Cross-sectional study to evaluate factors associated with adherence to antiretroviral therapy by Brazilian HIV-infected patients

Adherence to antiretroviral therapy for HIV/AIDS in Latin America and the Caribbean: Systematic review and meta-analysis

INTRODUCTION

Optimal adherence to antiretroviral therapy is closely related with suppression of the HIV viral load in plasma, slowing disease progression and decreasing HIV transmission rates. Despite its importance, the estimated proportion of people living with HIV in Latin America and the Caribbean with optimal adherence has not yet been reported in a meta-analysis. Moreover, little is known of the factors leading to poor adherence which may be setting-specific. We present a pooled estimate of adherence to antiretroviral therapy (ART) of people living with HIV in Latin America and Caribbean, report the methods used to measure adherence and describe the factors associated with poor adherence among the selected studies.

METHODS

We electronically searched published studies up to July 2016 on the PubMed, Web of Science and Virtual Health Library (Latin America and the Caribbean Regional Portal); considering the following databases: MEDLINE, LILACS, PAHO and IBECS. Two independent reviewers selected and extracted data on ART adherence and study characteristics. Pooled estimate of adherence was derived using a random-effects model. Risk of bias in individual studies was assessed independently by two investigators using the Risk of Bias Assessment tool for Non-randomized Studies (RoBANS).

RESULTS AND DISCUSSION

The meta-analysis included 53 studies published between 2005 and 2016, which analysed 22,603 people living with HIV in 25 Latin America and Caribbean countries. Overall adherence in Latin America and Caribbean was 70% (95% CI: 63-76; I²  = 98%), similar to levels identified by studies conducted in high-income regions. Self-report was the most frequently used method to measure adherence. Subgroup analysis showed that adherence was higher for the shortest recall time frame used, as well as in countries with lower income level, Gross National Income (GNI) per capita and Human Development Index (HDI). Studies reported diverse adherence barriers, such as alcohol and substance misuse, depression, unemployment and pill burden.

CONCLUSIONS

Our study suggests that adherence to ART in Latin America and Caribbean may be below the sufficient levels required for a successful long-term viral load suppression.

Monitoring of Delay to Pharmacy Refill in Assessing Adherence to Antiretroviral Therapy

BACKGROUND

Adherence to antiretroviral (ARV) therapy remains a major challenge in HIV therapeutics.

OBJECTIVE

To assess the adherence to ARV therapy by measuring the delay in monthly refilling of ARV drugs using pharmacy records and to correlate this with HIV plasma RNA measurements and CD4⁺ cell count.

METHOD

Records of 170 HIV-positive patients were examined to identify HIV viral load (VL)/CD4⁺ results and the time interval to refill ARVs at the pharmacy. The correlation between the number of days missed to refill ARVs and plasma HIV-RNA detectability/CD4⁺ count was performed using the Spearman's correlation coefficient (r).

RESULTS

Fewer days missed to refill ARV was positively correlated with undetectable VL and increase in CD4⁺ count (r = 0.407 and 0.237, respectively). Increase in adherence was correlated with longer retention in the cohort (r = 0.208).

CONCLUSION

Monitoring the delay to pick up ARVs from the pharmacy can be an important and simple tool to identify patients requiring assessment of their adherence.

Long-term immune and virological response in HIV-infected patients receiving antiretroviral therapy

WHAT IS KNOWN AND OBJECTIVE

The trajectory of HIV viral load and CD4 count and the occurrence of clinical events are primary considerations in the evaluation of antiretroviral therapy (ART) success or failure, yet a large number of studies do not describe these events from the point of therapy initiation. This study aims to describe the virological and immune response to ART and factors associated with immune and virological success in outpatients from a HIV/AIDS clinic in southern Brazil from therapy initiation.

METHODS

Longitudinal observational with ambidirectional data collection study with adult patients followed for at least 12 months after enrolment. Outcomes include (i) favourable immune response, defined as CD4 count ≥200 cells/mm³; and (ii) virological success, defined as viral load below the limit of detection (50 copies/mL).

RESULTS

The study included 332 patients, mostly men (63%), whose mean age was 40 (±10) years and with median family income of BR$ 490·00 per month (IQR: 350-875). Before starting ART, 43% of patients had indications of stable immune status (CD4 count ≥200 cells/mm³); the median CD4 count was 179 cells/mm³ (IQR: 93·5, 267) and increased to 379·5 cells/mm³ (IQR: 236·5, 591·3). The proportion of patients with CD4 count ≥200 cells/mm³ increased from 76% to 83%, and with undetectable viral load (UVL) increased from 51·7% to 73%. Factors associated with immune success at the end of study follow-up were as follows: female gender, pretreatment CD4 count ≥200 cells/mm³, previous UVL (measured when started prospective follow-up) and treatment with three drugs compared with ≥4. Factors associated with virological success were as follows: UVL (measured when started prospective follow-up) and use of three drugs compared with ≥4.

WHAT IS NEW AND CONCLUSIONS

Results of this study show that a large proportion (73%) of patients have rapid and successful immune and virological responses to ART and that factors which predict this response include starting ART early, whereas viral load is low and CD4 count is high, with fewer drugs. These results further support the ongoing need for ongoing programmes to increase early HIV testing, early linkage to and treatment with ART, and increased viral suppression.

The Information and Motivation and Behavioral Skills Model of ART Adherence among HIV-Positive Adults in Mexico

INTRODUCTION

Middle-income countries are in need of research that uses theoretical-based models to assess factors that predict adherence to antiretroviral therapy (ART) and help in the design, implementation, and evaluation of interventions for nonadherent populations. In Mexico, the Information and Motivation and Behavioral Skills (IMB) Model of ART Adherence constructs is useful in describing and predicting adherence behaviors in various samples but has not been articulated to people living with HIV (PLWH) on ART. The aim of this was to characterize the IMB core constructs and identify correlates of ART adherence in an HIV-positive clinic sample in Mexico.

METHODS

A convenience sample of 109 HIV-positive patients attending their monthly visits at a local public hospital were interviewed with the Spanish version of the LifeWindows IMB ART Adherence Questionnaire (LW-IMB-AAQ) as well as a sociodemographic questionnaire. All participants were recruited from a hospital-based outpatient clinical care site.

RESULTS

Partial confirmation of the relationships proposed by the IMB Model of ART Adherence was found. As predicted by the model, only behavioral skills had direct association with all measures of self-reported adherence, and motivation was associated with behavioral skills. Information did not demonstrate significant relations to either motivation or behavioral skills, nor did it directly associate with adherence. Self-reported adherence did not associate with CD4 counts, nor did any of the IMB model core constructs.

CONCLUSION

Applicability of the IMB Model of ART Adherence in this setting is discussed. The IMB Model of ART Adherence offered promise in this population and could help tailor population-specific interventions to promote high rates of ART adherence.

Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis

BACKGROUND

Adherence to combination antiretroviral therapy (ART) is a key predictor of the success of human immunodeficiency virus (HIV) treatment, and is potentially amenable to intervention. Insight into predictors or correlates of non-adherence to ART may help guide targets for the development of adherence-enhancing interventions. Our objective was to review evidence on predictors/correlates of adherence to ART, and to aggregate findings into quantitative estimates of their impact on adherence.

METHODS

We searched PubMed for original English-language papers, published between 1996 and June 2014, and the reference lists of all relevant articles found. Studies reporting on predictors/correlates of adherence of adults prescribed ART for chronic HIV infection were included without restriction to adherence assessment method, study design or geographical location. Two researchers independently extracted the data from the same papers. Random effects models with inverse variance weights were used to aggregate findings into pooled effects estimates with 95% confidence intervals. The standardized mean difference (SMD) was used as the common effect size. The impact of study design features (adherence assessment method, study design, and the United Nations Human Development Index (HDI) of the country in which the study was set) was investigated using categorical mixed effects meta-regression.

RESULTS

In total, 207 studies were included. The following predictors/correlates were most strongly associated with adherence: adherence self-efficacy (SMD = 0.603, P = 0.001), current substance use (SMD = -0.395, P = 0.001), concerns about ART (SMD = -0.388, P = 0.001), beliefs about the necessity/utility of ART (SMD = 0.357, P = 0.001), trust/satisfaction with the HIV care provider (SMD = 0.377, P = 0.001), depressive symptoms (SMD = -0.305, P = 0.001), stigma about HIV (SMD = -0.282, P = 0.001), and social support (SMD = 0.237, P = 0.001). Smaller but significant associations were observed for the following being prescribed a protease inhibitor-containing regimen (SMD = -0.196, P = 0.001), daily dosing frequency (SMD = -0.193, P = 0.001), financial constraints (SMD -0.187, P = 0.001) and pill burden (SMD = -0.124, P = 0.001). Higher trust/satisfaction with the HIV care provider, a lower daily dosing frequency, and fewer depressive symptoms were more strongly related with higher adherence in low and medium HDI countries than in high HDI countries.

CONCLUSIONS

These findings suggest that adherence-enhancing interventions should particularly target psychological factors such as self-efficacy and concerns/beliefs about the efficacy and safety of ART. Moreover, these findings suggest that simplification of regimens might have smaller but significant effects.

Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis

Background

Adherence to combination antiretroviral therapy (ART) is a key predictor of the success of human immunodeficiency virus (HIV) treatment, and is potentially amenable to intervention. Insight into predictors or correlates of non-adherence to ART may help guide targets for the development of adherence-enhancing interventions. Our objective was to review evidence on predictors/correlates of adherence to ART, and to aggregate findings into quantitative estimates of their impact on adherence.

Methods

We searched PubMed for original English-language papers, published between 1996 and June 2014, and the reference lists of all relevant articles found. Studies reporting on predictors/correlates of adherence of adults prescribed ART for chronic HIV infection were included without restriction to adherence assessment method, study design or geographical location. Two researchers independently extracted the data from the same papers. Random effects models with inverse variance weights were used to aggregate findings into pooled effects estimates with 95% confidence intervals. The standardized mean difference (SMD) was used as the common effect size. The impact of study design features (adherence assessment method, study design, and the United Nations Human Development Index (HDI) of the country in which the study was set) was investigated using categorical mixed effects meta-regression.

Results

In total, 207 studies were included. The following predictors/correlates were most strongly associated with adherence: adherence self-efficacy (SMD = 0.603, P = 0.001), current substance use (SMD = -0.395, P = 0.001), concerns about ART (SMD = -0.388, P = 0.001), beliefs about the necessity/utility of ART (SMD = 0.357, P = 0.001), trust/satisfaction with the HIV care provider (SMD = 0.377, P = 0.001), depressive symptoms (SMD = -0.305, P = 0.001), stigma about HIV (SMD = -0.282, P = 0.001), and social support (SMD = 0.237, P = 0.001). Smaller but significant associations were observed for the following being prescribed a protease inhibitor-containing regimen (SMD = -0.196, P = 0.001), daily dosing frequency (SMD = -0.193, P = 0.001), financial constraints (SMD -0.187, P = 0.001) and pill burden (SMD = -0.124, P = 0.001). Higher trust/satisfaction with the HIV care provider, a lower daily dosing frequency, and fewer depressive symptoms were more strongly related with higher adherence in low and medium HDI countries than in high HDI countries.

Conclusions

These findings suggest that adherence-enhancing interventions should particularly target psychological factors such as self-efficacy and concerns/beliefs about the efficacy and safety of ART. Moreover, these findings suggest that simplification of regimens might have smaller but significant effects.

Electronic supplementary material

The online version of this article (doi:10.1186/s12916-014-0142-1) contains supplementary material, which is available to authorized users.

Predictors of raised viral load during antiretroviral therapy in patients with and without prior antiretroviral use: a cross-sectional study

OBJECTIVES

In Lagos, Nigeria, Médecins Sans Frontières (MSF) and the Ministry of Health (MoH) commenced free antiretroviral treatment (ART) in a hospital-based clinic. We performed a cross-sectional study to compare factors associated with raised viral load between patients with ("experienced") and without ("naïve") prior antiretroviral (ARV) exposure at commencement of ART at the clinic. We also examined factors influencing ARV adherence in experienced patients prior to clinic entry.

METHODS

We included adult patients receiving ART from MSF who answered a questionnaire about previous antiretroviral use. Multivariate logistic regression was used to estimate odds ratios (OR) for raised viral load (≥1000 copies/mL).

RESULTS

1246 (96%) patients answered: 1075 (86%) reported no, and 171 (14%) some, prior ARV exposure. ARV-naïve patients were more immunosuppressed at baseline: 65% vs 37% (p<0.001) had CD4<200; 17% vs 9% (p = 0.013) were WHO stage 4. Proportionately more experienced than naïve patients had raised viral loads (20% vs 9%, p<0.001) on ART in the MSF/MoH clinic. Raised viral load was associated with prior ARV experience (adjusted OR = 3.74, 95%CI 2.09-6.70, p<0.001) and complete interruption of current ART (adjusted OR = 3.71, 95%CI 2.06-6.68, p<0.001). Higher CD4 at time of VL and a higher self-rated score of recent adherence were associated with lower OR of a raised viral load. Among experienced patients who missed pills before joining MSF/MoH, most common reasons were because ARVS were not affordable (58%) or available (33%), with raised viral load associated with being unsure how to take them (OR = 3.16, 95%CI 1.10-9.12, p = 0.033).

CONCLUSIONS

Patients previously exposed to ARVs had increased OR of raised viral load. The cost and availability of ARVs were common reasons for missing ARVs before joining the MSF/MoH clinic, and inadequate patient knowledge was associated with raised viral load.

A randomized controlled trial of a protocol of interviews designed to improve adherence to antiretroviral medications in southern Brazil

The aim of this study was to evaluate the efficacy of the Portuguese version of the Medication Adherence Training Instrument (MATI) for improving adherence to antiretroviral therapy (ART) in southern Brazil. Two different follow-up modalities were compared in this 225 days randomized controlled study: one based on the MATI protocol and a conventional (non-MATI) clinical follow-up. There were no differences between the groups with the exception of socioeconomic class ( P < 0.005). The mean length of continuance in treatment was 111.4 (SD = 13.9) and 137.6 (SD = 17.3) days in the MATI and non-MATI groups, respectively. A Mantel–Cox log-rank test revealed no significant difference between the two interventions ( P = 0.34). Despite the sample size limitation, the results from this study indicate that the Portuguese version of the MATI was not more efficacious than the regular follow-up intervention for improving adherence of outpatients to ART.

Women and vulnerability to HAART non-adherence: a literature review of treatment adherence by gender from 2000 to 2011

A literature review of original research articles on adherence to antiretroviral therapy (ART) in developed countries, covering January 2000 to June 2011, was conducted to determine if gender differences exist in the prevalence of nonadherence to ART. Of the 1,255 articles reviewed, only 189 included data on the proportion of the study population that was adherent and only 57 (30.2%) of these reported proportional adherence values by gender. While comparing articles was challenging because of varied reporting strategies, women generally exhibit poorer adherence than men. Thirty of the 44 articles (68.2%) that reported comparative data on adherence by gender found women to be less adherent than men. Ten articles (17.5%) reported significant differences in proportional adherence by gender, nine of which showed women to be less adherent than men. These findings suggest that in multiple studies from developed countries, female gender often predicts lower adherence. The unique circumstances of HIV-positive women require specialized care to increase adherence to ART.

Estudo do autorrelato de adesão e uso problemático de álcool em uma população de indivíduos com AIDS em uso de HAART

OBJETIVO: O objetivo deste estudo foi analisar a força de associação entre as variáveis autorrelato de adesão à medicação e uso problemático de álcool em uma população de indivíduos com AIDS que fazem uso de HAART. MÉTODO: Foram entrevistados 103 pacientes com AIDS, em uso de HAART há pelo menos seis meses, que frequentavam o ambulatório do Instituto de Doenças Tropicais Natan Portela (IDTNP), localizado na cidade de Teresina, PI. A variável independente estudada foi o uso problemático de álcool, além de variáveis sociodemográficas. O questionário utilizado para avaliar o uso problemático de álcool foi o AUDIT (Alcohol Use Disorders Identification Test). A variável dependente avaliada neste estudo foi o autorrelato de adesão ao tratamento para o HIV. Para sua mensuração, optou-se por utilizar o QSAM (Questionário Simplificado de Adesão à Medicação), por tratar-se de um questionário bastante simples e de fácil aplicação. RESULTADOS: A frequência de AUDIT > 08 foi de 33%; já o autorrelato de adesão, avaliado pelo QSAM, foi positivo em 45% da amostra. Testada a associação entre a frequência de QSAM positivo e o AUDIT positivo, encontrou-se forte associação entre essas variáveis (p = 0,004). CONCLUSÃO: Conclui-se deste estudo que o autorrelato de falha na adesão ao HAART aferido por meio do QSAM é um fator de risco para a presença de uso problemático de álcool.

Contrasting predictors of poor antiretroviral therapy outcomes in two South African HIV programmes: a cohort study

BACKGROUND

Many national antiretroviral therapy (ART) programmes encourage providers to identify and address baseline factors associated with poor treatment outcomes, including modifiable adherence-related behaviours, before initiating ART. However, evidence on such predictors is scarce, and providers judgement may often be inaccurate. To help address this evidence gap, this observational cohort study examined baseline factors potentially predictive of poor treatment outcomes in two ART programmes in South Africa, with a particular focus on determinants of adherence.

METHODS

Treatment-naïve patients starting ART were enrolled from a community and a workplace ART programme. Potential baseline predictors associated with poor treatment outcomes (defined as viral load > 400 copies/ml or having discontinued treatment by six months) were assessed using logistic regression. Exposure variables were organised for regression analysis using a hierarchical framework.

RESULTS

38/227 (17%) of participants in the community had poor treatment outcomes compared to 47/117 (40%) in the workplace. In the community, predictors of worse outcomes included: drinking more than 20 units of alcohol per week, having no prior experience of chronic medications, and consulting a traditional healer in the past year (adjusted odds ratio [aOR] 15.36, 95% CI 3.22-73.27; aOR 2.30, 95%CI 1.00-5.30; aOR 2.27, 95% CI 1.00-5.19 respectively). Being male and knowing someone on ART were associated with better outcomes (aOR 0.25, 95%CI 0.09-0.74; aOR 0.44, 95%CI 0.19-1.01 respectively). In the workplace, predictors of poor treatment outcomes included being uncertain about the health effects of ART and a traditional healer's ability to treat HIV (aOR 7.53, 95%CI 2.02-27.98; aOR 4.40, 95%CI 1.41-13.75 respectively). Longer pre-ART waiting time (2-12 weeks compared to <2 weeks) predicted better treatment outcomes (aOR 0.13, 95% CI 0.03-0.56).

CONCLUSION

Baseline predictors of poor treatment outcomes were largely unique to each programme, likely reflecting different populations and pathways to HIV care. In the workplace, active promotion of HIV testing may have extended ART to individuals who, without provider initiation, would not have spontaneously sought care. As provider-initiated testing makes ART available to individuals less motivated to seek care, patients may need additional adherence support, especially addressing uncertainty about the health benefits of ART.

Early adherence to antiretroviral medication as a predictor of long-term HIV virological suppression: five-year follow up of an observational cohort

OBJECTIVE

Previous studies have demonstrated a cross-sectional relationship between antiretroviral adherence and HIV virological suppression. We assessed the predictive value of baseline adherence in determining long-term virological failure.

DESIGN

We assessed baseline adherence via an adherence questionnaire between administered to all consenting patients attending antiretroviral clinics in Khayelitsha township, South Africa, between May 2002 and March 2004. Virological status was ascertained after five years of follow up and multivariate analysis used to model associations of baseline variables and medication adherence with time to viral suppression or failure.

RESULTS

Our adherence cohort comprised 207 patients, among whom 72% were female. Median age was 30 years and median CD4 count at initiation was 55 cells/mm(3). We found no statistically significant differences between baseline characteristics and early adherence groups. Multivariate analysis adjusting for baseline CD4 and age found that patients with suboptimal baseline adherence had a hazard ratio of 2.82 (95% CI 1.19-6.66, p = 0.018) for progression to virological failure compared to those whose baseline adherence was considered optimal.

CONCLUSIONS

Our longitudinal study provides further confirmation of adherence as a primary determinant of subsequent confirmed virological failure, and serves as a reminder of the importance of initial early investments in adherence counseling and support as an effective way to maximize long-term treatment success.

Associação entre uso de álcool em indivíduos com AIDS e adesão ao tratamento antirretroviral: uma revisão da literatura

OBJETIVO: O objetivo deste trabalho foi fazer uma revisão sistemática da literatura, utilizando a base de dados MedLine, sobre o tema: uso/abuso/dependência de álcool como um fator de risco à redução da adesão, à redução na supressão da carga viral ou ao pior desfecho clínico em pacientes com AIDS em uso de highly active antiretroviral therapy (HAART). MÉTODO: Foi realizada uma pesquisa sistemática na base de dados MedLine utilizando como unitermos "HAART", "adherence" e "alcohol", na busca de artigos que versassem sobre a temática: avaliação ou associação de uso/abuso/dependência de álcool e adesão/supressão da carga viral/ desfecho clínico nos pacientes em uso de terapia antirretroviral. RESULTADOS: A busca resultou em 65 artigos. Contudo, apenas 21 deles contemplaram os critérios de inclusão e foram selecionados. Foi encontrada associação positiva entre uso/abuso/dependência de álcool e baixa adesão/baixa supressão da carga viral/pior desfecho clínico em 18 (85,7%) artigos. CONCLUSÃO: O uso/abuso/dependência de álcool é um fator de risco para baixa adesão/baixa supressão da carga viral/pior desfecho clínico nos indivíduos em uso de HAART.

Consistent ART adherence is associated with improved quality of Life, CD4 counts, and reduced hospital costs in central China

This study aimed to assess levels of ART adherence and to examine the relationship between adherence and treatment outcomes. A longitudinal study in Hunan and Hubei provinces used the CPCRA Antiretroviral Medication Self-Report and a 7-day Visual Analogue Scale to assess levels of adherence, while quality of life was evaluated using SF-36. CD4 cell count and the number, duration, and cost of hospitalizations were collected from participant medical records. Measurements were obtained at baseline, month 3, and month 6. A total of 113 participants enrolled and 98 completed the study. The mean level of adherence was 91%, 89%, and 88% at baseline and at 3 and 6 months, respectively. Of participants, 54/98 (58%) reported taking all doses at all three interviews and were classified as consistent adherers (CA). CAs had better physical function (p = 0.001), general health (p = 0.009), vitality (p = 0.016), social functioning (p = 0.001), and mental health (p = 0.023), and presented a higher CD4 cell count (p = 0.028). CAs also had fewer hospital admissions and readmissions (p = 0.005), shorter hospital stays (p = 0.005), and lower hospital expenses (p = 0.006). Consistent adherence is associated with better outcomes including improved quality of life, higher CD4 counts, and lower health care costs.

Short communication: oral lesions in HIV/AIDS patients undergoing HAART including efavirenz

Oral lesions (OL) have an important prognostic value for HIV/AIDS patients. However, the behavior of OL in HIV/AIDS patients undergoing highly active antiretroviral therapy including efavirenz (HAART/EFV) has not been documented. Our objective was to establish the prevalence of OL in HIV/AIDS patients undergoing HAART/EFV and to compare it with the prevalence of OL in patients undergoing antiretroviral therapy including a protease inhibitor (HAART/PI). Seventy-three HIV/AIDS patients undergoing antiretroviral treatment for at least for 6 months at "La Raza" Medical Center's Internal Medicine Unit (IMSS, Mexico City) were included. To detect OL, a detailed examination of oral soft tissues was performed in each patient. Patient records recorded gender, seropositivity time, route of contagion, antiretroviral therapy type and duration, CD4 lymphocyte count/ml, and viral load. Two groups were formed: 38 patients receiving HAART/EFV [two nucleoside analogue reverse transcriptase inhibitors (NARTI) plus efavirenz] and 35 patients receiving HAART/PI (two NARTIs plus one PI). OL prevalence was established in each study group. The Chi-square test was applied (p < 0.05(IC95%)). OL prevalence in the HAART/EFV group (32%) was lower (p < 0.007) than in the HAART/PI group (63%). Candidosis was the most prevalent OL in both groups. Herpes labialis, HIV-associated necrotizing periodontitis, xerostomia, hairy leukoplakia, and nonspecific oral sores were identified. The highest prevalence for all OL was found in the HAART/PI group. These findings suggest that HIV/AIDS patients undergoing HAART/EFV show a lower prevalence of oral lesions than patients undergoing HAART/PI.