, an urban, university-based cohort. All patients were treated for HIV and diabetes or hypertension. HbA1c and HIV-1 RNA were captured electronically from laboratory data, and blood pressure was collected electronically from vital signs taken at clinic visits. We used HIV-1 RNA values within 30 days of the HbA1c measurement or blood pressure measurement. The relationships between HIV-1 RNA and HbA1c and HIV-1 RNA and blood pressure were examined using separate random effects generalized least squares linear regression models.

RESULTS

The study sample was predominantly male and black, with a high prevalence of comorbid hepatitis C virus infection and psychiatric illness. In multivariable analysis, each log(10) increase in HIV-1 RNA was associated with higher HbA1c (β = 0.47 units, P < 0.001) among diabetics and higher mean arterial pressure among hypertensive patients (β = 1.95 mmHg, P < 0.001).

CONCLUSIONS

Suboptimal control of HIV, indicated by detectable viral load, correlates with suboptimal control of diabetes and hypertension, indicated by higher HbA1c and mean arterial pressure. Achieving control of multiple medical comorbidities and HIV simultaneously may require expansion of current adherence interventions focused primarily on antiretroviral therapy.

Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis

We meta-analyzed the relationship between depression and HIV medication nonadherence to calculate the overall effect size and examine potential moderators. Overall, across 95 independent samples, depression was significantly (P < 0.0001) associated with nonadherence (r = 0.19; 95% confidence interval = 0.14 to 0.25). Studies evaluating medication adherence via interview found significantly larger effects than those using self-administered questionnaires. Studies measuring adherence along a continuum found significantly stronger effects than studies comparing dichotomies. Effect size was not significantly related to other aspects of adherence or depression measurement, assessment interval (ie, cross-sectional vs. longitudinal), sex, IV drug use, sexual orientation, or study location. The relationship between depression and HIV treatment nonadherence is consistent across samples and over time, is not limited to those with clinical depression, and is not inflated by self-report bias. Our results suggest that interventions aimed at reducing depressive symptom severity, even at subclinical levels, should be a behavioral research priority.