British HIV Association (BHIVA)/British Association for Sexual Health and HIV (BASHH) guidelines on provision of adherence support to individuals receiving antiretroviral therapy (2003)

Integrative literature review of evidence-based guidelines on antiretroviral therapy adherence among adult persons living with HIV

AIM

To summarize recommendations from available evidence-based guidelines that enhance, address or guide antiretroviral therapy adherence among adult persons living with human immunodeficiency virus.

DESIGN

An integrative literature review approach.

DATA SOURCE

Guidelines were accessed through Google from the databases of the Canadian Medical Association InfoBase clinical practice database, National Guidelines Clearinghouse, Writer's Guidelines database, the National Institute for Health and Clinical Excellence, UNICEF and WHO. Databases such as PubMed, Google Scholar, EBSCOhost (CINAHL, ERIC, Academic search complete, E-journals, Psych Info and MEDLINE), EMERALD INSIGHT, JSTOR, SCIENCE DIRECT and FINDPLUS were also searched, followed by a citation search. Data sources were searched between 1996 and January 2022.

REVIEW METHODS

The five steps of the integrative literature review process, as described by Whittemore and Knafl, were used. These steps are as follows: step one; problem identification, step two; literature search, step three; data evaluation; step four: data analysis and the final step was data presentation.

RESULTS

Sixteen guidelines related to antiretroviral therapy adherence were included for data extraction and synthesis. The findings revealed two themes as follows: theme 1: monitoring antiretroviral therapy adherence and theme 2: interventions to promote antiretroviral therapy adherence related to education and counselling, adherence tools, health service delivery and antiretroviral strategies.

CONCLUSION

Antiretroviral therapy adherence in adult persons requires both interventions as well as monitoring. The various contributing factors relating to antiretroviral therapy adherence should be further explored.

IMPACT

Evidence from the included guidelines can assist nurses in promoting a person's adherence to antiretroviral treatment, which could improve their health and well-being.

Trajectory of change in anxiety sensitivity in relation to anxiety, depression, and quality of life among persons living with HIV/AIDS following transdiagnostic cognitive-behavioral therapy

Persons living with HIV/AIDS (PLHIV) disproportionately suffer from anxiety and depressive symptoms and disorders. Although past work has examined the efficacy of cognitive-behavioral therapy (CBT) for depression, and to a lesser extent anxiety, among PLHIV, little is known regarding potential mechanisms underlying improvement in anxiety/depression among this group. Anxiety sensitivity is a well-established risk/maintenance factor for anxiety and depressive disorders and is hypothesized to play an important role in maintaining anxiety among PLHIV. Past work has identified anxiety sensitivity as a mechanism of action underlying changes in various anxiety domains yet it is unknown whether changes in anxiety sensitivity relate to changes in anxiety symptoms among PLHIV undergoing transdiagnostic CBT for anxiety. The current study sought to examine treatment-related changes in anxiety sensitivity and how the trajectory of change relates to anxiety and depressive symptoms as well as overall quality of life. Individuals (n = 35) with HIV/AIDS and elevated anxiety symptoms received CBT for anxiety. Results indicated that reductions in anxiety sensitivity were significantly related to changes in anxiety, depression, and quality of life. Together, these data suggest that changes in anxiety sensitivity are significantly related to changes in anxiety/depression and quality of life among PLHIV seeking treatment.

A systematic review and cost-effectiveness analyses of the new World Health Organization guidelines for the treatment of HIV-positive adults in India

Background

The World Health Organization (WHO) in 2013 has revised its guidelines on antiretroviral therapy (ART) treatment for human immunodeficiency virus (HIV)-positive adults and further updated it in 2016. Based on the WHO recommendations, in May 2017, National AIDS Control Organisation, India recommended initiation of ART treatment for all people living with HIV, regardless of CD4 count, clinical stage, age, or population. This systematic review aims to assess the clinical effectiveness and cost implication of the new guidelines for India.

Methods

A systematic and comprehensive literature search on PubMed, OvidSP, Cochrane Library, and Google Scholar was carried out. Studies reporting either acquired immunodeficiency syndrome (AIDS) or mortality or both as outcome variables were selected. A meta-analysis of the available studies was carried out. The risk ratio was calculated to assess the reduction in AIDS or mortality or both. Cost-effectiveness analysis using health technology principles evaluating the lives saved in terms of incremental cost-effectiveness ratio and cost per quality-adjusted life years gained was carried out.

Results

Nine eligible studies were included for the meta-analysis. For India, the pooled relative risk of AIDS or mortality or both being 0.84 (95% confidence interval [CI], 0.76-0.92) and 0.78 (95% CI, 0.68-0.89) for ART initiation at CD4 count of ≤350 vs CD4 count of ≤500 and at CD4 count of ≤500 vs CD4 count > 500 cells/mm³, respectively. The incremental cost for per additional life saved is US$ 2592 and US$ 2357 for ART initiation at ≤500 and > 500 CD4 count, respectively.

Conclusion

The adoption of the new WHO guidelines is beneficial with substantial reduction in AIDS or mortality or both. This study suggests that adopting new WHO guidelines is cost-effective for India.

Doing patient-centredness versus achieving public health targets: A critical review of interactional dilemmas in ART adherence support

Anti-retroviral Therapy (ART) transformed HIV into a chronic disease but its individual and public health benefits depend on high levels of adherence. The large and rising number of people on ART, now also used as prevention, puts considerable strain on health systems and providers in low and middle as well as high-income countries, which are our focus here. Delivering effective adherence support is thus crucial but challenging, especially given the promotion of patient-centredness and shared decision making in HIV care. To illuminate the complexities of ART adherence support delivered in and through clinical encounters, we conducted a multi-disciplinary interpretative literature review. We reviewed and synthesized 82 papers published post 1997 (when ART was introduced) belonging to three bodies of literature: public health and psychological studies of ART communication; anthropological and sociological studies of ART; and conversation analytic studies of patient-centredness and shared decision-making. We propose three inter-related tensions which make patient-centredness particularly complex in this infectious disease context: achieving trust versus probing about adherence; patient-centredness versus reaching public health targets; and empowerment versus responsibilisation as 'therapeutic citizens'. However, there is a dearth of evidence concerning how precisely ART providers implement patient-centredness, shared-decision making in practice, and enact trust and therapeutic citizenship. We show how conversation analysis could lead to new, actionable insights in this respect.

Developing a patient-reported outcome measure for HIV care on perceived barriers to antiretroviral adherence: assessing the needs of HIV clinicians through qualitative analysis

PURPOSE

To identify HIV clinicians' needs for the clinical use of a new patient-reported outcome measure (PRO) on barriers to antiretroviral therapy (ART) adherence.

METHODS

In 2015, five focus groups with 31 clinicians from France were transcribed, coded with Atlas.ti, and submitted to a typological analysis.

RESULTS

The analysis identified seven patient profiles, each tied to distinct barriers to adherence and to specific needs for the PRO's content, data collection and transmission. Clinicians preferred, for the patient who is: (1) 'passive,' that the PRO collect information on ART knowledge, to ensure that the prescription's instructions are being respected; (2) 'misleading,' that it be able to detect adherence to ART and socially desirable responses; (3) 'stoic,' that questions challenge the patient to recognize treatment-specific side effects; (4) 'hedonistic,' that the PRO contains content on lifestyle and risk-taking; (5) 'obsessive,' that the PRO captures quality of life and stressful life events; (6) 'overburdened,' that the PRO provides information on the person's home environment, socioeconomic status and cultural constraints. For all or most patient profiles, the clinicians wished that the PRO be completed, minimally, prior to the medical consultation and to receive alerts, under varying conditions, when problematic scores were detected. Depending on the profile, there was preference for the inclusion of open-ended questions and transmission of cross-sectional, periodic or longitudinal PRO data.

CONCLUSION

Overall, this study's findings suggest that to support the clinical management of ART adherence, our PRO must meet the needs of a wide variety of patients and must perform multiple functions.

Putting evidence into practice: evidence-based interventions for oral agents for cancer

BACKGROUND

The limited evidence available suggests that adherence to oral agents for cancer is a significant clinical problem and may have a substantial impact on treatment success or failure. Adherence is a difficult issue among patients who are very sick with a life-threatening disease who often must adhere to complex treatment protocols independently at home.

OBJECTIVES

This article aims to identify effective interventions for the promotion, treatment, and management of adherence to oral agents for cancer and to synthesize the literature for use in clinical practice.

METHODS

As part of the Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP) initiative, a comprehensive examination of the current literature was conducted to identify effective interventions for patients prescribed oral agents for cancer. The ONS PEP weight-of-evidence classification schema levels of evidence were used to categorize interventions to assist nurses in identifying strategies that are effective at improving adherence.

FINDINGS

The majority of evidence found was conducted in conditions other than cancer; therefore, research is needed to identify whether these interventions are effective at promoting adherence in patients with cancer.

Antiretroviral Adherence Perspectives of Pregnant and Postpartum Women in Guyana

The Caribbean region has the second highest HIV prevalence after Sub-Saharan Africa. Guyana's adult HIV prevalence is 1.9% among pregnant women, with women accounting for an estimated 58% of all persons living with HIV. However, there are few studies on ART adherence in the Caribbean, none from Guyana, and none focusing on adherence in pregnancy and the postpartum period. The objective of this study was to explore the perspectives of HIV-infected pregnant and postpartum women and healthcare providers in Guyana about barriers and facilitators to ART adherence. Data was collected using semi-structured interviews with 24 HIV-infected pregnant and postpartum women and nine healthcare professionals at five clinics between February and April 2012. The Framework Method for analysing qualitative data identified facilitators and barriers related to five core themes: (i) Concern for wellbeing of children; (ii) ART-related factors; (iii) Disclosure; (iv) Socio-economic issues; and (v) Religious and cultural beliefs. Non-disclosure did not adversely affect adherence, contrary to other studies in the literature. Two broad categories emerged from the lived experiences of women in Guyana. The first is related to the act of actually taking their medication where their tenacity is displayed in efforts made to ensure ART is taken. The second relates to the significance of ART to them in terms of reduced risk of MTCT, and the possibility of better health for themselves to enable them to care for their children. However, issues related to poverty, food insecurity and side effects reduced adherence need to be adequately addressed.

Systematic Review of Clinical Practice Guidelines for the Improvement of Medication Adherence

BACKGROUND

Poor adherence to medications is a significant problem that leads to increased morbidity, mortality, and health care costs. Recommended approaches to address medication adherence vary, and existing practice guidelines are unclear.

PURPOSE

This review evaluated clinical practice guidelines designed to help health care providers address patients' medication adherence.

METHOD

Multiple search methods were used to identify national or international guidelines addressing medication adherence. We included guidelines published in English, as well as guidelines with an English-language summary or translation.

RESULTS

We identified 23 guidelines of varying detail and quality. Recommendations were categorized as assessment strategies (n = 20 guidelines); educational strategies (n = 18); behavioral strategies (n = 17); therapeutic relationship, communication, and provider factors (n = 19); and addressing outside influences/co-morbidities (n = 10).

CONCLUSION

Future guidelines should be more clearly guided by research findings and comparative effectiveness methods. When implemented, guidelines will facilitate health care providers and health systems in supporting optimal adherence and improved health outcomes.

Adherence to antiretroviral treatment by adults in a rural area of Botswana

Background: As antiretroviral therapy (ART) is becoming increasingly available to people in developing countries, ART adherence challenges assume ever greater significance. Often underlying treatment failure is the fact that suboptimal adherence to ART is the strongest predictor of failure to achieve viral suppression below the level of detection.

Objectives: The study's main objective was to identify factors affecting ART adherence levels, as well as the impact on immunologic and virologic responses in adult patients in one rural district in Botswana.

Methods: A cross-sectional quantitative survey, was used. Structured interviews were conducted with 300 ART patients between November 2011 and February 2012. Data were analysed, then presented in charts, graphs and frequency tables.

Results: The prevalence of non-adherence to ART was 14.0%. Motivators of good adherence included disclosure of HIV-positive status to more than one person, frequent adherence counselling, self-efficacy for adherence to ART, positive interactions between patients and healthcare providers; and using adherence partners. Barriers to adherence were forgetfulness, transportation costs to and from the clinic, time away from work and side-effects. There was a strong positive correlation between adherence, CD4 counts and viral load. Adherence was closely tied to immunologic and virologic improvements. Respondents with poor adherence were likely to have unsuppressed viral loads (OR 12.98, 95% CI 4.9–34).

Conclusion: Adherence to ART is closely tied to virologic, immunologic, and clinical outcomes. Increases in adherence levels resulted in significant improvements in these outcomes. Near perfect adherence, however, is required to maximise the likelihood of long-term clinical success, which could pose challenges to many ART patients, especially in resource-limited rural settings.

Prevalence and determinants of adherence to HAART amongst PLHIV in a tertiary health facility in south-south Nigeria

BACKGROUND

Adherence to Highly active antiretroviral therapy (HAART) is a major predictor of the success of HIV/AIDS treatment. Good adherence to HAART is necessary to achieve the best virologic response, lower the risk of drug resistance and reduce morbidity and mortality. This study therefore aimed to determine the prevalence and determinants of adherence to HAART amongst PLHIV accessing treatment in a tertiary location in Cross River State, Nigeria.

METHODS

A cross-sectional study was conducted among patients on HAART attending the Presidential Emergency plan for AIDS relief (PEPFAR) clinic of the University of Calabar Teaching Hospital between October-December 2011. A total of 411 PLHIV visiting the study site during the study period were interviewed. PLHIV who met the inclusion criteria were consecutively recruited into the study till the desired sample size was attained. Information was obtained from participants using a semi-structured, pretested, interviewer administered questionnaire. Adherence was measured via patients self report and were termed adherent if they took at least 95% of prescribed medication in the previous week prior to the study. Data were summarized using proportions, and χ2 test was used to explore associations between categorical variables. Predictors of adherence to HAART were determined by binary logistic regression. Level of significance was set at p < 0.05.

RESULTS

The mean age of PLHIV who accessed treatment was 35.7 ± 9.32 years. Females constituted 68.6% of all participants. The self reported adherence rate based on a one week recall prior to the study was 59.9%. The major reasons cited by respondents for skipping doses were operating a busy schedule, simply forgot medications, felt depressed, and travelling out of town. On logistic regression analysis, perceived improved health status [OR 3.11; CI: 1.58-6.11], reduced pill load [OR 1.25; 95% CI: 0.46-2.72] and non-use of herbal remedies [OR 1.83; 95% CI: 1.22-2.72] were the major predictors for adherence to HAART. However, payment for ART services significantly decreased the likelihood of adherence to HAART. [OR 0.46; 95% CI: 0.25-0.87.].

CONCLUSIONS

The adherence rate reported in this study was quite low. Appropriate adherence enhancing intervention strategies targeted at reducing pill load and ensuring an uninterrupted access to free services regimen is strongly recommended.

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

Summary

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

Retention and loss to follow-up in antiretroviral treatment programmes in southeast Nigeria

BACKGROUND

This study generated new information about the outcomes of patients enrolled in antiretroviral treatment programmes, as well as the true outcomes of those lost to follow-up (LTF).

METHODS

Anonymized data were collected for patients enrolled over a 12-month period from two programmes (public and private) in southeast Nigeria. Estimates of retention, LTF, mortality and transfers were computed. All LTF enrollees (defined as patients who had missed three scheduled visits) whose contact information met pre-defined criteria were traced.

RESULTS

A total of 481 (public) and 553 (private) records were included. Median duration of follow-up was about 14 months. Cumulative retention and LTF proportions were 66·5 and 32·8% (public), and 82·6 and 11·0% (private) respectively. LTF rates at third, sixth, ninth and twelfth months were 7·5, 19·3, 25·4 and 29·6% respectively (public), and 4·1, 7·1, 9·0 and 10·0% (private). LTF was higher among males, patients with CD4(+) cell count ≤200 and public programme enrollees. For the public facility, 56·7% of 104 traceable patients were dead and 38·8% were alive; the figures were 34·2 and 60·5% of 46 patients respectively for the private. Most deaths had occurred by the third month.

CONCLUSION

Not all patients enrolled for treatment were retained. Though some died, many were LTF, lived within the community, and could develop and transmit resistant viral stains. Most traced patients were dead by the third month and poor contact information limited the effectiveness of tracing. Antiretroviral treatment programmes need to improve documentation processes and develop and implement tracing strategies.

Technology-based self-care methods of improving antiretroviral adherence: a systematic review

BACKGROUND

As HIV infection has shifted to a chronic condition, self-care practices have emerged as an important topic for HIV-positive individuals in maintaining an optimal level of health. Self-care refers to activities that patients undertake to maintain and improve health, such as strategies to achieve and maintain high levels of antiretroviral adherence.

METHODOLOGY/PRINCIPAL FINDINGS

Technology-based methods are increasingly used to enhance antiretroviral adherence; therefore, we systematically reviewed the literature to examine technology-based self-care methods that HIV-positive individuals utilize to improve adherence. Seven electronic databases were searched from 1/1/1980 through 12/31/2010. We included quantitative and qualitative studies. Among quantitative studies, the primary outcomes included ARV adherence, viral load, and CD4+ cell count and secondary outcomes consisted of quality of life, adverse effects, and feasibility/acceptability data. For qualitative/descriptive studies, interview themes, reports of use, and perceptions of use were summarized. Thirty-six publications were included (24 quantitative and 12 qualitative/descriptive). Studies with exclusive utilization of medication reminder devices demonstrated less evidence of enhancing adherence in comparison to multi-component methods.

CONCLUSIONS/SIGNIFICANCE

This systematic review offers support for self-care technology-based approaches that may result in improved antiretroviral adherence. There was a clear pattern of results that favored individually-tailored, multi-function technologies, which allowed for periodic communication with health care providers rather than sole reliance on electronic reminder devices.

Doctor-patient concordance during HIV treatment switching decision-making

OBJECTIVES

The aim of the study was to explore levels of doctor-patient concordance during the making of decisions regarding HIV treatment switching and stopping in relation to patient health-related outcomes.

METHODS

Adult patients attending five HIV clinics in the United Kingdom were requested to complete the study questionnaire, which included a Concordance Scale, and measures of symptoms [Memorial Symptom Assessment Short Form (MSAS) index], quality of life (EuroQol), satisfaction, adherence and sexual risk behaviour. Clinical health measures (HIV viral load and CD4 cell count) were also obtained. A total of 779 patients completed the questionnaire, giving a response rate of 86%; of these 779 patients, 430 had switched or stopped their HIV treatment and were thus eligible for inclusion. Of these patients, 217 (50.5%) fully completed the Concordance Scale.

RESULTS

Concordance levels were high (88% scored between 30 and 40 on the scale; score range 10-40). Higher concordance was related to several patient outcomes, including: better quality of life (P=0.003), less severe and burdensome symptom experience (lower MSAS-physical score, P=0.001; lower MSAS-psychological score, P=0.008; lower MSAS-global distress index score, P=0.011; fewer symptoms reported, P=0.007), higher CD4 cell count (at baseline, P=0.019, and 6-12 months later, P=0.043) and greater adherence (P=0.029).

CONCLUSIONS

High levels of doctor-patient concordance in HIV treatment decision-making are associated with greater adherence and better physical and psychological functioning. More research is needed to establish a causal relationship between concordance and these outcomes.

The role of HIV nursing consultants in the care of HIV-infected patients in Dutch hospital outpatient clinics

OBJECTIVE

In the Netherlands HIV nursing consultants have participated in HIV-care since 1985; their profession has changed with developments in HIV-treatment over time. The study goal was to gather information about their role in HIV-care and to provide an useful example to other (HIV-)care settings over the world.

METHODS

Interviews were held with HIV nursing consultants from all AIDS treatment centres. Descriptive analyses and statistical tests to detect differences between centres categorized by care model (parallel/unstructured/alternating), were performed.

RESULTS

58% centres perform substitution of care. HIV nursing consultants see almost all patients at least once a year and see all patients when treatment is started/altered. The frequency of consultations for HIV-patients in stable condition varies, 2-4 times a year. Substitution leads to a slight, non-significant decrease in number of consultations. Adherence support is provided at the start of and during treatment. Regular patient discussions are common. All respondents are acquainted with the guidelines. Detailed knowledge of the adherence issues is limited: 58.3% had read the adherence chapter.

CONCLUSION

Substitution of care model is an appropriate and effective method for the management of HIV-infected patients.

PRACTICE IMPLICATIONS

Further development of and research into this new role of HIV nurse consultants is appropriate.

Magnitude and determinants of nonadherence and nonreadiness to highly active antiretroviral therapy among people living with HIV/AIDS in Northwest Ethiopia: a cross-sectional study

Background

Adequate antiretroviral drug potency is essential for obtaining therapeutic benefit, however, the behavioral aspects of proper adherence and readiness to medication, often determine therapeutic outcome. Therefore, this study aimed to assess the level and determinants of nonadherence and nonreadiness to highly active antiretroviral therapy (HAART) among people living with HIV/AIDS (PLWHA) at Gondar University Teaching Hospital and Felege Hiwot Hospital in Northwest Ethiopia.

Methods

A cross-sectional study was conducted between July and September 2008 using structured interviewer-administered questionnaire. All consecutive adult outpatients who were receiving antiretroviral treatment for at least three months, seen at both hospitals during the study period and able to give informed consent were included in the study. Multivariate logistic regression was used to determine factors associated with nonadherence and nonreadiness.

Results

A total of 504 study subjects were included in this study. The prevalence rates of nonadherence and nonreadiness to HAART were 87 (17.3%) and 70 (13.9%) respectively. Multivariate logistic regression analysis revealed that medication adverse effects, nonreadiness to HAART, contact with psychiatric care service and having no goal had statistically significant association with nonadherence. Moreover, unwillingness to disclose HIV status was significantly associated with nonreadiness to HAART.

Conclusions

In this study the level of nonadherence and nonreadiness to HAART seems to be encouraging. Several factors associated with nonadherance and nonreadiness to HAART were identified. Efforts to minimize nonadherence and nonreadiness to HAART should be integrated in to regular clinical follow up of patients.

Determinants of non-adherence to subsidized anti-retroviral treatment in southeast Nigeria

The anti-retroviral (ARV) treatment programme in Nigeria is delivered through selected teaching and mission hospitals at a free/subsidized rate. The government aims to scale up ARV treatment in the country. However, non-adherence to ARV medication can lead to viral resistance, treatment failure, toxicities and waste of financial resources. This study examined the factors responsible for non-adherence to free/subsidized ARV treatment in south-east Nigeria. The study was cross-sectional and descriptive. Information was collected from 174 patients selected by simple random sampling from the register of all patients who had been on anti-retroviral therapy (ART) for at least 12 months at the beginning of the study period. Patients were identified during their clinic visits. Information on their socio-demographic profile, ARV treatment and determinants of non-adherence to ARV treatment was obtained from those who gave consent, using pre-tested interviewer-administered questionnaires. All patients clearly understood the need to take ARV drugs throughout their lives, and what the costs entailed. They understood the need for periodic testing, the probability that complications would develop, cost of transportation to treatment site and the daily treatment regimen. Seventy-five per cent of respondents were not adhering fully to their drug regimen; the mean number of days that respondents had been off drugs was 3.57 days the preceding month. Reasons for non-adherence included: physical discomfort (side effects); non-availability of drugs at treatment site; forgetting to carry drugs during the day; fear of social rejection; treatment being a reminder of HIV status; and selling of own drugs to those unable to enrol in the projects. Being female, under 35 years, single, and having higher educational status were significantly associated with non-adherence. It is important that policy makers and programme managers address the factors responsible for non-adherence when scaling up subsidized ARV treatment in Nigeria and other parts of sub-Saharan Africa.

Associations among correlates of schedule adherence to antiretroviral therapy (ART): a path analysis of a sample of crack cocaine using sexually active African-Americans with HIV infection

Adherence to HIV medication regimens is a function of multiple dimensions including psychological functioning, social support, adherence self-efficacy and optimism regarding treatment. Active substance use can also negatively affect adherence. An understanding of the nature of the associations among the correlates of adherence can better inform the design of interventions to improve adherence. This study developed an exploratory path model of schedule adherence using data from a sample 130 African-American HIV-positive crack cocaine users on highly active antiretroviral therapy (ART). This model was based on the Transactional Model of Stress and Coping developed by Lazarus and Folkman. Following the theory, the effects of psychological distress on schedule adherence were mediated by patients' relationship with their doctor and optimism towards antiretroviral treatment. Adherence was also associated with patients' self-efficacy regarding their medical regimen which, in turn, was associated with their social support.

Use of electronic reminder devices to improve adherence to antiretroviral therapy: a systematic review

Adherence to prescribed antiretroviral therapy (ART) is one of the strongest predictors of progression to AIDS and death among people living with HIV/AIDS. Incorrect or inconsistent adherence to ART compromises the effectiveness of medications in achieving viral suppression. The objective of this review is to systematically and critically appraise existing evidence on the use of electronic reminder devices (ERDs) to improve adherence to ART among people living with HIV/AIDS. Twelve electronic databases not limited by language or nationality were systematically searched using a combination of relevant search criteria through early August 2007. Primary outcomes of interest were level of adherence and virologic or immunologic response. Ten intervention studies, 5 qualitative studies, and 6 unpublished studies presented in conference abstracts were included. Methodological limitations across the 15 published studies precluded meta-analysis. Evidence that patient adherence to ART was significantly improved with the use of an ERD was reported in 4 of the 8 included studies that examined ERD use as a stand-alone adherence strategy. Patient satisfaction with devices was noted across studies, and conflicting evidence of improved virological and immunological outcomes was reported in the two studies that included such measures. The authors conclude that there is a lack of definitive data resulting in insufficient evidence about the effectiveness of ERDs as strategies for improving patient adherence to antiretroviral medications. Further and more rigorous research is warranted.

A nurse- and pharmacist-led treatment advice clinic for patients attending an HIV outpatient clinic

AIM

This paper is a report of a study to map care pathways, examine the approach of different treatment advisors and explore the acceptability of a nurse- and pharmacist-led treatment advice clinic in order to aid decision-making for the future development and evaluation of the clinic.

BACKGROUND

High levels of adherence to antiretroviral drugs are a prerequisite for a successful and durable virological and immunological response to HIV. Treatment guidelines acknowledge that adherence is a process, not a single event, and that adherence support must be integrated into clinical follow-up for all patients receiving these drugs.

METHOD

Data were collected between September 2004 and January 2005 through 17 consultation observations and 10 patient interviews in a specialist treatment advice clinic located within a central London HIV outpatient clinic providing care for over 2200 patients, of whom more than 1300 are taking highly active antiretroviral therapy.

FINDINGS

The nurses and pharmacist had similar consultation approaches, although follow-up care varied in extent. Benefits of the clinic approach included permitting patients to observe real tablets, tailoring regimens to lifestyles and telephone follow-up. These factors, particularly telephone support, were perceived by patients to assist with adherence.

CONCLUSION

The role of telephone support, perceived to assist with initial adherence, requires further investigation. Future work is also needed to explore the health economics of this approach and to determine the actual impact of the clinic on clinical and adherence outcomes.

Factors associated with suboptimal antiretroviral therapy adherence to dose, schedule, and dietary instructions

The purpose of this study was to assess the degree of suboptimal antiretroviral therapy adherence to dose, schedule, and dietary instructions and to examine the effects of extra-personal, intra-personal, and inter-personal factors on suboptimal adherence across the three types of instructions. Self-report and clinical data were collected from 193 sexually infected Swedish patients receiving ART. Effects of extra-personal, intra-personal, and inter-personal factors on suboptimal adherence were examined using multivariate logistic regression models. Suboptimal adherence to dose instructions was recorded in 12% of patients. Equivalent percentage for suboptimal adherence to schedule instructions was 37% and for suboptimal adherence to dietary instructions 58%. Anxiety was the only risk factor for suboptimal adherence to dose. Heavy pill burden was a risk factor for suboptimal adherence to schedule. Older age and HIV-related post-traumatic stress disorder (PTSD) symptoms decreased the risk of suboptimal adherence to schedule. No factors investigated had an effect on suboptimal adherence to dietary instructions. To improve adherence to dose and schedule instructions, clinicians caring for patients with HIV should assess and treat anxiety and be alert to HIV-related PTSD symptoms.

Physicians' communication with patients about adherence to HIV medication in San Francisco and Copenhagen: a qualitative study using Grounded Theory

BACKGROUND

Poor adherence is the main barrier to the effectiveness of HIV medication. The objective of this study was to explore and conceptualize patterns and difficulties in physicians' work with patients' adherence to HIV medication. No previous studies on this subject have directly observed physicians' behavior.

METHODS

This is a qualitative, cross-sectional study. We used a Grounded Theory approach to let the main issues in physicians' work with patients' adherence emerge without preconceiving the focus of the study. We included physicians from HIV clinics in San Francisco, U.S.A. as well as from Copenhagen, Denmark. Physicians were observed during their clinical work and subsequently interviewed with a semi-structured interview guide. Notes on observations and transcribed interviews were analyzed with NVivo software.

RESULTS

We enrolled 16 physicians from San Francisco and 18 from Copenhagen. When we discovered that physicians and patients seldom discussed adherence issues in depth, we made adherence communication and its barriers the focus of the study. The main patterns in physicians' communication with patients about adherence were similar in both settings. An important barrier to in-depth adherence communication was that some physicians felt it was awkward to explore the possibility of non-adherence if there were no objective signs of treatment failure, because patients could feel "accused." To overcome this awkwardness, some physicians consciously tried to "de-shame" patients regarding non-adherence. However, a recurring theme was that physicians often suspected non-adherence even when patients did not admit to have missed any doses, and physicians had difficulties handling this low believability of patient statements. We here develop a simple four-step, three-factor model of physicians' adherence communication. The four steps are: deciding whether to ask about adherence or not, pre-questioning preparations, phrasing the question, and responding to the patient's answer. The three factors/determinants are: physicians' perceptions of adherence, awkwardness, and believability.

CONCLUSION

Communication difficulties were a main barrier in physicians' work with patients' adherence to HIV medication. The proposed model of physicians' communication with patients about adherence--and the identification of awkwardness and believability as key issues--may aid thinking on the subject for use in clinical practice and future research.

Patient support and education for promoting adherence to highly active antiretroviral therapy for HIV/AIDS

BACKGROUND

Adherence to prescribed regimens is required to derive maximal benefit from many highly active antiretroviral therapy (HAART) regimens in people living with HIV/AIDS.

OBJECTIVES

To conduct a systematic review of the research literature on the effectiveness of patient support and education to improve adherence to HAART.

SEARCH STRATEGY

A systematic search of electronic databases was performed from January 1996 to May 2005.

SELECTION CRITERIA

Randomized controlled trials examining the effectiveness of patient support and education to improve adherence to HAART were considered for inclusion. Only those studies that measured adherence at a minimum of six weeks were included.

DATA COLLECTION AND ANALYSIS

Study selection, quality assessments and data abstraction were performed independently by two reviewers.

MAIN RESULTS

Nineteen studies involving a total of 2,159 participants met criteria for inclusion. It was not possible to conduct a meta-analysis due to study heterogeneity with respect to populations, interventions, comparison groups, outcomes, and length of follow-up. Sample sizes ranged from 22 to 367. The populations studied ranged from general HIV-positive populations to studies focusing exclusively on children, women, Latinos, or adults with a history of alcohol dependence, to studies focusing almost exclusively on men. Study interventions included cognitive behavioral therapy, motivational interviewing, medication management strategies, and interventions indirectly targeting adherence, such as programs directed to reduce risky sexual behaviours. Ten studies demonstrated a beneficial effect of the intervention on adherence. We found that interventions targeting practical medication management skills, those administered to individuals vs groups, and those interventions delivered over 12 weeks or more were associated with improved adherence outcomes. We also found that interventions targeting marginalized populations such as women, Latinos, or patients with a past history of alcoholism were not successful at improving adherence. We were unable to determine whether effective adherence interventions were associated with improved virological or immunological outcomes. Most studies had several methodological shortcomings leaving them vulnerable to potential biases.

AUTHORS' CONCLUSIONS

We found evidence to support the effectiveness of patient support and education interventions intended to improve adherence to antiretroviral therapy. Interventions targeting practical medication management skills, those interventions administered to individuals vs groups, and those interventions delivered over 12 weeks or more were associated with improved adherence outcomes. There is a need for standardization and increased methodological rigour in the conduct of adherence trials.

'Simply forgot' is the most frequently stated reason for missed doses of HAART irrespective of degree of adherence

OBJECTIVES

Previous studies have reported that forgetfulness is the most frequently mentioned reason for missed doses among patients on highly active antiretroviral therapy (HAART). However, no previous study has compared the reasons given by highly nonadherent patients with the reasons given by patients with better adherence. The objective of this study was to examine further patients' self-reported reasons for missing doses of HAART and to compare the reasons given by patients with lower adherence with those given by patients with higher adherence.

METHODS

All patients visiting the clinics participating in the Danish HIV cohort study during a 1-year period (July 2002 to June 2003) were eligible if they had started HAART at least 6 months previously. Consenting patients completed an anonymous self-administered questionnaire based upon the adult AIDS Clinical Trial Group adherence questionnaires. Lower adherence was defined as reporting a missed dose within the preceding 4 days.

RESULTS

We received usable questionnaires from 840 (75%) of the 1126 eligible patients. Patients with lower adherence reported the same reasons for missed doses as patients with higher adherence (Spearman's rho=0.952, P<0.0001). In both groups of patients the three most frequently reported reasons for missed doses were 'simply forgot', 'were away from home', and 'had a change in daily routines'.

CONCLUSIONS

Patients with poorer adherence to HAART state the same reasons for missing doses as patients with better adherence, and 'simply forgot' is the most frequently stated reason.

Baseline predictors of three types of antiretroviral therapy (ART) adherence: A 2-year follow-up

The purposes of the study were to measure adherence with antiretroviral therapy to dose, schedule, and dietary instructions in a sample of patients with HIV infection in Stockholm, Sweden, over a 2-year period and identify baseline predictors of the three types of adherence. The study cohort consists of 144 patients who completed at least six out of seven follow-up self-reported adherence questionnaires. Baseline self-administrated questionnaire examined socio-demographics, medication-related, psychological, cognitive, and social context factors and self-reported adherence. Biomedical data were obtained through patients' medical records. Summary dose, schedule, and dietary instructions adherence scores provided outcome measures reflecting 100% adherence across all time points or not 100% adherence during at least one measurement period. A total of 61% maintained consistent full-dose adherence throughout baseline and all follow-up visits and equivalent proportion of 100% schedule adherence was 39%. Among patients with dietary instructions, 37% retained consistent adherence at all visits. Only schedule adherence was predicted by baseline data; perceived pressures from medical staff to take HIV medications (OR 0.51, p < .05), life stress (OR 0.13, p < .01), ART health concerns (OR 0.19, p < .01), and ART prolongs one's life (OR 0.39, p < .05) predicted reduced schedule adherence over time. Perceived medication pressures from those close to the patient (OR 1.76, p < .05), post-traumatic stress disorder symptoms (OR 1.07 p<.01), and adherence self-efficacy (OR 3.50, p < .05) predicted positive schedule adherence over time. These results clearly illustrate difficulties in sustaining ART adherent behaviour, in particular schedule and dietary restrictions, over time and thus emphasizes the importance of multiple periodic assessments of all three types of adherence. Interventions aimed at improving schedule adherence should in particular focus on psychological and cognitive factors.

Baseline predictors of three types of antiretroviral therapy (ART) adherence: a 2-year follow-up

The purposes of the study were to measure adherence with antiretroviral therapy to dose, schedule, and dietary instructions in a sample of patients with HIV infection in Stockholm, Sweden, over a 2-year period and identify baseline predictors of the three types of adherence. The study cohort consists of 144 patients who completed at least six out of seven follow-up self-reported adherence questionnaires. Baseline self-administrated questionnaire examined socio-demographics, medication-related, psychological, cognitive, and social context factors and self-reported adherence. Biomedical data were obtained through patients' medical records. Summary dose, schedule, and dietary instructions adherence scores provided outcome measures reflecting 100% adherence across all time points or not 100% adherence during at least one measurement period. A total of 61% maintained consistent full-dose adherence throughout baseline and all follow-up visits and equivalent proportion of 100% schedule adherence was 39%. Among patients with dietary instructions, 37% retained consistent adherence at all visits. Only schedule adherence was predicted by baseline data; perceived pressures from those close to the patient to take HIV medications (OR 0.51, p<.05), life stress (OR 0.13, p 0.009), ART health concerns (OR 0.19, p 0.003), and ART prolongs one's life (OR 0.39, p 0.04) predicted reduced schedule adherence over time. Perceived medication pressures from medical staff (OR 1.76, p<.05), post-traumatic stress disorder symptoms (OR 1.07 p<.01), and adherence self-efficacy (OR 3.50, p<.05) predicted positive schedule adherence over time. These results clearly illustrate difficulties in sustaining ART adherent behaviour, in particular schedule and dietary restrictions, over time and thus emphasizes the importance of multiple periodic assessments of all three types of adherence. Interventions aimed at improving schedule adherence should in particular focus on psychological and cognitive factors.

Long-term adherence to first-line highly active antiretroviral therapy in a hospital-based cohort: predictors and impact on virologic response and relapse

A high level of adherence to highly active antiretroviral therapy (HAART) is essential to minimize the risk of treatment failure and HIV disease progression. This cohort study evaluated the prevalence and predictors of long-term adherence with first-line HAART in a hospital-based unselected sample of HIV patients from central Italy, and examined the association between adherence and virological response or relapse. Between July 1996 and June 2004, 171 patients (67.3% males; mean age, 41.2 years) were followed for at least 24 weeks and up to 8 years. Adherence was measured by patient self-reports and confirmed using pharmacy records. The prevalence of high-level adherence (>or=90%) at 6 months was 88.3%; slightly less than 80% at 12 months. The incidence of adherence failure in the sample remained fairly stable until 24 months of follow-up, then it declined about 5% every 6 months. Cox analysis showed that compared to single/separated patients, homeless and married persons were, respectively, 1.95 times more likely and two times less likely to experience adherence failure (p < 0.05). The adjusted risk of adherence failure among patients who did not suffer drug-related toxicity was 0.57 (p < 0.05). Medication adherence was significantly associated with shorter time to virological response and longer time to relapse. Adherents were 1.69 times more likely to achieve viral suppression and nine times less likely to experience relapse than nonadherents (p < 0.01). Efforts at improving adherence should be prolonged for at least 24 months. A protective role of marriage for adherence failure is promising but requires confirmation in further research, that should also clarify the exact mechanisms determining the association.

Immunological predictors of survival in HIV type 2-infected rural villagers in Guinea-Bissau

We investigated the association between beta2-microglobulin, neopterin, serum levels of soluble urokinase-type plasminogen activator receptor (suPAR), CD4 count, and plasma viremia with survival in 133 HIV-2-infected villagers and 160 controls living in rural Guinea-Bissau. Subjects were recruited in 1991 and visited at home every 3-6 months until 1998. Median beta2-microglobulin, neopterin, and suPAR were significantly higher and CD4% significantly lower among HIV-2-infected individuals than controls. Thirty-one HIV-2-infected individuals died and 7 were lost to follow-up. beta2-Microglobulin, CD4%, and plasma viral load were associated independently with survival in multivariate analyses. Neopterin and suPAR did not reach statistical significance. These findings suggest that immune activation is central to the pathogenesis of HIV. They also have important implications for resource-poor settings where CD4 count and plasma viral load are unaffordable.