HIV/AIDS patients' perspectives on adhering to regimens containing protease inhibitors

Durable viral suppression among persons with HIV in the deep south: an observational study

This study assessed predictors of stable HIV viral suppression in a racially diverse sample of persons living with HIV (PWH) in the southern US. A total of 700 PWH were recruited from one of four HIV clinics in Metro Atlanta, GA. Data were collected from September 2012 to July 2017, and HIV viral loads were retrieved from EMR for 18 months. The baseline visits and EMR data were used for current analyses. Durable viral suppression was categorized as 1. Remain suppressed, 2. Remain unsuppressed, and 3. Unstable suppression. The number of antiretroviral medications and age were significantly associated with durable viral suppression. Older age, fewer ART medications and availability of social support were positively associated with durable viral suppression over the 18-month observation period. Findings suggest that regimen complexity is potentially a better predictor of viral suppression than self-reported medication adherence. The need for consensus on the definition of durable viral suppression is also urged.

Communication with patients using negative wound pressure therapy and their adherence to treatment

Objective:

The purpose of this study was to explore the challenges of communication between patients and health professionals, and patient adherence to treatment for hard-to-heal wounds when using negative wound pressure therapy (NPWT).

Methods:

Face-to-face, semi-structured interviews were conducted with patients undergoing NPWT. Specific features of the NPWT device were the priority for discussion although other factors central to communication and adherence were also explored.

Results:

A total of 24 patients took part in the study. Data saturation was achieved during the analysis. Patients required ongoing support to understand complex and often protracted treatment and this was particularly important when specialist technology was used. A distinction was highlighted between those who decided not to adhere with therapy and those who did so unintentionally. Participants faced difficulties in their communications with health professionals and in ensuring their needs were listened to and addressed.

Conclusion:

Further research is needed to achieve a better understanding of this distinction and to evaluate interventions which can sustain adherence behaviours. Further exploration of how to establish concordant patient/health professional communications is warranted.

Risk factors for antiretroviral therapy (ART) discontinuation in a large multinational trial of early ART initiators

OBJECTIVE

We aimed to investigate potential causes of higher risk of treatment interruptions within the multicountry Strategic Timing of AntiRetroviral Treatment (START) trial in 2015.

METHODS

We defined baseline as the date of starting antiretroviral therapy (ART) and a treatment interruption as discontinuing ART for at least 2 weeks. Participants were stratified by randomization arm and followed from baseline to earliest end date of the initial phase of START, death, date of consent withdrawn or date of first treatment interruption. Cox regression was used to calculate hazard ratios and 95% confidence intervals for factors that may predict treatment interruptions in each arm.

RESULTS

Of the 3438 participants who started ART, 2286 were in the immediate arm and 1152 in the deferred arm. 12.9% of people in the immediate arm and 10.5% of people in the deferred arm experienced at least one treatment interruption by 3 years after starting ART. In adjusted analyses, age [hazard ratio for 35-50 years: 0.75 (95% confidence interval: 0.59-0.97) and >50 years: 0.53 (0.33-0.80) vs. <35 years], education status [hazard ratio for postgraduate education vs. less than high-school education (0.23 (0.10-0.50))] and region [hazard ratio for United States vs. Europe/Israel (3.16 (2.09-4.77))] were significantly associated with treatment interruptions in the immediate arm. In the deferred arm, age and education status were significantly associated with treatment interruptions.

CONCLUSION

Within START, we identified younger age and lower educational attainment as potential causes of ART interruption. There is a need to strengthen adherence advice and wider social support in younger people and those of lower education status.

Health care provider communication training in rural Tanzania empowers HIV-infected patients on antiretroviral therapy to discuss adherence problems

OBJECTIVES

Self-reported adherence assessment in HIV-infected patients on antiretroviral therapy (ART) is challenging and may overestimate adherence. The aim of this study was to improve the ability of health care providers to elicit patients' reports of nonadherence using a "patient-centred" approach in a rural sub-Saharan African setting.

METHODS

A prospective interventional cohort study of HIV-infected patients on ART for ≥ 6 months attending an HIV clinic in rural Tanzania was carried out. The intervention consisted of a 2-day workshop for health care providers on patient-centred communication and the provision of an adherence assessment checklist for use in the consultations. Patients' self-reports of nonadherence (≥ 1 missed ART dose/4 weeks), subtherapeutic plasma ART concentrations (< 2.5th percentile of published population-based pharmacokinetic models), and virological and immunological failure according to the World Health Organization definition were assessed before and after (1-3 and 6-9 months after) the intervention.

RESULTS

Before the intervention, only 3.3% of 299 patients included in the study reported nonadherence. Subtherapeutic plasma ART drug concentrations and virological and immunological failure were recorded in 6.5%, 7.7% and 14.5% of the patients, respectively. Two months after the intervention, health care providers detected significantly more patients reporting nonadherence compared with baseline (10.7 vs. 3.3%, respectively; P < 0.001), decreasing to 5.7% after 6-9 months. A time trend towards higher drug concentrations was observed for efavirenz but not for other drugs. The virological failure rate remained unchanged whereas the immunological failure rate decreased from 14.4 to 8.7% at the last visit (P = 0.002).

CONCLUSIONS

Patient-centred communication can successfully be implemented with a simple intervention in rural Africa. It increases the likelihood of HIV-infected patients reporting problems with adherence to ART; however, sustainability remains a challenge.

HIV Treatment in African Americans: Challenges and Opportunities

This article reviews the current standard of care for HIV infection as well as how health disparities in the HIV care of African Americans present challenges for both providers and patients. The potential side effects in these antiretroviral treatment regimens that may be a source of additional challenges in treating African Americans are highlighted. A brief review of these issues as they relate to treatment adherence further demonstrates how adherence is closely linked to the medical and psychosocial issues African Americans face including access to HIV care services. The article concludes with a discussion of gender-related issues that affect treatment and that may confound effective behavioral interventions aimed at reducing HIV risk and increasing treatment adherence.

Adherence to Antiretroviral Therapy: The Emerging Role of HIV Pharmacotherapy Specialists

Despite the availability of 25 antiretroviral agents to treat HIV infection and the significant progresses made in the clinical pharmacology of HIV drugs, viral suppression and immune restoration remain problematic in a large number of HIV-infected persons. One of the main factors responsible for this partial therapeutic success is the difficulty patients have adhering consistently to antiretroviral therapy. Barriers to adherence are diverse and complex and evolve over time, complicating the monitoring of medication-taking behaviors. Consequently, multilevel interventions are often needed to address thoroughly adherence issues. Given the rapid and constant evolution of HIV treatments, innovative multidisciplinary programs integrating HIV pharmacotherapy specialists, as the “medication expert,” are being implemented. Because of his or her advanced knowledge of antiretrovirals, the HIV pharmacotherapy specialist is highly qualified to evaluate patients with complex regimens who are facing barriers to successful care and who need tailored interventions and long-term follow-up.

The influence of personal communities on the self-management of medication taking: A wider exploration of medicine work

OBJECTIVES

There is a lack of focus on the broader social context, networks and influences on medicine-taking as part of illness work. This work adopts a social network approach and seeks to explicate the nature of medicine-taking work that people with multiple long-term conditions (LTCs) and their social network members (SNMs) do in attempting to take their medications on a daily basis, the division of labour amongst these members and when and why SNMs become involved in that work.

METHODS

Semi-structured interviews were conducted with 20 people who had multiple LTCs. Medication networks were constructed and the division of labour in relation to medication-work was explored.

RESULTS

Four types of medication-work emerged: medication articulation, surveillance, emotional and informational. Involvement of SNMs in medication-work was selective, performed primarily by family members, within the home. Involvement reflected network composition and/or an individual's conceptualisation/presentation of self.

DISCUSSION

Our findings support and extend the conceptualisation of routine medicine-taking as a type of work. Furthermore, we illustrate the involvement of SNMs in aspects of medicine-work. Health professionals should explore and support the role of SNMs in medicine-taking where possible. Future research should explore the implications of network types and compositions on medicine-taking and associated work.

HIV-Infected Individuals Who Delay, Decline, or Discontinue Antiretroviral Therapy: Comparing Clinic- and Peer-Recruited Cohorts

A substantial proportion of persons living with HIV/AIDS (PLHA) delay, decline, or discontinue antiretroviral therapy (ART) when it is medically indicated (40–45%), largely African-Americans and Latinos/Hispanics. This study explores the feasibility of locating PLHA, who are not on ART (PLHA-NOA) through clinics and peer-referral; compares the two cohorts on multi-level barriers to ART; and examines readiness to initiate/reinitiate ART, a predictor of treatment outcomes. We recruited adult HIV-infected African-American and Latino/Hispanic PLHA-NOA through HIV hospital clinics and peer-referral in 2012–2013. Participants were engaged in structured 1-h assessments with reliable/valid measures on barriers to ART. We found that recruitment through peers (63.2%, 60/95) was more feasible than in clinics (36.8%, 35/90). Participants were 48.0 years old and had lived with HIV for 14.7 years on average, and 56.8% had taken ART previously. Most (61.1%) were male and African-American (76.8%), and 23.2% were Latino/Hispanic. Peer-recruited participants were older, had lived with HIV longer, were less engaged in HIV care, and were more likely to have taken ART previously. The cohorts differed in reasons for discontinuing ART. Levels of ART knowledge were comparable between cohorts (68.5% correct), and there were no differences in attitudes toward ART (e.g., mistrust), which were in the neutral range. In bivariate linear regression, readiness for ART was negatively associated with physician mistrust (B = −10.4) and positively associated with self-efficacy (B = 5.5), positive outcome expectancies (B = 6.3), beliefs about personal necessity of ART (B = 17.5), and positive internal norms (B = 7.9). This study demonstrates the feasibility of engaging this vulnerable population through peer-referral. Peer-recruited PLHA evidence particularly high rates of risk factors compared to those in hospital clinics. Interventions to support ART initiation and continuation are sorely needed for both subgroups.

Factors associated with adherence amongst 5295 people receiving antiretroviral therapy as part of an international trial

BACKGROUND

 We assessed factors associated with antiretroviral therapy (ART) adherence, including specific ART medications.

METHODS

 The Strategies for Management of Antiretroviral Therapy study was an international antiretroviral therapy (ART) strategy trial that compared intermittent ART, using CD4(+) T-cell count as a guide, to continuous ART. Adherence during the 7 days before each visit was measured using self-report. We defined high adherence as self-report of taking "all" pills for each prescribed ART medication; all other reports were defined as suboptimal adherence. Factors associated with adherence were assessed using logistic regression with generalized estimating equations.

RESULTS

 Participants reported suboptimal adherence at 6016 of 35 695 study visits (17%). Factors independently associated with suboptimal adherence were black race, protease inhibitor-containing regimens, greater pill burden, higher maximum number of doses per day, and smoking. Factors independently associated with higher adherence were older age, higher education, region of residence, episodic treatment, higher latest (at the time of adherence) CD4(+) T-cell count, and being prescribed concomitant drugs (ie, medications for comorbidities). Of specific drugs investigated, atazanavir, atazanavir/ritonavir, fosamprenavir, indinavir, indinavir/ritonavir, and lopinavir/ritonavir were associated with suboptimal adherence, and tenofovir disoproxil fumarate/emtricitabine was associated with higher adherence.

CONCLUSIONS

 In this, the largest analysis of ART adherence to date, some protease inhibitor-containing regimens and regimens with >1 dose per day were associated with suboptimal adherence.

Psychosocial Issues in the Era of New AIDS Treatments from the Perspective of Persons Living with HIV

In the past, HIV disease meant an almost invariably downward health course. New highly active antiretroviral therapy (HAART) regimens have improved the health outlook for many persons living with HIV/AIDS but may create new psychological and coping challenges. In this study, open-ended, in-depth interviews were undertaken with an ethnically diverse sample of 44 purposively selected men and women with HIV disease who were on HAART regimens. The interviews were transcribed and qualitatively coded to identify major themes. While patients responding well to the regimens held optimistic views for their future, some who continued to have detectable viral load exhibited depression and feelings of hopelessness. Many patients reported stress associated with the demands of adhering to complex HAART regimens. Other common themes emerging in the interviews involved concerns about employment, romantic and non-romantic relationship formation, sexual behavior and serostatus disclosure, whether to plan families, and experiences of AIDS-related discrimination. There continue to be critical roles for psychological services in the care of persons living with HIV.

A collaborative awareness system for chronic disease medication adherence applied to HIV infection

Electronic reminder systems have been available for decades, yet medication adherence remains poor. Most systems rely on simple alarms and do not address other determinants of health-related behavior. This paper describes a collaborative awareness system for chronic disease medication adherence that relies on patient self-reflection and clinician support. Visualizations of adherence performance, including estimated plasma concentration graphs and a dynamic, personalized, disease-state simulation, are available to the patient (cell phone and internet media display) and clinician (computer) in real-time. The clinician can send asynchronous video messages of advice and encouragement to the patient regularly. A pilot was conducted with four HIV positive patients for four weeks. Three patients who started with suboptimal adherence improved (93.0% to 99.1%, 83.0% to 96.3%, and 63.9% to 81.3%). One patient who started with optimal medication adherence (>95%) maintained this level. All four patients appreciated the rich feedback and wanted to continue using the system.

Prediction of adherence to antiretroviral therapy: A one-year longitudinal study

The aim of this longitudinal study was to identify the determinants of adherence to antiretroviral therapy (ART) in HIV patients over a period of 12 months. A total of 376 individuals living with HIV treated with ART participated in the study. Data were collected at baseline and at three, six, nine and 12 months. Variables assessed were adherence, attitude, outcome expectancies, self-efficacy, patient satisfaction with the relationship with their physician, provision of social support, optimism, CD4 cell count, viral load and side effects. Predictors of adherence in the Generalized Estimated Equation (GEE) were: high perception of self-efficacy (OR=1.68; 95%CI 1.27-2.22), positive attitude towards taking medication (OR=1.56; 95%CI 1.18-2.06), not living alone (OR=1.47; 95%CI 1.04-2.08) and being a male (OR=2.81; 95%CI 1.47-5.34). Subsequent analysis showed that a positive attitude towards taking medication was associated with a high level of patient satisfaction with their physician, high perceived social support, being optimistic, living with HIV for five years or less and experiencing no side effects. Also, a strong sense of self-efficacy was associated with positive perception of social support, high level of patient satisfaction with their physician and not living alone. These results suggest that interventions aimed at improving adherence to ART should focus on reinforcing self-efficacy and developing a positive attitude towards taking medication.

Long-term trends in adherence to antiretroviral therapy from start of HAART

OBJECTIVE

People on antiretroviral therapy are likely to be required to maintain good adherence throughout their lives. We aimed to investigate long-term trends in highly active antiretroviral therapy (HAART) adherence to identify the main predictors and to evaluate whether participants experience periods of low adherence (<or=60%).

METHODS

Participants in the Royal Free Clinic Cohort were followed from the date of start of HAART until the end of the last recorded ART prescription or death. Follow-up was divided into 6-month periods, and for each period, a value of adherence, measured as the percentage of days in the 6-month period covered by a valid prescription for at least three antiretroviral drugs, was calculated.

RESULTS

Patients were assessed for drug coverage adherence for a median of 4.5 years [inter-quartile range (IQR) 2.4-7.2; maximum 9 years] covering a period up to 13 years from start of HAART. There was evidence of a slight increase in adherence over time [adjusted odds ratio (OR) of >95% adherence = 1.02 per year; 95% confidence interval (CI) 1.01-1.04; P = 0.0053]. Independent predictors of adherence were age, demographic group, calendar year period, drug regimen and previous virologic failures. The overall rate of at least one period of low adherence was 0.12 per person-year, but this rate decrease markedly over time to 0.01 in 2007/2008.

CONCLUSION

Adherence, as measured by drug coverage, does not decrease on average over more than a decade from start of HAART. This is encouraging, because it shows that patients could potentially maintain viral suppression for many years.

Time, self and the medication day: a closer look at the everyday work of 'adherence'

This article examines the everyday work of participating in pharmaceutical treatment for HIV infection in the context of urgent calls for adherence. Drawing on interviews and focus-group conversations with people taking antiretroviral drugs, the analysis explicates the work that goes into striving for adherence. What comes into view is a form of time work that brings about a temporary alignment between the inner experience of time, standard clock time, and the requirements of the medication schedule. Time work is largely cognitive; the pills, however, must actually be swallowed to complete the dose, occasioning, for some people, additional work to suppress or refashion emotional responses of anger and resistance. Both the time work and the emotional work of taking antiretroviral drugs draw people into forms of self work, including self-examination and self-adjustment, as they develop strategies for 'doing adherence'.

Discrimination, distrust, and racial/ethnic disparities in antiretroviral therapy adherence among a national sample of HIV-infected patients

OBJECTIVE

Although discriminatory health care experiences and health care provider distrust have been shown to be associated with health care disparities, little is known about their contribution to racial/ethnic disparities in antiretroviral therapy adherence. We therefore sought to assess the extent to which discriminatory health care experiences and health care provider distrust influence treatment-related attitudes, beliefs, and self-reported adherence in a national sample of HIV-infected patients.

STUDY DESIGN

This secondary analysis used data from the HIV Cost and Services Utilization Study. We used structural equation modeling to identify pathways from minority status to adherence through discrimination, distrust, and treatment-related attitudes and beliefs.

PARTICIPANTS

The sample was the 1886 participants who completed the baseline and 2 follow-up interviews and were prescribed antiretroviral therapy at the second follow-up interview (54% white, 28% black, 14% Hispanic, and 3% others).

RESULTS

Minorities were less likely to report perfect adherence than whites (40% vs. 50%, P < or = 0.001). Over one third (40%) of all participants reporting ever having discriminatory health care experiences since having HIV, and 24% did not completely or almost completely trust their health care providers. The effect of minority status on adherence persisted in the full model. More discrimination predicted greater distrust, weaker treatment benefit beliefs, and, in turn, poorer adherence. Distrust affected adherence by increasing treatment-related psychological distress and weakening treatment benefit beliefs.

CONCLUSIONS

The relationship between minority status and adherence was not fully explained by patient-level factors. Future studies should consider conceptualizing minority status as a contextual factor rather than predictor.

Factors influencing the acceptance of changes in antiretroviral therapy among HIV-1-infected patients

Physicians routinely consider modifying antiretroviral therapy (ART) regimen for their patients with HIV. Little is known about the factors associated with patients' willingness to accept providers' recommended ART changes. This multicenter prospective observational study examined factors associated with willingness to accept ART changes recommended by their providers among HIV-infected adults from six urban outpatient HIV clinics. Patients were surveyed using the Patient Attitudes about Altering Antiretroviral Therapy Survey questionnaire (PAAARTS). Factors associated with willingness to accept ART changes were assessed using a multivariate generalized estimating equation (GEE) model to account for correlated responses. The Classification and Regression Trees (CART) analysis was also performed to determine subgroups of patients with higher acceptance of change. 216 of 289 patients (75%) definitely accepted recommended changes. Odds for acceptance were 3.2, 2.3, and 2.8 times higher for patients with higher attitudes and beliefs about ART (p < 0.01; 95% confidence interval [CI] = 1.59, 6.52), patients who rated their provider's care as excellent (p < 0.05; 95% CI = 1.07, 4.78), and non-Hispanic patients (p < 0.05; 95% CI 1.03, 7.57), respectively. CART analysis showed similar results and identified that when patients had less positive attitude about ART, acceptance rates were higher for non-Hispanic patients with higher assessments of their patient-provider communication. While most patients accepted providers' recommendation for ART changes, this willingness was influenced by both patients' attitudes and beliefs about ART and their assessment of either the effectiveness of patient-provider communication or their rating of providers' care. ART acceptance rates among Hispanic patients were lower.

Adherence to HIV treatment among IDUs and the role of opioid substitution treatment (OST)

In the era of highly effective anti-retroviral therapy (ART), data show a significant difference in treatment outcomes between injecting drug users (IDUs) and non-IDUs. Factors that may contribute to suboptimal treatment outcomes in IDUs include delayed access to ART, competing comorbid diseases, psychosocial barriers and poor long-term adherence to ART. This review describes and compares several studies on adherence to ART and its correlates in HIV-infected individuals in general, then IDUs and finally those IDUs on opioid substitution treatment (OST). It highlights how ongoing drug use or OST can modify the pattern of these correlates. The aim is to extend all the experience acquired from these studies in order to optimise both access to care and adherence in those countries where HIV infection is mainly driven by IDUs and where ART and OST are only starting to be scaled up. The role of OST in fostering access to care and adherence to ART together with the promising results achieved to date using modified directly observed therapy (DOT) programs for patients taking methadone, allow us to emphasize the efficacy of a comprehensive care model which integrates substance dependence treatment, psychiatric treatment, social services, and medical treatment. The review concludes by suggesting areas of future research targeted at improving the understanding of both the role of perceived toxicity and patient-provider relationship for patients on ART and OST.

Adherence to treatment in Swedish HIV-infected patients

OBJECTIVES

The objectives were to assess the prevalence of adherence to antiretroviral treatment in Swedish human immunodeficiency virus (HIV)-infected patients and to evaluate factors associated with adherence.

METHODS

All HIV-treated patients, who attended one of 30 (of a total of 32) Swedish infectious diseases clinics, during 7 months, were asked to complete an anonymous questionnaire containing the 9-item Morisky Medication Adherence Scale (MMAS) and questions about other factors potentially affecting adherence. The summary score of MMAS ranges from 1 to 13, where 13 indicates perfect adherence; patients scoring 11 or above (corresponding to 95% adherence level) were classified as 'adherent'.

RESULTS AND DISCUSSION

In total 946 patients participated (response rate 97.5%). The proportion of patients who reported not missing a dose during the day prior to the completion of the questionnaire was 97% and the proportion classified as 'adherent' was 63%. 'Adherent' patients were more likely to have a good relationship with their health care professionals (P < 0.05) and not have problems with drugs or alcohol (P < 0.01). Being older (P < 0.01) and having a shorter time on current treatment (P < 0.01) and on treatment in total (P < 0.05) were factors also associated with good adherence.

CONCLUSION

Factors modifiable for interventions by health care professionals are patient-provider relationship, drug or alcohol problems and patients with long treatment periods.

Adherence to combined Lamivudine+Zidovudine versus individual components: A community-based retrospective medicaid claims analysis

Adherence to a fixed dose combination of dual nucleoside antiretroviral therapy was compared between human immunodeficiency virus (HIV)-infected patients newly started on a fixed dosed combination of lamivudine (3TC) 150 mg/zidovudine (ZDV) 300 mg versus its components taken as separate pills. Medicaid pharmacy claims data were used for analyses. To examine the association between treatment group and medication adherence, three types of multivariate regressions were employed. In addition, all regressions were conducted for the whole population using data from 1995 to 2001 as well as a subpopulation, which excluded data prior to September 1997. Model covariates included patient characteristics, healthcare utilization, and non-study antiretroviral therapy use. The likelihood of > or =95% adherence among patients on combination therapy was three times greater than patients taking 3TC and ZDV in separate pills. Also, combination therapy patients had on average 1.4 fewer adherence failures per year of follow-up and nearly double the time to adherence failure compared to the separate pills group. Consistency among study results suggests that fixed dose combination therapies such as lamivudine (3TC) 150 mg/ zidovudine (ZDV) 300 mg should be considered when prescribing HIV treatment that includes an appropriate dual nucleoside.

How qualitative methods contribute to understanding combination antiretroviral therapy adherence

Strict adherence to medication regimens is generally required to obtain optimal response to combination antiretroviral therapy (ART). Yet, we have made limited progress in developing strategies to decrease the prevalence of nonadherence. As we work to understand adherence in developed countries, the introduction of ART in resource-poor settings raises novel challenges. Qualitative research is a scientific approach that uses methods such as observation, interviews, and verbal interactions to gather rich in-depth information about how something is experienced. It seeks to understand the beliefs, values, and processes underlying behavioral patterns. Qualitative methods provide powerful tools for understanding adherence. Culture-specific influences, medication beliefs, access, stigma, reasons for nonadherence, patterns of medication taking, and intervention fidelity and measurement development are areas ripe for qualitative inquiry. A disregard for the social and cultural context of adherence or the imposition of adherence models inconsistent with local values and practices is likely to produce irrelevant or ineffective interventions. Qualitative methods remain underused in adherence research. We review appropriate qualitative methods for and provide an overview of the qualitative research on ART nonadherence. We discuss the rationales for using qualitative methods, present 2 case examples illustrating their use, and discuss possible institutional barriers to their acceptance.

Adherence to HAART: a systematic review of developed and developing nation patient-reported barriers and facilitators

BACKGROUND

Adherence to highly active antiretroviral therapy (HAART) medication is the greatest patient-enabled predictor of treatment success and mortality for those who have access to drugs. We systematically reviewed the literature to determine patient-reported barriers and facilitators to adhering to antiretroviral therapy.

METHODS AND FINDINGS

We examined both developed and developing nations. We searched the following databases: AMED (inception to June 2005), Campbell Collaboration (inception to June 2005), CinAhl (inception to June 2005), Cochrane Library (inception to June 2005), Embase (inception to June 2005), ERIC (inception to June 2005), MedLine (inception to June 2005), and NHS EED (inception to June 2005). We retrieved studies conducted in both developed and developing nation settings that examined barriers and facilitators addressing adherence. Both qualitative and quantitative studies were included. We independently, in duplicate, extracted data reported in qualitative studies addressing adherence. We then examined all quantitative studies addressing barriers and facilitators noted from the qualitative studies. In order to place the findings of the qualitative studies in a generalizable context, we meta-analyzed the surveys to determine a best estimate of the overall prevalence of issues. We included 37 qualitative studies and 47 studies using a quantitative methodology (surveys). Seventy-two studies (35 qualitative) were conducted in developed nations, while the remaining 12 (two qualitative) were conducted in developing nations. Important barriers reported in both economic settings included fear of disclosure, concomitant substance abuse, forgetfulness, suspicions of treatment, regimens that are too complicated, number of pills required, decreased quality of life, work and family responsibilities, falling asleep, and access to medication. Important facilitators reported by patients in developed nation settings included having a sense of self-worth, seeing positive effects of antiretrovirals, accepting their seropositivity, understanding the need for strict adherence, making use of reminder tools, and having a simple regimen. Among 37 separate meta-analyses examining the generalizability of these findings, we found large heterogeneity.

CONCLUSIONS

We found that important barriers to adherence are consistent across multiple settings and countries. Research is urgently needed to determine patient-important factors for adherence in developing world settings. Clinicians should use this information to engage in open discussion with patients to promote adherence and identify barriers and facilitators within their own populations.

Integrating services for injection drug users infected with hepatitis C virus with methadone maintenance treatment: challenges and opportunities

Despite the high prevalence of hepatitis C virus (HCV) infection among drug users enrolled in methadone maintenance treatment programs, few drug users are being treated with combination therapy. The most significant barrier to treatment is lack of access to comprehensive HCV-related care. We describe a pilot program to integrate care for HCV infection with substance abuse treatment in a setting of maintenance treatment with methadone. This on-site, multidisciplinary model of care includes comprehensive screening and treatment for HCV infection, assessment of eligibility, counseling with regard to substance abuse, psychiatric services, HCV support groups, directly observed therapy, and enhanced linkages to a tertiary care system for diagnostic procedures. Our approach has led to high levels of adherence, with liver biopsy and substantial rates of initiation of antiviral therapy. Two cases illustrate the successful application of this model to patients with HCV infection complicated by active substance abuse and psychiatric comorbidity.

To take or not to take: decision-making about antiretroviral treatment in people living with HIV/AIDS

Knowledge is limited regarding decision-making about antiretroviral treatment (ART) from the patient's perspective. This substudy of a longitudinal study of psychobiologic aspects of long-term survival, conducted in 2003, compares the rationales of HIV-positive individuals (n = 79) deciding to take or not to take ART. Inclusion criteria were HIV/AIDS symptoms, or CD4 nadir less than 350, or viral load greater than 55,000. Those not meeting any criteria for receiving ART (2/2003 U.S. DHHS treatment guidelines) were excluded. Diagnosis was on average 11 years ago; 36% were female, 42% African American, 28% Latino, 24% white, and 6% other. Qualitative content analysis of semistructured interviews identified 10 criteria for the decision to take or not to take ART: CD4/viral load counts (87%), quality of life (85%), knowledge/ beliefs about resistance (66%), mind-body beliefs (65%), adverse effects of ART (59%), easy-to-take regimen (58%), spirituality/worldview (58%), drug resistance (41%), experience of HIV/AIDS symptoms (39%), and preference for complementary/alternative medicine (17%). Participants choosing not to take ART (27%) preferred complementary/alternative medicine (r = 0.43, p = 0.001)1, perceived a better quality of life without ART (r = 0.32, p < 0.004), and weighted avoidance of adverse effects of ART more heavily (r = 0.24, p < 0.030) than participants taking ART (73%). Demographic characteristics related to taking ART were having a partner (r = 0.31, p < 0.008) and having health insurance (r = 0.26, p< 0.040). Decisions to take or not to take ART depend not only on patient medical characteristics, but also on individual beliefs about ART, complementary/alternative medicine, spirituality, and mind-body connection. HIV-positive individuals declining treatment place more weight on alternative medicine, avoiding adverse effects and perceiving a better quality of life through not taking ART.

Effect of long-cycle structured intermittent versus continuous HAART on quality of life in patients with chronic HIV infection

OBJECTIVE

To examine the effect of repeated, long-cycle structured intermittent versus continuous HAART on health-related quality of life (HRQL) and symptom distress in patients with chronic HIV infection and plasma HIV RNA of less than 50 copies/ml.

DESIGN

Prospective survey of adult patients (n = 46) enrolled in a randomized clinical trial evaluating intermittent versus continuous HAART on immunological and virologic parameters. Patients (n = 23) randomized to structured intermittent therapy received serial cycles of 4 weeks on/8 weeks off HAART.

OUTCOME MEASURES

HRQL was measured by the physical and mental health summary scores of the Medical Outcomes Study HIV Health Survey (MOS-HIV). Symptom distress was measured by the Symptom Distress Scale. Patients completed initial questionnaires prior to randomization and at weeks 4, 12, and 40 of the trial via a touch screen computer in an outpatient clinic.

RESULTS

Baseline demographic and clinical characteristics were equivalent in both treatment groups. Although the mental health summary score declined significantly over time for the structured intermittent group, linear mixed modeling ANOVA indicated no significant difference across time for MOS-HIV summary and Symptom Distress Scale scores between the two treatment arms.

CONCLUSION

In this small sample, repeated long-cycle structured intermittent therapy may not provide HRQL or symptom distress advantage compared to continuous HAART in patients with chronic HIV infection over 10 months of treatment. Further research in a heterogenous chronic HIV population and longer follow-up period is warranted.

Relationship of Emotional Intelligence and Adherence to Combination Antiretroviral Medications by Individuals Living With HIV Disease

Medications are an intentional and purposeful means to the successful management of many chronic diseases. In the treatment of disease caused by HIV, adherence to medication is of particular concern because any level of nonadherence, often a few missed doses, will lead eventually to the development of drug resistance. Many predictors of poor adherence to HIV medications have been identified as significant factors in adherence. Among these is the emotional aspect. The purpose of this study was to examine emotional intelligence (EI) and adherence to combination antiretroviral therapy in individuals who are infected with HIV. EI is defined as the ability to perceive and express emotions, facilitate emotions, understand and reason with emotion, and manage emotions. EI has been correlated with various aspects of success in life. In this study, EI was measured by the Mayer, Salovey, Caruso Emotional Intelligence Test. Adherence to medications was measured by self-report and defined as less than 10% missed doses of medications. Eighty-two participants were recruited from an urban hospital-based HIV clinic. Pearson's r was used to analyze the data for significance, and no correlation was reported. This data set was not large enough to prove significance, statistically, of the research question. However, an unexpected result of this study was that the overall EI scores for this particular population were markedly lower than the test norms. Further study would be warranted and recommended to explore El measurement in people at risk for HIV disease or in those who have the disease to further understand the impact of emotions and EI in this specific population.

Effect of a brief antiretroviral adherence intervention delivered by HIV care providers

Antiretroviral therapy (ART) is effective in controlling viral load in many people infected with HIV, but high levels of adherence to ART are needed for prolonged viral suppression. This study evaluated a brief adherence intervention delivered to HIV-positive patients by primary care providers during routine medical examinations. Six clinics were randomly allocated to deliver an intervention focusing on ART adherence (2 clinics) or safer sex (4 clinics). Interventions included written information (posters, brochures, and flyers) and brief counseling from providers and were evaluated with cohorts of randomly selected patients (n = 437) measured before and after a 10-month intervention. Among those 95% or greater adherent at baseline, 91% of patients who received the adherence intervention remained 95% or greater adherent at follow-up compared with 75% of the patients who received the safer sex intervention (chi = 12.59, P < 0.01). This difference was significant in a logistic regression analysis (odds ratio = 2.26; 95% confidence interval = 1.27-4.04), adjusting for baseline adherence, demographics, and HIV medical status. The adherence intervention did not significantly increase the prevalence of 95% or greater adherence among patients less than 95% adherent at baseline. Similar but nonsignificant results were observed for viral load. A brief intervention delivered to HIV patients by their primary providers helped to maintain adequate adherence to ART regimens. More intensive intervention is needed to improve adherence among patients who are initially less than 95% adherent.

Physician contributions to disparities in HIV/AIDS care: The role of provider perceptions regarding adherence

Racial/ethnic minorities in the United States are disproportionately affected by HIV/AIDS. In addition to having higher rates of HIV/AIDS, minorities with HIV/AIDS have higher mortality rates than others in the United States. Disparities in the care received by minorities living with HIV/AIDS contribute to these higher mortality rates. This article provides a review of HIV/AIDS health care disparities and explores providers' contributions to these disparities. An important source of provider contribution to disparities appears to be differential prescribing based on perceptions and assumptions that minority patients may have lower adherence to highly active antiretroviral therapy. Literature regarding this topic is reviewed and strategies for reducing disparities are suggested.

Information preferences and practices among people living with HIV/AIDS: results from a nationwide survey

OBJECTIVES

This study was designed to reach many segments of the diverse HIV/AIDS community and broaden understanding of how information can better assist people living with HIV/AIDS.

METHODS

Data were collected through a self-administered mail survey distributed nationwide at clinics, drug treatment centers, and other AIDS service organizations.

RESULTS

The 662 respondents preferred getting information from people--including health professionals, family, and friends--and considered people the most trustworthy, useful, understandable, and available information sources. Forty-three percent selected doctors as their most preferred source. The Internet was not rated highly overall but was preferred by those with more education or living in metropolitan areas. Seventy-two percent said they actively search for HIV/AIDS-related information, and 80% said they give advice or tell others where to get such information. However, 71% agreed that it is easy to feel overwhelmed by information, and 31% agreed that not seeking information can be beneficial.

CONCLUSIONS

Overall, information seeking is an important activity for this sample of people living with HIV/AIDS. Many sources are widely available to them but, together, can be overwhelming. They rely on health professionals far more than print or media sources and receive encouragement and support from family and friends.

Changes in attitudes toward antiviral medication: a comparison of women living with HIV/AIDS in the pre-HAART and HAART Eras

To examine potential changes in attitudes toward antiviral medication since the advent of highly active antiretroviral therapy (HAART), focused interviews were conducted with two samples of women living with HIV/AIDS; one in the pre-HAART era (1994-1996) and a second matched sample in the HAART era (2000-2003). Women in the pre-HAART era held highly negative attitudes toward antiviral medications, perceived them as ineffective with few benefits and viewed side effects as intolerable. In contrast, women in the HAART era were less likely to report negative attitudes, which were balanced by more frequent reports of perceived benefits and more likely to view side effects as temporary and manageable. African American women in both eras were more likely to hold negative attitudes and less likely to perceive benefits than White and Puerto Rican women. These findings suggest that views of antiviral medication have improved since the advent of HAART, but that negative attitudes and side-effect concerns remain which should be addressed in interventions to promote treatment acceptance and adherence.

Medication practice and feminist thought: a theoretical and ethical response to adherence in HIV/AIDS

Accurate self-administration of antiretroviral medication therapy for HIV/AIDS is a significant clinical and ethical concern because of its implications for individual morbidity and mortality, the health of the public, and escalating healthcare costs. However, the traditional construction of patient medication adherence is oversimplified, myopic, and ethically problematic. Adherence relies on existing social power structures and western normative assumptions about the proper roles of patients and providers, and principally focuses on patient variables, obscuring the powerful socioeconomic and institutional influences on behaviour. Some professionals advocate for alternate approaches to adherence, but many of the available alternatives remain conceptually underdeveloped. Using HIV/AIDS as an exemplar, this paper presents medication practice as a theoretical reconstruction and explicates its conceptual and ethical evolution. We first propose that one of these alternatives, medication practice, broadens the understanding of individuals' medication-taking behaviour, speaks to the inherent power inequities in the patient-provider interaction, and addresses the ethical shortcomings in the traditional construal. We then integrate medication practice with feminist thought, further validating individuals' situated knowledge, choices, and multiple roles; more fully recognizing the individual as a multidiminsional, autonomous human being; and reducing notions of obedience and deference to authority. Blame is thus extricated from the healthcare relationship, reshaping the traditionally adversarial components of the interaction, and eliminating the view of adherence as a patient problem in need of patient-centred interventions.

HIV/AIDS: a minority health issue

HIV infection among racial and ethnic minorities is an ongoing health crisis. The disproportionate impact of HIV infection on racial and ethnic minorities has affected communities already struggling with many social and economic challenges, such as poverty, substance abuse, homelessness,unequal access to health care, and unequal treatment once in the health care system. Superimposed on these challenges is HIV infection, the transmission of which is facilitated by many of these factors. Although the epidemic is disproportionately affecting all racial and ethnic minorities, within these minority populations women are particularly affected. The care and management of racial and ethnic minorities who have HIV infection has been complicated by the unequal access to health care and the unequal treatment once enrolled in health care. Health insurance status, lack of concordance between the race of the patient and the provider, and satisfaction with the quality of their care all impact on treatment outcomes in this population. In addition, the provider must be aware of the many comorbid conditions that may affect the delivery of care to minority patients living with HIV infection: depression, substance and alcohol abuse, and posttraumatic stress disorders. The impact of these comorbid conditions on the therapeutic relationship, including treatment and adherence, warrants screening for these disorders and treating them when identified. Because the patient provider relationship has been repeatedly identified as a predictor of higher adherence, developing and maintaining a strong therapeutic alliance is critical. Participation of racial and ethnic minorities in HIV clinical trials, as in other disease states, has been very poor. Racial and ethnic minorities have been chronically underrepresented in HIV clinical trials, despite their overrepresentation in the HIV epidemiology. This underrepresentation seems to be the result of a combination of factors including (1) provider bias in referring to clinical trials, (2) mistrust of clinical research, (3) past poor experience with the health care system, and (4) the conspiracy theories of HIV disease. The paucity of minority health care professionals and minority investigators in HIV research further affects minority participation in clinical research. To improve racial and ethnic minority participation in clinical trials a sustained effort is necessary at multiple levels. Increased recruitment and retention is an ongoing need, and one that will not be satisfactorily addressed until there are better community-academic and research partner-ships, and the research questions posed also address issues of concern and significance to the affected community. Reduction in barriers to participation in clinical trials, especially given the many competing needs of racial and ethnic minority patients, is also needed. Multidisciplinary HIV care teams and research staff with training in cultural competency and cultural sensitivity may also be helpful. Prevention of HIV infection remains essential, especially among those seeking care for HIV infection. Despite several published recommendations for the inclusion of HIV prevention in the clinical care setting, studies have documented how few providers actually achieve this goal, especially those who care for disadvantaged patients. Although there are many barriers to discussing HIV risk behaviors and prevention strategies in an office visit,including time constraints and potential provider discomfort in discussing these matters, clinical visits represent an important opportunity to reinforce HIV prevention and possibly decrease further HIV transmission.

Understanding the interface of HIV, trauma, post-traumatic stress disorder, and substance use and its implications for health outcomes

Many individuals living with HIV have been exposed to some type of traumatic event during their lives and may be living with symptoms of post-traumatic stress disorder (PTSD). A substantial number of these individuals are also likely to show evidence of a co-morbid substance use disorder (SUD). There is reason to believe that the co-occurrence of HIV and PTSD or co-morbid PTSD and SUD (PTSD/SUD) may predict poorer health outcomes. There are several pathways through which PTSD or PTSD/SUD might adversely impact the health of individuals living with HIV, including participation in negative health behaviours, low levels of adherence to antiretroviral medications, and/or a direct, deleterious effect on immune function. Psychological interventions are needed to treat PTSD and PTSD/SUD in HIV-positive individuals, and reduce the negative impact of these conditions on health outcomes. This article will explore data on the prevalence of trauma exposure, PTSD, and PTSD/SUD among individuals living with HIV, the pathways through which these conditions might affect health, possible interventions for PTSD and PTSD/SUD for individuals living with HIV, and methods for integrating care for individuals with these disorders. Future directions for research related to HIV, PTSD, and PTSD/SUD will also be discussed.

Resisting medicines: a synthesis of qualitative studies of medicine taking

The study aimed to synthesise qualitative studies of lay experiences of medicine taking. Most studies focused on the experience of those not taking their medicine as prescribed, with few considering those who reject their medicines or accept them uncritically. Most were concerned with medicines for chronic illnesses. The synthesis revealed widespread caution about taking medicines and highlighted the lay practice of testing medicines, mainly for adverse effects. Some concerns about medicines cannot be resolved by lay evaluation, however, including worries about dependence, tolerance and addiction, the potential harm from taking medicines on a long-term basis and the possibility of medicines masking other symptoms. Additionally, in some cases medicines had a significant impact on identity, presenting problems of disclosure and stigma. People were found to accept their medicines either passively or actively, or to reject them. Some were coerced into taking medicines. Active accepters might modify their regimens by taking medicines symptomatically or strategically, or by adjusting doses to minimise unwanted consequences, or to make the regimen more acceptable. Many modifications appeared to reflect a desire to minimise the intake of medicines and this was echoed in some peoples' use of non-pharmacological treatments to either supplant or supplement their medicines. Few discussed regimen changes with their doctors. We conclude that the main reason why people do not take their medicines as prescribed is not because of failings in patients, doctors or systems, but because of concerns about the medicines themselves. On the whole, the findings point to considerable reluctance to take medicine and a preference to take as little as possible. We argue that peoples' resistance to medicine taking needs to be recognised and that the focus should be on developing ways of making medicines safe, as well as identifying and evaluating the treatments that people often choose in preference to medicines.

Medical illness and comorbidities in drug users: implications for addiction pharmacotherapy treatment

Providing effective medical care to those with substance use disorders can be a challenge to clinicians. In this article, we briefly summarize issues that occur frequently in the medical treatment of substance users. The focus of this article is twofold. The first is to briefly summarize common co-occurring medical illnesses in those manifesting substance use disorders with an emphasis on issues related to providing effective treatment for these diseases in this population. Using specific examples of frequently occurring comorbid medical illness in substance users, including infectious diseases (hepatitis C and HIV disease), sexually transmitted diseases, and pregnancy as examples, the complexities of medical care for this population is demonstrated. Second, this article addresses some of the difficulties encountered in pharmacotherapy aimed specifically at treatment of substance use disorders. For example, difficulties in managing concomitant opiate therapy in those requiring medications for medical illness that may have strong and adverse interactions with opiates are addressed. Adverse events reported for some substance use disorder pharmacotherapies are also highlighted. We conclude with a brief review of models of care that have been effective in addressing the needs of this challenging population that can provide additional means for enhancing the clinical care of substance users.

Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection

BACKGROUND

There is little evidence to support the widely accepted assertion that better physician-patient relationships result in higher rates of adherence with recommended therapies.

OBJECTIVE

To determine whether and which aspects of a better physician-patient relationship are associated with higher rates of adherence with antiretroviral therapies for persons with HIV infection.

DESIGN

Cross-sectional analysis.

SETTING

Twenty-two outpatient HIV practices in a metropolitan area.

PARTICIPANTS

Five hundred fifty-four patients with HIV infection taking antiretroviral medications.

MEASUREMENTS

We measured adherence using a 4-item self-report scale (alpha= 0.75). We measured core aspects of physician-patient relationships using 6 previously tested scales (general communication, HIV-specific information, participatory decision making, overall satisfaction, willingness to recommend physician, and physician trust; alpha > 0.70 for all) and 1 new scale, adherence dialogue (alpha= 0.92). For adherence dialogue, patients rated their physician at understanding and solving problems with antiretroviral therapy regimens.

RESULTS

Mean patient age was 42 years, 15% were female, 73% were white, and 57% reported gay or bisexual sexual contact as their primary HIV risk factor. In multivariable models that accounted for the clustering of patients within physicians' practices, 6 of the 7 physician-patient relationship quality variables were significantly (P < .05) associated with adherence. In all 7 models worse adherence was independently associated (P < .05) with lower age, not believing in the importance of antiretroviral therapy, and worse mental health.

CONCLUSIONS

This study showed that multiple, mutable dimensions of the physician-patient relationship were associated with medication adherence in persons with HIV infection, suggesting that physician-patient relationship quality is a potentially important point of intervention to improve patients' medication adherence. In addition, our data suggest that it is critical to investigate and incorporate patients' belief systems about antiretroviral therapy into adherence discussions, and to identify and treat mental disorders.

Does racial concordance between HIV-positive patients and their physicians affect the time to receipt of protease inhibitors?

BACKGROUND

Compared to whites, African Americans have been found to have greater morbidity and mortality from HIV, partly due to their lower use of effective antiretroviral therapy. Why racial disparities in antiretroviral use exist is not completely understood. We examined whether racial concordance (patients and providers having the same race) affects the time of receipt of protease inhibitors.

METHODS

We analyzed data from a prospective, cohort study of a national probability sample of 1,241 adults receiving HIV care with linked data from 287 providers. We examined the association between patient-provider racial concordance and time from when the Food and Drug Administration approved the first protease inhibitor to the time when patients first received a protease inhibitor.

RESULTS

In our unadjusted model, white patients received protease inhibitors much earlier than African-American patients (median 277 days compared to 439 days; P < .0001). Adjusting for patient characteristics only, African-American patients with white providers received protease inhibitors significantly later than African-American patients with African-American providers (median 461 days vs. 342 days respectively; P < .001) and white patients with white providers (median 461 vs. 353 days respectively; P= .002). In this model, no difference was found between African-American patients with African-American providers and white patients with white providers (342 vs. 353 days respectively; P > .20). Adjusting for patients' trust in providers, as well as other patient and provider characteristics in subsequent models, did not account for these differences.

CONCLUSION

Patient-provider racial concordance was associated with time to receipt of protease inhibitor therapy for persons with HIV. Racial concordance should be addressed in programs, policies, and future racial and ethnic health disparity research.

Outpatient pharmacy care and HIV viral load response among patients on HAART

Adherence to highly active antiretroviral therapy (HAART) is necessary to achieve long-term effectiveness. The impact of HIV/AIDS-specific pharmacy services on patient adherence and HIV viral suppression is currently not well described. This study aimed to compare the impact of differing levels of HIV-pharmacy care on adherence and time to HIV viral suppression among participants on HAART enrolled in a population-based HIV/AIDS drug treatment programme in British Columbia. We performed a retrospective observational study of 788 treatment-naïve patients who started HAART between August 1997 and July 2000 and were followed until 31 March 2002. The degree of outpatient pharmacy care was defined according to pharmacy dispensing site for the participants' first prescription of HAART: highest at the AIDS-tertiary care hospital outpatient pharmacies, intermediate at HIV/AIDS drug treatment programme funded off-site pharmacies and lowest at family physician's offices. Cox-proportional hazard models examined the independent effect of pharmacy dispensing site on time to two consecutive HIV viral suppressions controlling for other prognostic factors including physicians' experience, age, gender, injection drug use, use of therapy containing NNRTI versus PI, adherence >90%, AIDS diagnosis at baseline, baseline CD4 cell count and HIV viral load. The median time on antiretrovirals was 28 months (IQR=14-38). There were 489 (62.1%) participants who obtained their medications from the AIDS-tertiary care outpatient pharmacies; 98 (12.4%) from off-site pharmacies and 201 (25.5%) from their physicians' offices. The proportion of patients exhibiting >90% adherence to treatment was observed to be higher among patients receiving their HAART at the AIDS-tertiary care pharmacies compared to off-site pharmacies and to physicians' offices (70.4, 59.2 and 55.7%, respectively; p=0.0001). After adjusting for other prognostic factors, subjects who were first dispensed medications from the AIDS-tertiary care pharmacy were 1.42 times (CI: 1.10-1.84) more likely to achieve HIV viral suppression than those getting their medications from off-site pharmacies and physicians' offices. Providing regular outpatient pharmacy care is independently associated with improved HIV viral load response through enhanced adherence to HAART. Standardization of pharmacy practices for dispensing HAART may improve outcomes for patients who receive their HIV medications from other non-tertiary care pharmacy sites.

Impact of indinavir on the quality of life in patients with advanced HIV infection treated with zidovudine and lamivudine

OBJECTIVE

In AIDS Clinical Trial Group (ACTG) study 320, triple-combination antiretroviral therapy including indinavir significantly slowed progression to acquired immunodeficiency syndrome or death, compared with treatment with dual nucleoside reverse-transcriptase inhibitors (NRTIs) alone, in zidovudine-experienced patients with advanced human immunodeficiency virus (HIV) infection. We examined the impact of indinavir on quality of life in participants from this study.

METHODS

A total of 1156 protease inhibitor- and lamivudine-naive patients stratified by CD4 cell count (<or=50 and 51-200 cells/mm(3)) were randomized to receive zidovudine (or stavudine) and lamivudine, with or without indinavir. Health-related quality of life was measured using the ACTG QoL601-602 questionnaire, which assesses general health status measured on a visual analogue scale and 8 specific health-related domains. Quality-adjusted survival time was estimated using the visual analogue scale for general health.

RESULTS

Mean changes in general health scores after 24 weeks were +2.9 in the triple-therapy group versus -0.2 in the dual-therapy group (P=.018). By week 24, scores in all specific domains were higher with triple-drug therapy than dual-drug therapy, with statistically significant differences in role function, energy, and pain scores. Benefits of triple-drug therapy were largely confined to patients with CD4 cell counts of <or=50 cells/mm(3). Quality-adjusted survival time did not differ significantly between the 2 treatment groups.

CONCLUSIONS

Triple-drug therapy with indinavir and 2 NRTIs resulted in a significant improvement in general health status after 24 weeks, especially in patients with low CD4 cell counts. Patients receiving triple-drug therapy also had significantly better role function, energy, and pain scores than did patients treated with dual-drug therapy.

Brief motivational interviewing to improve adherence to antiretroviral therapy: development and qualitative pilot assessment of an intervention

Because successful HIV treatment requires exceptional adherence to antiretroviral therapy (ART), interventions to improve ART adherence are essential. We developed and pilot-tested an intervention to improve ART adherence, based on brief motivational interviewing (MI), which has successfully improved selected health behaviors but has not been tested for ART adherence. We administered the 15- to 30-minute MI session to 20 HIV-positive adults and assessed its usefulness and relevance. Then, we content-analyzed the session for HIV care issues and strategies most salient to patients in the MI session. During the session, all participants chose an HIV-care-related topic that they wanted to discuss, and talked about issues, barriers, and facilitators related to their topic. Most participants (70%) developed strategies to help improve their health. Questions asked after the MI session revealed that almost all (95%-100%) participants found the session useful and helpful. This theoretically based, empowering health counseling approach for HIV-positive persons warrants further research.

Methamphetamine abuse as a barrier to HIV medication adherence among gay and bisexual men

Medication adherence among persons with HIV infection is important not only because of the effect of non-adherence on an individual's health but also because non-adherence can lead to medication-resistant viral strains. However, adherence to HIV medications is difficult due to complex dosing regimens and side effects. This paper is a qualitative analysis of HIV medication adherence among gay and bisexual methamphetamine-abusing men enrolled in an outpatient drug treatment research project. As part of an open-ended, semi-structured interview, 23 HIV-infected men discussed the effects of their methamphetamine use on their medication adherence. Substance-use barriers to adherence were coded into two main themes: (1) planned non-adherence and (2) unplanned non-adherence. Planned non-adherence was a strategy for coping with demanding HIV medication schedules, or was linked to sexual behaviours while using methamphetamine or to fears of interaction effects from mixing methamphetamine with HIV medications. Participants did not define their medication regimen adjustments as non-adherence but as a way to achieve a sense of control over their lives. Unplanned non-adherence was linked to methamphetamine-related disruptions in food and sleep schedules. Findings are helpful in designing culturally specific HIV medication adherence interventions for this population.

Optimizing the care of minority patients with HIV/AIDS

Persons belonging to racial/ethnic minorities are disproportionately affected by human immunodeficiency virus (HIV) infection and/or acquired immunodeficiency syndrome (AIDS) in the United States, with higher numbers of infected individuals and higher HIV/AIDS-related death rates. Despite its substantial medical toll among minorities, HIV/AIDS has had a complex sociocultural legacy in many minority communities in the United States, especially in the African American community, which can present a challenge for patients and medical care providers. Many studies have found that minorities receiving care for HIV/AIDS are less likely to be satisfied with their HIV care and less likely to receive highly active antiretroviral therapy (HAART) than are other patients. The root causes of these disparities in care have not yet been well delineated. However, clinicians can optimize the care they provide for minority patients by using a cultural competence framework, enhancing patient-provider communication, diversifying their clinical staff, proactively enhancing receipt of HAART, and being attentive to issues related to adherence to HAART.

Factors that influence adherence to HIV medications: perceptions of women and health care providers

The purpose of this pilot study was to explore factors that influence adherence to antiretroviral therapy (ART) in women with human immunodeficiency virus (HIV) disease. Antiretroviral medications that reduce viral count and prolong the time between a diagnosis of HIV disease and acquired immunodeficiency syndrome (AIDS) are expensive, numerous, and have multiple side effects. Common reasons for not adhering to the medication regimen include ART side effects and a dosage schedule that disrupts daily activities. Failure to take or errors in taking ART can result in an exacerbation of symptoms and disease progression or the development of drug-resistant strains of HIV. Women and providers in separate focus groups identified factors that facilitated and hindered adherence to ART. Knowledge of factors that influence adherence to ART will facilitate the development of interventions. Patient-provider relationships and side effects of weight gain are discussed as factors that influence adherence to ART.

Factors affecting adherence to antiretroviral therapy in people living with HIV/AIDS

Antiretroviral treatments have given hope to people living with HIV/AIDS and play a role in improving their quality of life. However, the effectiveness of these treatments is directly related to the level of adherence and commitment to them. Researchers have demonstrated that there are many factors that play an important role in adopting and maintaining adherence behavior. In this article, the authors present an indepth review of the literature and from this, enumerate the factors that link adherence behavior to the individual, the treatment, the illness, and the relationship with the health professional. An understanding of these factors is essential to develop interventions that will improve adherence to therapeutic regimens among people with HIV/AIDS.