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

The role of family factors in antiretroviral therapy (ART) adherence self-efficacy among HIV-infected adolescents in southern Uganda

Background

Adolescents living with HIV in sub-Saharan Africa are a vulnerable group at the intersection of poverty and health disparities. The family is a vital microsystem that provides financial and emotional support to achieve optimal antiretroviral therapy (ART) adherence. In this study, we explore the association between family factors and ART adherence self-efficacy, a significant psychological concept playing a critical role in ART adherence.

Methods

Data from an NIH-funded study called Suubi + Adherence, an economic empowerment intervention for HIV positive adolescents (average age = 12.4 years) in southern Uganda was analyzed. We conducted multilevel regression analyses to explore the protective family factors, measured by family cohesion, child-caregiver communication and perceived child-caregiver support, associated with ART adherence self-efficacy.

Results

The average age was 12.4 years and 56.4% of participants were female. The average household size was 5.7 people, with 2.3 children> 18 years. Controlling for sociodemographic and household characteristics, family cohesion (β = 0.397, p = 0.000) and child-caregiver communication (β = 0.118, p = 0.026) were significantly associated with adherence self-efficacy to ART.

Conclusion

Findings point to the need to strengthen family cohesion and communication within families if we are to enhance adherence self-efficacy among adolescents living with HIV.

Trial registration

This trial was registered with ClinicalTrials.gov (registration number: NCT01790373) on 13 February 2013.

Promoters and inhibitors of treatment adherence among HIV/AIDS patients receiving antiretroviral therapy in Ghana: Narratives from an underserved population

Adherence to antiretroviral therapy (ART) is essential to achieving an improved cluster of differentiation-4 (CD4) count, viral load, and quality of life while preventing drug resistance. Medication adherence among people living with Human Immunodeficiency Virus (HIV) is influenced by different factors. Several studies have identified adherence promoters and inhibitors that emanate from the internal and external environment. We conducted six (6) individual in-depth interviews and three (3) focus group discussions to explore adherence behaviour among patients diagnosed with HIV in a teaching hospital in Accra, Ghana. Participants were drawn from the intervention arm of a mobile phone adherence intervention program. They had been enrolled in the study for at least six (6) months before the interviews are conducted. Results revealed that participants adhered to treatment irrespective of prompts from significant others. Adherence promoters included perception of ART as part of daily routines, benefits of the ART, awareness of regimen, access to food, and transparency. Adherence inhibitors were forgetfulness, secrecy, waiting time, religious beliefs, and sleep. People living with HIV (PLWHIV) have the personal motivation to take medication; however, negative perceptions about HIV must be addressed to ensure optimum adherence behaviour.

Poor Self-efficacy for Healthcare Provider Interactions Among Individuals with HIV-Associated Neurocognitive Disorders

Two factors that influence HIV health behaviors and therefore may contribute to gaps in the HIV treatment continuum are poor health-related self-efficacy and HIV-associated neurocognitive disorders (HAND). However, the relationship between HAND and self-efficacy has not been assessed. In an HIV sample, 91 individuals with intact cognition (HAND-) and 40 individuals with HAND (HAND+) were administered a measure of self-efficacy for healthcare interactions with providers. Participants with HAND had significantly lower scores on this measure, which were correlated with poorer episodic and semantic memory performance, as well as self-reported memory symptoms in daily life. Findings suggest that neurocognitive impairment, and particularly memory dysfunction, may play an important role in self-efficacy for healthcare interactions in HIV. Further examination of the interplay between HAND and self-efficacy is warranted as these two factors may be important for the public health goal of identifying targets for improving access, delivery, and maintenance of HIV care.

Ethnopharmacological Applications Targeting Alcohol Abuse: Overview and Outlook

Excessive alcohol consumption is the cause of several diseases and thus is of a major concern for society. Worldwide alcohol consumption has increased by many folds over the past decades. This urgently calls for intervention and relapse counteract measures. Modern pharmacological solutions induce complete alcohol self-restraint and prevent relapse, but they have many side effects. Natural products are most promising as they cause fewer adverse effects. Here we discuss in detail the medicinal plants used in various traditional/folklore medicine systems for targeting alcohol abuse. We also comprehensively describe preclinical and clinical studies done on some of these plants along with the possible mechanisms of action.

Determinants and Outcomes of Late Presentation of HIV Infection in Migrants in Catalonia, Spain: PISCIS Cohort 2004-2016

This study using the Catalan PISCIS cohort explores risk factors of migrants' late presentation and the impact of late presentation on their health outcomes. We analyse 9590 new HIV diagnoses enrolled in the cohort between 2004 and 2016. Univariate and multivariate logistic regression models are used to identify risk factors associated with late presentation among migrants, giving crude and adjusted odds ratios and their 95% confidence intervals. Cox regression models are estimated to identify risk factors associated with AIDS/death, and crude and adjusted hazard ratios and 95% confidence intervals are reported. Late presentation is higher in migrants than non-migrants. Among migrants, region of origin is associated with late presentation and AIDS/death during follow-up. The results highlight persisting inequalities in HIV diagnosis and care among migrants in Catalonia. Targeted interventions addressed to specific subgroups in the migrant population are needed.

Intimate partner violence against HIV-positive Cameroonian women: Prevalence, associated factors and relationship with antiretroviral therapy discontinuity-results from the ANRS-12288 EVOLCam survey

Background:

Intimate partner violence in its various forms increases HIV exposure in female victims and potentially jeopardizes the HIV treatment cascade, for instance, by impeding engagement in and adherence to care. Elevated rates of HIV and intimate partner violence are reported in Central Africa. Evidence on the effect of intimate partner violence on antiviral therapy interruption is lacking in Cameroon, where only 330,000 women live with HIV and only 19% of HIV-positive people are virally suppressed. This study aimed to assess the prevalence and factors of intimate partner violence against HIV-positive women and its relationship with antiretroviral therapy interruption ⩾1 month.

Methods:

The EVOLCam cross-sectional survey was conducted in 19 hospitals in the Center and Littoral regions. The study sample comprised antiviral therapy–treated women declaring at least one sexual partner in the previous year. Scores of recent emotional, physical, extreme physical and sexual intimate partner violence were built using principal component analysis and categorized under no, occasional or frequent intimate partner violence. Multivariate logistic analyses were performed to investigate the relationship between intimate partner violence and recent antiretroviral therapy interruption ⩾1 month, and associated factors.

Results:

Among the 894 analyzed women, the prevalence of intimate partner violence was 29% (emotional), 22% (physical), 13% (extreme physical) and 18% (sexual). Frequent physical intimate partner violence was a significant risk factor of antiretroviral therapy interruption ⩾1 month (adjusted odds ratio = 2.42 (95% confidence interval = 1.00; 5.87)). It was also associated with HIV-related stigma (2.53 (1.58; 4.02)), living with a main partner (2.03 (1.20; 3.44) and non-defensive violence against this partner (5.75 (3.53; 9.36)).

Conclusion:

Intimate partner violence is a potential barrier to antiviral therapy continuity and aggravates vulnerability of Cameroonian HIV-positive women. The prevention and detection of intimate partner violence by HIV services might help to reach the last “90” of the 90-90-90 targets.

Exploring pathways from violence and HIV disclosure without consent to depression, social support, and HIV medication self-efficacy among women living with HIV in Metro Vancouver, Canada

We used path analysis to investigate complex pathways from HIV status disclosure without consent, physical/verbal violence and depression, social support, and HIV medication self-efficacy through mediators of HIV stigma among women living with HIV in Canada. In the final model, internalized stigma fully mediated the relationship between physical/verbal violence and reduced medication self-efficacy. Enacted stigma fully mediated the relationship between HIV status disclosure without consent and depression. Internalized stigma (β = 0.252; p < 0.001) had a significant negative direct effect on medication self-efficacy. Enacted stigma had a significant direct effect on depression (β = 0.162; p = 0.037). Findings will help improve services and interventions to promote quality of life and well-being of women living with HIV.

"We get double slammed!": Healthcare experiences of perceived discrimination among low-income African-American women

BACKGROUND

On account of their racial/ethnic minority status, class, and gender, African-American women of low socioeconomic status are among the least privileged, underserved, and most marginalized groups in the United States. Generally, African Americans continue to experience poorer health outcomes, in which disparities have been attributed to socioeconomic inequities and structural racism. This objective of this study was to explore the lived experiences of low-income African-American women in interacting with the healthcare system and healthcare providers.

METHODS

Twenty-two in-depth one-on-one interviews were conducted with low-income African-American women. The audio-recorded interviews were transcribed verbatim. An inductive content analysis was performed, using an analytical software, Dedoose® to enabled hierarchical coding. Codes were grouped into categories which were further analyzed for similarities that led to the emergence of themes.

RESULTS

A key finding was the experience of discriminatory treatment. The three themes that emerged relevant to this category were (1) perceived discrimination based on race/ethnicity, (2) perceived discrimination based on socioeconomic status, and (3) stereotypical assumptions such as drug-seeking and having sexually transmitted diseases.

CONCLUSION AND RECOMMENDATIONS

Low-income African-American women experience less than satisfactory patient care, where participants attribute to their experience of being stereotyped and their perception of discrimination in the healthcare system and from providers. Patients' experiences within the healthcare system have implications for their healthcare-seeking behaviors and treatment outcomes. Healthcare personnel and providers need to be more aware of the potential for implicit bias toward this population. Healthcare workforce training on culturally responsive patient care approaches and more community engagement will help providers better understand the context of patients from this population and more effectively meet their healthcare needs.

Resilience and Beliefs in the Effectiveness of Current Antiretroviral Therapies Among Recently Disengaged Low-Income People of Color Living with HIV

Consistent antiretroviral adherence is key to viral suppression, but many low-income people of color living with HIV are not optimally adherent due to a wide variety of interrelated social and structural factors. Previous studies have found that HIV medication beliefs are an important facet of adherence. In contrast to the AZT era , currently available antiretroviral therapies are significantly safer and more effective, but research suggests that negative beliefs may persist among racial and ethnic minority people. Twenty-seven semi-structured interviews were conducted with low-income Black and Latinx people living with HIV in New York City that were currently, or had been recently, disengaged from outpatient HIV medical care. This research suggests that socially and economically marginalized people living with HIV, many long-term survivors who lived through the AZT era, recognized that current treatments are very effective in making HIV a chronic, manageable illness and a significant improvement compared to the therapies early in the epidemic. Most importantly, the data suggests that people demonstrate great resilience despite their experiences of social and economic exclusion. Both clinical practice and public health interventions can benefit from these findings. HIV care providers should speak with patients about their beliefs related to HIV medication, and public health interventions should specifically address HIV medication-related beliefs in order to enhance adherence. In order to avoid reifying people's marginalization, public health should endeavor to recognize and support people's resilience.

Drug resistance patterns in HIV patients with virologic failure in Iran

We reviewed the medical charts of 1,700 patients diagnosed with HIV who referred to a central HIV clinic in Tehran between 2004 and 2017. Participants who had a viral load of > 200 copies/mL after six months or more on antiretroviral therapy (ART) were grouped as virologic failure (VF). We assessed the demographic characteristics, diagnosis date, first ART regimen, and resistance to various ART drugs. Out of 1,700 patients, 72 (4.2%) had a treatment failure. Among those with treatment failure, 51.3% were on zidovudine + lamivudine + efavirenz, 13.9% were on tenofovir + lamivudine + lopinavir/ritonavir, and 12.5% were on tenofovir + emtricitabine + efavirenz. In patients with treatment failure, the highest resistance was to nucleoside reverse transcriptase inhibitors (NRTIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) combination (44.4%). In these patients, resistance to tenofovir (one of the NRTIs) was 29.1%. The highest treatment failure was observed among patients treated with nevirapine (NVP) and efavirenz (EFV)-based regimen. Our findings suggest that protease inhibitors should be considered as first-line drugs in ART regimens in VF patients in Iran.

Alcohol, But Not Depression or IPV, Reduces HIV Adherence Among South African Mothers Living with HIV Over 5 Years

Alcohol, depression, and intimate partner violence (IPV) are endemic in sub-Saharan Africa. This article examines whether and how these conditions affect mothers living with HIV (MLH), compared to mothers without HIV (MWOH). In particular, we assess the influence of these comorbidities on engagement in HIV care and adherence to antiretroviral therapies (ARV) among MLH. Data on maternal HIV care are typically based on clinic samples, with substantial loss to follow-up. This study fills that gap by including all mothers in specified areas. A cohort study examines MLH in Cape Town, South Africa recruited in pregnancy and followed repeatedly for 5 years, compared to MWOH. Almost all (98%) pregnant women in 12 neighborhoods (N = 594) were recruited in pregnancy. Mothers and children were reassessed five times over 5 years with high retention rates at each of the six assessments, from 98.7% at 2 weeks to 82.8% at 5 years post-birth. MLH's uptake and adherence to HIV care was evaluated over time associated with maternal comorbidities of alcohol use, depressed mood, and IPV using mixed effects logistic regression. MLH have fewer resources (income, food, education) and are more likely to face challenges from alcohol, depression, and having seropositive partners over time than MWOH. Only 22.6% of MLH were consistently engaged in HIV care from 6 months to 5 years post-birth. At 5 years, 86.7% self-reported engaged in HIV care, 76.9% were receiving ARVs and 87% of those on ARV reported consistent ARV adherence. However, data on viral suppression are unavailable. Alcohol use, but not depressed mood or IPV, was significantly related to reduced uptake of HIV care and adherence to ARV over time. Adherence to lifelong ARV by MLH requires a combination of structural and behaviorally-focused interventions. Alcohol abuse is not typically addressed in low and middle-income countries, but is critical to support MLH.

Syndemic factors associated with adherence to antiretroviral therapy among HIV-positive adult heterosexual men

BACKGROUND

Suboptimal adherence to HIV antiretroviral therapy (ART) and concomitant lack of viral control can have severe consequences for health and onward transmission among persons living with HIV. Little is known about the barriers and facilitators of optimal ART adherence among heterosexual HIV-positive men.

METHODS

Structural equation modeling (SEM) was performed to test a theory-derived model of ART adherence using data from a cross-sectional sample of 317 HIV-positive self-identified heterosexual men residing in New York City. We assessed a conceptual model in which mental health (depression, anxiety) and substance use dependence mediated the effects of socio-structural factors (HIV-related stigma, social support) on ART adherence, and subsequently, undetectable viral load.

RESULTS

Structural equation modeling analyses indicated that men who reported higher levels of HIV-related stigma tended to experience higher levels of general anxiety, which in turn was associated with reduced probability of optimal ART adherence. Moreover, men who reported higher levels of social support tended to exhibit less dependence on illicit substance use, which in turn was associated with increased probability of optimal ART adherence. African-American men reported lower ART adherence compared to other racial/ethnic groups.

CONCLUSIONS

Our findings support the hypothesis that substance use dependence and mental health problems, particularly anxiety, may be primary drivers of suboptimal ART adherence among heterosexual men, and that socio-structural factors such as HIV-related stigma and social support are potential modifiable antecedents of these drivers.

Determinants of Restoration of CD4 and CD8 Cell Counts and Their Ratio in HIV-1-Positive Individuals With Sustained Virological Suppression on Antiretroviral Therapy

BACKGROUND

An increasing number of HIV-positive individuals now start antiretroviral therapy (ART) with high CD4 cell counts. We investigated whether this makes restoration of CD4 and CD8 cell counts and the CD4:CD8 ratio during virologically suppressive ART to median levels seen in HIV-uninfected individuals more likely and whether restoration depends on gender, age, and other individual characteristics.

METHODS

We determined median and quartile reference values for CD4 and CD8 cell counts and their ratio using cross-sectional data from 2309 HIV-negative individuals. We used longitudinal measurements of 60,997 HIV-positive individuals from the Antiretroviral Therapy Cohort Collaboration in linear mixed-effects models.

RESULTS

When baseline CD4 cell counts were higher, higher long-term CD4 cell counts and CD4:CD8 ratios were reached. Highest long-term CD4 cell counts were observed in middle-aged individuals. During the first 2 years, median CD8 cell counts converged toward median reference values. However, changes were small thereafter and long-term CD8 cell count levels were higher than median reference values. Median 8-year CD8 cell counts were higher when ART was started with <250 CD4 cells/mm. Median CD4:CD8 trajectories did not reach median reference values, even when ART was started at 500 cells/mm.

DISCUSSION

Starting ART with a CD4 cell count of ≥500 cells/mm makes reaching median reference CD4 cell counts more likely. However, median CD4:CD8 ratio trajectories remained below the median levels of HIV-negative individuals because of persisting high CD8 cell counts. To what extent these subnormal immunological responses affect specific clinical endpoints requires further investigation.

HIV-Related Stigma, Motivation to Adhere to Antiretroviral Therapy, and Medication Adherence Among HIV-Positive Methadone-Maintained Patients

BACKGROUND

Opioid agonist therapies with methadone are associated with higher levels of adherence to antiretroviral therapy (ART); yet, no studies have explored factors associated with optimal ART levels in HIV-positive patients on methadone maintenance treatment, including explanatory pathways using mediation analysis.

SETTING

Participants included 121 HIV-positive, methadone-maintained patients who reported HIV-risk behaviors and were taking ART.

METHODS

Participants were assessed using an audio computer-assisted self-interview. Multivariable logistic regression was used to identify significant correlates and PROCESS macro to test the explanatory pathway (ie, mediational effect) for optimal ART adherence.

RESULTS

Among 121 participants, almost 40% reported suboptimal adherence to ART. Optimal ART adherence was significantly associated with being virally suppressed [adjusted odds ratio (aOR) = 6.470, P = 0.038], higher motivation to adhere to ART (aOR = 1.171, P = 0.011), and lower anticipated HIV-related stigma (aOR = 0.384, P = 0.015). Furthermore, results revealed an indirect effect of motivation on the relationship between HIV stigma and ART adherence (effect = -0.121, P = 0.043), thus supporting the mediation effect.

CONCLUSIONS

Our findings underscore the complexities surrounding ART adherence, even in patients on methadone maintenance treatment. These findings provide insights on how to more effectively intervene to optimize HIV treatment outcomes, including HIV treatment-as-prevention initiatives, in methadone-maintained patients.

Factors Associated With Early Virological Response in HIV-Infected Individuals Starting Antiretroviral Therapy in Brazil (2014-2015): Results From a Large HIV Surveillance Cohort

Objective:

To identify clinical, sociodemographic, and treatment-related factors associated with early virological response in HIV-infected adults starting antiretroviral treatment (ART) in Brazil in 2014–2015.

Methods:

Data from 4 information systems from the Brazilian AIDS Program were combined to create a historical cohort. Unconditional logistic regression models were used to assess the likelihood of not achieving viral load suppression (VLS), defined as having either a viral load (VL) count >200 copies per milliliter or an aids-related death recorded within 180 ± 90 days after treatment initiation.

Results:

Among 76,950 individuals, 64.8% were men; median age, CD4⁺, and VL counts were 34 years, 378 cells per micro liter, and 38,131 copies per milliliter, respectively, and 85.2% achieved VLS. In the multivariate analysis, some factors which increased the odds of non-VLS were as follows: lower CD4⁺ and higher VL counts, younger age, heterosexual or injection drug use groups (relative to men who have sex with men), lower educational level, black/brown race, higher pill burden, and higher dosing frequency. Regimens containing boosted protease inhibitors were similar to those containing nonnucleoside reverse transcriptase inhibitors and superior to those containing unboosted protease inhibitors (all P values <0.001). No difference was observed between patients with CD4⁺ counts 350–499 and 500+ cells per micro liter.

Conclusions:

Our findings support the decision made in Brazil in 2013 to recommend immediate initiation of ART regardless of clinical stage or CD4⁺. Several factors were found to be associated with poorer virologic outcomes and should be addressed to maximize ART adherence and success rates.

HIV-Positive Patients' Perceptions of Antiretroviral Therapy Adherence in Relation to Subjective Time: Imprinting, Domino Effects, and Future Shadowing

Antiretroviral treatment adherence barriers are major concerns in HIV care. They are multiple and change over time. Considering temporality in patients' perceptions of adherence barriers could improve adherence management. We explored how temporality manifests itself in patients' perceptions of adherence barriers. We conducted 2 semi-structured focus groups on adherence barriers with 12 adults with HIV which were analyzed with grounded theory. A third focus group served to validate the results obtained. Three temporal categories were manifest in HIV-positive patients' perceptions of barriers: (1) imprinting (events with lasting impacts on patients), (2) domino effects (chain of life events), and (3) future shadowing (apprehension about long-term adherence). An overarching theme, weathering (gradual erosion of abilities to adhere), traversed these categories. These temporalities explain how similar barriers may be perceived differently by patients. They could be useful to providers for adapting their interventions and improving understanding of patients' subjective experience of adherence.

Barriers to HIV Treatment Adherence: A Qualitative Study of Discrepancies Between Perceptions of Patients and Health Providers in Tanzania and Uganda

Previous qualitative studies about antiretroviral therapy (ART) adherence have largely focused on patient experiences. Less is known about the perspective of health care providers-particularly in low-income countries-who serve as gatekeepers and influencers of patients' HIV care experiences. This study explored patients' and providers' perceptions of important ART adherence determinants. Interviews were conducted at HIV treatment sites in Tanzania and Uganda, with adult patients on ART (n = 148), and with health care providers (n = 49). Patients were asked about their experiences with ART adherence, and providers were asked about their perceptions of what adherence challenges are faced by their patients. All interviews were conducted in local languages; transcripts were translated into English and analyzed using a codebook informed by the social ecological model. Themes were examined across and within countries. Adherence-related challenges were frequently reported, but patients and providers did not often agree about the reasons. Many patients cited challenges related to being away from home and therefore away from their pill supply; and, in Uganda, challenges picking up refills (access to care) and related to food sufficiency/diet. Providers also identified these access to care barriers, but otherwise focused on different key determinants (e.g., they rarely mentioned food/diet); instead, providers were more likely to mention alcohol/alcoholism, stigma, and lack of understanding about the importance of adhering. These findings suggest areas of opportunity for future research and for improving clinical care by aligning perceptions of adherence challenges, to deliver better-informed and useful ART counseling and support.

Necessity and concerns beliefs and HIV medication adherence: a systematic review

According to the Necessity-Concerns Framework, beliefs about medication necessity and concerns are two core themes from diverse patient medication beliefs across chronic illnesses that may directly influence adherence. Past work has supported associations of necessity and concerns to adherence in the chronic disease literature and in HIV research. However, there has not been a focused review of the literature on associations of necessity and concerns to HIV medication adherence, nor on what variables may influence these associations. This systematic review synthesized findings from 26 studies regarding associations of necessity and concerns to HIV medication adherence. Both beliefs showed small, clinically significant effects on adherence. A subset of studies identified perceptions of healthcare providers as determinants of necessity and concerns beliefs with indirect effects on adherence. Overall, necessity and concerns demonstrated clinically significant associations to adherence among people with HIV.

Evaluating cabotegravir/rilpivirine long-acting, injectable in the treatment of HIV infection: emerging data and therapeutic potential

Cabotegravir and rilpivirine long-acting injectable antiretroviral therapy for the treatment of HIV-1 infection brings promise of a new mode of delivery and potential solutions to some problems of oral therapy, but also new challenges and unanswered questions. Adding to the increasing body of evidence for newer two-drug combinations, phase II and phase III trial data to date demonstrate cabotegravir and rilpivirine combination injectable therapy to be non-inferior to selected oral triple-therapy alternatives. Most importantly, this therapy is reported to be acceptable to individuals taking the 4-weekly or 8-weekly injections, despite frequent injection-site reactions. Key outstanding questions include management of missed or delayed dosing, drug interactions and management of virological failure, as well as the efficacy of cabotegravir and rilpivirine in all HIV-1 subtypes. We describe clinical evidence to date and efficacy and challenges in selected populations, including women; those with prior virological failure; individuals with a history of difficulty adhering to oral therapy and individuals with co-infections. We await real-world data and longer-term evidence while moving forward to this new era of antiretroviral therapy.

Poverty stigma is associated with suboptimal HIV care and treatment outcomes among women living with HIV in the United States

OBJECTIVE

To examine whether experienced poverty stigma is associated with worse HIV care and treatment outcomes.

DESIGN

We analyzed cross-sectional data from 433 women living with HIV enrolled in the Women's Adherence and Visit Engagement substudy of the Women's Interagency HIV Study.

METHODS

Exposure was experienced poverty stigma, measured using the Perceived Stigma of Poverty Scale. Outcomes were viral suppression, CD4 cell count at least 350 cells/μl, and attending all HIV care visits in the past 6 months. Multivariable logistic regression models adjusted for income, age, race/ethnicity, education, substance use, months taking antiretroviral therapy (ART), number of antiretroviral pills in ART regimen, unstable housing, relationship status, and exchanging sex for money, drugs, or shelter. We also explored whether self-reported at least 95% ART adherence mediated the relationship between poverty stigma and viral suppression and CD4 cell count at least 350 cells/μl.

RESULTS

Experienced poverty stigma was associated with lower adjusted odds of viral suppression [adjusted odds ratio (aOR) 0.76; 95% confidence interval (CI) 0.61-0.96], CD4 cell count at least 350 cells/μl (aOR 0.69; 95% CI 0.52-0.91), and attending all HIV care visits (aOR 0.73; 95% CI: 0.54-0.98). Exploratory mediation analysis suggests that at least 95% ART adherence significantly mediates the relationship between experienced poverty stigma and viral suppression and CD4 cell count at least 350 cells/μl.

CONCLUSION

Longitudinal research should assess these relationships over time. Findings support interventions and policies that seek to reduce poverty stigma among people living with HIV.

Nursing Practice to Support People Living With HIV With Antiretroviral Therapy Adherence: A Qualitative Study

Antiretroviral therapy (ART) management is a core competency for nursing practice in HIV as documented in best practice guidelines. Nurse-led interventions are effective in fostering ART adherence in people living with HIV (PLWH). However, these evidence-based interventions and professional expectations pertaining to these guidelines do not reflect current practice, nor do they expose the challenges faced by nurses. We conducted a qualitative exploratory study with nurses to explore their professional practices in the context of ART adherence. Sixteen nurses participated in data collection: nine in a focus group and seven in individual interviews. We identified four themes: building a therapeutic relationship with PLWH as a foundation of HIV nursing care; nursing activities to support PLWH with ART adherence; challenges faced by nurses providing ART-related care; and resource mobilization supporting nursing practice development in ART management and HIV care. Aspects of HIV nursing practice need to be strengthened to enhance best practice care, such as managing powerlessness in the context of ART nonadherence.

Prevalence and determinants of adherence to antiretroviral treatment among HIV patients on first-line regimen: a cross-sectional study in Dakar, Senegal

Introduction

Successful and long-term positive impact of antiretroviral treatment requires high rates of adherence (> 90%). In Senegal, there is a lack of data regarding adherence to antiretroviral treatment and only a few studies have looked at the determinants. The aim of this study is to assess the prevalence and determinants contributing to antiretroviral (ARV) adherence among Human Immunodeficiency Virus (HIV) infected outpatients receiving care at four public hospitals in Dakar, Senegal.

Methods

A cross-sectional based study was carried out among HIV-positive ART adults in Dakar, Senegal. Patients were systematically sampled during either their clinical visits or visit to collect ARV drugs from six public hospitals and data collected with a questionnaire. The study outcome was adherence to antiretroviral treatment assessed by a multiple approach method which combined three self-reported adherence tools: self-reporting, Visual Analog Scale (VAS), and the Simplified Medication Adherence Questionnaire (SMAQ). Data were entered with an Excel spreadsheet and transferred to STATA for descriptive, bivariate and multivariate analysis. All the statistical tests were done at the threshold level of 0.05.

Results

A total of 150 HIV-positive patients on first line ART regimen at six public health facilities were enrolled into the study. The mean age of patients was 43.1 years with a sex ratio of 0.3. Most of the patients were prescribed Tenofovir-based regimen. Of these patients, 26.67% were found to be highly adherent. After adjusting for health-related variables, demographic and socio-economic variables, better adherence was associated with participating actively within an association of persons living with HIV (AoR=2.89; 95% CI: 1.04 - 7.99; p value 0.041) while being widowed patient was associated with lower adherence (AoR=0.17; 95% CI: 0.03 - 0.94; p value 0.043).

Conclusion

Our study findings imply that adherence should be routinely assessed during medical visits. Ongoing strategies to improve adherence such as out-of-clinic group-based models or psychological support should be directed toward outpatients' clinics to assist in improving adherence and long term virologic suppression in Senegal.

Substance Use Stigma and Antiretroviral Therapy Adherence Among a Drug-Using Population Living with HIV

Among people living with HIV (PLWH), HIV-related stigma predicts nonadherence to antiretroviral therapy (ART); however, the role of stigma associated with drug use is largely unknown. We examined the association between substance use (SU) stigma and optimal ART adherence in a sample of 172 self-reported HIV-infected drug users. Participants completed surveys on SU, stigma, and ART adherence. The three substance classes with the greatest number of participants exhibiting moderate/high-risk scores were for cocaine/crack cocaine (66.28%), cannabis (64.53%), and hazardous alcohol consumption (65.70%). Multivariable logistic regression was conducted to investigate associations between levels of SU stigma and optimal ART adherence, adjusting for sociodemographic characteristics, severity of illicit drug use (alcohol, smoking and substance involvement screening test) and alcohol use severity (Alcohol Use Disorders Identification Test-C), HIV-related stigma, and social support. The odds of optimal adherence among participants experiencing moderate [Adjusted Odds Ratio (AOR) = 0.36, p = 0.039] and very high (AOR = 0.25, p = 0.010) levels of anticipated SU stigma were significantly lower than participants experiencing low levels of anticipated SU stigma. No other stigma subscales were significant predictors of ART adherence. Interventions aiming to improve ART adherence among drug-using PLWH need to address anticipated SU stigma.

Effectiveness of integrase strand transfer inhibitors among treatment-experienced patients in a clinical setting

OBJECTIVE

Characterize virologic and immunologic outcomes of INSTI-based antiretroviral therapy (ART) in experienced patients with and without virologic failure.

DESIGN

Prospective clinical cohort.

METHODS

ART-experienced, INSTI-naive participants in the University of North Carolina Center for AIDS Research HIV Clinical Cohort (UCHCC) initiating an INSTI-containing regimen 2007-2016 were followed from INSTI initiation (baseline) to the earliest of: outcome of interest, loss to follow-up (LTFU, 1 year without clinical visit), or death. Outcomes of interest were virologic failure (first of two consecutive viral loads at least 200 copies/ml more than 2 weeks apart, or one viral load ≥200 before LTFU) and immune recovery (first CD4 ≥500 cells/μl). Patients with baseline viral load at least 50 copies/ml were given 24 weeks before meeting virologic failure criteria. Kaplan-Meier curves and Cox proportional hazards models compared INSTI regimens and patient characteristics.

RESULTS

Of 773 patients, 32% were women, 59% African-American, and 42% had a viral load at least 50 copies/ml at INSTI initiation. After 2 years, 5% of patients with baseline viral load less than 50 copies/ml experienced virologic failure, compared with 35% of patients with baseline viral load at least 50 copies/ml (P < 0.01). Among patients with baseline viral load less than 50 copies/ml, dolutegravir/NRTIs was associated with longer time to virologic failure [adjusted hazard ratio (aHR) 0.11, 95% confidence interval (CI) 0.01-0.80], whereas among patients with baseline viral load at least 50 copies/ml, raltegravir/NRTIs was associated with longer time to virologic failure (aHR 0.35, 95% CI 0.18-0.68), both compared with elvitegravir/NRTIs. After 5 years suppressed, irrespective of baseline viral load, 61% of patients experienced immune recovery.

CONCLUSION

In this cohort, INSTI-containing regimens led to low virologic failure rates in patients switching ART while suppressed. Viremic patients initiating INSTIs were at high risk of virologic failure during follow-up.

Knowledge, attitudes, perception and practices regarding antiretroviral therapy among HIV-infected adults in Antananarivo, Madagascar: a cross-sectional survey

Background

Adherence to antiretroviral therapy (ART) may be influenced by knowledge, perception and perception regarding ART. The purpose of this study was to assess knowledge, attitude/perception and practice regarding ART among people living with HIV/AIDS (PLHIV).

Methods

We conducted a cross-sectional survey to assess knowledge, attitudes, perception and practices ART in PLHIV. The survey was suggested to all PLHIV of at least 18 years old and who were on ART for at least 1 month. PLHIV who were unable to answer questions correctly and those who did not complete the survey for any reason were excluded.

Results

During the study period, 234 PLHIV were included. Participants were mostly men (75.2%). The median age was 33 years (IQR: 27–41). The median time since HIV diagnosis was 25 months (IQR: 9–56) and the median duration of ART was 18 months (IQR: 8–48). 87.6% had an overall good knowledge of ART. However, only 3.2% knew the name of their ART, 31.2% were aware that ART should be taken at a fixed time and 17.1% knew how to take ART in relation to food intake. 75.6% of participants had an overall positive attitude/perception of ART. However, 10.7% were convinced that other methods were more effective than ART for treating HIV and 42.7% thought that taking ART was shameful. The assessment of practices showed that in case of missed dose, 48.3% of participants routinely skipped this dose instead of trying to take it as soon as possible. In multivariate analysis, good knowledge of ART was independently associated with high level of education (aOR: 4.7, IC95%: 1.6–13.7, p = 0.004) and disclosure of HIV status (aOR: 2.7, IC95%: 1.1–6.6, p = 0.029).

Conclusions

This study showed an overall good knowledge and a predominantly positive attitude/perception of ART. However, accurate knowledge of ART intake was insufficient and the stigma associated with taking ART remained very present. Furthermore, very heterogeneous practices may reflect lack of instruction given by the physician regarding ART intake.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4173-3) contains supplementary material, which is available to authorized users.

Prevalence and Correlates of Reporting Difficulty Taking Antiretroviral Treatment Among HIV-Positive Illicit Drug Users in Vancouver, Canada: A Longitudinal Analysis

People living with HIV who use illicit drugs continue to experience high rates of suboptimal treatment outcomes from antiretroviral therapy (ART). Although previous studies have identified important behavioural, social and structural barriers to ART adherence, the effects of patient-level factors have not been fully evaluated. Thus, we sought to investigate the prevalence and correlates of reporting ART was difficult to take among a cohort of illicit drug users in Vancouver, Canada. We accessed data from the AIDS Care Cohort to evaluate Exposure to Survival Services (ACCESS), an ongoing prospective cohort of HIV-positive illicit drug users linked to comprehensive HIV clinical monitoring records. We used generalized linear mixed-effects modeling to identify factors longitudinally associated with periods in which individuals reported they found ART difficult to take. Between December 2005 and May 2014, 746 ART-exposed illicit drug users were recruited and contributed at least one study interview. Finding ART hard to take was reported by 209 (28.0%) participants at baseline, and 460 (61.7%) participants throughout the study period. Patients ingesting a greater daily pill count (adjusted odds ratio [AOR] = 1.12 per pill, 95% confidence interval [CI] 1.08-1.17) and experiencing barriers to healthcare (AOR = 1.64, 95% CI 1.34-2.01) were more likely to report difficulty taking ART. Patients less likely to report satisfaction with their HIV physician (AOR = 0.76, 95% CI 0.58-1.00) and achieve a non-detectable HIV viral load (AOR = 0.62, 95% CI 0.51-0.74) were more likely to report finding ART hard to take. In this community-recruited cohort of ART-exposed illicit drug users, a substantial proportion reported they found HIV treatment hard to take, which was clearly linked to higher dissatisfaction with healthcare experiences and, most importantly, a lower likelihood of experiencing optimal virologic outcomes. Our findings reveal a number of opportunities to improve HIV treatment experiences and outcomes for people who use illicit drugs, including the use of treatment regimens with lower pill burdens, as well as reducing barriers to healthcare access.

A triaged real-time alert intervention to improve antiretroviral therapy adherence among young African American men who have sex with men living with HIV: focus group findings

BACKGROUND

Among persons living with HIV, poorer antiretroviral therapy adherence has been reported in African Americans and disproportionate mortality reported in young African American men who have sex with men (AAMSM) compared to whites. We report the results of focus groups with young AAMSM living with HIV that explore their opinions about the acceptability and feasibility of a triaged real-time missed dose alert intervention to improve treatment adherence. The purpose of this study is to develop a theory-driven triaged real-time adherence monitoring intervention to promote HIV medication adherence in young AAMSM.

METHODS

We performed five focus groups and two individual interviews among young HIV-positive AAMSM (n = 25) in Chicago guided by the Technology Acceptance Model and explored perceptions regarding the monitoring concept including device issues and concerns about inclusion of support persons whose involvement is triggered by sustained missed doses. The purpose was to inform the development of this intervention in this population.

RESULTS

Generally, the participants found the proposed intervention acceptable and useful. Privacy was a major concern for participants especially with attention to possible disclosure of their HIV status by receiving a medication-related text that someone else might view and could lead to unwanted attention. There was concern that the device could be confused with a taser. Approximately half of the men already had a close personal contact that helped them with medication taking. Some participants acknowledged that the notification might lead to friction.

CONCLUSIONS

A triaged real-time alert intervention to improve treatment adherence is acceptable and feasible among young AAMSM living with HIV.

Adherence Connection for Counseling, Education, and Support: Research Protocol for a Proof-of-Concept Study

Background

The highest rates of new HIV infections are observed in African Americans and Hispanics/Latinos (ethnic minority) adolescents and young adults (youth). HIV-infected ethnic minority youth are less likely to initiate and maintain adherence to antiretroviral treatment (ART) and medical care, as compared with their adult counterparts.

Objective

The objective of this research protocol was to describe our proposed methods for testing a peer-led mobile health cognitive behavioral intervention, delivered via remote videoconferencing and smartphones with HIV-infected ethnic minority youth, Adherence Connection for Counseling, Education, and Support (ACCESS). Our secondary aim was to obtain initial estimates of the biobehavioral impact of ACCESS on HIV virologic outcomes and self-reported ART adherence, beliefs and knowledge about ART treatment, adherence self-efficacy, and health care utilization (retention in care).

Methods

An exploratory, sequential mixed-methods study design will be used with conceptual determinants of adherence behavior informed by the information-motivation-behavioral skills model. HIV-infected ethnic minority youth aged 16 to 29 years with a detectable HIV serum viral load of more than 200 copies/ml (N=25) will be recruited. Qualitative pretesting will be conducted, including semistructured, in-depth, individual interviews with a convenience sample meeting the study inclusion criteria. Preliminary analysis of qualitative data will be used to inform and tailor the ACCESS intervention. Testing and implementation will include a one-group pre-posttest pilot, delivered by a trained successful peer health coach who lives with HIV and is well-engaged in HIV care and taking ART. A total of 5 peer-led remote videoconferencing sessions will be delivered using study-funded smartphones and targeting adherence information (HIV knowledge), motivation (beliefs and perceptions), and behavioral skills (self-efficacy). Participant satisfaction will be assessed with poststudy focus groups and quantitative survey methodology. Bivariate analyses will be computed to compare pre- and postintervention changes in HIV biomarkers, self-reported ART adherence, beliefs and knowledge about ART, adherence self-efficacy, and retention in care.

Results

As of December 2018, we are in the data analysis phase of this pilot and anticipate completion with dissemination of final study findings by spring/summer 2019. The major outcomes will include intervention feasibility, acceptability, and preliminary evidence of impact on serum HIV RNA quantitative viral load (primary adherence outcome variable). Self-reported ART adherence and retention in care will be assessed as secondary outcomes. Findings from the qualitative pretesting will contribute to an improved understanding of adherence behavior.

Conclusions

Should the ACCESS intervention prove feasible and acceptable, this research protocol will contribute to a shift in existent HIV research paradigms by offering a blueprint for technology-enabled peer-led interventions and models.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12543

Tailoring Cognitive Behavioral Therapy for Trauma-Exposed Persons Living With HIV

This Treatment Development Report describes the need for evidence-based psychosocial trauma-focused treatment for people living with comorbid posttraumatic stress disorder (PTSD) and HIV. Individuals with HIV have higher rates of exposure to traumatic events and PTSD than the general public, and they also experience additional consequences of PTSD on the management of their chronic disease (e.g., established link between PTSD symptoms and lack of adherence to antiretroviral therapy [ART]). We used the empirically-supported ADAPT-ITT approach to consider the initial steps in adapting evidence-based Cognitive Processing Therapy (CPT) for individuals with PTSD and HIV. This paper reviews a case example that involved various clinical issues that may arise when providing trauma-focused treatment for people living with HIV including HIV-stigma, disease management, and the need for making multicultural adaptations to psychotherapy. This case example illustrates how trauma-focused treatment may benefit from enhancement to address additional barriers that may arise over the course of PTSD treatment in this population. Feasibility of engaging and delivering a "full dose" of evidence-based PTSD treatment among individuals living with HIV is discussed. While evidence-based treatments can reduce PTSD symptom severity, issues related to chronic disease coping and HIV-related stigma management could be integrated to augment the efficacy of treatment for individuals with HIV. Adaptive intervention research targeting PTSD in persons living with HIV warrants further attention, especially given the association between PTSD and adherence to ART.

The Association of Material Hardship with Medication Adherence and Perceived Stress Among People Living with HIV in Rural Zambia

The intersection of poverty and HIV/AIDS has exacerbated socioeconomic inequalities in Zambia. For example, the downstream consequences of HIV/AIDS are likely to be severe among the poor. Current research has relied on multidimensional indicators of poverty, which encompass various forms of deprivation, including material. Although comprehensive measures help us understand what constitutes poverty and deprivation, their complexity and scope may hinder the development of appropriate and feasible interventions. These limitations prompted us to examine whether material hardship, a more practicable, modifiable aspect of poverty, is associated with medication adherence and perceived stress among people living with HIV (PLHIV) in Zambia. We used cross-sectional data from 101 PLHIV in Lundazi District, Eastern Province. Data were collected using a questionnaire and hospital records. Material hardship was measured using a five-item scale. Perceived stress was measured using the ten-item perceived stress scale. Adherence was a binary variable measured using a visual analog scale and medication possession ratio (MPR) obtained from pharmacy data. We analyzed the data with multivariable linear and logistic regressions using multiply imputed datasets. Results indicated that greater material hardship was significantly associated with MPR nonadherence (odds ratio = 0.83) and higher levels of perceived mental distress (β = 0.34). Our findings provide one of the first evidence on the association of material hardship with treatment and mental health outcomes among PLHIV. The findings also draw attention to the importance of economic opportunities for PLHIV and their implications for reducing material hardship and improving adherence and mental health status.

What causes non-adherence among some individuals on long term antiretroviral therapy? Experiences of individuals with poor viral suppression in Uganda

Background

Antiretroviral therapy (ART) use by people living with HIV reduces HIV transmission, morbidity, mortality, and improves quality of life. Good ART adherence is required to achieve these benefits. We investigated how the environmental, social, economic and behavioural experiences of people living with HIV with poor viral suppression could explain their non-adherence to long term ART.

Methods

This qualitative cross-sectional study was conducted in Uganda between September 2015 and April 2016. Thirty individuals on ART for 5 years or more (10 on first line and 20 on second line), with poor viral suppression, were randomly selected from a cohort of people living with HIV on ART. In-depth interviews about ART; awareness, adherence counselling, obstacles to daily adherence and regimen switches were conducted. Emerging themes from the interviews transcripts and field notes were identified and thematic content analysis done. Participants’ consent, compensation, confidentiality and study ethical approvals were ensured.

Results

We found that poor adherence to long term ART was due to: travel for work or social activities, stigma, receiving little or no continuous ART adherence education, alcohol consumption and use of alternative ‘HIV cure’ medicines. Other reasons included; ART side effects, treatment fatigue, belief that long-term ART or God can ‘cure HIV’, and food security.

Conclusions

Achieving optimal ART benefits requires continuous provision of ART adherence education to individuals on long term ART. This helps them overcome the challenges related to living with HIV: worries of food insecurity, alcohol misuse, economic hardship, and beliefs in HIV cures and use of unproven alternative HIV treatments. People living with HIV who travel require adherence support and larger quantities of ART refills to cover their time away.

Determinants of poor adherence to antiretroviral treatment using a combined effect of age and education among human immunodeficiency virus infected young adults attending care at Letaba Hospital HIV Clinic, Limpopo Province, South Africa

INTRODUCTION

sustained viral suppression using antiretroviral treatment (ART) occurs with adherence to treatment of at least 95%. Non-adherence promotes the development of drug-resistance and treatment failure in individuals infected with Human Immunodeficiency Virus. In Limpopo Province, the adherence rate is approximately 61%, but the prevalence and the factors associated with adherence at Letaba hospital HIV clinic are not well established. Therefore, the aim of this study was to identify the factors associated with adherence among HIV-infected young adults, aged 18-35 years, attending the clinic.

METHODS

a cross-sectional survey was conducted in Letaba HIV clinic among young adults of 18-35 years old. Logistic regression analysis was performed to determine factors associated with ART adherence. We reported odds ratios with the corresponding 95% confidence intervals and p-values. A p-value < 0.1 was considered as statistically significant. ART adherence was defined as taking more than 95% of the prescribed treatment, 3 days prior to completion of the questionnaire.

RESULTS

a total of 281 participants were enrolled with 163 (58.0%) females and more than three quarter, 222 (79.0%) between the ages of 18 and 29 years. The overall ART adherence stood at (87.2%) (95% CI: 63.0%-89.0%) representing 245 participants. Non-adherers to treatment, 36 (12.8%): patients reported no reason (3.9%), forgetting (3.2%), feeling good (3.2%), fear and running out of treatment (2.5%) as some of the reasons for not taking treatment within the three days prior to data collection. The following factors: tertiary education (p = 0.07), age (30-35; p-value: 0.07), drug availability (p-value: 0.07), were only marginally significantly associated with ART adherence.

CONCLUSION

the study found unsatisfactory ART adherence among our participants. Our study suggests that factors other than sociodemographic and clinical factors might better explain differences in adherence. This highlights the need for a more complex study that would look at the entire system in which these patients are navigating as well as their mental models.

Efficacy and tolerability of lamivudine plus dolutegravir compared with lamivudine plus boosted PIs in HIV-1 positive individuals with virologic suppression: a retrospective study from the clinical practice

BACKGROUND

Direct comparisons between lamivudine plus bPIs and lamivudine plus dolutegravir as maintenance strategies in virologically-suppressed HIV positive patients are lacking.

METHODS

Time to treatment discontinuation (TD) and virological failure (VF) were compared in a cohort of HIV+ patients on a virologically-effective ART starting lamivudine with either darunavir/r, atazanavir/r or dolutegravir. Changes in laboratory parameters were also evaluated.

RESULTS

Four-hundred-ninety-four patients were analyzed (170 switching to darunavir/r, 141 to atazanavir/r, 183 to dolutegravir): median age was 49 years, with 8 years since ART start. Groups differed for age, HIV-risk factor, time since HIV-diagnosis and on ART, previous therapy and reasons for switching. Estimated proportions free from TD at week 48 and 96 were 79.8 and 48.3% of patients with darunavir/r, 87.0 and 70.9% with atazanavir/r, and 88.2 and 82.6% with dolutegravir, respectively (p < 0.001). Calendar years, HIV-risk factor, higher baseline cholesterol and an InSTI-based previous regimen predicted TD, whereas lamivudine+dolutegravir therapy and previous tenofovir use were protective. VF was the cause of TD in 6/123 cases with darunavir/r, 4/97 with atazanavir/r and 3/21 with dolutegravir. Other main reasons for TD were: toxicity (43.1% with darunavir/r, 39.2% with atazanavir/r, 52.4% with dolutegravir), further simplification (36.6% with darunavir/r, 30.9% with atazanavir/r, 14.3% with dolutegravir). Incidence of VF did not differ among study groups (p = 0.747). No factor could predict VF. Lipid profile improved in the dolutegravir group, whereas renal function improved in the bPIs groups.

CONCLUSIONS

In real practice, a switch to lamivudine+dolutegravir showed similar efficacy but longer durability than a switch to lamivudine+bPIs.

Resilience and HIV: a review of the definition and study of resilience

We use a socioecological model of health to define resilience, review the definition and study of resilience among persons living with human immunodeficiency virus (PLWH) in the existing peer-reviewed literature, and discuss the strengths and limitations of how resilience is defined and studied in HIV research. We conducted a review of resilience research for HIV-related behaviors/outcomes of antiretroviral therapy (ART) adherence, clinic attendance, CD4 cell count, viral load, viral suppression, and/or immune functioning among PLWH. We performed searches using PubMed, PsycINFO and Google Scholar databases. The initial search generated 14,296 articles across the three databases, but based on our screening of these articles and inclusion criteria, n = 54 articles were included for review. The majority of HIV resilience research defines resilience only at the individual (i.e., psychological) level or studies individual and limited interpersonal resilience (e.g., social support). Furthermore, the preponderance of HIV resilience research uses general measures of resilience; these measures have not been developed with or tailored to the needs of PLWH. Our review suggests that a socioecological model of health approach can more fully represent the construct of resilience. Furthermore, measures specific to PLWH that capture individual, interpersonal, and neighborhood resilience are needed.

A Task-Shifting Problem-Solving Therapy Intervention for Depression and Barriers to Antiretroviral Therapy Adherence for People Living With HIV in Zimbabwe: Case Series

HIV is prevalent in Sub-Saharan Africa, and depression frequently co-occurs. Depression is one of the most important predictors of poor adherence to antiretroviral therapy (ART). Little has been done to develop integrated interventions that are feasible and appropriate for task-shifting to nonspecialists that seek to address both depression and barriers to ART adherence in Sub-Saharan Africa. This case series describes an integrated intervention for depression and ART adherence delivered by a lay adherence counselor and supervised by a local psychologist. The 6-session intervention was based on problem-solving therapy for depression and for barriers to adherence (PST-AD), with stepped care for those whose depression did not recover with PST-AD. Primary outcomes were acceptability and depression. Acceptability was measured by participant attendance to the 6 sessions. Three case studies illustrate the structured intervention, solutions identified to adherence barriers and to problems underlying low mood, and changes seen in the clients' psychological symptoms. Acceptability of the intervention was high and common mental disorder symptoms scores measured using the SRQ-8 decreased overall. An integrated intervention for depression and adherence to ART appeared feasible in this low-income setting. An RCT of the intervention versus an appropriate comparison condition is needed to evaluate clinical and cost-effectiveness.

Conceptualizing and Assessing Everyday Functioning in the Context of HIV-Associated Neurocognitive Disorders

Combination antiretroviral therapy has reduced the rates of severe HIV-associated neurocognitive disorders (HAND), but the prevalence of milder forms of HAND that can affect everyday functioning remains high. As HIV-infected adults approach near-normal life expectancies, they may become increasingly susceptible to declines in everyday functioning secondary to a variety of physical and mental factors, including HAND. Although impairments in everyday functioning are a hallmark of HAND diagnoses and can adversely influence quality of life, there are no gold standard measures of this fundamentally important and complex construct. This chapter provides a brief review of the various self-report, clinician-rated, and performance-based methods by which everyday functioning is measured in the setting of HIV disease, including global activities of daily living and specific domains of medication adherence, financial management, automobile driving, and vocational functioning.

New antiretroviral agent use affects prevalence of HIV drug resistance in clinical care populations

OBJECTIVE

To estimate the prevalence of HIV drug resistance over time and identify risk factors for multiclass resistance.

DESIGN

Prospective clinical cohort of HIV-infected patients at the University of North Carolina.

METHODS

Among antiretroviral therapy (ART)-experienced patients in care 2000-2016, we estimated annual prevalences of cumulative resistance, defined as at least one major mutation by drug class. Clinical data and multiple imputation were used when genotypic data were missing, and mutations were carried forward in time. We estimated resistance odds ratios comparing characteristics of patients in care in 2016.

RESULTS

A total of 3682 patients contributed 23 169 person-years. Prevalence of at least one major resistance mutation, irrespective of viral suppression, peaked in 2005 with 49% (95% confidence interval 46, 52) and decreased to 38% (35, 40) in 2016. Resistance to nucleoside reverse transcriptase inhibitors, protease inhibitors, and nonnucleoside reverse transcriptase inhibitors also peaked in 2005-2007 and decreased to 28 (26, 31), 14 (12, 16), and 27% (24, 29) in 2016, respectively. In 2016, prevalence of integrase strand transfer inhibitor (INSTI) resistance was 2% (1, 3) and triple-class resistance 10% (9, 12). Over the study period, cumulative resistance was frequent among patients with detectable viremia, but uncommon among patients initiating ART post-2007. Among 1553 patients in care in 2016, ART initiation at an older age, with an INSTI, and with higher CD4 cell counts were associated with resistance to fewer or no classes.

CONCLUSION

Prevalence of resistance to older ART classes has decreased in the last 10 years in this clinical cohort, whereas INSTI resistance has increased but remained very low. Patients with viremia continue to have a high burden of resistance even if they initiated ART recently.

Cognitive-affective depressive symptoms and substance use among Latino and non-Latino White patients in HIV care: an analysis of the CFAR network of integrated clinical systems cohort

The disparity in viral suppression rates between Latino and non-Latino White patients in HIV care appears to be narrowing, but it is unclear if depression and substance use perpetuate this disparity. We analyzed electronic medical records from the CFAR network of integrated clinical systems cohort. First observations/enrollment data collected between 2007 and 2013 were analyzed, which included survey (race/ethnicity, depression, substance use, adherence) and clinical data (viral suppression). We estimated indirect effects with a regression-based bootstrapping method. In 3129 observations, Latinos and non-Latino Whites did not differ in depression or alcohol use (ORs 1.11, 0.99, ns), but did in drug use (OR 1.13, p < .001). For all patients, depression and substance use were indirectly associated with small increases (ORs 1.02-1.66) in the odds for a detectable viral load, via worse adherence. We conclude that variables not captured in EMR systems (e.g., health literacy, structural factors) may better explain viral suppression disparities that persist.

Substance Use and Adherence to Antiretroviral Therapy: What Is Known and What Is Unknown

PURPOSE OF REVIEW

People who use drugs face multiple challenges to achieve optimal HIV treatment outcomes. This review discusses the current knowledge in substance use and antiretroviral therapy adherence, highlighting recent findings and potential interventions.

RECENT FINDINGS

Studies continue to demonstrate the negative impacts of substance use and related disorders on antiretroviral therapy adherence, with the exception of cannabis. Evidence-based addiction treatment, in particular, opioid agonist therapy, appears to improve adherence levels. Most individual-level adherence specific interventions did not provide sustained effects, and no studies evaluating structural-level interventions were found. Findings suggest the urgent need to scale-up opioid agonist therapy, as well as to simultaneously address multiple structural barriers to care to optimize HIV treatment outcomes among people who use drugs.

Determinants of suboptimal adherence and elevated HIV viral load in pregnant women already on antiretroviral therapy when entering antenatal care in Cape Town, South Africa

Across sub-Saharan Africa, prevention of mother-to-child transmission services are encountering increasing numbers of women already established on antiretroviral therapy (ART) when entering antenatal care. However, there are few data examining ART adherence and HIV viral load in this group. We used multivariable logistic regression models to examine self-reported suboptimal adherence (defined as missed ART doses on ≥2 days during the preceding 30 days), elevated viral load (≥1000 copies/mL), and factors associated with each among women entering antenatal care on ART. Participants were recruited from one primary care clinic in Gugulethu, Cape Town, as part of a larger study of HIV-positive pregnant and postpartum women. Among 482 pregnant women established on ART and enrolled between May 2013 and June 2014 (median age: 31 years; median duration of ART use: 3 years), 15% reported suboptimal adherence and 12% had elevated viral load. After adjustment for age, suboptimal adherence was significantly more common among women who were not married/cohabiting and women who reported a higher level of concern about taking ART; a higher level of adherence self-efficacy was associated with a reduced odds of suboptimal adherence. In a multivariable model, elevated viral load was significantly associated with previous discontinuation of ART, a higher level of concern about taking ART, and report of an unintended pregnancy. Suboptimal adherence and elevated viral load are common among women entering antenatal care already on ART. Our findings highlight specific beliefs and concerns about ART use during pregnancy that should be addressed in counselling messaging, and suggest that family planning should be more effectively integrated into HIV care. Including adherence and viral load monitoring as part of pregnancy planning for women on ART may be important to achieve safer conception and promote healthy pregnancies.

Brain 18F-FDG PET of SIV-infected macaques after treatment interruption or initiation

BACKGROUND

Although rates of severe HIV-associated neurocognitive disorders have declined in the post-antiretroviral treatment (ART) era, subtle deficits persist, possibly exacerbated by treatment non-adherence. The actual effects of ART interruption/initiation on brain glucose metabolism as a reflection of viral replication and neuroinflammation remain unclear. Our study investigates how treatment initiation and interruption alter brain glucose metabolism in SIV-infected macaques, using 18F-FDG PET in correlation with plasma and CSF viral loads (VL) and cytokine levels.

METHODS

SIV-infected macaques (n = 7) underwent ART initiation only, ART interruption only, or both. Five uninfected animals served as controls. 18F-FDG PET imaging was performed at baseline and 1, 3, and 6 months after treatment modification. Mean and maximum standardized uptake values (SUV) for the whole-brain and subregions were calculated. Plasma and CSF VL and cytokine levels were measured. Paired t tests evaluated acute changes in whole-brain SUV from baseline to 1 month, while mixed-effect linear regression models evaluated changes over multiple timepoints and correlated SUV values with disease markers.

RESULTS

ART interruption was associated with increased SUVmean and SUVmax acutely, after 1 month (SUVmean 95% CI [0.044-0.786 g/ml], p = 0.037; SUVmax 95% CI [0.122-3.167 g/ml], p = 0.041). The correlation between SUV and time, however, was not significant when evaluated across all timepoints. Increased SUVmean and SUVmax correlated with decreased CD4+ and CD8+ T-cell counts and increased plasma VL. SUVmax was positively associated with increases in CSF VL, and there were borderline positive associations between SUVmax and IL-2, and between SUVmean and IL-15. The treatment initiation group showed no associations between imaging and disease biomarkers despite viral suppression, reduced cytokine levels, and increased CD4+ and CD8+ T-cell counts.

CONCLUSIONS

ART interruption is associated with increased brain glucose metabolism within 1 month of treatment cessation, which, in concert with increased levels of pro-inflammatory cytokines in the CSF, may reflect neuroinflammation in the setting of viral rebound. Although we cannot assert neurologic damage in association with cerebral hypermetabolism, it is a concerning outcome of ART non-adherence. Treatment initiation, meanwhile, did not result in significant changes in brain metabolism. HIV-induced neuroinflammation may require a longer period to abate than our follow-up period allowed.

Psychiatric Disorders, Antiretroviral Medication Adherence and Viremia in a Cohort of Perinatally HIV-Infected Adolescents and Young Adults

BACKGROUND

Perinatally HIV-infected (PHIV+) adolescents and young adults (AYA) are at risk for suboptimal antiretroviral therapy (ART) adherence and mental health and substance use problems that, in HIV-infected adults, predict nonadherence. Studies on the relationship between psychiatric and substance use disorders (SUD) and adherence among PHIV+ AYA are limited, but may be important for informing evidence-based interventions to promote adherence.

METHODS

Data were analyzed from 3 annual follow-up interviews (FU2-FU4, N = 179) in a longitudinal study of PHIV+ AYA. Psychiatric disorders (anxiety, disruptive behavior, mood and SUD) were assessed with the Diagnostic Interview Schedule for Children. Adherence was self-reported missed ART doses within the past week. Viral load (VL) results were abstracted from medical charts. Multiple logistic regression analyzed cross-sectional associations between psychiatric disorders and (1) missed ART dose and (2) VL > 1000 copies/mL. Multiple linear regression assessed associations between psychiatric disorders and proportion of VL values >1000 copies/mL over time.

RESULTS

At FU2, 53% of PHIV+ AYA had any psychiatric disorder, 35% missed an ART dose in the past week and 47% had a VL > 1000 copies/mL. At FU2, behavioral disorders were associated with missed dose (P = 0.009) and VL > 1000 (P = 0.019), and mood disorders were associated with missed dose (P = 0.041). At FU4, behavioral disorders were associated with missed dose (P = 0.009). Behavioral disorders (P = 0.041), SUD (P = 0.016) and any disorder (P = 0.008) at FU2 were associated with higher proportion of VLs >1000 across FU2-FU4.

CONCLUSIONS

Addressing psychiatric disorder and SUD among PHIV+ AYA may improve ART adherence outcomes in this population. Targeted interventions should be developed and tested.

Age and racial disparities in substance use and self-reported viral suppression among men who have sex with men with HIV

HIV disproportionately affects men who have sex with men (MSM). Substance use is common among people living with HIV and may affect antiretroviral therapy adherence. Nevertheless, research examining the association between substance use and viral suppression is lacking. The aims of this study were to determine the association between substance use and self-reported viral suppression, and by age and race among MSM living with HIV. Data were obtained from 309 HIV-positive MSM. Logistic regression was used to determine the association between substance use and self-reported viral suppression at baseline, and by age and race. Approximately 67% of participants reported they were virally suppressed. After adjusting for sociodemographics, every increase in substance use score was associated with a 7% decrease in the odds of reporting viral suppression (odds ratio [OR]: 0.93; 95% confidence interval [CI]: 0.89-0.98; p = 0.003). The negative association between substance use and self-reported viral suppression remained statistically significant among MSM aged 25-34 years (OR = 0.89; 95% CI: 0.79-1.00; p = 0.041) and statistically significant for Black MSM (OR = 0.92; 95% CI: 0.86-0.98; p = 0.009). Intervention programs for MSM living with HIV aimed at improving viral suppression should address substance use and consider the differences by age and race.

Antiretroviral treatment among commercially insured persons living with HIV in an era of universal treatment in the United States - 2012-2014

In 2012, antiretroviral (ARV) treatment guidelines expanded indications and recommended antiretroviral treatment for all HIV-infected persons in the United States, regardless of CD4 cell count. This analysis describes ARV prescriptions among commercially insured HIV-infected adults from 2012 to 2014. We analyzed persons aged 18-64 years from 2012 to 2014 Truven Health MarketScan Commercial Claims and Encounters® database. We identified HIV-infected persons who had at least one inpatient or two outpatient medical claims and identified pharmacy claims using National Drug Codes. We calculated changes over time in ARV prescription and performed a multivariable regression analysis to examine differences in ARV prescriptions by age, sex, and geographic region. We identified 29,419 HIV-infected persons in 2012, 26,380 in 2013, and 25,414 in 2014. Overall percentage with ARV prescription increased by 7.3%. There was a 23% increase in ARV prescriptions among people new to care and a 6% increase among people already established in care. In 2014, more persons who were new to HIV care did not have an ARV prescription compared to persons established in HIV care (37.5% vs 19.3%, respectively; p  < 0.001). The percentage of persons without an ARV prescription was highest for persons residing in the Northeast (30.8%) compared to those residing in the West (21.7%), North Central (15.9%) and South (16.5%) and was higher among women (26.2%) compared to men (19.5%) (p < 0.001). Uptake of ARV medication has increased since the guidelines expanded their indications in 2012. Despite improvements from 2012 to 2014, a significant proportion of HIV-infected adults with a commercial health insurance plan were not prescribed ARV medications. Insurance-based strategies could be a novel method to increase the percentage of HIV-infected adults who receive optimal care in the United States.

Emotion Dysregulation: An Explanatory Construct in the Relation Between HIV-Related Stigma and Hazardous Drinking among Persons Living with HIV/AIDS

The prevalence of hazardous alcohol use among people living with HIV/AIDS (PLHIV) is common and related to numerous health problems among individuals in this group. Stigma is associated with hazardous drinking among stigmatized groups, but this relationship has yet to be examined among PLHIV. Moreover, there is a lack of research in identifying the mechanisms underlying this association. Emotion dysregulation is one potential construct that may explain the association between stigma and hazardous alcohol use among PLHIV. The present study examined the indirect effect of HIV stigma and hazardous alcohol use via emotion dysregulation. The sample included 98 PLHIV (60.2% male, M _age = 48.40, SD = 7.75). Results indicated significant and medium-sized indirect effects of HIV stigma and its subfacets (enacted stigma and negative self-image) in terms of hazardous alcohol use via emotion dysregulation. Alternative models did not yield significant indirect effects. The results document an indirect association between HIV stigma and hazardous alcohol use via emotion dysregulation. These findings may provide novel, initial empirical insight into the nature of the stigma-hazardous drinking relation among PLHIV.

Non-adherence to anti-retroviral medication in Shiraz, 2014: a cross sectional study

Background

Medication adherence is a dynamic and complex behavioral process, which is strongly influenced by personal, social and environmental factors.

Objectives

To determine the prevalence and factors affecting non-adherence to medication among HIV-infected patients.

Methods and materials

Design

A cross-sectional study.

Setting

Voluntary Counseling and Testing Center (VCT), Shiraz, Fars province, in the South of Iran.

Patients

Among HIV-positive patients who received anti-retroviral therapy, 214 adult patients were selected through convenience sampling. Their medication adherence was checked by interview and counting the pills on visits during two months. Clinical and laboratory data were obtained from the patients' records.

Results

Non-adherence and adherence groups included 30.4% (65) and 69.6% (149) of the patients, respectively. The mean age of patients was 40.80±7.77 years, and ranged from 20 to 65 years. Majority of cases (65%) were male. A significant relationship was found between non-adherence to medications and the variables of transmission method, marital status, housing status, and CD4, but there was no significant relationship with gender.

Conclusion

The prevalence of medication adherence was similar to other regions with limited financial resources. To increase patient's medication adherence, they should be exposed to motivational interventions to promote their drug consumption, social and occupational support.

Universal test and treat is not associated with sub-optimal antiretroviral therapy adherence in rural South Africa: the ANRS 12249 TasP trial

INTRODUCTION

HIV treatment guidelines now recommend antiretroviral therapy (ART) initiation regardless of CD4 count to maximize benefit both for the individual and society. It is unknown whether the initiation of ART at higher CD4 counts would affect adherence levels. We investigated whether initiating ART at higher CD4 counts was associated with sub-optimal adherence (<95%) during the first 12 months of ART.

METHODS

A prospective cohort study nested within a two-arm cluster-randomized trial of universal test and treat was implemented from March 2012 to June 2016 to measure the impact of ART on HIV incidence in rural KwaZulu-Natal. ART was initiated regardless of CD4 count in the intervention arm and according to national guidelines in the control arm. ART adherence was measured monthly using a visual analogue scale (VAS) and pill counts (PC). HIV viral load was measured at ART initiation, three and six months, and six-monthly thereafter. We pooled data from participants in both arms and used random-effects logistic regression models to examine the association between CD4 count at ART initiation and sub-optimal adherence, and assessed if adherence levels were associated with virological suppression.

RESULTS

Among 900 individuals who initiated ART ≥12 months before study end, median (IQR) CD4 at ART initiation was 350 cells/mm3 (234, 503); median age was 34.6 years (IQR 27.4 to 46.4) and 71.7% were female. Adherence was sub-optimal in 14.7% of visits as measured by VAS and 20.7% by PC. In both the crude analyses and after adjusting for potential confounders, adherence was not significantly associated with CD4 count at ART initiation (adjusted OR for linear trend in sub-optimal adherence with every 100 cells/mm3 increase in CD4 count: 1.00, 95% CI 0.95 to 1.05, for VAS, and 1.03, 95% CI 0.99 to 1.07, for PC). Virological suppression at 12 months was 97%. Optimal adherence by both measures was significantly associated with virological suppression (p < 0.001 for VAS; p = 0.006 for PC).

CONCLUSIONS

We found no evidence that higher CD4 counts at ART initiation were associated with sub-optimal ART adherence in the first 12 months. Our findings should alleviate concerns about adherence in individuals initiating ART at higher CD4 counts, however long-term outcomes are needed. ClinicalTrials.gov NCT01509508.

Differential item functioning for items in Berger's HIV Stigma Scale: an analysis of cohorts from the Indian, Swedish, and US contexts

PURPOSE

To examine whether items in Berger's HIV Stigma Scale function differently with persons of different age, gender, and cultural backgrounds.

METHODS

Secondary data from cohorts, collected in South India (n = 250), Sweden (n = 193), and the US (n = 603) were reanalyzed to evaluate DIF within, between, and across these cohorts. All participants had answered the revised version of the HIV stigma scale consisting of 32 items forming the subscales Personalized stigma, Disclosure concerns, Concerns about public attitudes, and Negative self-image. Differential Item Functioning (DIF) for these items was assessed using hybrid ordinal regression-IRT technique. When DIF was detected, the cumulative impact of DIF on individual subscale scores was evaluated.

RESULTS

DIF was detected for 9 items within, between, or across cohorts, but the DIF was negligible in general. Detected DIF between the Swedish and Indian cohorts had a cumulative salient impact on individual scores for the subscale Disclosure Concerns; Disclosure concerns were overestimated in the Swedish cohort and both over- and underestimated in the Indian cohort.

CONCLUSIONS

The items in the 32-item version of the HIV stigma scale did not seem to be particularly prone to present DIF. The DIF between the Indian and Swedish cohort for items in the subscale Disclosure Concerns could, however, result in both type I and type II errors if scores should be compared between the Indian and Swedish cohort.

Mental health and retention in HIV care: A systematic review and meta-analysis

OBJECTIVE

Mental health (MH) diagnoses, which are prevalent among persons living with HIV infection, might be linked to failed retention in HIV care. This review synthesized the quantitative evidence regarding associations between MH diagnoses or symptoms and retention in HIV care, as well as determined if MH service utilization (MHSU) is associated with improved retention in HIV care.

METHOD

A comprehensive search of the Centers for Disease Control and Prevention's HIV/AIDS Prevention Research Synthesis database of electronic (e.g., MEDLINE, EMBASE, PsycINFO) and manual searches was conducted to identify relevant studies published during January 2002-August 2017. Effect estimates from individual studies were pooled by using random-effects meta-analysis, and a moderator analysis was conducted.

RESULTS

Forty-five studies, involving approximately 57,334 participants in total, met the inclusion criteria: 39 examined MH diagnoses or symptoms, and 14 examined MHSU. Overall, a significant association existed between MH diagnoses or symptoms, and lower odds of being retained in HIV care (odds ratio, OR = 0.94; 95% confidence interval [CI] [0.90, 0.99]). Health insurance status (β = 0.004; Z = 3.47; p = .001) significantly modified the association between MH diagnoses or symptoms and retention in HIV care. In addition, MHSU was associated with an increased odds of being retained in HIV care (OR = 1.84; 95% CI [1.45, 2.33]).

CONCLUSIONS

Results indicate that MH diagnoses or symptoms are a barrier to retention in HIV care and emphasize the importance of providing MH treatment to HIV patients in need. (PsycINFO Database Record

Association of Cannabis, Stimulant, and Alcohol use with Mortality Prognosis Among HIV-Infected Men

Questionnaires over a 9-year study period (2002-2010) were used to characterize cannabis, stimulant, and alcohol use among 3099 HIV-infected men participating in the Veterans Aging Cohort Study (VACS) to determine whether use of these substances is associated with changes in the VACS Index, a validated prognostic indicator for all-cause mortality. At baseline, 18% of participants reported no substance use in the past year, 24% lower risk alcohol use only, 18% unhealthy alcohol use only, 15% cannabis use (with or without alcohol), and 24% stimulant use (with or without alcohol or cannabis). In adjusted longitudinal analyses, cannabis use [β = -0.97 (95% CI -1.93, 0.00), p = 0.048] was not associated with mortality risk, while stimulant use [1.08 (0.16, 2.00), p = 0.021] was associated with an increased mortality risk, compared to lower risk alcohol use. Our findings show no evidence of a negative effect of cannabis use on mortality risk, while stimulant use was associated with increased mortality risk among HIV-infected men. Interventions to reduce stimulant use in this patient population may reduce mortality.