Prevalence and correlates of nonadherence to antiretroviral therapy in a population of HIV patients using Medication Event Monitoring System

Unhealthy Alcohol Use Is Associated With Suboptimal Adherence to Isoniazid Preventive Therapy in Persons With HIV in Southwestern Uganda

BACKGROUND

Unhealthy alcohol use is associated with increased progression to tuberculosis (TB) disease, but its effect on adherence to isoniazid (INH) preventive therapy is not known.

METHODS

This was a prospective study of persons with HIV with latent TB in southwestern Uganda reporting any current (previous 3 months) alcohol use or no alcohol consumption in the previous year (2:1 ratio). All received INH. We defined suboptimal adherence as <90% of days with at least 1 Medication Event Monitoring System cap opening, over the previous 90 days. Alcohol use was categorized as follows: none: no self-report and phosphatidylethanol (PEth) <8 ng/mL; moderate: Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) 1-2 (women) or 1-3 (men) and/or PEth 8 ≥ 50 ng/mL; and unhealthy: AUDIT-C ≥3 (women) or ≥4 (men) and/or PEth ≥50 ng/mL. We used generalized estimating equation logistic regression analyses to assess the association between the level of alcohol use and suboptimal INH adherence.

RESULTS

Three hundred two persons were enrolled; 279 were on INH for 3 or more months. The prevalence of suboptimal INH adherence was 31.3% at 3 months and 43.9% at 6 months. The odds of suboptimal INH adherence were higher for unhealthy (adjusted odds ratio, 2.78; 95% confidence interval: 1.62 to 4.76) and moderate (adjusted odds ratio, 1.59; 95% confidence interval: 0.94 to 2.71) compared with no alcohol consumption.

CONCLUSIONS

Suboptimal adherence to INH at 3 and 6 months was high among prospective study of persons with HIV and associated with unhealthy alcohol use. Adherence support and alcohol reduction strategies are needed for this group at high risk for active TB.

Evaluation of factors associated with medication adherence in patients with bipolar disorder using a medication event monitoring system: a 6-month follow-up prospective study

BACKGROUND

Non-adherence in patients with bipolar disorder (BD) results in symptoms, such as aggravation, BD recurrence, emergency room visits, re-hospitalization, and poor psychosocial outcomes. Though non-adherence rates have been reported to range between 30-50% in patients with BD, the problem of adherence is often either overlooked by the physician or denied by the patient. An essential first step to enhancing medication adherence is to objectively estimate adherence. The Medication Event Monitoring System (MEMS), which is a pill bottle cap with a microprocessor, is an accurate device for assessing medication adherence. Using the MEMS, we aimed to measure medication adherence in patients with BD and evaluate the factors associated with and 6-month changes in medication adherence.

METHODS

Participants with BD were recruited from the psychiatric outpatient clinic of the Korea University Guro Hospital. The medication adherence of each participant was assessed using the MEMS, a self-report, pill count, and clinician rating. MEMS-measured adherence was reassessed after 6 months. Patient demographics were recorded and clinical assessments were conducted. Data were analyzed using Kappa statistics and Pearson's correlation analysis.

RESULTS

Of the 59 participants, 50 records were included in the analysis. Patient adherence and adherence rate assessed by the MEMS were lower than those assessed by the other measures. MEMS-measured adherence was correlated more closely with pill counts than with self-reports or clinician ratings. MEMS-measured adherence was negatively associated with prescription duration and the Brief Psychiatric Rating Scale-Affect Subscale Score. Six-month changes in MEMS-measured adherence were positively associated with attitude toward drugs and negatively associated with weight gain assessed by the Udvalg for Kliniske Undersøgelser Side Effect Rating Scale.

CONCLUSIONS

Clinicians may have to consider the limited accuracy of self-reporting and clinician rating methods and exercise caution when assessing the medication adherence of patients with BD using these methods. Our findings may assist clinicians in the assessment and improvement of medication adherence in patients with BD and, consequently, may be useful for the treatment and prevention of BD recurrence.

Interventions to support adherence to oral anticancer therapies: research challenges, lessons learned, and strategies to overcome them from Australia and Switzerland

Not monitoring adherence to oral anticancer therapies (OAT) can lead to poor clinical outcomes, including premature death as reported by Foulon et al. (Acta Clin Belg 66(2):85-96, 2011) and Greer et al. (Oncologist 21(3):354-76, 2016). Barriers to the implementation of supportive cancer care interventions in medication adherence occur with multiple hospital sites, cancer diagnoses, and numerous healthcare professionals. This commentary describes challenges and strategies from two OAT adherence trials in Australia and Switzerland to assist researchers in the design and implementation of future interprofessional trials.

A smartphone program to support adherence to oral chemotherapy in people with cancer: Proof-of-concept trial

AIM

Nonadherence to oral chemotherapy (OC) can lead to health complications, including premature death. Mobile phones are increasingly used to deliver medication adherence interventions. However, there is limited evidence about mobile phone-based interventions to increase adherence to OC, specifically. This study explores the proof-of-concept of a smartphone program to support adherence to OC in people with cancer.

METHODS

This was a 10-week, nonrandomized, multisite trial. The outcomes assessed were acceptability, satisfaction with the intervention, adherence to OC, knowledge about OC, and side-effects presence and severity. The program consisted of short message service (SMS) reminders to take OC, as well as information about OC, including the management of side-effects.

RESULTS

Twenty-two participants (17-74 y/o, median age 60 y/o) were recruited at six hospitals. The sample included 10 different cancer diagnoses (predominance of breast cancer) and 11 OC medications. Acceptability of the intervention was high, with 95% of the enrolled participants completing postintervention measures, and 81% reporting high satisfaction with the program. The intervention was found to have no effect on supporting adherence to OC (assessed by self-report and medication event monitoring system) in this sample. An increase in knowledge about OC was observed at postintervention (p = 0.010).

CONCLUSIONS

This study demonstrated proof-of-concept of the smartphone program and highlighted the need for intervention and trial design-related refinements. Future work should evaluate the effect of the program on adherence to OC with nonadherent patients.

Changes in ART Adherence Relate to Changes in depression as Well! Evidence for the Bi-directional Longitudinal Relationship Between Depression and ART Adherence from a Prospective Study of HIV Clients in Uganda

Studies have documented how levels and change in depression correspond to ART non-adherence. However, few studies have examined how levels of and change in adherence may relate to levels of and change in depression, although one might expect mental health to be related to physical health and how successful one is in managing disease. To assess the bidirectional nature of the association between these two constructs, we examined data from a prospective trial of an ART adherence intervention in Uganda that followed 143 participants over 20 months. Adherence was measured using electronic monitoring caps; non-adherence was defined as missing > 10% of prescribed doses; self-reported depression was measured using the Patient Health Questionnaire (PHQ-9), and PHQ-9 > 4 defined the presence of at least minor depression. Adjusted linear and logistic regression models were used to examine the longitudinal relationships between depression and non-adherence. At baseline, 40.6% had at least minor depression and 37.1% were non-adherent. Time varying change in the classification of depression (e.g., becoming depressed) predicted change in non-adherence status (e.g., becoming non-adherent), and this association remained when examining continuous measures of the constructs. Similarly, time varying measures of increases in non-adherence predicted increases in depression, regardless of whether continuous or binary classification measures were used. A temporal trend of increased non-adherence over time was observed, and this was accelerated by an increase in depression. Furthermore, those who had at least minor depression at baseline were more likely to be non-adherent at follow-up. These findings support the potential benefits of depression care and adherence support for improving adherence and mental health, respectively, and call for further research to examine such benefits.The trial has been registered with ClinicalTrials.gov (NCT02503072).

Self-reported antiretroviral therapy adherence and viral load in criminal justice-involved populations

Background

Self-reported antiretroviral therapy (ART) adherence measures that are associated with plasma viral load (VL) are valuable to clinicians and researchers, but are rarely examined among groups vulnerable to dropping out of care. One-seventh of all those living with HIV pass through incarceration annually and criminal-justice (CJ) involved people living with HIV (PLH) are vulnerable to falling out of care. We examined the association of self-reported ART adherence with VL in a criminal-justice sample compared to a routine-care sample.

Methods

Samples: We examined data from a multisite collaboration of studies addressing the continuum of HIV care among CjJ involved persons in the Seek, Test, Treat, and Retain cohort. Data pooled from seven CJ- studies (n = 414) were examined and compared with the routine-care sample from the Centers for AIDS Research Network of Integrated Clinical Systems’ seven sites (n = 11,698).

Measures: In both samples, data on self-reported percent ART doses taken were collected via the visual analogue scale adherence measure. Viral load data were obtained by blood-draw.

Analysis: We examined the associations of adherence with VL in both cohorts using mixed effects linear regression of log-VL, and mixed effects logistic regression of binary VL (≥ 200 copies/mL) outcomes. Interactions by CD4 count and self-reported health status were also tested.

Results

Among the CJ sample, the coefficient for log-VL was − 0.31 (95% CI = − 0.43, − 0.18; P < 0.01) and that in the routine-care sample was − 0.42 (95% CI = − 0.45, − 0.38; P < 0.01). For the logistic regression of binary detectable VL on 10% increments of adherence we found the coefficient was − 0.26 (95% CI = − 0.37, − 0.14; P < 0.01) and in the routine-care sample it was − 0.38 (95% CI = − 0.41, − 0.35; P < 0.01). There was no significant interaction by CD4 count level in the CJ sample, but there was in the routine-care sample. Conversely, there was a significant interaction by self-reported health status level in the criminal-justice sample, but not in the routine-care sample.

Conclusions

The visual analogue scale is valid and useful to measure ART adherence, supporting treatment for CJ- involved PLH vulnerable to falling out of care. Research should examine adherence and VL in additional populations.

Health benefits of positive reappraisal coping among people living with HIV/AIDS: A systematic review

People living with HIV/AIDS (PLWHA) often face significant stress, ranging from perceiving identity changes to encountering barriers to daily health behavior engagement. To manage these experiences, many people use positive reappraisal coping (including benefit finding and perceiving growth). Effective coping is highly important for PLWHA; stress reduction has salutary effects on multiple indicators of health. The present systematic review, conducted in PubMed, PsycINFO, and CINAHL, synthesises findings from 33 studies of PLWHA, addressing effects of positive reappraisal on health-related outcomes for adults living with HIV as a chronic illness. Studies were evaluated based on methodological considerations, measurement of key variables, and implications for specific aspects of health. Results suggest that positive reappraisal is often beneficial when dealing with the implications of a potentially traumatic HIV diagnosis on one's identity, although effects may be contextually bound. Implications of these findings are reviewed, emphasizing the importance of positive reappraisal for enhancing health promotion and self-management of HIV. Although the present review is limited by inclusion of multiple disparate outcomes and exclusion of non-English-language articles, these findings inform a comprehensive model of direct and indirect effects of positive reappraisal on emotional, functional, physiological, and behavioural aspects of health useful for guiding future research.

Outcome measures for adherence data from a medication event monitoring system: A literature review

WHAT IS KNOWN

Currently, medication bottles with an electronic cap are frequently used to measure medication adherence. This system is termed medication event monitoring system (MEMS). To our knowledge, the optimal method to summarize data from MEMS has not yet been determined.

OBJECTIVE

Look for best practices on how to quantify adherence data from MEMS.

METHODS

Review of PubMed, Embase and Cochrane databases for the articles on medication adherence with MEMS.

RESULTS

Of 1493 identified articles, 207 were included in this review. The MEMS cap was used for a median of 3 months (IQR: 4; range: 1 week to 24 months) in various health conditions. Many different outcome measures were used. Most studies computed an adherence score, expressed as the percentage of days on which the correct dose of medication was taken. The threshold to mark people as adherent was most frequently, arbitrarily, set at 80% (range: 67%-95%). We found no data to support a specific threshold.

DISCUSSION

Although the commonly used definition of adherence has face validity, we found no validation studies, and not all studies used the same cut-off for adherence. Ideally, a cut-off should be defined and validated in the context of the specific drug and its pharmacokinetic and dynamic characteristics, and perhaps other contextual factors, rather than generically. In addition, there was large heterogeneity in the definition of what "correct intake" of medication is.

WHAT IS NEW AND CONCLUSION

Outcome measures for MEMS data lacked standardization, and no demonstrable effort to validate any definition against a relevant clinical outcome is available. Consensus on the definition of adherence is urgently needed.

Deception in clinical trials and its impact on recruitment and adherence of study participants

Deceptive practices by participants in clinical research are prevalent. It has been shown that as high as 75% of participants withheld information to avoid exclusion from studies. Self-reported adherence has been found to be largely inaccurate. Overcoming deception is a critical issue, since the safety of study participants, the integrity of research data and research resources are at risk. In this review article, we examine deception from the perspective of investigators conducting clinical trials; we describe the types (concealment, fabrication, drug holidays and collusion), prevalence, risks, and predictors of deception, and propose an approach to reduce the impact of deception, especially on adherence, in clinical trials.

Factors influencing oral adherence: qualitative metasummary and triangulation with quantitative evidence

BACKGROUND

Concern about adherence to oral agents among patients with cancer has grown as more oral agents are being used for cancer treatment. Knowledge of common factors that facilitate or inhibit adherence to oral medication regimens can be beneficial to clinicians in identifying patients at risk for nonadherence, in planning care to address barriers to adherence, and in educating patients about ways to improve adherence.

OBJECTIVES

The focus of this review is to synthesize the evidence about factors that influence adherence and identify implications for practice.

METHODS

Literature was searched via PubMed and CINAHL®. Evidence regarding factors influencing adherence was synthesized using a metasummary of qualitative research and triangulated with findings from quantitative research.

FINDINGS

Forty-four factors influencing adherence were identified from 159 research studies of patients with and without cancer. Factors associated with adherence in oncology and non-oncology cases included provider relations, side effects, forgetfulness, beliefs about medication necessity, establishing routines for taking medication, social support, ability to fit medications in lifestyle, cost, and medication knowledge. Among patients with cancer, depression and negative expectations of results also were shown to have a negative relationship to adherence.

Psychosocial Correlates of Medication Adherence among HIV-Positive, Cognitively Impaired Individuals

Although cognitive impairment has been shown to adversely affect antiviral medication adherence, a subset of cognitively impaired adults nonetheless are able to adequately adhere to their medication regimen. However, little is known about factors that serve as buffers against suboptimal adherence among the cognitively impaired. This study consisted of 160 HIV-positive, cognitively impaired adults (Global Deficit Score ≥ 0.50) whose medication adherence was monitored over 6-months using an electronic monitoring device (MEMS caps). Logistic regressions were run to determine psychosocial variables associated with medication adherence. Higher self-efficacy and treatment related support, a stable medication regimen, stable stress levels, and absence of current stimulant use were predictive of optimal adherence. A distinct array of psychosocial factors was found that buffer against the adverse effects of cognitive impairment on medication adherence. Assessment and interventions targeting these factors may improve adherence rates among cognitively impaired adults.

The Clarification of Depression and Social Support's Contribution to the Prediction of Antiretroviral Medication Adherence and the Rate of CD4 in People with HIV

With the development of the antiretroviral therapy, the number of the people with HIV is increasing; therefore, identifying the factors affecting HIV is of great importance. This study aimed to investigate the relationship between the antiretroviral medication adherence and the rate of CD4 with depression and social support in the people with HIV. The research method was a descriptive study kind of correlation. The statistical population included all patients with HIV in Shiraz, of whom, 220 people who had referred to the Behavioral Diseases Consultation Center were selected using the available sampling method. Philips et al.'s Social Support Questionnaire, Beck's Depression Questionnaire II, and ACTG Medication Adherence Questionnaire were used as the research tools. Results were analyzed using the stepwise regression and stepwise hierarchical multiple regression. Regression analysis showed that social support and depression variables could predict totally 47% (P<0.001) of changes of medication adherence variable, and depression could predict only 2% (P<0.01) of rate variance of CD4.

Toward appropriate criteria in medication adherence assessment in older persons: Position Paper

Nonadherence to medication regimens is a worldwide challenge; adherence rates range from 38 to 57 % in older populations with an average rate of less than 45 % and nonadherence contributes to adverse drug events, increased emergency visits and hospitalisations. Accurate measurement of medication adherence is important in terms of both research and clinical practice. However, the identification of an objective approach to measure nonadherence is still an ongoing challenge. The aim of this Position Paper is to describe the advantages and disadvantages of the known medication adherence tools (self-report, pill count, medication event monitoring system (MEMS) and electronic monitoring devices, therapeutic drug monitoring, pharmacy records based on pharmacy refill and pharmacy claims databases) to provide the appropriate criteria to assess medication adherence in older persons. To the best of our knowledge, no gold standard has been identified in adherence measurement and no single method is sufficiently reliable and accurate. A combination of methods appears to be the most suitable. Secondly, adherence assessment should always consider tools enabling polypharmacy adherence assessment. Moreover, it is increasingly evident that adherence, as a process, has to be assessed over time and not just at one evaluation time point (drug discontinuation). When cognitive deficits or functional impairments may impair reliability of adherence assessment, a comprehensive geriatric assessment should be performed and the caregiver involved. Finally, studies considering the possible implementation in clinical practice of adherence assessment tools validated in research are needed.

A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence

Different methods are available for measuring medication adherence. In this paper, we conducted a scoping review to identify and summarize evidence of all studies comparing the Medication Event Monitoring System (MEMS) with alternative methods for measuring medication adherence. A literature search was performed using the open database www.iAdherence.org that includes all original studies reporting findings from the MEMS. Papers comparing methods for measuring adherence to solid oral formulations were included. Data was extracted using a standardized extraction table. A total of 117 articles fulfilled the inclusion criteria, including 251 comparisons. Most frequent comparisons were against self-report (n = 119) and pill count (n = 59). Similar outcome measures were used in 210 comparisons (84%), among which 78 used dichotomous variables (adherent or not) and 132 used continuous measures (adherence expressed as percentage). Furthermore, 32% of all comparisons did not estimate adherence over the same coverage period and 44% of all comparisons did not use a statistical method or used a suboptimal one. Only eighty-seven (35%) comparisons had similar coverage periods, similar outcome measures and optimal statistical methods. Compared to MEMS, median adherence was grossly overestimated by 17% using self-report, by 8% using pill count and by 6% using rating. In conclusion, among all comparisons of MEMS versus alternative methods for measuring adherence, only a few used adequate comparisons in terms of outcome measures, coverage periods and statistical method. Researchers should therefore use stronger methodological frameworks when comparing measurement methods and be aware that non-electronic measures could lead to overestimation of medication adherence.

Binge drinking is associated with differences in weekday and weekend adherence in HIV-infected individuals

BACKGROUND

Understanding patterns of antiretroviral adherence and its predictors is important for designing tailored interventions. Alcohol use is associated with non-adherence. This study aimed to evaluate: (1) if there was a difference in weekday compared with weekend adherence in HIV-infected individuals from low and middle income countries (LMIC), and (2) whether binge drinking was associated with this difference.

METHODS

Data from a randomized trial conducted at 9 sites in 8 LMIC were analyzed. Microelectronic monitors were used to measure adherence. Differences between weekday and weekend adherence in each quarter (successive 12-week periods) were compared using Wilcoxon signed rank tests and predictors of adherence, including baseline binge drinking, were evaluated using Generalized Estimating Equations.

RESULTS

Data from 255 participants were analyzed: 49.8% were male, median age was 37 years and 28.6% enrolled in Haiti. At study entry, only 2.7% reported illicit substance use, but 22.3% reported binge drinking at least once in the 30 days prior to enrollment. Adherence was higher on weekdays than weekends (median percent doses taken: 96.0% vs 94.4%; 93.7% vs 91.7%; 92.6% vs 89.7% and 93.7% vs 89.7% in quarters 1-4 respectively, all p<0.001). Binge drinking at baseline and time on study were both associated with greater differences between weekday and weekend adherence.

CONCLUSIONS

Adherence was worse on weekends compared to weekdays: difference was small at treatment initiation, increased over time and was associated with binge drinking. Screening and new interventions to address binge drinking, a potentially modifiable behavior, may improve adherence in HIV-infected individuals in LMIC.

Cost-effectiveness analysis of antiretroviral therapy in a cohort of HIV-infected patients starting first-line highly active antiretroviral therapy during 6 years of observation

Objectives

Costs may play a role in deciding how and when to start highly active antiretroviral therapy (HAART) in a naïve patient. The aim of the present study was to assess the cost- effectiveness of treatment with HAART in a large clinical cohort of naïve adults to determine the potential role of single-tablet regimens in the management of patients with human immunodeficiency virus (HIV). An incremental cost-effectiveness ratio analysis was performed, including a quality-adjusted life year approach.

Results

In total, 741 patients (females comprising 25.5%) were retrospectively included. The mean age was 39 years, the mean CD4 cell count was 266 cells/μL, and the mean viral load was 192,821 copies/mL. The most commonly used backbone was tenofovir + emtricitabine (77.6%); zidovudine + lamivudine was used in 10%, lamivudine + abacavir in 3%, and other nucleoside reverse transcriptase inhibitor (NRTI) or NRTI-free regimens in 9.4% of patients. NNRTIs were used in 52.8% of cases, boosted protease inhibitors in 44.1%, and unboosted protease inhibitors and integrase inhibitors in 0.7% and 2.4%, respectively. Starting therapy at CD4 >500 cells/μL and CD4 351–500 cells/μL rather than at <201 cells/μL was the more cost-effective approach. The same consideration was not true comparing current indications with the possibility to start HAART at any CD4 value (eg, >500 cells per μL); in this case, the incremental cost-effectiveness ratio value was €199,130 per quality-adjusted life year gained, a higher value than the one suggested in guidelines. The single-tablet regimen (STR) invariably dominated any other therapeutic approach. Sensitivity analysis was performed, and starting right away with an STR was cost-effective even when compared with therapeutic strategies contemplating STR as simplification.

Conclusion

By integrating clinical data with economic variables, our study offers an estimate of the cost-effectiveness of the various first-line treatment strategies for patients infected with HIV and provides significant evidence to be used in future prospective pharmacoeconomic evaluations.

Communication Between HIV Patients and Their Providers: A Qualitative Preference Match Analysis

Since the introduction of cART (combination antiretroviral therapy), HIV has evolved into a chronic disease such that it requires lifelong medical treatment to which patients must adhere. Communication with health care providers is pivotal in supporting patients to adapt to having HIV and adhering to treatment, in order to maintain health and quality of life. Previous research indicates that communication is optimal when it matches patient preferences for information exchange, relationship establishment, and involvement in treatment decisions. The aim of the present study is to explore HIV patient communication preferences as well as patient experiences with their providers (not) matching their preferences. A second aim is to explore provider beliefs about patient preferences and provider views on optimal communication. Data were collected through interviews with 28 patients and 11 providers from two academic hospitals. Results indicate that patient preferences reflect their cognitive, emotional, and practical needs such that patients look to increase their sense of control over their HIV. Patients aim to further increase their sense of control (by proxy) through their relationship with their providers and through their decisional involvement preferences. Providers are well aware of patient communication preferences but do not explicate underlying control needs. Implications for clinical practice are discussed.

Single-Tablet Regimens in HIV Therapy

Combined antiretroviral therapy (cART) has evolved considerably over the past decades leading to a better control of human immunodeficiency virus replication. Recently, regimens have evolved so as to simplify dosing frequency and reduce pill burden to improve adherence. Several national and international guidelines suggest antiretroviral (ARV) regimen simplification as a method of improving adherence. Decreased cART adherence has been associated with both patient-related factors and regimen-related factors. Adherence rates are statistically higher when simpler, once-daily (OD) regimens are combined with smaller daily regimen pill burdens. The avoidance of selective non-adherence, where a patient takes part of a regimen but not the full regimen, is a further potential benefit offered by single-tablet regimens (STRs). Simplification of cART has been associated with a better quality of life (QoL). Although tempered by other factors, better adherence, higher QoL and patients' preferences are all key points which might combine to assure long-lasting efficacy and durability of cART. All studies underlined the favorable tolerability profile of newer STRs. Three STRs are currently available. Tenofovir (TDF) plus emtricitabine (FTC)/efavirenz (EFV) was the first OD complete ARV regimen available as a STR. TDF plus FTC/rilpivirine is a second-generation STR. The most recently approved STR, TDF plus FTC/cobicistat/elvitegravir, is the first non-nucleoside reverse transcriptase inhibitor-based STR. All of them have shown excellent efficacy; safety and tolerability have been improved by more recent formulations. Several other STRs are anticipated both combining completely different drugs, abacavir (ABC) plus lamivudine (3TC)/dolutegravir, utilizing innovative formulations of older drugs, tenofovir alafenamide fumarate, or taking advance of bioequivalent drugs, lamivudine (3TC) plus ABC/EFV. The future challenge would be to develop completely alternative STRs (including for example protease inhibitors or new molecules) to extend the advantages of simplicity to heavily pre-treated individuals.

Heterogeneity among studies in rates of decline of antiretroviral therapy adherence over time: results from the multisite adherence collaboration on HIV 14 study

OBJECTIVE

To use electronic drug monitoring to determine if adherence to HIV antiretroviral therapy (ART) changes over time, whether changes are linear, and how the declines vary by study.

DESIGN

We conducted a longitudinal study of pooled data from 11 different studies of HIV-infected adults using ART. The main outcome was ART adherence (percent of prescribed doses taken) measured by electronic drug monitoring. We modeled and compared changes in adherence over time using repeated measures linear mixed effects models and generalized additive mixed models (GAMMs). Indicator variables were used to examine the impact of individual studies, and the variation across studies was evaluated using study-specific parameter estimates calculated by using interaction terms of study and time.

RESULTS

The mean age of the subjects was 41 years, 35% were female, most had high school education or less, and 46% were African American. In GAMMs, adherence declined over time. The GAMMs further suggested that the decline was nonlinear, and in both sets of models, there was considerable study-to-study variability in how adherence changed over time.

LIMITATIONS

Findings may not be generalizable to non-US populations or to patients not in clinical studies.

CONCLUSIONS

Although overall ART adherence declined with time, not all studies showed declines, and a number of patterns of change were seen. Studies that identify clinical and organizational factors associated with these different patterns are needed. Models of changes in adherence with time should take account of possible nonlinear effects.

Psychosocial predictors of non-adherence to chronic medication: systematic review of longitudinal studies

OBJECTIVES

Several cross-sectional studies suggest that psychosocial factors are associated with non-adherence to chronic preventive maintenance medication (CPMM); however, results from longitudinal associations have not yet been systematically summarized. Therefore, the objective of this study was to systematically synthesize evidence of longitudinal associations between psychosocial predictors and CPMM non-adherence.

MATERIALS AND METHODS

PUBMED, EMBASE, CINAHL, and PsychINFO databases were searched for studies meeting our inclusion criteria. The reference lists and the ISI Web of Knowledge of the included studies were checked. Studies were included if they had an English abstract, involved adult populations using CPMM living in Western countries, and if they investigated associations between psychosocial predictors and medication non-adherence using longitudinal designs. Data were extracted according to a literature-based extraction form. Study quality was independently judged by two researchers using a framework comprising six bias domains. Studies were considered to be of high quality if ≥four domains were free of bias. Psychosocial predictors for non-adherence were categorized into five pre-defined categories: beliefs/cognitions; coping styles; social influences and social support; personality traits; and psychosocial well-being. A qualitative best evidence synthesis was performed to synthesize evidence of longitudinal associations between psychosocial predictors and CPMM non-adherence.

RESULTS

Of 4,732 initially-identified studies, 30 (low-quality) studies were included in the systematic review. The qualitative best evidence synthesis demonstrated limited evidence for absence of a longitudinal association between CPMM non-adherence and the psychosocial categories. The strength of evidence for the review's findings is limited by the low quality of included studies.

CONCLUSION

The results do not provide psychosocial targets for the development of new interventions in clinical practice. This review clearly demonstrates the need for high-quality, longitudinal research to identify psychosocial predictors of medication non-adherence.

Effectiveness of Psycho-Educational Intervention in HIV Patients' Treatment

Adherence to Highly Active Antiretroviral Therapy (HAART) is the main prognostic factor associated with HIV disease progression and death. The aim was to evaluate the effectiveness of a psycho-educational program to promote adherence to HAART in HIV patients. A longitudinal study (n = 102) over 9 months in an Infectious Diseases Hospital was carried out. Adherence to HAART was measured with standardized scales and values of viral load. Two groups were defined: adherents and non-adherents. In the latter, a psycho-educational program was implemented and 6 months later measured adherence to HAART. Knowledge about the infection, CD4 T lymphocytes and HIV-ribonucleic acid values were measured before and after this program. The sample was predominantly male (70%), heterosexual (78%), with a mean age of 49 (SD = 12.7) years, and 48% of participants were not adhering to HAART. After the program, non-adherence decreased to 21.6%. Knowledge about the infection increased from 79 to 97%. A significant increase in CD4 T lymphocytes (mean 540-580) and a decrease in viral load (mean 5411-3052) were observed, the latter of statistical significance. This program seems to be feasible and efficient, improving adherence to HAART.

[Consensus Statement by GeSIDA/National AIDS Plan Secretariat on antiretroviral treatment in adults infected by the human immunodeficiency virus (Updated January 2013)]

OBJECTIVE

This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients.

METHODS

To formulate these recommendations a panel composed of members of the GeSIDA/National AIDS Plan Secretariat (Grupo de Estudio de Sida and the Secretaría del Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations and the evidence which support them are based on a modification of the criteria of Infectious Diseases Society of America.

RESULTS

cART is recommended in patients with symptoms of HIV infection, in pregnant women, in serodiscordant couples with high risk of transmission, in hepatitisB co-infection requiring treatment, and in HIV nephropathy. cART is recommended in asymptomatic patients if CD4 is <500cells/μl. If CD4 are >500cells/μl cART should be considered in the case of chronic hepatitisC, cirrhosis, high cardiovascular risk, plasma viral load >100.000 copies/ml, proportion of CD4 cells <14%, neurocognitive deficits, and in people aged >55years. The objective of cART is to achieve an undetectable viral load. The first cART should include 2 reverse transcriptase inhibitors (RTI) nucleoside analogs and a third drug (a non-analog RTI, a ritonavir boosted protease inhibitor, or an integrase inhibitor). The panel has consensually selected some drug combinations, for the first cART and specific criteria for cART in acute HIV infection, in tuberculosis and other HIV related opportunistic infections, for the women and in pregnancy, in hepatitisB or C co-infection, in HIV-2 infection, and in post-exposure prophylaxis.

CONCLUSIONS

These new guidelines update previous recommendations related to first cART (when to begin and what drugs should be used), how to monitor, and what to do in case of viral failure or adverse drug reactions. cART specific criteria in comorbid patients and special situations are similarly updated.

Economic evaluation of initial antiretroviral therapy for HIV-infected patients: an update of Italian guidelines

Introduction

Highly active antiretroviral therapy (HAART) has allowed many HIV-infected patients to enjoy longer survival and a better quality of life. We performed an economic analysis to estimate the cost-effectiveness of HAART regimens in Italy for managing HIV-naïve infected patients with a viral load below 100,000 copies/mL.

Patients and methods

The population considered in the model consisted of adult subjects with an HIV viral load below 100,000 copies/mL who received antiretroviral HAART treatment for the first time, according to the Italian National Guidelines with recommendation grade A1. The incremental cost-effectiveness analysis of quality-adjusted life years (QALYs) was carried out by means of a Markov model. Both the outcomes (QALYs) and the costs were discounted by 3.5%. The time horizon adopted in the model was 10 years. The point of view of the analysis was that of the Italian national health service.

Results

The tenofovir (TDF)/emtricitabine (FTC)/rilpivirine (RPV) single-tablet regimen (STR) (€7,417.00) revealed the lowest mean treatment cost. TDF/FTC + raltegravir (RAL) showed a better quality of life (0.906 QALY/year), followed by TDF/FTC/RPV (STR; 0.900 QALY/year), TDF/FTC + RPV (multipill regimen) (0.889 QALY/year), and TDF/FTC + atazanavir (ATV/r) (0.886 QALY/year). TDF/FTC/RPV (STR) appeared to be the most cost-effective therapeutic choice (€13,655.00), followed by TDF/FTC + RPV (multipill regimen) (€15,803.00), and TDF/FTC + efavirenz (EFV) (€16,181.00). The sensitivity analysis on the main variables confirmed the validity of the base case scenario.

Conclusion

STR (TDF/FTC/RPV) is the most cost-effective treatment strategy compared with the other therapeutic regimens recommended by the Italian guidelines for the treatment of naïve patients with a viral load <100,000 copies/mL. The inclusion of adverse-event management of HIV-infected patients affects the cost-effectiveness ratio of all HAART regimens.

Cost of behavioral interventions utilizing electronic drug monitoring for antiretroviral therapy adherence

OBJECTIVE

To provide data on the actual costs associated with behavioral ART adherence interventions and electronic drug monitoring used in a clinical trial to inform their implementation in future studies and real-world practice.

METHODS

Direct and time costs were calculated from a multisite 3-arm randomized controlled ART adherence trial. HIV-positive participants (n = 204) were randomized to standard care, enhanced counseling (EC), or EC and modified directly observed therapy (mDOT) interventions. Electronic drug monitoring (EDM) was used. Costs were calculated for various components of the 24-week adherence intervention. This economic evaluation was conducted from the perspective of an agency that may wish to implement these strategies. Sensitivity analyses were conducted to examine costs and savings associated with different scenarios.

RESULTS

Total direct costs were $126,068 ($618 per patient). Initial time costs were $53,590 ($262 per patient). Base cost of labor was $0.36/min. EC costs for 134 patients were $18,427 ($137 per patient) and mDOT for 64 patients cost $18,638 ($291 per patient). Total per patient costs were as follows: standard care = $880, EC = $1018, EC/mDOT = $1309. Removing driving costs evidenced the most variable impact on savings between the 3 study arms. The tornado diagram (sensitivity analysis) showed a graphical representation of how each sensitivity assumption reduced costs compared with each other and the resulting comparative costs for each group.

CONCLUSIONS

This novel economic analysis provides valuable cost information to guide treatment implementation and research design decisions.

Antiretroviral therapy in HIV-infected patients: a proposal to assess the economic value of the single-tablet regimen

BACKGROUND

The aim of this study was to assess the economic value of a reduced number of pills in patients infected with the immunodeficiency virus (HIV) and on highly active antiretroviral therapy by a cost-effectiveness model.

METHODS

An incremental cost-effectiveness analysis of efavirenz, tenofovir, and emtricitabine (TDF-FTC-EFV) as a single-tablet regimen versus a multipill regimen, with reference to untreated HIV-infected patients, was carried out from the perspective of the Italian National Health Service. The comparisons were performed with the help of a Markov decision model over a 10-year time horizon. Based on the ADONE (ADherence to ONE pill) study, it was then possible to identify the utility score increment in patients switching from a multipill regimen of TDF-FTC + EFV therapy to a single-tablet regimen.

RESULTS

The single-tablet regimen (0.755 quality-adjusted life-years [QALYs]/year) resulted in better patient quality of life, with a higher number of QALYs than for the TDF-FTC + EFV multipill regimen (0.716 QALYs/year). The single-tablet regimen was the most cost-effective treatment strategy, with an incremental cost-effectiveness ratio of €22,017.00 versus €26,558.00 for the multipill regimen. A 24% decrease in cost of the multipill regimen determined equivalence with the single-tablet regimen in terms of the incremental cost-effectiveness ratio. Univariate sensitivity and probabilistic analysis carried out on the main variables did not highlight significant variations with respect to the base case scenario.

CONCLUSION

The single-tablet regimen resulted in better adherence, and therefore better quality of life as perceived by patients, corresponding to a €4541.00 lower cost-effectiveness ratio per QALY versus the multipill regimen, with a 17% lower cost in favor of the single-tablet regimen. The value determined could be used to identify a maximum potential "premium price" of 29% to be assigned to therapeutic regimens proposing a single-tablet regimen for HIV-infected patients.

Understanding how adherence goals promote adherence behaviours: a repeated measure observational study with HIV seropositive patients

BACKGROUND

The extent to which patients follow treatments as prescribed is pivotal to treatment success. An exceptionally high level (> 95%) of HIV medication adherence is required to suppress viral replication and protect the immune system and a similarly high level (> 80%) of adherence has also been suggested in order to benefit from prescribed exercise programmes. However, in clinical practice, adherence to both often falls below the desirable level. This project aims to investigate a wide range of psychological and personality factors that may lead to adherence/non-adherence to medical treatment and exercise programmes.

METHODS

HIV positive patients who are referred to the physiotherapist-led 10-week exercise programme as part of the standard care are continuously recruited. Data on social cognitive variables (attitude, intention, subjective norms, self-efficacy, and outcome beliefs) about the goal and specific behaviours, selected personality factors, perceived quality of life, physical activity, self-reported adherence and physical assessment are collected at baseline, at the end of the exercise programme and again 3 months later. The project incorporates objective measures of both exercise (attendance log and improvement in physical measures such as improved fitness level, weight loss, improved circumferential anthropometric measures) and medication adherence (verified by non-invasive hair analysis).

DISCUSSION

The novelty of this project comes from two key aspects, complemented with objective information on exercise and medication adherence. The project assesses beliefs about both the underlying goal such as following prescribed treatment; and about the specific behaviours such as undertaking the exercise or taking the medication, using both implicit and explicit assessments of patients' beliefs and attitudes. We predict that i) the way people think about the underlying goal of their treatments explains medication and exercise behaviours over and above the effects of the behaviour-specific thinking and ii) the relationship between adherence to exercise and to medical treatment is stronger among those with more favourable views about the goal. Results from this study should identify the key contributing factors to inform subsequent adherence research and afford a more streamlined assessment matrix. The project also aims to inform patient care practices. UK CLINICAL RESEARCH NETWORK REGISTRATION NUMBER: UKCRN 7842.

[Consensus document of Gesida and Spanish Secretariat for the National Plan on AIDS (SPNS) regarding combined antiretroviral treatment in adults infected by the human immunodeficiency virus (January 2012)]

This consensus document has been prepared by a panel consisting of members of the AIDS Study Group (Gesida) and the Spanish Secretariat for the National Plan on AIDS (SPNS) after reviewing the efficacy and safety results of clinical trials, cohort and pharmacokinetic studies published in medical journals, or presented in medical scientific meetings. Gesida has prepared an objective and structured method to prioritise combined antiretroviral treatment (cART) in naïve patients. Recommendations strength (A, B, C) and the evidence which supports them (I, II, III) are based on a modification of the Infectious Diseases Society of America criteria. The current antiretroviral treatment (ART) of choice for chronic HIV infection is the combination of three drugs. ART is recommended in patients with symptomatic HIV infection, in pregnancy, in serodiscordant couples with high transmission risk, hepatitis B fulfilling treatment criteria, and HIV nephropathy. Guidelines on ART treatment in patients with concurrent diagnosis of HIV infection and an opportunistic type C infection are included. In asymptomatic patients ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: 1) therapy should be started in patients with CD4 counts <350 cells/μL; 2) when CD4 counts are between 350 and 500 cells/μL, therapy will be recommended and only delayed if patient is reluctant to take it, the CD4 are stabilised, and the plasma viral load is low; 3) therapy could be deferred when CD4 counts are above 500 cells/μL, but should be considered in cases of cirrhosis, chronic hepatitis C, high cardiovascular risk, plasma viral load >10(5) copies/mL, proportion of CD4 cells <14%, and in people aged >55 years. ART should include 2 reverse transcriptase inhibitors nucleoside analogues and a third drug (non-analogue reverse transcriptase inhibitor, ritonavir boosted protease inhibitor or integrase inhibitor). The panel has consensually selected and given priority to using the Gesida score for some drug combinations, some of them co-formulated. The objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after ART failures, but an undetectable viral load may be possible nowadays. Adverse events are a fading problem of ART. Guidelines in acute HIV infection, in women, in pregnancy, and to prevent mother-to-child transmission and pre- and post-exposition prophylaxis are commented upon. Management of hepatitis B or C co-infection, other co-morbidities, and the characteristics of ART in HIV-2 infection are included.

Medication adherence and symptom reduction in adults treated with mixed amphetamine salts in a randomized crossover study

OBJECTIVES

The study objectives were to 1) evaluate medication adherence for adults with attention-deficit/hyperactivity disorder (ADHD) treated with 3 times daily (TID) mixed amphetamine salts immediate release (MAS IR) versus once-daily (qAM) MAS extended release (MAS XR) in a randomized, crossover study; and 2) to examine the associations between adherence and efficacy for MAS IR and MAS XR.

METHODS

Sixty-two adults with ADHD were enrolled and 49 completed the study. The treatment condition order (TID-qAM or qAM-TID) was counterbalanced across participants, with an intervening washout period of ≥ 7 days. Adherence was assessed via 3 measures: 1) self-report, 2) pill count, and 3) the Medication Event Monitoring System (MEMS(®)). The primary efficacy measure was the ADHD Rating Scale (ADHD-RS); secondary measures included the Time-Sensitive ADHD Symptom Scale (TASS) and Clinical Global Impressions-Severity of Illness (CGI-S) scale.

RESULTS

Adherence to treatment as measured by self-report and pill count was not significantly different between MAS XR and MAS IR. Adherence was significantly better for MAS XR than MAS IR for all of the MEMS(®) measures. The mean change in ADHD-RS, TASS, and CGI-S scores at endpoint was significantly improved for both MAS IR and MAS XR and did not differ significantly between groups. There was not a significant adherence by efficacy interaction.

CONCLUSION

Adults with ADHD adhered equally well with MAS IR as with MAS XR when assessed by pill count and self-report, but not by the MEMS(®) measures. Both treatments significantly reduced ADHD symptoms, and efficacy was not significantly different between groups. Adherence was not associated with treatment outcome.

Stigma mediates the relationship between self-efficacy, medication adherence, and quality of life among people living with HIV/AIDS in China

Although the relationship between self-efficacy and health-related behaviors is well known, limited data are available describing the association between self-efficacy and HIV stigma. Specifically, it is not known if the relationship between self-efficacy and health outcomes is mediated by HIV stigma. This study aimed to test these relationships. Data were collected from 202 HIV/AIDS patients in China using questionnaires measuring self-efficacy for disease management, self-reported 7 day medication adherence, perceived HIV/AIDS stigma and quality of life. The total mean score for self-efficacy was 6.73 (range, 2.78-10.0), and the total mean score for HIV stigma was 102.24 (range, 57.0-148.0). Seventy-four percent (150/202) of subjects reported missing no medication doses during past 7 days, and 73% (148/202) subjects reported a quality of life score over 60. There was a moderate level of association between self-efficacy and HIV stigma (Pearson r=-0.43, p=0.000). High self-efficacy predicted better medication adherence (odds ratio [OR]=1.82, 95% confidence interval [CI]=1.40-2.36) and better quality of life (OR=1.28, 95% CI=1.03-1.60) after controlling for demographic and HIV related characteristics. HIV stigma partially mediated the relationship between self-efficacy and medication adherence (OR=1.64, 95% CI=1.26-2.15; Sobel test result Z=1.975, p=0.048). HIV stigma totally mediated the relationship between self-efficacy and quality of life (OR=1.15, 95% CI=0.91-1.46; Sobel test result Z=2.362, p=0.018). The results suggest that, although self-efficacy is an important predictor for medication adherence and quality of life, HIV stigma as a mediator should not be neglected. Health care providers should also evaluate HIV stigma conditions when seeking to improve self-efficacy through interventions.

The spectrum of nonadherence with medication in heart, liver, and lung transplant patients assessed in various ways

Adherence to medication regimes is crucial for transplant patients. Addressing methodological limitations and gaps in the literature, we studied: (i) the prevalence of nonadherence (NA) with immunosuppression (IS) using various measurement methods, (ii) NA prevalence regarding intake and timing, (iii) changes in NA over time, (iv) differences in NA across organ transplant populations, (v) NA regarding co-medication. Using a descriptive, prospective, comparative design over 3 months, we included convenience samples of adult heart (n=79), liver (n=55), and lung (n=104) transplant patients. NA with IS was measured using self-report, collateral report, blood assay, electronic monitoring (Helping Hand™ , Bang and Olufsen Medicom, Denmark), and their combinations. In the overall sample, depending on the method used, IS NA ranged from 23.9% to 70.0%. For co-medication, the overall NA rate was 30.1% using self-report. Nonadherence rates remained stable over time. At inclusion, significant NA differences between organ groups were reported via self- and collateral report; lung transplant patients were less adherent than heart or liver transplant recipients, both to IS and to co-medication.

Trauma, dissociation, and antiretroviral adherence among persons living with HIV/AIDS

BACKGROUND

There are approximately 1,000,000 persons living with HIV/AIDS (PLH) in the United States; to reduce rates of new infection and curb disease progression, adherence to HIV medication among PLH is critical. Despite elevated trauma rates in PLH, no studies to date have investigated the relationship between dissociation, a specific symptom of trauma, and HIV medication adherence. We hypothesized that Post-Traumatic Stress Disorder (PTSD) symptoms would be associated with lower adherence, and that dissociation would moderate this relationship.

METHODS

Forty-three individuals with HIV were recruited from community-based clinics to participate in a cross-sectional study. The relationship of trauma, dissociation, and their interaction to the probability of antiretroviral adherence was assessed using a hierarchical binary logistic regression analysis.

RESULTS

Among 38 eligible participants, greater PTSD was associated with lower odds of adherence (OR = .92, p < .05). Dissociation moderated the effect of PTSD on adherence, resulting in lower odds of adherence (OR = .95, p < .05). PTSD symptoms were significantly associated with lower odds of adherence in individuals reporting high levels of dissociation (OR = .86, p < .05) but not in those reporting low levels of dissociation (OR = 1.02, p > .05).

CONCLUSIONS

This is the first study to demonstrate a relationship between dissociation and medication adherence. Findings are discussed in the context of clinical management of PLH with trauma histories and the need for interventions targeting dissociative symptomatology to optimize adherence.

Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders

OBJECTIVE

There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya.

DESIGN

A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up.

METHODS

Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h.

RESULTS

In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P = 0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03).

CONCLUSION

These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.

Discrimination as a key mediator of the relationship between posttraumatic stress and HIV treatment adherence among African American men

Posttraumatic stress disorder (PTSD) is relatively common among people living with HIV/AIDS (PLHA) and may be associated with antiretroviral therapy (ART) adherence. We examined the relationship between PTSD symptom severity and adherence among 214 African American males. Because PLHA may experience discrimination, potentially in the form of traumatic stress (e.g., hate crimes), we also examined whether perceived discrimination (related to race, HIV status, sexual orientation) is an explanatory variable in the relationship between PTSD and adherence. Adherence, monitored electronically over 6 months, was negatively correlated with PTSD total and re-experiencing symptom severity; all 3 discrimination types were positively correlated with PTSD symptoms and negatively correlated with adherence. Each discrimination type separately mediated the relationship between PTSD and adherence; when both PTSD and discrimination were included in the model, discrimination was the sole predictor of adherence. Findings highlight the critical role that discrimination plays in adherence among African American men experiencing posttraumatic stress.

Measuring adherence to antiretroviral therapy in northern Tanzania: feasibility and acceptability of the Medication Event Monitoring System

BACKGROUND

An often-used tool to measure adherence to antiretroviral therapy (ART) is the Medication Event Monitoring System (MEMS), an electronic pill-cap that registers date and time of pill-bottle openings. Despite its strengths, MEMS-data can be compromised by inaccurate use and acceptability problems due to its design. These barriers remain, however, to be investigated in resource-limited settings. We evaluated the feasibility and acceptability of using MEMS-caps to monitor adherence among HIV-infected patients attending a rural clinic in Tanzania's Kilimanjaro Region.

METHODS

Eligible patients were approached and asked to use the MEMS-caps for three consecutive months. Thereafter, qualitative, in-depth interviews about the use of MEMS were conducted with the patients. MEMS-data were used to corroborate the interview results.

RESULTS

Twenty-three of the 24 patients approached agreed to participate. Apart from MEMS-use on travel occasions, patients reported no barriers regarding MEMS-use. Unexpectedly, the MEMS-bottle design reduced the patients' fear for HIV-status disclosure. Patients indicated that having their behavior monitored motivated them to adhere better. MEMS-data showed that most patients had high levels of adherence and there were no bottle-openings that could not be accounted for by medication intake. Non-adherence in the days prior to clinic visits was common and due to the clinic dispensing too few pills.

CONCLUSION

MEMS-bottle use was readily accepted by patients. Although the MEMS-bottle was used accurately by most patients, patients need to be more explicitly instructed to continue MEMS-use when travelling. Even HIV-clinics with sufficient staff and free medication may impose structural adherence barriers by supplying an insufficient amount of pills.

Standard measures are inadequate to monitor pediatric adherence in a resource-limited setting

This study aims to compare the use and cost of objective and subjective measures of adherence to pediatric antiretroviral treatment in a primary care facility in South Africa. In a 1-month longitudinal study of 53 caregiver-child dyads, pharmacy refill (PR), measurement of returned syrups (RS), caregiver self-report (3DR) and Visual Analogue Scale (VAS) were compared to Medication Event Monitoring System (MEMS). Adherence was 100% for both VAS and 3DR; by PR and RS 100% and 103%, respectively. MEMS showed that 92% of prescribed doses were administered, but only 66% of these within the correct 12-hourly interval. None of the four measures correlated significantly with MEMS. MEMS data suggest that timing of doses is often more deviant from prescribed than expected and should be better addressed when monitoring adherence. Of all, MEMS was by far the most expensive measure. Alternative, cheaper electronic devices need to be more accessible in resource-limited settings.

A longitudinal investigation of the impact of life stress on HIV treatment adherence

Suboptimal antiretroviral adherence is associated with poorer HIV outcomes. Psychosocial factors, including life stress, depression and coping, may influence adherence behavior. This prospective investigation sought to examine the impact of life stress (acute life events, chronic stress, and perceived stress), depression, and coping style on adherence to HIV treatment regimes over time. Participants were 87 treatment-seeking HIV-infected individuals recruited from an urban HIV clinic. They completed clinician-administered interviews and self-report questionnaires at baseline and 3-month follow-up. Acute life events and chronic stress prospectively predicted decreases in treatment adherence more strongly among individuals in a major depressive episode (n = 21) compared to non-depressed individuals (n = 66). Coping style did not appear to be the mechanism by which life stress influenced adherence among depressed HIV-infected individuals. These findings demonstrate that life stress has toxic effects for depressed individuals and suggest that treatment adherence interventions with depressed individuals could be enhanced via development of stress management skills.

[AIDS Study Group/Spanish AIDS Plan consensus document on antiretroviral therapy in adults with human immunodeficiency virus infection (updated January 2010)]

OBJECTIVE

This consensus document is an update of antiretroviral therapy recommendations for adult patients with human immunodeficiency virus infection.

METHODS

To formulate these recommendations a panel made up of members of the Grupo de Estudio de Sida (Gesida, AIDS Study Group) and the Plan Nacional sobre el Sida (PNS, Spanish AIDS Plan) reviewed the advances in the current understanding of the pathophysiology of human immunodeficiency virus (HIV) infection, the efficacy and safety of clinical trials, and cohort and pharmacokinetic studies published in biomedical journals or presented at scientific meetings. Three levels of evidence were defined according to the data source: randomized studies (level A), cohort or case-control studies (level B), and expert opinion (level C). The decision to recommend, consider or not to recommend ART was established in each situation.

RESULTS

Currently, the treatment of choice for chronic HIV infection is the combination of three drugs of two different classes, including 2 nucleosides or nucleotide analogs (NRTI) plus 1 non-nucleoside (NNRTI) or 1 boosted protease inhibitor (PI/r), but other combinations are possible. Initiation of ART is recommended in patients with symptomatic HIV infection. In asymptomatic patients, initiation of ART is recommended on the basis of CD4 lymphocyte counts, plasma viral load and patient co-morbidities, as follows: 1) therapy should be started in patients with CD4 counts below 350 cells/microl; 2) When CD4 counts are between 350 and 500 cells/microl, therapy should be started in case of cirrhosis, chronic hepatitis C, high cardiovascular risk, HIV nephropathy, HIV viral load above 100,000 copies/ml, proportion of CD4 cells under 14%, and in people aged over 55; 3) Therapy should be deferred when CD4 are above 500 cells/microl, but could be considered if any of previous considerations concurs. Treatment should be initiated in case of hepatitis B requiring treatment and should be considered for reduce sexual transmission. The objective of ART is to achieve an undetectable viral load. Adherence to therapy plays an essential role in maintaining antiviral response. Therapeutic options are limited after ART failures but undetectable viral loads maybe possible with the new drugs even in highly drug experienced patients. Genotype studies are useful in these situations. Drug toxicity of ART therapy is losing importance as benefits exceed adverse effects. Criteria for antiretroviral treatment in acute infection, pregnancy and post-exposure prophylaxis are mentioned as well as the management of HIV co-infection with hepatitis B or C.

CONCLUSIONS

CD4 cells counts, viral load and patient co-morbidities are the most important reference factors to consider when initiating ART in asymptomatic patients. The large number of available drugs, the increased sensitivity of tests to monitor viral load, and the ability to determine viral resistance is leading to a more individualized therapy approach in order to achieve undetectable viral load under any circumstances.

Intentionality of medication non-adherence among individuals living with HIV/AIDS in Hong Kong

Adherence to antiretroviral therapy is essential to treatment success for individuals living with HIV/AIDS. Despite the wealth of studies in examining antiretroviral non-adherence, few have distinguished between intentional and unintentional non-adherence. The present study attempted to identify factors associated with adherence, intentional non-adherence, and unintentional non-adherence among HIV+ individuals using a longitudinal design. Dietary instructions and medication schedule were also included to measure the subtleties of antiretroviral adherence. One hundred and two HIV+ patients who were under antiretroviral therapy were recruited in an outpatient clinic in Hong Kong at baseline with six months follow-up. Using the conventional adherence rate, only 12 (11.8%) of participants reported having missed/ altered medication in the past four days. However, using a more comprehensive assessment, only 27 (26.5%) participants were classified as adherers. Results showed that, adherers were significantly older and had higher adherence self-efficacy than those who were unintentional or intentional non-adherers. Participants classified as unintentional non-adherers had longer length of diagnosis and started medication longer than adherers and intentional non-adherers. Participants classified as intentional non-adherers had worse mental health, higher level of self-stigma, and reported higher score in avoidant coping than adherers and unintentional non-adherers. They also scored higher in physical symptoms than adherers. Findings highlight the importance of a reliable, comprehensive measurement for adherence and extend on previous adherence literature that intentional and unintentional non-adherence are separate entities and are associated with different factors. Future research should understand the intentions behind non-adherence and this would serve as an important guide in the development of interventions aimed at improving antiretroviral adherence for HIV+ patients.

How accurate are electronic monitoring devices? A laboratory study testing two devices to measure medication adherence

In a prospective descriptive laboratory study, 25 Helping Hand(™) (HH) (10 without and 15 with reminder system) and 50 Medication Event Monitoring Systems (MEMS) (25 with 18-month and 25 with 2-year battery life) were manipulated twice daily following a predefined protocol during 3 consecutive weeks. Accuracy was determined using the fixed manipulation scheme as the reference. Perfect functioning (i.e., total absence of missing registrations and/or overregistrations) was observed in 70% of the HH without, 87% of the HH with reminder, 20% MEMS with 18 months, and 100% with 2-year battery life respectively.

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.

A comparison of adherence assessment methods utilized in the United States: perspectives of researchers, HIV-infected children, and their caregivers

This study sought to elucidate methodological issues in adherence research by comparing multiple methods of assessing adherence to antiretroviral medication. From 2003 to 2004, 24 youths with vertically infected HIV disease (mean age = 14.0 years; range, 8-18) and their caregivers participated in a 6-month study. These children were all on highly active antiretroviral therapy (HAART) and were relatively healthy (mean CD4 absolute count = 711.8 +/- 604.5). Adherence was assessed with the Medication Event Monitoring System (MEMS), pill counts, and interviews. Patients and caregivers completed the Perceptions of Adherence Study Participation (PASP) questionnaire. MEMS provided the most detailed adherence information, and good reliability was indicated by significant correlations with medical markers. Pill counts provided similar adherence rates, while patients and caregivers reported nearly perfect adherence in interviews. Problems were experienced with each method: MEMS were expensive, had cap malfunctions, and lack a consistent guiding principle for data interpretation. With pill counts, families forgot to bring all medication bottles to clinic, and interviews were compromised by social desirability and difficulty reaching families by telephone. Most patients and caregivers believed study participation improved the child's adherence, although PASP ratings were unrelated to adherence at the study endpoint. While MEMS may be most reliable, pill counts offer comparable data and are less costly, while interviews seemed least accurate in this study. Most participants reported positive perceptions of their research experience. A consensus among researchers is needed for defining and measuring adherence, and specific recommendations are offered for achieving this goal.

Pretransplant predictors of posttransplant adherence and clinical outcome: an evidence base for pretransplant psychosocial screening

INTRODUCTION

There is growing awareness, yet scant prospective evidence that pretransplant (TX) psychosocial factors may predict post-TX outcome. We examined which pre-TX psychosocial factors predict post-TX nonadherence with immunosuppression (NA) and clinical outcomes in heart, liver, and lung TX.

METHODOLOGY

We prospectively followed 141 patients (28 heart, 61 liver, and 52 lung) from pre-TX until 1 year post-TX. Multivariable analyses determined which pre-TX factors (i.e., anxiety, depression, personality traits, social support, adherence with medication, and smoking status) predict poor post-TX outcome (i.e., NA, late acute rejection, graft loss, and resource utilization), controlling for medical predictors of poor outcome.

RESULTS

Pre-TX self-reported medication nonadherence (odds ratio [OR]=7.9), lower received social support (OR=0.9), a higher education (OR=2.7), and lower "conscientiousness" (OR=0.8) were independent predictors of post-TX NA. Not living in a stable relationship predicted graft loss (OR=4.9). Pre-TX medication NA was the only predictor for presence of late acute rejection (OR=4.4). No other pre-TX predictors for poor outcome could be found.

CONCLUSION

This is the first prospective study demonstrating that selected pre-TX psychosocial factors predict post-TX NA and poor clinical outcome, implying that pre-TX screening should include this set of factors in addition to traditional medical criteria.

Functional consequences of HIV-associated neuropsychological impairment

This review focuses on the "real world" implications of infection with HIV/AIDS from a neuropsychological perspective. Relevant literature is reviewed which examines the relationships between HIV-associated neuropsychological impairment and employment, driving, medication adherence, mood, fatigue, and interpersonal functioning. Specifically, the relative contributions of medical, cognitive, psychosocial, and psychiatric issues on whether someone with HIV/AIDS will be able to return to work, adhere to a complicated medication regimen, or safely drive a vehicle will be discussed. Methodological issues that arise in the context of measuring medication adherence or driving capacity are also explored. Finally, the impact of HIV/AIDS on mood state, fatigue, and interpersonal relationships are addressed, with particular emphasis on how these variables interact with cognition and independent functioning. The purpose of this review is to integrate neuropsychological findings with their real world correlates of functional behavior in the HIV/AIDS population.

Impact of different patterns of nonadherence on the outcome of highly active antiretroviral therapy in patients with long-term follow-up

OBJECTIVES

The aim of the study was to evaluate the impact of different patterns of nonadherence on treatment outcomes in patients with long-term follow-up.

METHODS

This cohort study included patients who began highly active antiretroviral therapy during 1996-1999, with the last follow-up in 2007. Adherence was evaluated every 2 months by monitoring of pharmacy refills and by using self-reports. Patients were considered nonadherent at a specific visit when less than 90% of the prescribed drugs had been taken. Adherence was categorized as follows. (A) Continuous adherence: a patient had to be adherent in all of the evaluations throughout the period of follow-up. (B) Treatment interruption: drugs were not taken for more than 3 days, for any reason. Treatment failure was defined as viral load >500 HIV-1 RNA copies/mL or death. Cox proportional risk models were used to calculate adjusted relative hazards (ARHs) of treatment failure.

RESULTS

A total of 540 patients were included in the study, with a median follow-up of 8.3 years. Only 32.78% of patients achieved and maintained continuous adherence, and 42.78% of patients had treatment interruptions. Noncontinuous adherence [ARH 1.48; 95% confidence interval (CI) 1.02-2.14] and treatment interruptions (ARH 1.39; 95% CI 1.04-1.85) were associated with treatment failure for the overall cohort; however, for patients with more than 3 years of follow-up, only treatment interruptions were independently associated with treatment failure.

CONCLUSIONS

Only one-third of patients managed to achieve continuous adherence, and almost half of the patients had treatment interruptions, which have a particularly marked effect on treatment outcomes over the long term.

Diagnostic value of different adherence measures using electronic monitoring and virologic failure as reference standards

Nonadherence to antiretroviral therapy is a substantial problem in HIV and jeopardizes the success of treatment. Accurate measurement of nonadherence is therefore imperative for good clinical management but no gold standard has been agreed on yet. In a single-center prospective study nonadherence was assessed by electronic monitoring: percentage of doses missed and drug holidays and by three self reports: (1) a visual analogue scale (VAS): percentage of overall doses taken; (2) the Swiss HIV Cohort Study Adherence Questionnaire (SHCS-AQ): percentage of overall doses missed and drug holidays and (3) the European HIV Treatment Questionnaire (EHTQ): percentage of doses missed and drug holidays for each antiretroviral drug separately. Virologic failure prospectively assessed during 1 year, and electronic monitoring were used as reference standards. Using virologic failure as reference standard, the best results were for (1) the SHCS-AQ after electronic monitoring (sensitivity, 87.5%; specificity, 78.6%); (2) electronic monitoring (sensitivity, 75%; specificity, 85.6%), and (3) the VAS combined with the SHCS-AQ before electronic monitoring (sensitivity, 87.5%; specificity, 58.6%). The sensitivity of the complex EHTQ was less than 50%. Asking simple questions about doses taken or missed is more sensitive than complex questioning about each drug separately. Combining the VAS with the SHCS-AQ seems a feasible nonadherence measure for daily clinical practice. Self-reports perform better after electronic monitoring: their diagnostic value could be lower when given independently.

Using motivational interviewing to promote adherence to antiretroviral medications: a randomized controlled study

The primary aim of this study was to test an intervention to support antiretroviral medication adherence among primarily low-income men and women with HIV. The study was a randomized controlled trial (Get Busy Living) with participants assigned to treatment (Motivational Interviewing [MI]) and control groups. Participants were recruited from an HIV/AIDS clinic in Atlanta, Georgia, US. Of those referred to the study, 247 completed a baseline assessment and were enrolled with 125 randomized to the intervention group and 122 to the control group. Participants were patients beginning antiretroviral therapy or changing to a new drug regimen. The intervention consisted of five MI sessions delivered by registered nurses in individual counselling sessions. Participants were paid for each session attended. The intervention sought to build confidence, reduce ambivalence and increase motivation for ART medication-taking. Medication adherence was measured by the Medication Event Monitoring System (MEMS) from the time of screening until the final follow-up conducted approximately 12 months following the baseline assessment. Participants in the intervention condition showed a trend towards having a higher mean percent of prescribed doses taken and a greater percent of doses taken on schedule when compared to the control group during the months following the intervention period. This effect was noted beginning at about the eighth month of the study period and was maintained until the final study month. Although the finding was weaker for overall percent of prescribed doses taken, the results for the percent of doses taken on schedule suggests that the MI intervention may be a useful approach for addressing specific aspects of medication adherence, such as adherrence to a specified dosing schedule.

Virologic response using directly observed therapy in adolescents with HIV: an adherence tool

Virologic response to highly active antiretroviral therapy (HAART) treatment of HIV infection depends on viral sensitivity to antiretrovirals and excellent medication adherence. Adolescents with vertically acquired HIV may require complicated regimens because of significant treatment experience and often have poor medication adherence. A retrospective chart review identified five adolescents with vertically acquired HIV and plasma HIV viral load rebound or nonresponse on a stable HAART regimen followed by a period of directly observed therapy (DOT) in a clinic or hospital setting with serial viral load measurements. Four subjects had a virologic response (mean decline, 1.15 log10) after DOT. A response to HAART can be seen despite antiretrovirals resistance using DOT and treatment-experienced patients seemingly unresponsive to HAART may be nonadherent even with reassuring adherence measures. A period of clinic-monitored DOT may allow diagnosis of nonadherence, discussion of medication barriers, and avoidance of unnecessary medication changes.