HIV Treatment Adherence - A Shared Burden for Patients, Health-Care Providers, and Other Stakeholders

Impact of COVID-19 on Adherence to Treatment in Patients with HIV

In patients with human immunodeficiency virus (HIV), adherence to treatment is affected by the adverse effects of treatment, the presence of additional comorbidities, the complexity of dosage, and family and community support. However, one recent circumstance that was likely to have influenced therapeutic adherence was the COVID-19 pandemic and the applied containment measures. An observational retrospective study of a sample of patients with HIV was conducted to establish the relationship between sociodemographic, clinical, and pharmacological variables and therapeutic adherence before and after the pandemic. Adherence was measured using the validated simplified medication adherence questionnaire (SMAQ) and medication possession rate. A statistical analysis was performed to determine the mean, standard deviation, and median of the quantitative variables and the frequencies of the qualitative variables, and the relationship between the dependent and independent variables was analysed using the chi-squared test and Student's t-test. No statistically significant differences were found between treatment adherence measured before and 22 months after the start of the pandemic. Sex, occupation, treatment regimen, viral load levels, and COVID-19 disease status did not influence adherence during either period. However, the age of patients with HIV had an impact on adherence during both periods (p = 0.008 and p = 0.002, respectively), with the age group under 45 years being less adherent. In addition, experiencing adverse drug reactions (ADRs) was shown to have an impact on adherence before the pandemic (p = 0.006) but not afterwards. The COVID-19 pandemic was not shown to have an impact on the degree of adherence to antiretroviral treatment in patients with HIV. Instead, adherence was influenced by patient age and ADR occurrence; therefore, measures must be taken in this regard. The SMAQ demonstrated sensitivity in assessing adherence.

Medication Adherence Measurement Methods in Registration Trials Supporting the Approval of New Medicines: A Cross-Sectional Analysis of Centralized Procedures in the European Union 2010-2020

Medication adherence is a key factor impacting efficacy and safety of medicines, yet how it is dealt with in European registration trials is unknown. A cross-sectional analysis of European Medicines Agency (EMA) marketing authorization dossiers for new medicines approved through centralized procedures in the European Union between 2010 and 2020 was performed. Data were extracted from European Public Assessment Reports and Clinical Study Reports. Clinical trials covering five therapeutic areas were included: diabetes, respiratory conditions, cardiovascular diseases, infectious diseases, and oncology. Outcomes included adherence assessment, measurement methods, and rates. Overall, 102 medicines studied in 253 clinical trials were reviewed. All but one study reported measuring adherence. Two hundred twenty trials (87%) measured adherence using quantitative methods, while 32 (13%) trials monitored adherence but did not further quantify. Reported adherence rates were high (> 90%) across trials yet marked disparities in measurement methods and definitions were found. The most frequently used adherence measurement method was pill/dose count (single method: 52.7%; in combination: 37.7%; with patient diary/report: 17.3%; electronic methods: 1.4%; bioanalytical methods: 4.1%). Patient diary/report (6.4%) and electronic methods (2.7%) were also used as single methods. Electronic methods were more often used in respiratory and anti-infective trials, while bioanalytical methods were more frequently used in diabetes. Overall, adherence is measured in EMA registration trials, yet the methods used and the way in which adherence rates are presented vary widely between trials and therapeutic areas. To better understand and compare efficacy of medicines, standardization of adherence definitions and measurement methods is needed.

Measuring patient engagement with HIV care in sub-Saharan Africa: a scoping study

INTRODUCTION

Engagement with HIV care is a multi-dimensional, dynamic process, critical to maintaining successful treatment outcomes. However, measures of engagement are not standardized nor comprehensive. This undermines our understanding of the scope of challenges with engagement and whether interventions have an impact, complicating patient and programme-level decision-making. This study identified and characterized measures of engagement to support more consistent and comprehensive evaluation.

METHODS

We conducted a scoping study to systematically categorize measures the health system could use to evaluate engagement with HIV care for those on antiretroviral treatment. Key terms were used to search literature databases (Embase, PsychINFO, Ovid Global-Health, PubMed, Scopus, CINAHL, Cochrane and the World Health Organization Index Medicus), Google Scholar and stakeholder-identified manuscripts, ultimately including English evidence published from sub-Saharan Africa from 2014 to 2021. Measures were extracted, organized, then reviewed with key stakeholders.

RESULTS AND DISCUSSION

We screened 14,885 titles/abstracts, included 118 full-texts and identified 110 measures of engagement, categorized into three engagement dimensions ("retention," "adherence" and "active self-management"), a combination category ("multi-dimensional engagement") and "treatment outcomes" category (e.g. viral load as an end-result reflecting that engagement occurred). Retention reflected status in care, continuity of attendance and visit timing. Adherence was assessed by a variety of measures categorized into primary (prescription not filled) and secondary measures (medication not taken as directed). Active self-management reflected involvement in care and self-management. Three overarching use cases were identified: research to make recommendations, routine monitoring for quality improvement and strategic decision-making and assessment of individual patients.

CONCLUSIONS

Heterogeneity in conceptualizing engagement with HIV care is reflected by the broad range of measures identified and the lack of consensus on "gold-standard" indicators. This review organized metrics into five categories based on the dimensions of engagement; further work could identify a standardized, minimum set of measures useful for comprehensive evaluation of engagement for different use cases. In the interim, measurement of engagement could be advanced through the assessment of multiple categories for a more thorough evaluation, conducting sensitivity analyses with commonly used measures for more comparable outputs and using longitudinal measures to evaluate engagement patterns. This could improve research, programme evaluation and nuanced assessment of individual patient engagement in HIV care.

Factors Impacting Video Telehealth Appointment Completion During COVID-19 Pandemic Among People Living with HIV in a Community-Based Health System

As the threat of COVID-19 on vulnerable populations continues, mitigation protocols have escalated the use of telehealth platforms, secure 2-way video platforms with audio capabilities. The goal of the current study was to examine factors associated with successful completion of video telehealth appointments in HIV care. We utilized a random effects logistic model to assess characteristics of patient encounters that predicted completed telehealth visits. Results show that factors such as identifying as black (AOR = 0.30, 95% CI 0.23–0.40, p < 0.01), identifying as heterosexual (AOR = 0.40, 95% CI, 0.29–0.55, p < 0.01), identifying as Hispanic/Latinx (AOR = 0.67, 95% CI, 0.48–0.95), having public insurance (e.g., Ryan White funding, Medicare/Medicaid) (AOR = .25, 95% CI 0.19–0.33, p < .001), and having detectable viral load (AOR = .049, 95% CI, 0.31–0.76) are negatively associated with completion of telehealth appointments. Results suggest that greater efforts to address the digital divide are needed to increase access to video telehealth.

Missing appointments by patients on antiretroviral therapy: Professional nurses’ perspective

Background: Missed appointments for medicine pick-ups are regarded as a predictor of poor adherence, and should trigger immediate questions about issues that may affect follow-up visits to healthcare settings.Objectives: The study explored and described professional nurses’ perspectives about the factors that contribute to missing appointments by people living with Human Immunodeficiency Virus (PLWHIV) on antiretroviral therapy (ART) at Mopani and Vhembe district in Limpopo Province.Method: A qualitative explorative contextual approach was used for the study. Non-probability, purposive sampling was used to select 14 professional nurses who met the inclusion criteria. Data were collected through face-to-face unstructured interviews. One central question was asked and probing questions were based on the participants’ responses to the central question. Thematic analysis of the findings was carried out. Trustworthiness was ensured through intercoder agreement, audio recording, triangulation, bracketing, and member checking. Required permission, approval, and ethical clearance were also ensured.Results: Organisational health system and management of the healthcare facility were found to be the barriers that negatively impacted on the ability of the PLWHIV on ART to maintain clinic visits appointments. Lack of patient involvement, stereotyped appointment dates selection, poor patient-provider relationships, errors of recording appointment dates and long waiting times came up as sub-themes derived from the main theme.Conclusion: The results suggest that there is a need to increase and improve mutual trust in patient-provider relationships, improve nurses working conditions, develop proper booking systems and reduce clinic waiting hours.

Assessment of the Perception of People Living With HIV Regarding the Quality of Outpatient Care at a Reference Facility in the Federal District, Brazil

The effectiveness of antiretroviral treatment has transformed HIV infection into a chronic transmissible condition, requiring health systems to adapt in order to care for people living with HIV. The Chronic Care Model (CCM) is the gold standard for this type of care in many countries. Among its tools, the Patient Assessment of Chronic Illness Care (PACIC) questionnaire gives the patient’s perspective of the care provided. The aim of the present study was to adapt and apply, for the first time, the questionnaire to people living with HIV to determine their perception of the quality of care provided at a reference hospital in the Federal District of Brazil. This is a case study conducted in 2019 at a teaching hospital, with a convenience sample of 30 individuals treated for at least 1 year at the facility. The median PACIC score (3.5 with a range of 1.0–5.0) seems to suggest that the users perceive the outpatient care provided by the hospital as being basic. The “delivery system design/decision support” component was deemed the best (5.0, with a range of 1.0–5.0) and “follow-up/coordination” the worst (1.0, with a range of 1.0–5.0). The results suggest the need to improve the organization of care and make adequate use of community resources, in line with the CCM. The questionnaire makes it possible to determine the strengths and weaknesses of the care provided to people living with HIV and can be used as a planning and monitoring tool to improve management of the condition, with the contribution of the patient, in particular, thereby strengthening self-care.

Factors Associated with Medication Adherence for People Living with Acute HIV Infection in a Tertiary Chinese Hospital in Beijing

Both the management and caregiving intervention of people living with HIV (PLWH), especially during acute HIV-1 infection, represent a public health issue and a form of social support. This current study analyzed the demographic and clinical factors associated with antiretroviral therapy (ART) adherence of PLWH from positive HIV diagnosis to ART initiation in a tertiary Chinese hospital in Beijing. A total of 200 participants diagnosed with acute HIV-1 infection were enrolled in this study. We collected demographic and clinical data by the use of a self-reported questionnaire. Bivariate and multivariate logistic regressions were used to determine associations between potential variables and outcomes. We found that medication adherence was impacted by years of ART and number of reminders (all P < 0.05). In addition, medication adherence was associated with viral load at 48 weeks (P = 0.035). Future studies are needed to investigate effective interventions that could facilitate ART adherence.

Psychometric properties of the scale for non-adherence to antiretroviral medication (NAME) among HIV-infected patients

Background

Adherence to HIV medication is necessary for long-term HIV disease management. The objective of this study was to develop and examine the psychometric properties of a scale for measuring the barriers of antiretroviral medication adherence among Iranian Patients.

Method

This was a sequential, exploratory mixed methods investigation composed of two phases. In the qualitative phase, item pool generation and questionnaire designing was carried out through in-depth individual interviews and group discussions; in the quantitative phase, psychometric properties of the questionnaire were assessed. In both phases, the participants were people who were living with HIV/AIDS and were taking antiretroviral medications.

Results

In the first phase, an item pool containing 181 statements related to barriers of adherence to antiretroviral medication was generated. In the second phase, item reduction was applied, and a questionnaire containing 30 items was developed. The psychometric properties of the questionnaire were assessed, which indicated good validity and reliability of the instrument. In exploratory factor analysis, the items were loaded on six factors that altogether explain for 61.98 of the variance. The Cronbach’s alpha and the intra class correlation coefficient of the questionnaire was 0.91 and 0.80, respectively.

Conclusion

This study provided a reliable and valid instrument to identify the barriers of adherence to antiretroviral medication in patients with HIV/AIDS. Identify these barriers and design of interventions to eliminate or reduce of barriers can be an effective means of enhancing adherence to antiretroviral medication among these patients.