A systematic review of antiretroviral adherence interventions for HIV-infected people who use drugs

High rates of deferring antiretroviral treatment for patients with HIV and substance use disorders: Results from a national sample of HIV physicians in Ukraine

BACKGROUND

HIV incidence and mortality are increasing in Ukraine despite their reductions globally, in part due to suboptimal antiretroviral therapy (ART) coverage in key populations of people with HIV (PWH) where the epidemic is concentrated. As physicians are gatekeepers to ART prescription, stigma and discrimination barriers are understudied as a key to meeting HIV treatment targets in key populations.

METHODS

A national sample (N = 204) of ART-prescribing physicians in Ukraine were surveyed between August and November 2019. Participants underwent a series of randomized, hypothetical HIV clinical scenarios and decided whether to initiate or defer (or withhold) ART. Scenarios varied based on 5 distinct CD4 counts (CD4: 17, 176, 305, 470, or 520 cells/mL) and 10 different PWH key populations. Z scores and McNemar's test for paired samples were used to assess differences between key populations and CD4 count. Feeling thermometers were used to assess stigma-related measures toward key populations among physicians.

RESULTS

Physicians were highly experienced (mean = 19 years) HIV treaters, female (80.4%), and trained in infectious diseases (76.5%). Patients who drink alcohol (range: 21.6%-23.5%) or use (PWUD range: 16.7%-20.1%) or inject (PWID range: 15.5%-20.1%) drugs were most likely to have ART deferred, even at AIDS-defining CD4 counts. PWID maintained on methadone, however, were significantly (p<0.001) less likely to have ART deferred compared with those who were not (range: 7.8%-12.7%) on methadone. Men who have sex with men (range: 5.4%-10.8%), transgender women (range: 4.9%-11.3%), sex workers (range: 3.9%-10.3%),and having an HIV-uninfected sex partner (range: 3.9%-9.3%) had the lowest likelihood of ART deferral. Increasing levels of stigma (i.e., feeling thermometers) towards a key population was correlated with ART deferral (i.e., discrimination).

CONCLUSIONS

Despite international and Ukrainian guidelines recommending ART prescription for all PWH, irrespective of risk or CD4 count, ART deferral by experienced HIV experts remains high in certain key populations, especially in PWH and substance use disorders. Strategies that initiate ART immediately after diagnosis (i.e., rapid start antiretroviral therapy), independent of risk group, should be prioritized to truly mitigate the current epidemic.

Empirical Development of a Behavioral Intervention for African American/Black and Latino Persons with Unsuppressed HIV Viral Load Levels: An Application of the Multiphase Optimization Strategy (MOST) Using Cost-Effectiveness as an Optimization Objective

We used results from an optimization randomized controlled trial which tested five behavioral intervention components to support HIV antiretroviral adherence/HIV viral suppression, grounded in the multiphase optimization strategy and using a fractional factorial design to identify intervention components with cost-effectiveness sufficiently favorable for scalability. Results were incorporated into a validated HIV computer simulation to simulate longer-term effects of combinations of components on health and costs. We simulated the 32 corresponding long-term trajectories for viral load suppression, health related quality of life (HRQoL), and costs. The components were designed to be culturally and structurally salient. They were: motivational interviewing counseling sessions (MI), pre-adherence skill building (SB), peer mentorship (PM), focused support groups (SG), and patient navigation (short version [NS], long version [NL]. All participants also received health education on HIV treatment. We examined four scenarios: one-time intervention with and without discounting and continuous interventions with and without discounting. In all four scenarios, interventions that comprise or include SB and NL (and including health education) were cost effective (< $100,000/quality-adjusted life year). Further, with consideration of HRQoL impact, maximal intervention became cost-effective enough to be scalable. Thus, a fractional factorial experiment coupled with cost-effectiveness analysis is a promising approach to optimize multi-component interventions for scalability. The present study can guide service planning efforts for HIV care settings and health departments.

Does Problematic Substance Use Moderate Efficacy of Cognitive Behavioral Therapy for Adherence and Depression in HIV?

Problematic substance use may attenuate the effect of treating depression in people living with HIV (PLWH). We examined the potential moderating effect of problematic substance use on depression and adherence outcomes in PLWH (N = 143) who participated in a randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) and were randomized to either CBT-AD or enhanced treatment as usual (ETAU). Problematic substance use was operationalized as either having substance use-related diagnosis or current substance use in the past 30 days with a lifetime history of problematic use. Acute (baseline to 4-month) and follow up (4, 8, and 12-month) general linear modeling with time, condition, problematic baseline substance use, and corresponding interactions demonstrated that substance use did not significantly moderate the effects of CBT-AD on adherence or depression improvements. Therefore, CBT-AD was beneficial for PLWH with depression, regardless of problematic substance use when starting depression treatment. Based on these results, clinicians should not withhold CBT treatment for depression in patients with HIV and problematic substance use to attain reductions in depression and gains in adherence.

Implementation of a Dyad-Based Intervention to Improve Antiretroviral Therapy Adherence Among HIV-Positive People Who Inject Drugs in Kazakhstan: A Randomized Trial

Purpose

HIV-positive people who inject drugs (PWID) in Kazakhstan face many challenges to antiretroviral therapy (ART) adherence. Interventions that leverage social support from an intimate partner, family member, or friend may be effective in improving ART adherence among this population. The purpose of this paper is to describe the implementation process of a dyad-based intervention among HIV-positive PWID and their treatment support partners.

Method

Sixty-six HIV-positive PWID and 66 of their treatment support partners will be enrolled in this pilot randomized controlled trial in Almaty, Kazakhstan, and randomized as dyads to receive an adapted version of the SMART Couples intervention or standard of care.

Results

Several implementation strategies were used to facilitate intervention delivery, including remote delivery, training of staff, supervision, technical assistance, quality assurance, and collection of assessments through diverse sources.

Discussion

This trial responds to a need for dyad-based ART adherence interventions adapted specifically for HIV-positive PWID.

Peer Case Management Promoting Advancement Along the HIV Care Continuum Among Black Men Who Have Sex with Men Living with HIV: Building Brothers Up

Black men who have sex with men (BMSM) in the United States are at elevated risk for HIV relative to their heterosexual and/or non-BMSM counterparts, yet on average demonstrate suboptimal HIV care linkage and rates of HIV primary care retention. From October 2019 to December 2020, 69 adult (i.e., aged 18-65) BMSM enrolled in Building Brothers Up (2BU), a 6-session peer case management intervention delivered across 3 months and designed to improve retention in HIV primary care through to full viral suppression. Peer case management sessions included detailed assessment of participants' needs and barriers to treatment, which led to the development of a participant-centered treatment plan. All participants self-identified as Black, about three-quarters self-identified as gay (72.5%), and 46.4% reported an annual income of $5000 or less. A total of 69 participants enrolled in 2BU; however, multiply imputed chained equation logistic regressions were carried out on the final analytical data set (n = 40; 99 imputations) due to a large amount of COVID-19-related missing data. Although analyses of retention and achievement of viral suppression did not reach full significance, the probability of a Type-II hypothesis testing error was high, and viral load results (adjusted odds ratio = 1.56; 95% confidence interval = 0.94-2.60; p = 0.08) suggested that increased attendance to peer case management sessions may be associated with improved odds of achieving full viral suppression among BMSM. The significant impact of national race-related civil unrest and the COVID-19 pandemic on the target population during implementation of 2BU is underscored.

Contingency Management and SARS-CoV-2 Testing Among People Who Inject Drugs

OBJECTIVES

People who inject drugs (PWID) are especially vulnerable to morbidity and mortality as a result of SARS-CoV-2 infection because of social and physical health vulnerabilities. Routine testing for SARS-CoV-2 is critical to reduce transmission. Contingency management-the provision of tangible rewards to reinforce positive behavior-can promote the use of health services among PWID. Evidence is scarce on the utility of contingency management to promote SARS-CoV-2 testing. The objective of this study was to evaluate the effectiveness of contingency management to increase testing among PWID.

METHODS

SARS-CoV-2 testing was implemented at 9 syringe exchange program sites in partnership with an Oregon-based nonprofit organization for 5 weeks without contingency management and for 6 weeks with contingency management (a $10 financial incentive for testing) from February 1 through mid-April 2021. We measured rates of testing among syringe exchange program clients before and after implementation of contingency management.

RESULTS

Before contingency management, SARS-CoV-2 testing occurred during approximately 131 of 1410 (9.3%) client encounters, and 123 of 997 (12.3%) unique clients were tested. During contingency management, testing occurred during approximately 571 of 1756 (32.5%) client encounters, and 407 of 1151 (35.4%) unique clients were tested. Rates of testing increased from 0.04 (SD, 0.04) before contingency management implementation to 0.25 (SD, 0.15) after implementation (t₈ = -3.88; P = .005; Cohen d = 1.46).

CONCLUSIONS

Contingency management facilitated uptake of SARS-CoV-2 testing among PWID. Contingency management may be an effective strategy for improving communicable disease testing beyond testing for SARS-CoV-2 and for improving vaccine uptake among PWID and warrants additional research.

Twelve-Month Retention in Opioid Agonist Treatment for Opioid Use Disorder Among Patients With and Without HIV

Although opioid agonist therapy (OAT) is associated with positive health outcomes, including improved HIV management, long-term retention in OAT remains low among patients with opioid use disorder (OUD). Using data from the Veterans Aging Cohort Study (VACS), we identify variables independently associated with OAT retention overall and by HIV status. Among 7,334 patients with OUD, 13.7% initiated OAT, and 27.8% were retained 12-months later. Likelihood of initiation and retention did not vary by HIV status. Variables associated with improved likelihood of retention included receiving buprenorphine (relative to methadone), receiving both buprenorphine and methadone at some point over the 12-month period, or diagnosis of HCV. History of homelessness was associated with a lower likelihood of retention. Predictors of retention were largely distinct between patients with HIV and patients without HIV. Findings highlight the need for clinical, systems, and research initiatives to better understand and improve OAT retention.

A qualitative investigation of HIV treatment dispensing models and impacts on adherence among people living with HIV who use drugs

Antiretroviral therapy (ART) dispensing is strongly associated with treatment adherence. Among illicit drug-using populations, whom experience greater structural barriers to adherence, directly administered antiretroviral therapy (DAAT) is often regarded as a stronger predictor of optimal adherence over self-administered medications. In Vancouver, Canada, people living with HIV (PLHIV) who use drugs and live in low-income housing are a critical population for treatment support. This group is typically able to access two key DAAT models, daily delivery and daily pickup, in addition to ART self-administration. This ethno-epidemiological qualitative study explores how key dispensing models impact ART adherence among PLHIV who use drugs living in low-income housing, and how this is framed by structural vulnerability. Semi-structured interviews lasting 30-45 minutes were conducted between February and May 2018 with 31 PLHIV who use drugs recruited from an ongoing prospective cohort of PLHIV who use drugs. Interviews were audio-recorded, transcribed verbatim, and analyzed using QSR International's NVivo 12 software. Interviews focused on housing, drug use, and HIV management. Models that constrained agency were found to have negative impacts on adherence and quality of life. Treatment interruptions were framed by structural vulnerabilities (e.g., housing vulnerability) that impacted ability to maintain adherence under certain dispensing models, and led participants to consider other models. Participants using DAAT models which accounted for their structural vulnerabilities (e.g., mobility issues, housing instability), credited these models for their treatment adherence, but also acknowledged factors that constrained agency, and the negative impacts this could have on both adherence, and quality of life. Being able to integrate ART into an established routine is key to supporting ART adherence. ART models that account for the structural vulnerability of PLHIV who use drugs and live in low-income housing are necessary and housing-based supports could be critical, but the impacts of such models on agency must be considered to ensure optimal adherence.

Smartphone-based incentives for promoting adherence to antiretroviral therapy: A randomized controlled trial

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Contingency management (CM) intervention can promote adherence to ART.

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CM for ART adherence can be delivered via a smartphone platform.

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Smartphone CM reduces barriers to adoption of CM relative to in-person CM.

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Low-income people with HIV found smartphone CM to be acceptable and easy to use.

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CM produced detectable ART adherence improvements despite high baseline levels.

Antiretroviral therapy can improve the lives of people living with HIV and reduce the rate of transmission. However, high levels of adherence are required. Some people living with HIV, including people who use drugs, are at elevated risk for non-adherence. Contingency management is a promising intervention for promoting adherence to antiretroviral therapy. Barriers to adoption of contingency management include lack of provider expertise and implementation effort. To address these barriers, a smartphone-based adherence intervention was developed. HIV + people with a substance use disorder were required to submit video selfies of medication consumption that met validity criteria. Monetary incentives were delivered to participants via reloadable debit cards, contingent upon a valid video. The intervention was evaluated in a small (n = 50) randomized controlled trial. Intervention participants submitted 75% of possible videos, and 81% of videos met validity criteria, indicating a high level of usability. Participants also rated the intervention as highly acceptable. Adherence was measured as the percent of participants who achieved a 95% adherence threshold, and also as the overall percent of days in which participants were adherent to their antiretroviral therapy. The former showed a significant effect for group, (p = .034) but this was not maintained when adjusting for stratification variables as covariates (p = .094). The latter measure showed a significant group × time interaction. Smartphone-based contingency management is a promising method for promoting adherence to antiretroviral therapy. Assessing the cost-benefit of the intervention and development of strategies for long-term adherence are priorities for future research.

Methadone maintenance therapy service components linked to improvements in HIV care cascade outcomes: A systematic review of trials and observational studies

BACKGROUND

The beneficial links between engagement in methadone maintenance therapy (MMT) and HIV treatment outcomes have been extensively described. Nevertheless, people who use drugs (PWUD) continue to experience suboptimal HIV treatment outcomes. In this systematic review, we sought to identify components of MMT service provision that are associated with improvements in HIV care outcomes across the HIV care cascade.

METHODS

We searched for peer-reviewed studies in online databases. To be eligible for inclusion in this review, studies must have involved a population or sub-population of PWUD engaged in MMT; report improved uptake of HIV testing, exposure to ART, or HIV-1 RNA plasma viral load suppression; provide details on MMT services; and be published in English between 1 January 2006 until 31 December 2018.

RESULTS

Out of the 5594 identified records, 22 studies were eligible for this systematic review. Components of MMT services associated with HIV care cascade outcomes described in the studies were classified in three categories of care models: 1) standard MMT care with adequate doses, 2) standard MMT care and alongside additional medical component(s), and 3) standard MMT care, additional medical component(s) as well as informational or instrumental social support.

CONCLUSION

The few studies identified reflect a scarcity of evidence on the role of social support to increase the benefits of MMT for PWUD who are living with HIV. Further research is needed to assess the role of medical and social service components in MMT care delivery in advancing PWUD along the HIV care cascade.

Magnitude of Opportunistic Infections and Associated Factors Among HIV-Positive Adults on ART at Selected Public Hospitals in Sidama National Regional State, Southern Ethiopia

Background

Opportunistic infections are late complications of HIV infection due to the depletion of the immune system. It is a major public health problem and high morbidity AIDS patients die of AIDS-related infections in developing countries like Ethiopia. Identification of opportunistic infections (OIs) is important to develop a specific intervention. Therefore, the aim of this study was to assess the burden and associated factors of opportunistic infections.

Methods

A facility-based cross-sectional study was conducted on 420 randomly selected HIV/AIDS patients taking anti-retroviral therapy. Data were collected from selected hospitals in Sidama Regional State based on population proportion to size. Data were collected by a pre-tested questionnaire and a pre-tested checklist from the medical records of patients. Data were entered and analyzed for descriptive and logistic regression models by SPSS v.23. The result declared as statistically significant at p < 0.05.

Results

The magnitude of opportunistic infections was 39.6%. Major identified OIs were oral candidiasis 23.2%, recurrent bacterial pneumonia 21.5%, herpes zoster 6.3%, and pulmonary tuberculosis 6.0%. The magnitude of opportunistic associated with older age [AOR=3.50, 95% CI:1.85, 6.61], no formal education [AOR=4.54, 95% CI:1.81, 11.37], initial CD4 count less than 200 cells/mm3 [AOR=3.10, 95% CI:1.61, 5.96], who interrupt ART medicines [AOR=3.21, 95% CI:1.86, 5.56] and khat chewing [AOR=4.24, 95% CI:2.07, 8.68] when compared to their counterparts.

Conclusion

The overall magnitude of opportunistic infections was high when compared with other studies. Health officials and clinicians need to give attention to the strengthening of the provision if ART with prophylaxis on early stage and adherence, implementation of the TB/HIV collaboration activity, and early initiation of ART to reduce opportunistic infections.

Overview of systematic reviews on strategies to improve treatment initiation, adherence to antiretroviral therapy and retention in care for people living with HIV: part 1

OBJECTIVES

We sought to map the evidence and identify interventions that increase initiation of antiretroviral therapy, adherence to antiretroviral therapy and retention in care for people living with HIV at high risk for poor engagement in care.

METHODS

We conducted an overview of systematic reviews and sought for evidence on vulnerable populations (men who have sex with men (MSM), African, Caribbean and Black (ACB) people, sex workers (SWs), people who inject drugs (PWID) and indigenous people). We searched PubMed, Excerpta Medica dataBASE, Cumulative Index to Nursing and Allied Health Literature, PsycINFO, Web of Science and the Cochrane Library in November 2018. We screened, extracted data and assessed methodological quality in duplicate and present a narrative synthesis.

RESULTS

We identified 2420 records of which only 98 systematic reviews were eligible. Overall, 65/98 (66.3%) were at low risk of bias. Systematic reviews focused on ACB (66/98; 67.3%), MSM (32/98; 32.7%), PWID (6/98; 6.1%), SWs and prisoners (both 4/98; 4.1%). Interventions were: mixed (37/98; 37.8%), digital (22/98; 22.4%), behavioural or educational (9/98; 9.2%), peer or community based (8/98; 8.2%), health system (7/98; 7.1%), medication modification (6/98; 6.1%), economic (4/98; 4.1%), pharmacy based (3/98; 3.1%) or task-shifting (2/98; 2.0%). Most of the reviews concluded that the interventions effective (69/98; 70.4%), 17.3% (17/98) were neutral or were indeterminate 12.2% (12/98). Knowledge gaps were the types of participants included in primary studies (vulnerable populations not included), poor research quality of primary studies and poorly tailored interventions (not designed for vulnerable populations). Digital, mixed and peer/community-based interventions were reported to be effective across the continuum of care.

CONCLUSIONS

Interventions along the care cascade are mostly focused on adherence and do not sufficiently address all vulnerable populations.

The risk of depression among racially diverse people living with HIV: the impact of HIV viral suppression

Understanding the correlates of depression in HIV patients can help identify groups whose members are at increased risk for depression. We conducted a cross-sectional retrospective study among racially diverse, indigent patients living with HIV (PLWH) who were obtaining care in an urban safety-net hospital system and had completed a Patient Health Questionnaire-9 (PHQ-9) in 2014 or 2015. We collected demographics, HIV risk factors, HIV viral loads, CD4 counts, missed visits, and emergency department (ED) visits. Data from the Substance Abuse and Mental Illness Symptoms Screener (SAMISS) were abstracted. Missing data on substance use and CD4 cell counts were imputed to examine the odds of depression (PHQ-9 ≥ 10) by multivariable analysis for a complete case and sensitivity analysis. Stratified analysis by HIV viral suppression (VS) was used to determine the odds of depression among subgroups. Of the 5126 HIV patients (70.8% male,56.3% Black, 44.6% MSM, 6.0% IDU), 1271 (24.8%) experienced depression (PHQ ≥ 10). In a multivariable logistic model female gender, White race, injection drug use (IDU) or men who have sex with men (MSM) as an HIV risk factor, making ≥1 ED visit, having missed any HIV visit, having AIDS, and having a positive drug screen by SAMISS increased the odds for depression. Those who had achieved HIV VS or received efavirenz had lower odds of depression. Even among those with AIDS, those failing to achieve VS were at increased odds for depression, whereas those achieving VS were not. Moderate to severe depression is prevalent among PLWH. Among those with AIDS, HIV VS modifies the odds of depression.

Investigating the potentially important role of psychological flexibility in adherence to antiretroviral therapy in people living with HIV

Antiretroviral therapy (ART) has significantly improved immune health and survival rates in HIV, but these outcomes rely on near perfect adherence. While many psychosocial factors are related to sub-optimal adherence, effectiveness of associated interventions are modest or inconsistent. The Psychological Flexibility (PF) model underlying Acceptance and Commitment Therapy (ACT) identifies a core set of broadly applicable transdiagnostic processes that may be useful to explain and improve non-adherence. However, PF has not previously been examined in relation to ART adherence. Therefore, this cross-sectional study (n = 275) explored relationships between PF and intentional/unintentional ART non-adherence in people with HIV. Adults with HIV prescribed ART were recruited online. Participants completed online questionnaires assessing self-reported PF, adherence and emotional and general functioning. Logistic regressions examined whether PF processes were associated with intentional/unintentional non-adherence. Fifty-eight percent of participants were classified as nonadherent according to the Medication Adherence Rating Scale, of which 41.0% reported intentional and 94.0% unintentional non-adherence. Correlations between PF and adherence were small. PF did not significantly explain intentional/unintentional non-adherence after controlling for demographic and disease factors. Further clarification of the utility of PF in understanding ART non-adherence is warranted using prospective or experimental designs in conjunction with more objective adherence measures.

The impact of socioeconomic factors on the healthcare costs of people living with HIV in Turkey

Background

This study addresses an important field within HIV research, the impact of socioeconomic factors on the healthcare costs of people living with HIV/AIDS (PLHIV). We aimed to understand how different socioeconomic factors could create diverse healthcare costs for PLHIV in Turkey.

Methods

Data were collected between January 2017 and December 2017. HIV-positive people attending the clinic who had been referred to the national ART programme from January 1992 until December 2017 were surveyed. The questionnaire collected socioeconomic data. The cost data for the same patients was taken from the electronic database Probel Hospital Information Management System (PHIMS) for the same period. The PHIMS data include costs for medication (highly active antiretroviral therapy or HAART), laboratory, pathology, radiology, polyclinic, examination and consultation, hospitalisation, surgery and intervention, blood and blood products, supplies and other costs. Data were analysed using STATA 14.2 to estimate the generalised linear model (GLM).

Results

The findings of our GLM indicate that age, gender, marital and parental status, time since diagnosis, employment, wealth status, illicit drug use and CD4 cell count are the factors significantly related to the healthcare cost of patients. We found that compared with people who have AIDS (CD4 cells < 200 cells/mm³), people who have a normal range of CD4 cells (≥ 500 cells/mm³) have $1046 less in expenditures on average. Compared to younger people (19–39 years), older people (≥ 55) have $1934 higher expenditures on average. Costs are $644 higher on average for married people and $401 higher on average for people who have children. Healthcare costs are $518 and $651 higher on average for patients who are addicted to drugs and who use psychiatric drug(s), respectively. Compared to people who were recently diagnosed with HIV, people who were diagnosed ≥10 years ago have $743 lower expenditures on average.

Conclusion

Our results suggest that in addition to immunological status, socioeconomic factors play a substantial role in the healthcare costs of PLHIV. The key factors influencing the healthcare costs of PLHIV are also critical for public policy makers, healthcare workers, health ministries and employment community programs.

Menopausal symptoms are associated with non-adherence to highly active antiretroviral therapy in human immunodeficiency virus-infected middle-aged women

Objective: This study aimed to evaluate the association between the intensity of menopausal symptoms and highly active antiretroviral therapy (HAART) adherence in middle-aged women with human immunodeficiency virus (HIV) infection.Methods: In this cross-sectional study, 313 Peruvian women with HIV infection (age 40-59 years) were surveyed and classified as adherent or non-adherent to HAART based on the Antiretroviral Treatment Adherence Evaluation Questionnaire. The intensity of menopausal symptoms was assessed with the Menopause Rating Scale, and categorized as none, mild, moderate, and/or severe. Age, sexual orientation, used HAART scheme, time since HIV diagnosis, menopausal status, risk of depression, and presence of comorbidities were also assessed. Poisson generalized linear models with robust variance were performed in order to estimate crude prevalence ratios (PRs) and adjusted PRs using statistical (a₁PR) and epidemiological criteria (a₂PR).Results: A total of 19.9%, 32.6%, and 15.0% of all women presented mild, moderate, and severe menopausal symptoms, respectively. Overall, 70.6% women were non-adherent to HAART. The probability of non-adherence was higher in women with mild, moderate, and severe symptoms as compared to asymptomatic women in the non-adjusted model (PR: 1.79, 95% confidence interval [CI]: 1.39-2.29; PR: 1.76, 95% CI: 1.38-2.23; and PR: 2.07, 95% CI: 1.64-2.61, respectively) and the adjusted model.Conclusion: The severity of menopausal symptoms was associated with HAART non-adherence in HIV-infected middle-aged women.

Analysis of Systematic Reviews of Medication Adherence Interventions for Persons with HIV, 1996-2017

This overview of reviews summarizes the evidence from systematic reviews (SR) on the effectiveness of antiretroviral therapy (ART) adherence interventions for people with HIV (PWH) and descriptively compares adherence interventions among key populations. Relevant articles published during 1996-2017 were identified by comprehensive searches of CDC's HIV/acquired immunodeficiency syndrome (AIDS) Prevention Research Synthesis Database and manual searches. Included SRs examined primary interventions intended to improve ART adherence, focused on PWH, and assessed medication adherence or biologic outcomes (e.g., viral load). We synthesized the qualitative data and used the Assessment of Multiple Systematic Reviews (AMSTAR) for quality assessment. Forty-one SRs met inclusion criteria. Average quality was high. SRs that evaluated text-messaging interventions (n = 9) consistently reported statistically significant improvements in adherence and biologic outcomes. Other ART adherence strategies [e.g., behavioral, directly administered antiretroviral therapy (DAART)] reported improvements, but did not report significant effects for both outcomes, or intervention effects that did not persist postintervention. In the review focused on people who inject drugs (n = 1), DAART alone or in combination with medication-assisted therapy improved both outcomes. In SRs focused on children or adolescents aged <18 years (n = 5), regimen-related and hospital-based DAART improved biologic outcomes. ART adherence interventions (e.g., text-messaging) improved adherence and biologic outcomes; however, results differed for other intervention strategies, populations, and outcomes. Because few SRs reported evidence for populations at high risk (e.g., men who have sex with men), the results are not generalizable to all PWH. Future implementation studies are needed to examine medication adherence interventions in specific populations and address the identified gaps.

Stimulant Use and Viral Suppression in the Era of Universal Antiretroviral Therapy

BACKGROUND

HIV-positive persons who use stimulants such as methamphetamine experience difficulties navigating the HIV care continuum that undermine the benefits of antiretroviral therapy (ART). However, few studies have examined the association of stimulant use with viral suppression in the era of universal ART.

SETTING

Zuckerberg San Francisco General Hospital.

METHODS

HIV-positive persons participating in a clinical cohort study and taking ART completed assessments every 4-6 months. The exposure was the cumulative, time-varying proportion of assessments with any self-reported stimulant use. The time-varying outcome, HIV viral suppression (ie, <200 copies/mL), was measured at assessments or extracted from the clinical record.

RESULTS

In total, 1635 HIV-positive participants on ART contributed 17,610 person-visits over a median of 2.3 [interquartile range (IQR) = 1.0-5.3] years of follow-up. Participants were middle-aged (median = 45.0; IQR = 38.0-52.0), predominantly white (57%), sexual minority men (78%), with a median CD4 T-cell count of 409 (IQR = 225-640) cells/mm at enrollment. Significant increases in odds of viral suppression over time were less pronounced among stimulant users compared with nonusers, particularly before the advent of universal ART. Increasing odds of viral suppression were paralleled by declining stimulant use over time. In the universal ART era, increasing odds of viral suppression were observed at lower levels of stimulant use, but not when participants reported using stimulants at every visit.

CONCLUSIONS

Although ART benefits are still not achieved as rapidly in stimulant users, this disparity is not as large in the era of universal ART.

A Longitudinal Analysis of Daily Pill Burden and Likelihood of Optimal Adherence to Antiretroviral Therapy Among People Living With HIV Who Use Drugs

OBJECTIVES

Among people living with HIV (PLWH), high levels of adherence to prescribed antiretroviral therapy (ART) is required to achieve optimal treatment outcomes. However, little is known about the effects of daily pill burden on adherence amongst PLWH who use drugs. We sought to investigate the association between daily pill burden and adherence to ART among members of this key population in Vancouver, Canada.

METHODS

We used data from the AIDS Care Cohort to Evaluate Exposure to Survival Services study, a long-running community-recruited cohort of PLWH who use illicit drugs linked to comprehensive HIV clinical records. The longitudinal relationship between daily pill burden and the odds of ≥95% adherence to ART among ART-exposed individuals was analyzed using multivariable generalized linear mixed-effects modeling, adjusting for sociodemographic, behavioural, and structural factors linked to adherence.

RESULTS

Between December 2005 and May 2014, the study enrolled 770 ART-exposed participants, including 257 (34%) women, with a median age of 43 years. At baseline, 437 (56.7%) participants achieved ≥95% adherence in the previous 180 days. Among all interview periods, the median adherence was 100% (interquartile range 71%-100%). In a multivariable model, a greater number of pills per day was negatively associated with ≥95% adherence (adjusted odds ratio [AOR] 0.87 per pill, 95% confidence interval [CI] 0.84-0.91). Further analysis showed that once-a-day ART regimens were positively associated with optimal adherence (AOR 1.39, 95% CI 1.07-1.80).

CONCLUSIONS

In conclusion, simpler dosing demands (ie, fewer pills and once-a-day single tablet regimens) promoted optimal adherence among PLWH who use drugs. Our findings highlight the need for simpler dosing to be encouraged explicitly for PWUD with multiple adherence barriers.

A Multidimensional Electronic Hydroxyurea Adherence Intervention for Children With Sickle Cell Disease: Single-Arm Before-After Study

Background

Hydroxyurea is a disease-modifying medication for patients with sickle cell disease (SCD). Despite demonstrated efficacy, hydroxyurea nonadherence in clinical practice is common and results in worse health outcomes for nonadherent patients. Mobile Directly Observed Therapy (Mobile DOT) is a pilot-tested, electronic, multidimensional hydroxyurea adherence intervention for children with SCD. Mobile DOT includes sending daily text message reminders to patients to take hydroxyurea, patients recording and sending daily videos that capture their hydroxyurea administrations for the research team to review and track adherence, providing personalized feedback to patients about their adherence, and providing small monetary incentives to patients if they achieve high hydroxyurea adherence.

Objective

This study aimed to determine if Mobile DOT increases hydroxyurea adherence in children with SCD and to explore its impact on hematologic and clinical outcomes.

Methods

This was a single-arm, 6-month intervention study of patients with SCD on hydroxyurea who were aged ≤19 years and reported having access to an electronic device. Participants’ hydroxyurea adherence when they received Mobile DOT was compared with their adherence 6 months before and after receiving Mobile DOT. Participants’ medication possession ratio (MPR) was calculated from their pharmacy dispensing records and was used to measure adherence. Laboratory and clinical outcomes were abstracted from participants’ electronic medical records. Infrequently hospitalized patients who received at least 160 days of the intervention were considered to be engaged participants.

Results

Of 91 patients who were approached, 55 enrolled and 34 engaged with Mobile DOT. The median age of the engaged participants was 10 years (range 2-18.8 years), and 21 (62%, 21/34) participants were male, 28 (82%, 21/34) had hemoglobin SS SCD, and 19 (56%, 19/34) were prescribed hydroxyurea for at least a year before enrollment. With Mobile DOT, engaged participants’ median MPR increased from 61.7% to 84.4% (P<.001) and significantly more (67% vs 30%; P=.002) achieved ≥80% hydroxyurea adherence compared with baseline values. Engaged participants’ mean fetal hemoglobin (HgbF) levels and mean corpuscular volumes (MCV) improved significantly after 6 months of Mobile DOT (P=.04 and P=.001, respectively), but their adherence, HgbF levels, and MCV returned to baseline values during the 6 months after the intervention. Hospitalizations and the clinical outcomes that were measured occurred infrequently during the study. Nonengagement was associated with being female and having a recent SCD complication. In addition, having insufficient electronic data, being unable to quickly complete Mobile DOT each day, and not perceiving that Mobile DOT was beneficial may have further decreased engagement.

Conclusions

Mobile DOT shows promise as an effective intervention for some children with SCD. Modifications that may improve recruitment, reduce attrition, and increase engagement were identified and could increase the impact that Mobile DOT has on children with SCD.

Trial Registration

ClinicalTrials.gov NCT02578017; https://clinicaltrials.gov/ct2/show/NCT02578017

Temporal associations between medication adherence for patients with schizophrenia and opioid dependence: A 17-year Canadian Cohort Study

The current study investigated whether a previously reported beneficial effect of methadone maintenance therapy (MMT) on antiretroviral adherence is also present in relation to antipsychotic treatment for schizophrenia. Administrative data were linked over a 17-year period for 1996 people who were dually diagnosed with schizophrenia and opioid dependence and, as an indicator of further marginalization, experienced at least one episode of correctional supervision in British Columbia. Adherence was estimated using the medication possession ratio (MPR ≥ 0.80), calculated in each 120-day period beginning with the first date of concurrent use of MMT and antipsychotic medication. Generalized Estimating Equations were used to estimate the association between independent and dependent variables. The probability of antipsychotic adherence doubled in periods that were preceded by a period of MMT adherence (AOR: P: 2.07; 95% CI: 1.90-2.26). Subgroup and sensitivity analyses yielded results similar to those derived through the primary analysis, examining: conviction history; length of follow-up; initiation of MMT prior to antipsychotic induction; excluding participants who died during the study period; and restricted to participants who received methadone exclusively as part of a MMT program. Despite a strong temporal association between MMT and antipsychotic adherence, overall MPRs for both prescriptions remained <0.50 throughout the study period. Antipsychotic adherence was more than twice as likely following periods of adherence to MMT among dually-diagnosed patients. Research is needed to identify the conditions responsible for MMT adherence, and to further clarify the relationship between opioid agonist treatment and antipsychotic pharmacotherapy in this vulnerable and under-studied population.

Prevalence and patterns of illicit drug use in people living with HIV in Spain: A cross-sectional study

This study assessed the prevalence and patterns of drug use among people living with HIV (PLHIV) in Spain. We conducted an observational cross-sectional study including 1401 PLHIV. Data were collected through 33 sites across Spain using an online computer-assisted self-administered interview. The survey measured use of illicit drugs and other substances, treatment adherence and health-related variables. To analyse patterns of drug use we performed cluster analysis in two stages. The most frequently consumed substances were: alcohol (86.7%), tobacco (55.0%), illicit drugs (49.5%), other substances (27.1%). The most prevalent illicit drugs used were cannabis (73.8%), cocaine powder (53.9%), and poppers (45.4%). Results found four clusters of PLHIV who used drugs. Two of them were composed mainly of heterosexuals (HTX): Cluster 1 (n = 172) presented the lowest polydrug use and they were mainly users of cannabis, and Cluster 2 (n = 84) grouped mostly men who used mainly heroin and cocaine; which had the highest percentage of people who inject drugs and presented the lowest level of treatment adherence (79.8±14.2; p < .0001). The other two clusters were composed mainly of men who have sex with men (MSM), who were mostly users of recreational drugs. Cluster 3 (n = 285) reported moderate consumption, both regarding frequency and diversity of drugs used, while Cluster 4 (n = 153) was characterized by the highest drug polyconsumption (7.4±2.2; p < .0001), and 4 grouped MSM who injected recreational drugs, and who reported the highest frequency of use of drugs in a sexual context (2.6±0.8; p < .0001) and rates of sexually transmitted infections (1.8±1.1; p < .01). This is the largest multi-centre cross-sectional study assessing the current prevalence and patterns of drug use among PLHIV in Spain. The highest prevalence of drug use was found among MSM, although HTX who used heroin and cocaine (Cluster 2) had the most problems with adherence to HIV treatment and the worst health status.

Long-Term Effects of Psychological Interventions to Improve Adherence to Antiretroviral Treatment in HIV-Infected Persons: A Systematic Review and Meta-Analysis

We examined the efficacy of psychological adherence-enhancing interventions (AEIs) compared with usual care in HIV-infected adults under antiretroviral treatment (ART) by focusing on adherence and clinical HIV markers as outcomes in the short term and long term. We searched relevant databases for controlled studies that compared psychological AEIs with usual care. We included 31 comparisons from 27 individual studies in our meta-analyses. Psychological AEIs were significantly superior to usual care in improving adherence [standardized mean difference (SMD) 0.30, 95% CI 0.20-0.40] and reducing HIV viral load (SMD 0.15, 0.07-0.23) at the end of treatment. At the last follow-up, we found no difference between psychological AEIs and usual care, neither on adherence (SMD 0.07, -0.11-0.24) nor on clinical markers (SMD 0.06, -0.03-0.15). After excluding outliers from the analyses, between-study heterogeneity was small, and we did not identify any relevant moderators of intervention effects. In summary, psychological AEIs may significantly improve ART adherence and HIV viral load compared with usual care in the short term, but fail to be superior in achieving long-lasting improvements on ART adherence and clinical HIV markers as compared with usual care. Owing to limited quality and the majority of studies being conducted in the United States or Europe, our results have to be interpreted with caution, and are most relevant to the United States and Europe. The consistently reported difficulties to achieve sustained ART adherence improvements in previous and the present meta-analyses highlight the need to focus on maintaining ART adherence improvements in future research.

Contextual compatibility of three empirically supported behavior therapies for cART adherence among patients with substance use disorders

Though substance use disorders complicate adherence to combination antiretroviral therapy (cART), cognitive-behavioral therapy (CBT), contingency management (CM), and motivational interviewing (MI) each demonstrate efficacy to improve cART adherence among substance-using patients. To inform dissemination of these therapies, this mixed-method study was undertaken involving a full-day site visit to each of four HIV care settings. At each setting, an initial administrator interview elicited setting data. Paired focus groups with setting staff and patients then served as forums for open discussion and live polling of the therapies' respective contextual compatibility. Focus group recordings were subjected to a phenomenological narrative analysis by multidisciplinary investigators, and staff/patient compatibility ratings were analyzed via generalized linear models. Findings include: (1) emergent themes among staff of adaptability, patient-centeredness, and mission-congruence as desired therapy attributes, (2) emergent themes among patients of intrinsic motivation, respect for patient autonomy in illness management, and fairness among service recipients as desired therapy attributes; and (3) comparatively stronger staff perception of compatibility for MI than CBT or CM, and a similar albeit less robust or reliable pattern among patients. Collective findings support MI as a behavior therapy of choice for broad dissemination to HIV care settings to improve cART adherence of patients with substance use disorders.

Effectiveness of Motivational Interviewing on adult behaviour change in health and social care settings: A systematic review of reviews

BACKGROUND

The challenge of addressing unhealthy lifestyle choice is of global concern. Motivational Interviewing has been widely implemented to help people change their behaviour, but it is unclear for whom it is most beneficial. This overview aims to appraise and synthesise the review evidence for the effectiveness of Motivational Interviewing on health behaviour of adults in health and social care settings.

METHODS

A systematic review of reviews. Methods were pre-specified and documented in a protocol (PROSPERO-CRD42016049278). We systematically searched 7 electronic databases: CDSR; DARE; PROSPERO; MEDLINE; CINAHL; AMED and PsycINFO from 2000 to May 2018. Two reviewers applied pre-defined selection criteria, extracted data using TIDIER guidelines and assessed methodological quality using the ROBIS tool. We used GRADE criteria to rate the strength of the evidence for reviews including meta-analyses.

FINDINGS

Searches identified 5222 records. One hundred and four reviews, including 39 meta-analyses met the inclusion criteria. Most meta-analysis evidence was graded as low or very low (128/155). Moderate quality evidence for mainly short term (<6 months) statistically significant small beneficial effects of Motivational Interviewing were found in 11 of 155 (7%) of meta-analysis comparisons. These outcomes include reducing binge drinking, frequency and quantity of alcohol consumption, substance abuse in people with dependency or addiction, and increasing physical activity participation.

CONCLUSIONS

We have created a comprehensive map of reviews relating to Motivational Interviewing to signpost stakeholders to the best available evidence. More high quality research is needed to be confident about the effectiveness of Motivational Interviewing. We identified a large volume of low quality evidence and many areas of overlapping research. To avoid research waste, it is vital for researchers to be aware of existing research, and the implications arising from that research. In the case of Motivational Interviewing issues relating to monitoring and reporting fidelity of interventions need to be addressed.

Regional differences between people who inject drugs in an HIV prevention trial integrating treatment and prevention (HPTN 074): a baseline analysis

INTRODUCTION

People who inject drugs (PWID) experience high HIV incidence and face significant barriers to engagement in HIV care and substance use treatment. Strategies for HIV treatment as prevention and substance use treatment present unique challenges in PWID that may vary regionally. Understanding differences in the risk structure for HIV transmission and disease progression among PWID is essential in developing and effectively targeting intervention strategies of HIV treatment as prevention.

METHODS

We present a baseline analysis of HIV Prevention Trials Network (HPTN) 074, a two-arm, randomized controlled trial among PWID in Indonesia (n = 258), Ukraine (n = 457) and Vietnam (n = 439). HPTN 074 was designed to determine the feasibility, barriers and uptake of an integrated intervention combining health systems navigation and psychosocial counselling for the early engagement of antiretroviral therapy (ART) and substance use treatment for PWID living with HIV. Discordant PWID networks were enrolled, consisting of an HIV-positive index and their HIV-negative network injection partner(s). Among the enrolled cohort of 1154 participants (502 index participants and 652 network partners), we examine regional differences in the baseline risk structure, including sociodemographics, HIV and substance use treatment history, and injection and sexual risk behaviours.

RESULTS

The majority of participants were male (87%), with 82% of the enrolled females coming from Ukraine. The overall mean age was 34 (IQR: 30, 38). Most commonly injected substances included illegally manufactured methadone in Ukraine (84.2%), and heroin in Indonesia (81.8%) and Vietnam (99.5%). Injection network sizes varied by region: median number of people with whom participants self-reported injecting drugs was 3 (IQR: 2, 5) in Indonesia, 5 (IQR: 3, 10) in Ukraine and 3 (IQR: 2, 4) in Vietnam. Hazardous alcohol use, assessed using the Alcohol Use Disorders Identification Test - Alcohol Consumption Questions (AUDIT-C), was prominent in Ukraine (54.7%) and Vietnam (26.4%). Reported sexual risk behaviours in the past month, including having two or more sex partners and giving/receiving money or drugs in exchange for sex, were uncommon among all participants and regions.

CONCLUSIONS

While regional differences in risk structure exist, PWID particularly in Ukraine need immediate attention for risk reduction strategies. Substantial regional differences in risk structure will require flexible, tailored treatment as prevention interventions for distinct PWID populations.

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.

Adaptation and delivery of a motivational interviewing-based counseling program for persons acutely infected with HIV in Malawi: Implementation and lessons learned

OBJECTIVE

Individuals diagnosed with acute HIV infection (AHI) are highly infectious and require immediate HIV prevention efforts to minimize their likelihood of transmitting HIV to others. We sought to explore the relevance of Motivational Interviewing (MI), an evidence-based counseling method, for Malawians with AHI.

METHODS

We designed a MI-based intervention called "Uphungu Wanga" to support risk reduction efforts immediately after AHI diagnosis. It was adapted from Options and SafeTalk interventions, and refined through formative research and input from Malawian team members and training participants. We conducted qualitative interviews with counselors and participants to explore the relevance of MI in this context.

RESULTS

Intervention adaptation required careful consideration of Malawian cultural context and the needs of people with AHI. Uphungu Wanga's content was relevant and key MI techniques of topic selection and goal setting were viewed positively by counselors and participants. However, rating levels of importance and confidence did not appear to help participants to explore behavior change as intended.

CONCLUSION

Uphungu Wanga may have provided some added benefits beyond "brief education" standard of care counseling for Malawians with AHI.

PRACTICE IMPLICATIONS

MI techniques of topic selection and goal setting may enhance prevention education and counseling for Malawians with AHI.

Healthcare Empowerment and HIV Viral Control: Mediating Roles of Adherence and Retention in Care

INTRODUCTION

This study assessed longitudinal relationships between patient healthcare empowerment, engagement in care, and viral control in the Women's Interagency HIV Study, a prospective cohort study of U.S. women living with HIV.

METHODS

From April 2014 to March 2016, four consecutive 6-month visits were analyzed among 973 women to assess the impact of Time 1 healthcare empowerment variables (Tolerance for Uncertainty and the state of Informed Collaboration Committed Engagement) on Time 2 reports of ≥95% HIV medication adherence and not missing an HIV primary care appointment since last visit; and on HIV RNA viral control across Times 3 and 4, controlling for illicit drug use, heavy drinking, depression symptoms, age, and income. Data were analyzed in 2017.

RESULTS

Adherence of ≥95% was reported by 83% of women, 90% reported not missing an appointment since the last study visit, and 80% were categorized as having viral control. Logistic regression analyses revealed a significant association between the Informed Collaboration Committed Engagement subscale and viral control, controlling for model covariates (AOR=1.08, p=0.04), but not for the Tolerance for Uncertainty subscale and viral control (AOR=0.99, p=0.68). In separate mediation analyses, the indirect effect of Informed Collaboration Committed Engagement on viral control through adherence (β=0.04, SE=0.02, 95% CI=0.02, 0.08), and the indirect effect of Informed Collaboration Committed Engagement on viral control through retention (β=0.01, SE=0.008, 95% CI=0.001, 0.030) were significant. Mediation analyses with Tolerance for Uncertainty as the predictor did not yield significant indirect effects.

CONCLUSIONS

The Informed Collaboration Committed Engagement healthcare empowerment component is a promising pathway through which to promote engagement in care among women living with HIV.

What works in inclusion health: overview of effective interventions for marginalised and excluded populations

Inclusion health is a service, research, and policy agenda that aims to prevent and redress health and social inequities among the most vulnerable and excluded populations. We did an evidence synthesis of health and social interventions for inclusion health target populations, including people with experiences of homelessness, drug use, imprisonment, and sex work. These populations often have multiple overlapping risk factors and extreme levels of morbidity and mortality. We identified numerous interventions to improve physical and mental health, and substance use; however, evidence is scarce for structural interventions, including housing, employment, and legal support that can prevent exclusion and promote recovery. Dedicated resources and better collaboration with the affected populations are needed to realise the benefits of existing interventions. Research must inform the benefits of early intervention and implementation of policies to address the upstream causes of exclusion, such as adverse childhood experiences and poverty.

Effects of Counselling on Adherence to Antiretroviral Treatment Among People with HIV in Estonia: A Randomized Controlled Trial

To assess the efficacy of an education- and strengths-based counselling programme to promote antiretroviral therapy (ART) adherence in a cohort of HIV-infected individuals with high prevalence of injection drug use in Estonia. Parallel-group randomized (1:1) controlled trial (RCT). Adults receiving ART in two clinics were followed for 12 months. The trial compared: (i) an intervention (three sessions) incorporated into routine clinic visits, providing education about HIV, ART, the role of adherence, and tailoring regimen to daily routines using problem-solving skills to address adherence barriers versus (ii) usual care (control). Primary and secondary outcomes were self-reported ART adherence (3-day recall) and viral load (respectively). 519 patients were randomized and 82% completed the study. Recent optimal ART adherence (3-day recall ≥95%) was reported by 75.6% in the intervention group and 72.9% of controls at baseline and 76.7% and 67.5%, respectively, at 12 months (RR 1.14, 95% CI 1.00-1.28; adjusted RR 1.13, 95% CI 1.00-1.27). There was no difference in the proportion of patients with undetectable viral load. At 12 months the intervention group reported significantly higher perceptions of ART necessity versus ART concerns [mean ART necessity-concerns differential: intervention group 1.32 (SD 1.22) vs control group 1.08 (SD 1.12); p = 0.048]. All-cause mortality among study participants was 27.7 per 1000 person years (95% CI 15.6-44.8). A brief, clinic-based adherence intervention alone may assist with adherence but lacks impact on viral load at 12 months.

Novel nanoformulation to mitigate co-effects of drugs of abuse and HIV-1 infection: towards the treatment of NeuroAIDS

Drug abuse (e.g., methamphetamine-Meth or cocaine-Coc) is one of the major risk factors for becoming infected with HIV-1, and studies show that in combination, drug abuse and HIV-1 lead to significantly greater damage to CNS. To overcome these issues, we have developed a novel nanoformulation (NF) for drug-abusing population infected with HIV-1. In this work, a novel approach was developed for the co-encapsulation of Nelfinavir (Nel) and Rimcazole (Rico) using layer-by-layer (LbL) assembled magnetic nanoformulation for the cure of neuroAIDS. Developed NF was evaluated for blood-brain barrier (BBB) transmigration, cell uptake, cytotoxicity and efficacy (p24 assay) in HIV-1 infected primary astrocyte (HA) in presence or absence of Coc and Meth. Developed magnetic nanoformulation (NF) fabricated using the LbL approach exhibited higher amounts of drug loading (Nel and Rico) with 100% release of both the therapeutic agents in a sustained manner for 8 days. NF efficacy studies indicated a dose-dependent decrease in p24 levels in HIV-1-infected HA (~55%) compared to Coc + Meth treated (~50%). The results showed that Rico significantly subdued the effect of drugs of abuse on HIV infectivity. NF successfully transmigrated (38.8 ± 6.5%) across in vitro BBB model on the application of an external magnetic field and showed >90% of cell viability with efficient cell uptake. In conclusion, our proof of concept study revealed that sustained and concurrent release of sigma σ1 antagonist and anti-HIV drug from the developed novel sustained release NF can overcome the exacerbated effects of drugs of abuse in HIV infection and may solve the issue of medication adherence in the drug-abusing HIV-1 infected population.

Social Support and the Mediating Roles of Alcohol Use and Adherence Self-Efficacy on Antiretroviral Therapy (ART) Adherence Among ART Recipients in Gauteng, South Africa

We sought to (a) replicate and (b) extend (via the addition of alcohol use) Cha et al.'s cross-sectional multi-component model of ART adherence on the relationship between social support, depression, self-efficacy beliefs, and antiretroviral therapy (ART) adherence, among HIV patients in Tshwane, South Africa. Using purposive sampling, 304 male and female ART recipients were recruited. ART adherence was assessed using three manifest indicators: total adherence ratio, the CASE adherence index and 1-month adherence measure. Data were analysed using structural equation modeling. In our replicated model, social support had both direct and indirect relationships with ART adherence, and inclusion of alcohol use improved prediction of ART adherence. Direct and indirect effects of alcohol use on ART adherence emerged: adherence self-efficacy beliefs partially mediated the latter path. Findings highlight the importance of integrating into ART promotion interventions, the reduction of alcohol use, provision of social support, and enhancement of adherence self-efficacy beliefs.

Cannabis Use, Medication Management and Adherence Among Persons Living with HIV

Cannabis is used to relieve nausea, trigger weight gain, and reduce pain among adults living with HIV; however, the relationship between its use and medication adherence and management is unclear. Participants (N = 107) were from an ongoing cohort study of community-dwelling HIV+ adults, stratified by cannabis (CB) use: HIV+/CB+ (n = 41) and HIV+/CB- (n = 66). CB+ participants either tested positive in a urine toxicology screen for THC or had a self-reported history of regular and recent use. HIV-status was provided by physician results and/or biomarker assessment. Adherence was measured via the Morisky scale and medication management was assessed via the Medication Management Test-Revised. After adjusting for gender, we found no association between cannabis use group and adherence nor medication management. The amount of cannabis used was also not associated with measures of adherence and management. Preliminary findings suggest that cannabis use may not adversely influence medication adherence/management among adults living with HIV.

Using the multiphase optimization strategy (MOST) to optimize an HIV care continuum intervention for vulnerable populations: a study protocol

BACKGROUND

More than half of persons living with HIV (PLWH) in the United States are insufficiently engaged in HIV primary care and not taking antiretroviral therapy (ART), mainly African Americans/Blacks and Hispanics. In the proposed project, a potent and innovative research methodology, the multiphase optimization strategy (MOST), will be employed to develop a highly efficacious, efficient, scalable, and cost-effective intervention to increase engagement along the HIV care continuum. Whereas randomized controlled trials are valuable for evaluating the efficacy of multi-component interventions as a package, they are not designed to evaluate which specific components contribute to efficacy. MOST, a pioneering, engineering-inspired framework, addresses this problem through highly efficient randomized experimentation to assess the performance of individual intervention components and their interactions. We propose to use MOST to engineer an intervention to increase engagement along the HIV care continuum for African American/Black and Hispanic PLWH not well engaged in care and not taking ART. Further, the intervention will be optimized for cost-effectiveness. A similar set of multi-level factors impede both HIV care and ART initiation for African American/Black and Hispanic PLWH, primary among them individual- (e.g., substance use, distrust, fear), social- (e.g., stigma), and structural-level barriers (e.g., difficulties accessing ancillary services). Guided by a multi-level social cognitive theory, and using the motivational interviewing approach, the study will evaluate five distinct culturally based intervention components (i.e., counseling sessions, pre-adherence preparation, support groups, peer mentorship, and patient navigation), each designed to address a specific barrier to HIV care and ART initiation. These components are well-grounded in the empirical literature and were found acceptable, feasible, and promising with respect to efficacy in a preliminary study.

METHODS/DESIGN

Study aims are: 1) using a highly efficient fractional factorial experimental design, identify which of five intervention components contribute meaningfully to improvement in HIV viral suppression, and secondary outcomes of ART adherence and engagement in HIV primary care; 2) identify mediators and moderators of intervention component efficacy; and 3) using a mathematical modeling approach, build the most cost-effective and efficient intervention package from the efficacious components. A heterogeneous sample of African American/Black and Hispanic PLWH (with respect to age, substance use, and sexual minority status) will be recruited with a proven hybrid sampling method using targeted sampling in community settings and peer recruitment (N = 512).

DISCUSSION

This is the first study to apply the MOST framework in the field of HIV prevention and treatment. This innovative study will produce a culturally based HIV care continuum intervention for the nation's most vulnerable PLWH, optimized for cost-effectiveness, and with exceptional levels of efficacy, efficiency, and scalability.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02801747 , Registered June 8, 2016.

Kazakhstan can achieve ambitious HIV targets despite expected donor withdrawal by combining improved ART procurement mechanisms with allocative and implementation efficiencies

BACKGROUND

Despite a non-decreasing HIV epidemic, international donors are soon expected to withdraw funding from Kazakhstan. Here we analyze how allocative, implementation, and technical efficiencies could strengthen the national HIV response under assumptions of future budget levels.

METHODOLOGY

We used the Optima model to project future scenarios of the HIV epidemic in Kazakhstan that varied in future antiretroviral treatment unit costs and management expenditure-two areas identified for potential cost-reductions. We determined optimal allocations across HIV programs to satisfy either national targets or ambitious targets. For each scenario, we considered two cases of future HIV financing: the 2014 national budget maintained into the future and the 2014 budget without current international investment.

FINDINGS

Kazakhstan can achieve its national HIV targets with the current budget by (1) optimally re-allocating resources across programs and (2) either securing a 35% [30%-39%] reduction in antiretroviral treatment drug costs or reducing management costs by 44% [36%-58%] of 2014 levels. Alternatively, a combination of antiretroviral treatment and management cost-reductions could be sufficient. Furthermore, Kazakhstan can achieve ambitious targets of halving new infections and AIDS-related deaths by 2020 compared to 2014 levels by attaining a 67% reduction in antiretroviral treatment costs, a 19% [14%-27%] reduction in management costs, and allocating resources optimally.

SIGNIFICANCE

With Kazakhstan facing impending donor withdrawal, it is important for the HIV response to achieve more with available resources. This analysis can help to guide HIV response planners in directing available funding to achieve the greatest yield from investments. The key changes recommended were considered realistic by Kazakhstan country representatives.

Caring for youth living with HIV across the continuum: turning gaps into opportunities

With the increasing proportion of youth living with human immunodeficiency virus (YLHIV) and the aging of the perinatally infected population, there is a need for clinical services that are "youth friendly" to address the multiple challenges YLHIV face in terms of engagement in care and maintenance of combination antiretroviral therapy (cART). Little is known about how and where YLHIV receive their care. Further, the impact of the care structure on engagement and retention outcomes for YLHIV is ill defined. In order to better classify how YLHIV receive care in the United States, we performed a review of published literature characterizing the structure and outcomes of care for YLHIV. Several key concepts emerged: 1. The majority of YLHIV (13-24 years old) are cared for at adult sites, 2. Clinics providing care to YLHIV are varied in terms of the services offered and the types of services offered can impact outcomes, 3. YLHIV cared for in adult clinical sites have poor retention and antiretroviral treatment initiation, and 4. YLHIV cared for at adult sites had poorer retention and cART outcomes compared to YLHIV cared for at pediatric sites. There were no studies identified that specifically examined "youth friendly" care for YLHIV within the context of adult clinical sites. The results of this review highlight disparities for YLHIV and the need for interventions to improve outcomes for YLHIV in the context of adult care.

"Life-Steps" for PrEP Adherence: Demonstration of a CBT-Based Intervention to Increase Adherence to Preexposure Prophylaxis (PrEP) Medication Among Sexual-Minority Men at High Risk for HIV Acquisition

One dramatic advance in human immunodeficiency virus (HIV) prevention efforts has been the prescription of medications typically used for HIV treatment as prophylaxis against acquiring HIV. As a preventative agent, this practice is referred to as "preexposure prophylaxis" (PrEP). The U.S. Federal Drug Administration approved daily PrEP for adults at risk for HIV who do not consistently use condoms during sex with HIV-infected or unknown-status partners. In this paper, we describe a cognitive-behavioral therapy (CBT) PrEP adherence intervention developed for use in high-risk sexual-minority men in the United States, adapted from "Life-Steps," an evidence-based CBT intervention to promote adherence to HIV treatment. Modules include creating a PrEP dosing schedule, adhering to daily PrEP, problem solving barriers to adherence, and sexual risk-reduction techniques. Supplemented with practical video vignettes, this novel intervention may help to enhance the clinical practice of health care providers in outpatient settings to increase PrEP adherence in sexual-minority men.

Substance Use and Adherence Among People Living with HIV/AIDS Receiving cART in Latin America

This cross-sectional study describes substance use prevalence and its association with combination antiretroviral therapy (cART) adherence among 3343 individuals receiving care at HIV clinics in Argentina, Brazil, Chile, Honduras, Mexico, and Peru. A rapid screening tool evaluated self-reported 7-day recall of alcohol, marijuana, cocaine, heroin, and methamphetamine use, and missed cART doses. Overall, 29.3 % individuals reported having ≥1 alcoholic drinks, 5.0 % reported any illicit drug use and 17.0 % reported missed cART doses. In the logistic regression model, compared to no substance use, alcohol use [adjusted odds ratio (AOR) = 2.46, 95 % confidence interval (CI): 1.99-3.05], illicit drug use (AOR = 3.57, 95 % CI: 2.02-6.30), and using both alcohol and illicit drugs (AOR = 4.98, 95 % CI: 3.19-7.79) were associated with missed cART doses. The associations between substance use and likelihood of missing cART doses point to the need of targeting alcohol and illicit drug use to improve adherence among people living with HIV in Latin America.

ENHANCE-(Electronic Hydroxyurea Adherence): A Protocol to Increase Hydroxyurea Adherence in Patients with Sickle Cell Disease

Background

Hydroxyurea (HU) is the only disease-modifying medication for patients with sickle cell disease (SCD). HU can reduce SCD-related complications but only 35% to 50% of pediatric patients adhere to HU at the rates achieved in clinical trials and this limits its clinical effectiveness. Mobile Directly Observed Therapy (Mobile DOT) is a pilot-tested, electronic, multidimensional, HU adherence intervention that targets many components of the Health Behavior Model.

Objective

The aim of this study is to evaluate the impact of Mobile DOT on HU adherence in children with SCD. The objective of our study is to inform the development of future adherence interventions and pediatric SCD protocols.

Methods

This is a single-arm crossover study of pediatric patients with SCD. Participants self-record videos of their daily HU administrations and receive text message alerts to take HU, feedback on their HU adherence, and incentives when they achieve adherence goals during the 6-month Mobile DOT phase. Participants’ HU adherence during the Mobile DOT phase is compared with their baseline HU adherence (6 months prior to study entry) and to their HU adherence 6 months after completing the Mobile DOT phase. The primary outcome of this study is HU adherence measured by medication possession ratio.

Results

The trial is ongoing. Preliminary review of participant satisfaction results suggest that most participants can complete Mobile DOT in less than 5 minutes per day and are satisfied with the intervention.

Conclusions

If effective, the Mobile DOT strategy will increase HU adherence and this could improve patients’ clinical outcomes and reduce costs of care.

Positive affect and its association with viral control among women with HIV infection

OBJECTIVE

We assessed the relationship between positive affect and viral suppression among women with HIV infection.

METHOD

Three waves of 6-month data were analyzed from 995 women on HIV antiretroviral therapy participating in the Women's Interagency HIV Study (10/11-3/13). The predictor variable was self-reported positive affect over 2 waves of data collection, and the outcome was suppressed viral load, defined as plasma HIV-1 RNA <200 copies/mL, measured at a third wave.

RESULTS

Women with higher positive affect (36%) were more likely to have viral suppression at a subsequent wave (OR 1.92, 95% CI [1.34, 2.74]). Adjusting for covariates and their interactions, including negative affect, Wave 1 viral suppression, adherence, study site, recruitment cohort, substance use, heavy drinking, relationship status, interpersonal difficulties, and demographics, a statistically significant interaction was detected between negative affect, positive affect and viral suppression, t(965) = -2.7, p = .008. The association of positive affect and viral suppression differed at negative affect quartile values. For those reporting no negative affect, the AOR for positive affect and viral suppression was 2.41 (95% CI [1.35, 4.31]); at a negative affect score of 2, the AOR was 1.44 (95% CI [0.87, 2.36]); and at a score of 5.5, the AOR was 0.58 (95% CI [0.24, 1.42]).

CONCLUSION

Our central finding related to the interaction effect, that positive affect is associated with viral control under conditions of lower negative affect, is consistent with previous theory and research with other health outcomes, and can help guide efforts to further delineate mechanisms linking affect and health. (PsycINFO Database Record

Faster entry into HIV care among HIV-infected drug users who had been in drug-use treatment programs

OBJECTIVE

We evaluated whether being in drug use treatment improves linkage to HIV medical care for HIV-infected drug users. We assessed whether an evidence-based intervention for linkage to care ['ARTAS'] works better for HIV-infected drug users who had been in drug use treatment than those who had not.

DESIGN

Randomized trial.

METHODS

295 Participants in the Antiretroviral Treatment Access Study ['ARTAS'] trial were followed for time to first HIV medical care. Drug use (injected and non-injected drugs) in the last 30days and being in drug treatment in the last 12 months were assessed by audio-CASI. We used a proportional hazards model of time to care in drug users with and without drug treatment, adjusting for barriers to care, AIDS symptoms, and demographic factors. We tested whether drug treatment modified the intervention effect by using a drug use/drug treatment*intervention interaction term.

RESULTS

Ninety-nine participants (30%) reported drug use in the 30days before enrollment. Fifty-three (18%) reported being in a drug treatment program in the last 12 months. Drug users reporting methadone maintenance became engaged in care in less than half the time of drug users without a treatment history [HR 2.97 (1.20, 6.21)]. The ARTAS intervention effect was significantly larger for drug users with a treatment history compared to drug users without a treatment history (AHR 5.40, [95% CI, 2.03-14.38]).

CONCLUSIONS

Having been in drug treatment programs facilitated earlier entry into care among drug users diagnosed with HIV infection, and improved their response to the ARTAS linkage intervention.

Medication beliefs mediate the association between medical mistrust and antiretroviral adherence among African Americans living with HIV/AIDS

Medical mistrust is a significant barrier to medication adherence among African Americans living with HIV. In this study 380 African American people receiving antiretroviral therapy (ART) in a southern US city completed computerized measures at a community-based research site. Multiple mediation modeling showed that medical provider mistrust was associated with medication beliefs and ART adherence. Also, medication beliefs predicted adherence. The indirect effects of medical mistrust on adherence via medication beliefs was significant; the indirect effect was significant for medication concerns beliefs, but not medication necessity beliefs. Medication concerns beliefs therefore mediate the association between medical mistrust and ART adherence.

Predictors and Profiles of Antiretroviral Therapy Adherence Among African American Adolescents and Young Adult Males Living with HIV

Adherence to antiretroviral therapy (ART) is crucial for thwarting HIV disease progression and reducing secondary HIV transmission, yet youth living with HIV (YLH) struggle with adherence. The highest rates of new HIV infections in the United States occur in young African American men. A sample of 387 HIV-positive young African American males on ART was selected from a cross-sectional assessment of (YLH) receiving medical care within the Adolescent Trials Network for HIV/AIDS Interventions (ATN) from 2010 to 2012 (12-24 years old, median 22.00, SD 2.08). Participants completed self-reported adherence, demographic, health, and psychosocial measures. Sixty-two percent self-reported 100% ART adherence. Optimal data analysis identified frequency of cannabis use during the past 3 months as the strongest independent predictor of adherence, yielding moderate effect strength sensitivity (ESS) = 27.1, p < 0.001. Among participants with infrequent cannabis use, 72% reported full adherence; in contrast, only 45% of participants who used cannabis frequently reported full adherence. Classification tree analysis (CTA) was utilized to improve classification accuracy and to identify the pathways of ART adherence and nonadherence. The CTA model evidenced a 38% improvement above chance for correctly classifying participants as ART adherent or nonadherent. Participants most likely to be adherent were those with low psychological distress and minimal alcohol use (82% were adherent). Participants least likely to be adherent were those with higher psychological distress and engaged in weekly cannabis use (69% were nonadherent). Findings suggest multiple profiles of ART adherence for young African American males living with HIV and argue for targeted psychosocial interventions.

A qualitative study of barriers to and facilitators of optimal engagement in care among PLWH and substance use/misuse

BACKGROUND

Persons living with HIV (PLWH) and substance use/misuse experience significant barriers to engagement in HIV care at every step of the HIV care continuum including: (1) HIV testing and diagnosis (2) linkage to clinical care (3) retention in care pre-antiretroviral therapy (ART) (4) ART initiation and adherence (5) viral suppression. We qualitatively explored the facilitators of and barriers to participation in the HIV care continuum among PLWH with substance use/misuse.

METHODS

We performed semi-structured in-depth interviews with 34 PLWH in care with recent substance use. The transcripts were analyzed in an iterative process using an editing style analysis. Interviews were conducted until thematic saturation was achieved.

RESULTS

Participants attributed an escalation in drug use at the time of diagnosis to denial of their disease and the belief that their death was inevitable and cited this as a barrier to treatment entry. In contrast, participants reported that experiencing adverse physical effects of uncontrolled HIV infection motivated them to enroll in care. Reported barriers to retention and adherence to care included forgetting medications and appointments because of drug use, prioritizing drug use over HIV treatment and side effects associated with medications. Participants described that progression of illness, development of a medication taking ritual and a positive provider-patient relationship all facilitated engagement and reengagement in care.

CONCLUSIONS

PLWH with substance use engaged in care describe barriers to and facilitators of optimal engagement related to and distinct from substance use. Greater understanding of the biologic, psychological and social factors that promote and impair engagement in care can inform interventions and reduce the increased morbidity and mortality experienced by PLWH with substance use.

Factors associated with HIV viral load suppression on antiretroviral therapy in Vietnam

BACKGROUND

Limited data are available on HIV viral suppression rates among men and women on antiretroviral therapy (ART) and factors associated with HIV RNA viral load (VL) suppression in Vietnam.

METHODS

We conducted a cross-sectional survey of 1255 adult patients on ART for at least 1 year across four provinces in Vietnam. Data collection included a standardised questionnaire, routine laboratory testing, and an HIV VL assay. Bivariate and logistic multivariate analyses were conducted to assess viral suppression rates and factors associated with unsuppressed HIV VL.

RESULTS

The median age was 34.5 years and the median time on ART was 46 months. Gender was 66% male (n=828) and 34% female (n=427). HIV viral suppression below 1000 copies/mL was 93%. Viral suppression among woman was not significantly different than among men (93.7% vs 92.9%; P=0.59). On multivariate analysis, unsuppressed HIV VL was independently associated with lower CD4 cell count, social isolation, high stigma, not receiving a single-tablet daily regimen, multiple late appointments in past year, and immunological failure.

CONCLUSION

On-treatment viral load suppression rates in Vietnam are high and already exceed the UNAIDS 90% target for viral suppression on ART. Gender does not impact viral suppression rates of patients on ART in Vietnam. Access to routine viral load testing should be improved, adherence monitoring and counselling streamlined, and ART regimens simplified to maintain viral suppression rates, as more people start ART. Psychological and social factors are also associated with unsuppressed HIV VL, necessitating treatment support interventions to address social isolation and stigma among people living with HIV in Vietnam.

Intentional Medication Nonadherence Because of Interactive Toxicity Beliefs Among HIV-Positive Active Drug Users

BACKGROUND

Drug use poses significant challenges to medical management of HIV infection. Although most research has focused on the influence of intoxication on unintentional adherence to HIV treatment, drug use may also lead to intentional nonadherence, particularly when individuals believe that mixing medications with drugs is harmful. This study examined whether interactive toxicity beliefs predict nonadherence to antiretroviral therapy (ART) over a prospective period of adherence monitoring.

METHODS

Men and women living with HIV who screened positive for drug use and were being treated with ART (n = 530) completed computerized self-interviews and 3 prospective unannounced pill counts to measure ART adherence and provided urine specimens for drug screening and HIV viral load results from medical records.

RESULTS

Results showed that 189 (35%) participants indicated that they intentionally miss their ART when they are using drugs. These participants also reported common beliefs regarding the perceived hazards of mixing HIV medications with alcohol and other drugs. Multivariable models controlled for demographic and health characteristics and frequency of alcohol use showed that intentional nonadherence predicted poorer ART adherence over the prospective month and also predicted poorer treatment outcomes as indexed by unsuppressed HIV viral load.

CONCLUSIONS

These findings extend previous research to show that interactive toxicity beliefs and intentional nonadherence play a significant role in medication nonadherence for a substantial number of people living with HIV and should be actively addressed in HIV clinical care.

Optimization of Multicomponent Behavioral and Biobehavioral Interventions for the Prevention and Treatment of HIV/AIDS

To move society toward an AIDS-free generation, behavioral interventions for prevention and treatment of HIV/AIDS must be not only effective, but also cost-effective, efficient, and readily scalable. The purpose of this article is to introduce to the HIV/AIDS research community the multiphase optimization strategy (MOST), a new methodological framework inspired by engineering principles and designed to develop behavioral interventions that have these important characteristics. Many behavioral interventions comprise multiple components. In MOST, randomized experimentation is conducted to assess the individual performance of each intervention component, and whether its presence/absence/setting has an impact on the performance of other components. This information is used to engineer an intervention that meets a specific optimization criterion, defined a priori in terms of effectiveness, cost, cost-effectiveness, and/or scalability. MOST will enable intervention science to develop a coherent knowledge base about what works and does not work. Ultimately this will improve behavioral interventions systematically and incrementally.

Association of patterns of methadone use with antiretroviral therapy discontinuation: a prospective cohort study

BACKGROUND

Methadone maintenance therapy (MMT) is a proven treatment strategy for opioid dependent patients. Although studies have demonstrated that MMT increases contact with the medical system and improves adherence to antiretroviral therapy (ART) in HIV-positive people who inject drugs (PWID), the effect of MMT discontinuation on ART discontinuation has not been well described.

METHODS

We examined the impact of continuous MMT use, MMT non-use and MMT discontinuation on the time to ART discontinuation (defined as 90 days of continuous non-use following previous enrolment) in a community-recruited prospective cohort of HIV-positive PWID followed between May 1996 and May 2013 in Vancouver, Canada. Multivariate Cox proportional hazards regression was used to examine the association between MMT use patterns and time to ART discontinuation while adjusting for socio-demographic confounders.

RESULTS

A total of 794 HIV-positive PWID were included during the study period. In an adjusted analysis, in comparison to those who were continuously on MMT, MMT non-use (Adjusted Hazard Ratio [AHR] = 1.44, 95 % Confidence Interval [CI]: 1.19-1.73) as well as discontinuing MMT (AHR = 1.82, 95 % CI: 1.27-2.60) were both found to be independently associated with time to ART discontinuation.

CONCLUSIONS

This study reinforces the known benefits of MMT use on ART adherence and demonstrates how discontinuation of MMT is independently associated with an increased risk of ART cessation. These data highlight the importance of retaining PWID on MMT.