HIV patient insight on adhering to medication: a qualitative analysis

Cannabis Use Is Associated With Decreased Antiretroviral Therapy Adherence Among Older Adults With HIV

Background

Conflicting evidence exists on the impact of cannabis use on antiretroviral therapy (ART) adherence among people with human immunodeficiency virus (PWH). We leveraged data collected among older PWH to characterize longitudinal associations between cannabis use and ART adherence.

Methods

AIDS Clinical Trials Group (ACTG) A5322 study participants were categorized as <100% (≥1 missed dose in past 7 days) or 100% (no missed doses) ART adherent. Participants self-reported current (past month), intermittent (past year but not past month), and no cannabis (in past year) use at each study visit. Generalized linear models using generalized estimating equations were fit and inverse probability weighting was used to adjust for time-varying confounders and loss to follow-up.

Results

Among 1011 participants (median age, 51 years), 18% reported current, 6% intermittent, and 76% no cannabis use at baseline; 88% reported 100% ART adherence. Current cannabis users were more likely to be <100% adherent than nonusers (adjusted risk ratio [aRR], 1.53 [95% CI, 1.11-2.10]). There was no association between ART adherence and current versus intermittent (aRR, 1.39 [95% CI, .85-2.28]) or intermittent versus no cannabis use (aRR, 1.04 [95% CI, .62-1.73]).

Conclusions

Among a cohort of older PWH, current cannabis users had a higher risk of <100% ART adherence compared to nonusers. These findings have important clinical implications as suboptimal ART adherence is associated with ART drug resistance, virologic failure, and elevated risk for mortality. Further research is needed to elucidate the mechanisms by which cannabis use decreases ART adherence in older PWH and to advance the development of more efficacious methods to mitigate nonadherence in this vulnerable population.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks

OBJECTIVE

To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups.

METHODS

We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data.

RESULTS

We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups.

CONCLUSION

Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence.

PROTOCOL REGISTRATION

PROSPERO Identifier: CRD42020181316.

Medication Management Frameworks in the Context of Self-Management: A Scoping Review

PURPOSE

Many individuals take multiple prescribed and unprescribed medications, also known as polypharmacy, which can be problematic. Improving medication self-management is important; however, most medication management frameworks focus on adherence and limit the integration of the core components of self-management. Therefore, the objective of this scoping review was to identify what is reported in the literature on medication management frameworks or models within the context of self-management.

METHODS

Electronic databases (Medline, Embase, CINAHL and Cochrane Library) and grey literature (healthcare and government organization websites) were searched for articles that described a framework or model developed or adapted for medication management, included components of self-management and was published from January 2000 to January 2020. During the screening of titles and abstracts, 5668 articles were reviewed, 5242 were excluded and 426 were then assessed at the full-text level. Thirty-nine articles met the eligibility criteria and were included in the review.

RESULTS

About half of the frameworks were newly developed (n=20), while the other half were adapted from, or applied, a previous model or framework (n=19). The majority of frameworks focused on medication adherence and most of the self-management domains were categorized as medical management, followed by emotional and role management.

CONCLUSION

Medication self-management is a complex process and often impacts multiple areas of an individual's life. It is important for future frameworks to incorporate a comprehensive, holistic conceptualization of self-management that is inclusive of the three self-management domains - medical, emotional and role management.

A Qualitative Application of Temporal Self-Regulation Theory to Understand Adherence to Simple and Complex Medication Regimens

Medication adherence is a global health concern, and variables of temporal self-regulation theory (TST) have been shown to be important in improving adherence. This qualitative study aims to explore how TST can help explain medication adherence in people’s daily lives, and whether there are differences in the adherence to simple and complex medication regimens. Twenty-nine participants from Australia engaged in semi-structured interviews based on TST (intention, behavioural prepotency, self-regulation), and other variables important to adherence. Interviews were analysed using thematic analysis. Six themes were identified (Routines, External Supports, Cost, Sense of Agency, Adverse Outcomes, and Weighing Up Pros and Cons), with partial support for TST (specifically intention, past behaviour, cues and planning). Four themes not related to TST were also identified. Individuals with more complex medication regimens spoke of the importance of routines, planning, and knowledge-seeking, whereas those with simpler regimens spoke of the importance of visual cues. TST may be useful for identifying some variables important in medication adherence, however, additional factors were also identified. For simple regimens, future research should focus on the manipulation of visual cues. For complex regimens, health professionals should consider supporting the use of medication management apps to assist in planning and ensuring a consistent routine.

It's Not Just the Pills: A Qualitative Meta-Synthesis of HIV Antiretroviral Adherence Research

Antiretroviral therapy (ART) improves the health and longevity of people living with HIV infection (PLWH) and also prevents transmission of the virus. Yet, lack of adherence to ART regimens has been a persistent problem, even with simpler regimens. Guidelines that deal with ART adherence are based almost solely on quantitative studies; this focus ignores the context and complexity of patients' lives. Guidelines are also focused on the individual. We argue that the solution is to include the broader communities in which patients live, and to deal with systemic disparities that persist worldwide; this can be done in part through demedicalizing HIV care for healthy PLWH. We present findings from a qualitative meta-synthesis of 127 studies conducted around the world on the last two pillars of the HIV treatment cascade: starting and remaining on ART until optimal viral suppression is achieved. We use Maslow's hierarchy of needs to frame our findings.

The Role of ARV Associated Adverse Drug Reactions in Influencing Adherence Among HIV-Infected Individuals: A Systematic Review and Qualitative Meta-Synthesis

Poor adherence remains a major barrier to achieving the clinical and public health benefits of antiretroviral drugs (ARVs). A systematic review and qualitative meta-synthesis was conduct to evaluate how ARV adverse drug reactions may influence ARV adherence. Thirty-nine articles were identified, and 33 reported that ARV adverse drug reactions decreased adherence and six studies found no influence. Visually noticeable adverse drug reactions and psychological adverse reactions were reported as more likely to cause non-adherence compared to other adverse drug reactions. Six studies reported a range of adverse reactions associated with EFV-containing regimens contributing to decreased adherence. Informing HIV-infected individuals about ARV adverse drug reactions prior to initiation, counselling about coping mechanisms, and experiencing the effectiveness of ARVs on wellbeing may improve ARV adherence.

Evaluating patient preference and satisfaction for human immunodeficiency virus therapy in France

OBJECTIVES

The objectives were 1) to elicit relative preferences for attributes of antiretroviral therapies (ART) in people living with HIV (PLWH) and 2) to explore satisfaction and adherence with current ART.

PATIENTS AND METHODS

We conducted a multicenter cross-sectional study, consecutively enrolling PLWH receiving an ART. The quantitative part estimated the strength of preference for different attributes using an online discrete choice experiment (DCE). DCE data were analyzed using a mixed logit regression model. Qualitative data were collected through individual interviews. A preliminary coding framework was developed which was then further refined and applied during thematic analysis of factors influencing satisfaction and adherence.

RESULTS

A total of 101 PLWH took part in the quantitative part and 31 in the qualitative part. Over 90% had an undetectable viral load. Quantitative data revealed a strong preference for a treatment with limited drug-drug interactions, diarrhea and long-term health problems (P<0.0001), and that did not need to be taken on an empty stomach (P<0.0001). Patients also preferred to avoid problems associated with treatment failure (P<0.0001) or one that left them with a higher viral load after the first weeks of treatment (P=0.044). Differences in CD4 cell count, and pills that must be taken with food were not significant drivers of treatment choice. The strength of these attributes was reflected in the qualitative data, highlighting the importance patients place on treatment efficacy, and also suggesting that some of these attributes may impact adherence. Many factors influencing adherence and satisfaction with treatment were identified, including pill size, worry about sexual transmission and impact on social life.

CONCLUSION

Most of the attributes included in this survey were important to participants when choosing an ART, in particular those related to quality of life, and these should be taken into account in order to optimize adherence and satisfaction.

The Social and Health Problems of People Living with HIV/AIDS in Izmir, Turkey

OBJECTIVE

The aim of this study was to describe how AIDS, as well as the stigma associated with it, affects the lives of HIV positive patients and their family members.

MATERIALS AND METHODS

Three large state hospitals in the metropolitan area of Izmir participated in the study. Six focus groups were conducted with people infected with HIV (n=32) and their family members (n=11). Participants were asked to fill out a questionnaire to assess their HIV/AIDS knowledge and to convey how the stigma had affected them.

RESULTS

The most important problems identified were society and work-related social problems and access to health services. The patients and their family members stated that education was needed to correct misconceptions about HIV and to help them cope with related problems. We found that patients and their family members were sensitive about disclosure.

CONCLUSION

We determined the education, counseling and support needs of HIV-infected patients and their families. Additionally, we found that health personnel who monitor the patients should make more efforts on patients' education and counselling.

Knowledge, attitudes and beliefs of patients and carers regarding medication adherence: a review of qualitative literature

PURPOSE

The aim of this review is to cohere evidence on the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. Medication adherence refers to "the extent to which the patient's action matches the agreed recommendations". Medication adherence is vital in preventing, managing and curing illnesses and, hence, is linked with positive health outcomes.

METHODS

A search was conducted using the following databases: CINAHL, Embase, PubMed and Web of Knowledge from inception to November 2013. Titles and abstracts were screened for inclusion in the review according to pre-defined inclusion and exclusion criteria. Studies were assessed for quality, and data were extracted into a data extraction form. Results were analysed thematically.

RESULTS

The final results included 34 articles. Eight analytical themes were identified: (i) beliefs and experiences of medicines, (ii) family support and culture, (iii) role of and relationship with health-care practitioners, (iv) factors related to the disease, (v) self-regulation, (vi) communication, (vii) cost and (viii) access. The theme, "beliefs and experiences of medicines", was present in 33 studies, with many discussing the influence that side effects have on medication adherence.

CONCLUSIONS

There are a number of variables that impact upon the knowledge, attitudes and beliefs of patients and carers regarding medication adherence. This review presents an overview of the analytical themes which offers the opportunity to examine interventions and their relative efficacies to increase medication adherence.

Complexity perplexity: a systematic review to describe the measurement of medication regimen complexity

INTRODUCTION

Complex medication regimens are error prone and challenging for patients, which may impact medication adherence and safety. No universal method to assess the complexity of medication regimens (CMRx) exists. The authors aim to review literature for CMRx measurements to establish consistencies and, secondarily, describe CMRx impact on healthcare outcomes.

AREAS COVERED

A search of EMBASE and PubMed for studies analyzing at least two medications and complexity components, among those self-managing medications, was conducted. Out of 1204 abstracts, 38 studies were included in the final sample. The majority (74%) of studies used one of five validated CMRx scales; their components and scoring were compared.

EXPERT OPINION

Universal CMRx assessment is needed to identify and reduce complex regimens, and, thus, improve safety. The authors highlight commonalities among five scales to help build consensus. Common components (i.e., regimen factors) included dosing frequency, units per dose, and non-oral routes. Elements (e.g., twice daily) of these components (e.g., dosing frequency) and scoring varied. Patient-specific factors (e.g., dexterity, cognition) were not addressed, which is a shortcoming of current scales and a challenge for future scales. As CMRx has important outcomes, notably adherence and healthcare utilization, a standardized tool has potential for far-reaching clinical, research, and patient-safety impact.

Optimal use of acute headache medication: a qualitative examination of behaviors and barriers to their performance

OBJECTIVE

This study aims to qualitatively examine the behaviors required to optimally use acute headache medication and the barriers to successful performance of these behaviors.

BACKGROUND

The efficacy of drug treatment is partly determined by medication adherence. The adherence literature has focused almost exclusively on the behaviors required to optimally use medications that are taken on a fixed schedule, as opposed to medications taken on an as needed basis to treat acute episodes of symptoms, such as headaches.

METHODS

Twenty-one people with headache and 15 health care providers participated in qualitative phenomenological interviews that were transcribed and coded by a multidisciplinary research team using phenomenological analysis.

RESULTS

Interviews revealed 8 behaviors required to optimally use acute headache medication, including cross-episode behaviors that people with headache regularly perform to ensure optimal acute headache medication use, and episode-specific behaviors used to treat an individual headache episode. Interviews further revealed 9 barriers that hinder successful performance of these behaviors.

CONCLUSIONS

Behaviors required to optimally use acute headache medication were numerous, often embedded in a larger chain of behaviors, and were susceptible to disruption by numerous barriers.

Memory-based strategies for antiretroviral medication management: an evaluation of clinical predictors, adherence behavior awareness, and effectiveness

"Forgetting" is the most commonly endorsed reason for missing an antiretroviral therapy (ART) dose, yet little is known about the prevalence, predictors, and effectiveness of the mnemonic strategies to support ART adherence. The current study assessed 28 self-reported memory-based medication strategies in 233 HIV-infected individuals with 30-day ART adherence measured via the medication event monitoring system. Participants endorsed using multiple (8.7 ± 5.6) strategies with the most common being internally-driven. More frequent strategy use was uniquely associated with affective distress, dependent daily functioning, higher non-ART pill burden, and poorer ART adherence. Individuals who used strategies frequently, but perceived them as minimally effective, had more affective, physical, and functional distress. More frequent strategy use was associated with worse ART adherence and was unrelated to perceived effectiveness. Primary reliance on internally-based mnemonic strategies may reflect a lack of awareness of adherence behaviors and may be insufficient to support optimal ART adherence in vulnerable populations.

The role of social support and negative affect in medication adherence for HIV-infected men who have sex with men

Combinations of medications that control HIV viral replication are called antiretroviral therapy (ART). Regimens can be complex, so medication adherence is often suboptimal, although high rates of adherence are necessary for ART to be effective. Social support, which has been directly and indirectly associated with better treatment adherence in HIV-infected individuals, influences negative affect, including depression and anxiety. Our study assessed whether current anxious and depressive symptoms mediated the relationship between general social support and recent self-reported medication adherence in HIV-infected men who have sex with men (N= 136; 65% White, 15% Black/African American). Results revealed no direct effect, but an indirect effect of depressive (95% CI [-.011, -.0011]) and anxious symptoms (95% CI [-.0097, -.0009]), between social support and medication adherence. Greater levels of social support were associated with lower levels of depression and anxiety, which in turn were associated with lower ART adherence.

"I want to stand on my own legs": A qualitative study of antiretroviral therapy adherence among HIV-positive women in Egypt

A review of the antiretroviral therapy (ART) literature revealed that not a single published study has examined the factors that influence patients' adherence to HIV medications in the Arab world. To mend this gap, this qualitative study collected data via face-to-face interviews with 27 HIV-positive Egyptian women who had been on ART for at least three months. Using a thematic analysis technique, five themes were identified: fear of stigma, financial constraints, characteristics of ART, social support, and reliance on faith. Notwithstanding the overwhelming number of inhibiting factors, most patients in this study were highly motivated to achieve perfect adherence.

The phenomenology of body image in men living with HIV

Research into how people living with HIV or AIDS (PLWHA) experience and make sense of feared or actual body changes, such as lipodystrophy, is limited. The present study conducted in-depth interviews with gay men living with HIV. Interpretative phenomenological analysis (IPA) yielded themes across five domains. The ambiguity of early-stage lipodystrophy was a cause of distress. There was a drive to detect changes early, leading to anxiety, uncertainty and negative feelings about the body as well as possible misperception of change. In later stages, lipodystrophy was felt to be highly distinctive. Participants struggled to live with a shape that transgressed a body ideal. Feelings of loss of control were evident in both the increased ineffectiveness of strategies to maintain a desirable appearance and in the tendency for such changes to act as a visible marker of status. Conflicting feelings emerged in ideas of thinness and of health, with loss of fat seen as desirable in certain contexts. The study builds on previous research suggesting that the high value of appearance, particularly within gay communities, may lead to extreme compensatory behaviours. HIV places increased risk on a group highly vulnerable to body dissatisfaction and eating disorders. The study concludes with a cognitive-behavioural model of body image for PLWHA and suggestions for intervention. Further research is needed to validate the model and investigate whether the findings are generalisable. However, body image concerns should be acknowledged when addressing HIV-related health.