Habit formation in support of antiretroviral medication adherence in clinic-enrolled HIV-infected adults: a qualitative assessment using free-listing and unstructured interviewing in Kampala, Uganda

A day-to-day management model improves patient compliance to treatment for Helicobacter pylori infection: a prospective, randomized controlled study

BACKGROUND

The day-to-day (DTD) management model encourages patients to actively participate in their healthcare by setting goals. We determined the effectiveness of the DTD model in the treatment of Helicobacter pylori (H. pylori) infection, as compared with conventional outpatient education (OE).

METHODS

We randomized 254 H. pylori-positive patients into a DTD group (127 patients) and an OE group (127 patients) prior to primary treatment with 14-day bismuth-containing quadruple therapy, including esomeprazole, amoxicillin, and clarithromycin. Both groups received consistent medication instructions. Patients in the DTD group recorded daily attendance after completing their daily medication plan from day 1 to day 14. The medication compliance, follow-up compliance, H. pylori eradication rates, and adverse events (AEs) were evaluated.

RESULTS

In the modified intention-to-treat (MITT) and per-protocol (PP) analyses, the DTD group showed significantly higher medication compliance than the OE group (P = 0.001 and P = 0.031, respectively). Both the MITT and PP analyses showed significant differences in follow-up compliance (P < 0.001 and P = 0.003, respectively) and timing of the review urea breath test (P < 0.001 and P = 0.001, respectively) between the two groups. However, no significant differences were observed in the H. pylori eradication rates (95.8% vs. 93.8%, P = 0.529) in the PP analysis, or AEs incidence (25.4% vs. 28.3%, P = 0.603) between the two groups.

CONCLUSION

This study demonstrated the novel application of the DTD model in the treatment of H. pylori infection, which enabled patients to develop habitual medication-taking behaviors without physician intervention.

Barriers and facilitators of antiretroviral therapy (ART) adherence habit formation in Sub-Saharan Africa: Evidence from a qualitative study in Kampala, Uganda

RATIONALE

In 2020, nearly 40 million people lived with HIV/AIDS (PLWHA) worldwide, of whom 70% were receiving antiretroviral therapy (ART). Two-thirds of PLWHA reside in Sub-Saharan Africa (SSA), where rates of viral load suppression are often suboptimal and frequently attributed to low ART adherence. Strong pill-taking habits are often reported as a key strategy among those who successfully maintain medication adherence, yet not enough is known about the barriers and facilitators in SSA to pill-taking in response to the same contextual cue, which is a necessary step in the habit formation process.

OBJECTIVE

To address this knowledge gap and to inform a subsequent intervention to promote context-dependent repetition, called anchoring, we used a formative qualitative approach to collect in-depth narratives about barriers and facilitators of the anchoring intervention for establishing ART pill-taking habits at the Mildmay Hospital in Kampala, Uganda.

METHODS

We conducted interviews with 25 randomly selected patients starting ART, 5 expert patients, and 10 providers at Mildmay, and performed a rapid analysis to inform the intervention in a timely manner.

RESULTS

We found that pill taking in response to the same contextual cue, or anchor, was threatened by stigma and food insecurity and that the COVID-19 pandemic exacerbated these barriers. We also determined that important linguistic changes were needed to the instructional materials and reminder messages in the subsequent intervention to avoid words and phrases with negative connotations for this target population.

CONCLUSIONS

Several important barriers and facilitators to context-dependent pill taking in Uganda were identified through our formative research that helped to inform important revisions to our subsequent intervention. These findings underscore the importance of understanding local barriers and facilitators when designing and planning interventions, particularly when implementing theory-based intervention approaches that have yet to be tested in a new setting.

The role of material deprivations in determining ART adherence: Evidence from a conjoint analysis among HIV-positive adults in Uganda

Despite sustained global scale-up of antiretroviral therapy (ART), adherence to ART remains low. Less than half of those in HIV care in Uganda achieve 85% adherence to their ART medication required for clinically meaningful viral suppression, leaving them at higher risk of transmission. Key barriers to ART adherence include poverty-related structural barriers that are inter-connected and occur simultaneously, making it challenging to examine and disentangle them empirically and in turn design effective interventions. Many people living with HIV (PLWH) make tradeoffs between these various barriers (e.g., between expenses for food or transportation) and these can influence long-term health behavior such as adherence to ART. To be able to estimate the distinct influence of key structural barriers related to poverty, we administered a conjoint analysis (CA) to 320 HIV-positive adults currently taking ART at an urban clinic in Uganda between July 2019 and September 2020. We varied the levels of four poverty-related attributes (food security, sleep deprivation, monthly income, and physical pain) that occur simultaneously and asked respondents how they would adhere to their medication under different combinations of attribute levels. This allows us to disentangle the effect of each attribute from one another and to assess their relative importance. We used regression analysis to estimate the effects of each attribute level and found that food security impacts expected adherence the most (treatment effect = 1.3; 95% CI 1.11-1.49, p<0.001), followed by income (treatment effect = 0.99; 95% CI 0.88-1.10, p<0.001. Sleep and pain also impact adherence, although by a smaller magnitude. Sub-group analyses conducted via regression analysis examine heterogeneity in results and suggest that the effects of material deprivations on expected adherence are greater among those with high levels of existing food insecurity. Results from this CA indicate that external factors inherent in the lives of the poor and unrelated to direct ART access can be important barriers to ART adherence. This study applies a CA (typically administered in marketing applications) among PLWH to better understand individual-level perceptions relating to poverty that often occur simultaneously. Policy interventions should address food insecurity and income to improve adherence among HIV-positive adults.

"The one who doesn't take ART medication has no wealth at all and no purpose on Earth" - a qualitative assessment of how HIV-positive adults in Uganda understand the health and wealth-related benefits of ART

BACKGROUND

Increases in life expectancy from antiretroviral therapy (ART) may influence future health and wealth among people living with HIV (PLWH). What remains unknown is how PLWH in care perceive the benefits of ART adherence, particularly in terms of improving health and wealth in the short and long-term at the individual, household, and structural levels. Understanding future-oriented attitudes towards ART may help policymakers tailor care and treatment programs with both short and long-term-term health benefits in mind, to improve HIV-related outcomes for PLWH.

METHODS

In this qualitative study, we conducted semi-structured interviews among a subsample of 40 PLWH in care at a clinic in Uganda participating in a randomized clinical trial for treatment adherence in Uganda (clinicaltrials.gov: NCT03494777). Interviews were transcribed verbatim and translated from Luganda into English. Two co-authors independently reviewed transcripts, developed a detailed codebook, achieved 93% agreement on double-coded interviews, and analyzed data using inductive and deductive content analysis. Applying the social-ecological framework at the individual, household, and structural levels, we examined how PLWH perceived health and wealth-related benefits to ART.

RESULTS

Our findings revealed several benefits of ART expressed by PLWH, going beyond the short-term health benefits to also include long-term economic benefits. Such benefits largely focused on the ability of PLWH to live longer and be physically and mentally healthy, while also fulfilling responsibilities at the individual level pertaining to themselves (especially in terms of positive long-term habits and motivation to work harder), at the household level pertaining to others (such as improved relations with family and friends), and at the structural level pertaining to society (in terms of reduced stigma, increased comfort in disclosure, and higher levels of civic responsibility).

CONCLUSIONS

PLWH consider short and long-term health benefits of ART. Programming designed to shape ART uptake and increase adherence should emphasize the broader benefits of ART at various levels. Having such benefits directly integrated into the design of clinic-based HIV interventions can be useful especially for PLWH who face competing interests to increase medication adherence. These benefits can ultimately help providers and policymakers better understand PLWH's decision-making as it relates to improving ART-related outcomes.

Effect of Reminder System on Pre-exposure Prophylaxis Adherence in Men Who Have Sex with Men: A Prospective Cohort Study Based on WeChat Intervention (Preprint)

Background

Objective

Methods

Results

Conclusions

Trial Registration

Acceptability of a feasibility randomized clinical trial of a microenterprise intervention to reduce sexual risk behaviors and increase employment and HIV preventive practices (EMERGE) in young adults: a mixed methods assessment

BACKGROUND

Acceptability is a critical requisite in establishing feasibility when planning a larger effectiveness trial. This study assessed the acceptability of conducting a feasibility randomized clinical trial of a 20-week microenterprise intervention for economically-vulnerable African-American young adults, aged 18 to 24, in Baltimore, Maryland. Engaging MicroenterprisE for Resource Generation and Health Empowerment (EMERGE) aimed to reduce sexual risk behaviors and increase employment and uptake of HIV preventive behaviors.

METHODS

Thirty-eight participants were randomized to experimental (n = 19) or comparison group (n = 19). The experimental group received text messages on job openings plus educational sessions, mentoring, a start-up grant, and business and HIV prevention text messages. The comparison group received text messages on job openings only. Qualitative and quantitative post-intervention, in-person interviews were used in addition to process documentation of study methods.

RESULTS

Our results found that the study design and interventions showed promise for being acceptable to economically-vulnerable African-American young adults. The largely positive endorsement suggested that factors contributing to acceptability included perceived economic potential, sexual health education, convenience, incentives, and encouraging, personalized feedback to participants. Barriers to acceptability for some participants included low cell phone connectivity, perceived payment delays, small cohort size, and disappointment with one's randomization assignment to comparison group. Use of peer referral, network, or wait-list designs, in addition to online options may enhance acceptability in a future definitive trial. Expanding administrative and mentoring support may improve overall experience.

CONCLUSION

Microenterprise interventions are acceptable ways of providing young adults with important financial and sexual health content to address HIV risks associated with economic vulnerability.

TRIAL REGISTRATION

ClinicalTrials.gov. NCT03766165 . Registered 04 December 2018.