Psychosocial factors associated with adherence to antiretroviral medications in a sample of HIV-positive African American drug users

Forgetting to take HIV antiretroviral therapy: a qualitative exploration of medication adherence in the third decade of the HIV epidemic in the United States

Optimal adherence to HIV antiretroviral therapy (ART) is challenging, and racial/ethnic disparities in adherence rates are substantial. The most common reason persons living with HIV (PLWH) give for missed ART doses is forgetting. We took a qualitative exploratory approach to describe, from the perspectives of African American/Black and Hispanic/Latino PLWH, what it means to forget to take ART and factors that influence forgetting. Participants (N = 18) were purposively sampled for maximum variability and engaged in semi-structured/in-depth interviews on HIV/ART management. The analysis took a directed content analysis approach. Participants were mostly male (56%) and African American/Black (79%), between 50 and 69 years old, and had lived with HIV for an average of 21 years. Findings were organised into six inter-related themes: (1) forgetting to take ART was a shorthand description of a complex phenomenon, but rarely a simple lapse of memory; (2) ‘forgetting’ was means of managing negative emotions associated with HIV; (3) life events triggered mental health distress/substance use which disrupted adherence; (4) historical traumatic events (including AZT monotherapy) and recent trauma/loss contributed to forgetting; (5) patient-provider interactions could support or impede adherence; and (6) intrinsic motivation was fundamental. Implications for HIV social service and health care settings are described.

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.

What do HIV-positive drug users' experiences tell us about their antiretroviral medication-taking? An international integrated literature review

BACKGROUND AND AIMS

HIV-positive drug users' poor adherence to antiretroviral regimens can pose a significant and negative impact on individual and global health. This review aims to identify knowledge gaps and inconsistencies within the current evidence base and to measure HIV-positive drug users' adherence rates and the factors that influence their adherence.

METHODS

A search of quantitative and qualitative studies in relation to HIV-positive drug users' adherence to antiretroviral treatment was performed using five databases: Applied Social Sciences Index and Abstract (ASSIA), Cumulative Index to Nursing and Allied Health Literature (CINAHL), Medline, Embase and PsycINFO (Ovid interface). Relevant studies were retrieved based on the inclusion and exclusion criteria stated in the review. Findings were compared, contrasted and synthesized to provide a coherent account of HIV-positive drug users' adherence rates and the factors that influence their adherence.

RESULTS

The proportion of HIV-positive drug users who achieved ≥ 95% adherence across the studies varied widely, from 19.3 to 83.9%. Adherence rates changed over the course of HIV treatment. The factors that influenced adherence were reported as follows: stigmatization, motivation, active drug use, accessibility and conditionality of HIV and addiction care, side effects and complexity of treatment regimens, forgetfulness and non-incorporation of dosing times into daily schedules.

CONCLUSIONS

HIV-positive drug users' medication-taking is a dynamic social process that requires health professionals to assess adherence to HIV treatment on a regular basis.

Understanding HIV-positive drug users' experiences of taking highly active antiretroviral treatment: Identity-Values-Conscious engagement model

AIM

To explore HIV-positive drug users' experiences of taking antiretroviral medications in Taiwan and further develop a conceptual model that can be used to understand their adherence to the long-term treatment.

BACKGROUND

The global vision of ending AIDS by 2030 cannot be achieved without addressing HIV-positive drug users' experience of taking antiretroviral treatment. There remains a paucity of qualitative evidence on HIV-positive drug users' experiences of taking antiretroviral medications globally and in East Asia. Nurses play a key role in supporting HIV-positive drug users throughout their treatment process. Therefore, it is pivotal to understand HIV-positive drug users' experiences of managing long-term anti-HIV treatment.

DESIGN

This qualitative study drew on a constructivist grounded theory approach to achieve the aims. Semi-structured in-depth interviews with 22 HIV-positive drug users were conducted in Taiwan between September 2015 and July 2016. Data were analysed using Charmaz's coding principles. The integration and formation of the model began with focused coding and proceeded through the subsequent analytic process. The reporting of this study was based on the Consolidated Criteria for Reporting Qualitative Research checklist.

RESULTS

This study shows that integrating HIV-positive identity into sense of self laid a solid foundation for the acceptance of self and antiretroviral treatment. Valuing of antiretroviral treatment played a central role in driving their medication-taking behaviour. While valuing the treatment appeared to drive participants' behavioural change, data revealed that conscious engagement was an important element for their behaviour maintenance.

CONCLUSION

The evidence from this study can extend our knowledge of the mechanisms that influence the change and maintenance of HIV-positive drug users' adherence to antiretroviral treatment.

RELEVANCE TO CLINICAL PRACTICE

The Identity-Values-Conscious engagement model developed and proposed in this study can serve as a guide for the development of tailored adherence assessment and associated nursing interventions for this population.

Methods for Measuring Multiple Medication Adherence: A Systematic Review-Report of the ISPOR Medication Adherence and Persistence Special Interest Group

BACKGROUND

A broad literature base exists for measuring medication adherence to monotherapeutic regimens, but publications are less extensive for measuring adherence to multiple medications.

OBJECTIVES

To identify and characterize the multiple medication adherence (MMA) methods used in the literature.

METHODS

A literature search was conducted using PubMed, PsycINFO, the International Pharmaceutical Abstracts, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library databases on methods used to measure MMA published between January 1973 and May 2015. A two-step screening process was used; all abstracts were screened by pairs of researchers independently, followed by a full-text review identifying the method for calculating MMA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic review. For studies that met the eligibility criteria, general study and adherence-specific characteristics and the number and type of MMA measurement methods were summarized.

RESULTS

The 147 studies that were included originated from 32 countries, in 13 disease states. Of these studies, 26 used proportion of days covered, 23 used medication possession ratio, and 72 used self-reported questionnaires (e.g., the Morisky Scale) to assess MMA. About 50% of the studies included more than one method for measuring MMA, and different variations of medication possession ratio and proportion of days covered were used for measuring MMA.

CONCLUSIONS

There appears to be no standardized method to measure MMA. With an increasing prevalence of polypharmacy, more efforts should be directed toward constructing robust measures suitable to evaluate adherence to complex regimens. Future research to understand the validity and reliability of MMA measures and their effects on objective clinical outcomes is also needed.

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

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

Intimacy versus isolation: a qualitative study of sexual practices among sexually active HIV-infected patients in HIV care in Brazil, Thailand, and Zambia

The success of global treatment as prevention (TasP) efforts for individuals living with HIV/AIDS (PLWHA) is dependent on successful implementation, and therefore the appropriate contribution of social and behavioral science to these efforts. Understanding the psychosocial context of condomless sex among PLWHA could shed light on effective points of intervention. HPTN 063 was an observational mixed-methods study of sexually active, in-care PLWHA in Thailand, Zambia, and Brazil as a foundation for integrating secondary HIV prevention into HIV treatment. From 2010–2012, 80 qualitative interviews were conducted with PLWHA receiving HIV care and reported recent sexual risk. Thirty men who have sex with women (MSW) and 30 women who have sex with men (WSM) participated in equal numbers across the sites. Thailand and Brazil also enrolled 20 biologically-born men who have sex with men (MSM). Part of the interview focused on the impact of HIV on sexual practices and relationships. Interviews were recorded, transcribed, translated into English and examined using qualitative descriptive analysis. The mean age was 25 (SD = 3.2). There were numerous similarities in experiences and attitudes between MSM, MSW and WSM across the three settings. Participants had a high degree of HIV transmission risk awareness and practiced some protective sexual behaviors such as reduced sexual activity, increased use of condoms, and external ejaculation. Themes related to risk behavior can be categorized according to struggles for intimacy and fears of isolation, including: fear of infecting a sex partner, guilt about sex, sexual communication difficulty, HIV-stigma, and worry about sexual partnerships. Emphasizing sexual health, intimacy and protective practices as components of nonjudgmental sex-positive secondary HIV prevention interventions is recommended. For in-care PLWHA, this approach has the potential to support TasP. The overlap of themes across groups and countries indicates that similar intervention content may be effective for a range of settings.

The problem of late ART initiation in Sub-Saharan Africa: a transient aspect of scale-up or a long-term phenomenon?

Efforts to scale-up HIV care and treatment have been successful at initiating large numbers of patients onto antiretroviral therapy (ART), although persistent challenges remain to optimizing scale-up effectiveness in both resource-rich and resource-limited settings. Among the most important are very high rates of ART initiation in the advanced stages of HIV disease, which in turn drive morbidity, mortality, and onward transmission of HIV. With a focus on sub-Saharan Africa, this review article presents a conceptual framework for a broader discussion of the persistent problem of late ART initiation, including a need for more focus on the upstream precursors (late HIV diagnosis and late enrollment into HIV care) and their determinants. Without additional research and identification of multilevel interventions that successfully promote earlier initiation of ART, the problem of late ART initiation will persist, significantly undermining the long-term impact of HIV care scale-up on reducing mortality and controlling the HIV epidemic.

Assessing and treating forgetfulness and cognitive problems in adults with HIV

In addition to the immune system, HIV affects the nervous system and the brain, producing neurological sequelae, often resulting in forgetfulness and cognitive problems. These problems can compromise medication adherence, interfere with instrumental activities of daily living such as driving and managing finances, increase dependency, and decrease quality of life. Cognitive problems emerge due to a variety of reasons; likewise, several evidence-based methods to mitigate causes and compensate for cognitive problems can be used alone or in combination. This article focuses on nonpathological, nondementia forgetfulness and cognitive problems. However, dementia must be considered and assessed as measured by marked cognitive decline over time. Methods for assessing and measuring forgetfulness and cognitive problems are provided. In addition, methods of treating nonpathological cognitive problems are provided, ranging from Recommended for Practice to Not Recommended for Practice. A case study is presented to demonstrate how to implement recommended treatment options.

Racial/Ethnic disparities in ART adherence in the United States: findings from the MACH14 study

BACKGROUND

Minority race/ethnicity is generally associated with antiretroviral therapy nonadherence in US-based studies. Limitations of the existing literature include small samples, subjective adherence measures, and inadequate control for potential confounders such as mental health and substance use, which have been consistently associated with poorer adherence.

METHODS

Individual-level data were pooled from 13 US-based studies employing electronic drug monitoring to assess adherence. Adherence was operationalized as percent of prescribed doses taken from the first 12 (monthly) waves of data in each study. Depression symptoms were aggregated from several widely used assessments, and substance use was operationalized as any use of cocaine/stimulants, heroin/opiates, ecstasy, hallucinogens, or sedatives in the 30-365 days preceding baseline.

RESULTS

The final analytic sample of 1809 participants ranged in age from 18 to 72 years and was 67% male. Participants were 53% African American, 14% Latino, and 34% White. In a logistic regression adjusting for age, gender, income, education, and site, race/ethnicity was significantly associated with adherence (P < 0.001) and persisted in a model that also controlled for depression and substance use (P < 0.001), with African Americans having significantly lower adherence than Latinos [odds ratio (OR) = 0.72, P = 0.04] and whites (OR = 0.60, P < 0.001). Adherence did not differ between whites and Latinos (OR = 0.84, P = 0.27).

CONCLUSIONS

Racial/ethnic differences in demographics, depression, and substance abuse do not explain the lower level of antiretroviral therapy adherence in African Americans observed in our sample. Further research is needed to explain the persistent disparity and might examine factors such as mistrust of providers, health literacy, and inequities in the health care system.

Potential risk factors for medication non-adherence in patients with chronic obstructive pulmonary disease (COPD)

AIMS

To investigate the effect of a range of demographic and psychosocial variables on medication adherence in chronic obstructive pulmonary disease (COPD) patients managed in a secondary care setting.

METHODS

A total of 173 patients with a confirmed diagnosis of COPD, recruited from an outpatient clinic in Northern Ireland, participated in the study. Data collection was carried out via face-to-face interviews and through review of patients' medical charts. Social and demographic variables, co-morbidity, self-reported drug adherence (Morisky scale), Hospital Anxiety and Depression (HAD) scale, COPD knowledge, Health Belief Model (HBM) and self-efficacy scales were determined for each patient.

RESULTS

Participants were aged 67 ± 9.7 (mean ± SD) years, 56 % female and took a mean (SD) of 8.2 ± 3.4 drugs. Low adherence with medications was present in 29.5 % of the patients. Demographic variables (gender, age, marital status, living arrangements and occupation) were not associated with adherence. A range of clinical and psychosocial variables, on the other hand, were found to be associated with medication adherence, i.e. beliefs regarding medication effectiveness, severity of COPD, smoking status, presence of co-morbid illness, depressed mood, self-efficacy, perceived susceptibility and perceived barriers within the HBM (p < 0.05). Logistic regression analysis showed that perceived ineffectiveness of medication, presence of co-morbid illness, depressed mood and perceived barriers were independently associated with medication non-adherence in the study (P < 0.05).

CONCLUSIONS

Adherence in COPD patients is influenced more by patients' perception of their health and medication effectiveness, the presence of depressed mood and co-morbid illness than by demographic factors or disease severity.

Binge use of crack cocaine and sexual risk behaviors among African-American, HIV-positive users

This study describes binge use of crack cocaine, binge users, and their sexual risk behaviors in a sample of 303 African-American, HIV-positive users. Recent binge use was defined as, "using as much crack cocaine as you can, until you run out of crack or are unable to use any more" in the last 30 days. Fifty-one percent reported a recent crack binge. The typical crack binge lasted 3.7 days and involved smoking 40 rocks on average. Nearly two-thirds reported their last binge was in their own or another's home. Seventy-two percent had sex during the last binge, with an average of 3.1 partners. In multivariable logistic regression analyses, recent bingers were more likely than non-bingers to consider themselves homeless, to have any income source, to have used crack longer, and to score higher on risk-taking and need for help with their drug problem. In multivariable ordinal and logistic regression analyses, recent bingers had more sex partners in the last six months and 30 days and were more likely to have never used a condom in the last 30 days. Among male users, recent bingers were more likely to report lifetime and recent exchange of money for sex and drugs for sex. Among both male and female users, recent bingers were more likely to report lifetime trading of sex for drugs. African-American, HIV-positive binge users of crack cocaine appear to be at increased risk for HIV transmission. Further investigations of binge crack use and sexual risk behaviors and interventions targeting and tailored to this group should be considered.

Exploring physical activity behaviour of persons with multiple sclerosis: a qualitative pilot study

PURPOSE

Identify facilitators and barriers to physical activity (PA), and explore the utility of Social Cognitive Theory (SCT) and Transactional Model of Stress and Coping (TMSC) in understanding PA behaviour among persons with multiple sclerosis (MS).

METHODS

Thirteen participants from a clinical trial were interviewed and classified as physically active, sometimes active or inactive based on the Health-Promoting Lifestyle Profile-II. Interviews were analysed using analytical induction, which consisted of coding data into pre-established categories and then exploring similarities and differences between groups. Pre-established coding categories were constructs from SCT (i.e. environment, expectations, self-efficacy and self-regulation) and TMSC (i.e. stress appraisal and coping style).

RESULTS

Inactive and active participants differed in their self-regulation skills, self-efficacy and coping styles. Common barriers to PA included symptoms and the physical and social environment. Facilitators of PA included strong self-regulation skills, confidence to overcome symptoms to engage in PA (i.e. barrier self-efficacy) and positive coping styles.

CONCLUSION

Results from this pilot study suggest that PA interventions will need to implement multiple strategies that target self-efficacy, social environment and coping styles. We found SCT and TMSC useful in understanding PA behaviour among persons with MS; however, a limitation to these theories is that they are not explicit in the relationship between health and cognitions. Future research will need to explore how to incorporate models of health and function into existing behaviour change theories.

Diagnostic value of different adherence measures using electronic monitoring and virologic failure as reference standards

Nonadherence to antiretroviral therapy is a substantial problem in HIV and jeopardizes the success of treatment. Accurate measurement of nonadherence is therefore imperative for good clinical management but no gold standard has been agreed on yet. In a single-center prospective study nonadherence was assessed by electronic monitoring: percentage of doses missed and drug holidays and by three self reports: (1) a visual analogue scale (VAS): percentage of overall doses taken; (2) the Swiss HIV Cohort Study Adherence Questionnaire (SHCS-AQ): percentage of overall doses missed and drug holidays and (3) the European HIV Treatment Questionnaire (EHTQ): percentage of doses missed and drug holidays for each antiretroviral drug separately. Virologic failure prospectively assessed during 1 year, and electronic monitoring were used as reference standards. Using virologic failure as reference standard, the best results were for (1) the SHCS-AQ after electronic monitoring (sensitivity, 87.5%; specificity, 78.6%); (2) electronic monitoring (sensitivity, 75%; specificity, 85.6%), and (3) the VAS combined with the SHCS-AQ before electronic monitoring (sensitivity, 87.5%; specificity, 58.6%). The sensitivity of the complex EHTQ was less than 50%. Asking simple questions about doses taken or missed is more sensitive than complex questioning about each drug separately. Combining the VAS with the SHCS-AQ seems a feasible nonadherence measure for daily clinical practice. Self-reports perform better after electronic monitoring: their diagnostic value could be lower when given independently.

Associations among correlates of schedule adherence to antiretroviral therapy (ART): a path analysis of a sample of crack cocaine using sexually active African-Americans with HIV infection

Adherence to HIV medication regimens is a function of multiple dimensions including psychological functioning, social support, adherence self-efficacy and optimism regarding treatment. Active substance use can also negatively affect adherence. An understanding of the nature of the associations among the correlates of adherence can better inform the design of interventions to improve adherence. This study developed an exploratory path model of schedule adherence using data from a sample 130 African-American HIV-positive crack cocaine users on highly active antiretroviral therapy (ART). This model was based on the Transactional Model of Stress and Coping developed by Lazarus and Folkman. Following the theory, the effects of psychological distress on schedule adherence were mediated by patients' relationship with their doctor and optimism towards antiretroviral treatment. Adherence was also associated with patients' self-efficacy regarding their medical regimen which, in turn, was associated with their social support.

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.

Factors associated with nonadherence to highly active antiretroviral therapy: a 5-year follow-up analysis with correction for the bias induced by missing data in the treatment maintenance phase

This study aimed to identify factors associated with nonadherence during the maintenance phase of highly active antiretroviral therapy (months 12-60) in the Anti PROtease Cohort (APROCO) cohort after correcting for the bias due to missing outcome data. A Heckman 2-stage approach (generalized estimating equations probit model) was used to compare visits with moderate or poor adherence and visits with high adherence. Between months 12 and 60, at least 1 self-reported adherence measure was available for 970 of the 1110 patients with at least 12 months of follow-up (3889 visits with adherence assessments). Adherence was rated as high at 2466 visits, moderate at 1125, and poor at 298. After adjustment for "missingness," moderate and poor adherence were independently associated with age (younger), perceived treatment side effects, dosing frequency different from twice daily, and a protease inhibitor-based regimen. They were also associated with depression and lack of support from the main partner. High adherence was most likely among patients born outside the European Union. A comparison restricted to poor-adherence and high-adherence visits yielded a similar pattern of predictors. Adjusting for missing outcome data changed the predictor set. Reasons for nonadherence are multifactorial. Psychosocial interventions and the selection of the best-tolerated regimens are needed to improve long-term adherence of HIV-infected patients to their lifelong treatment.

Caregiver psychosocial characteristics and children's adherence to antiretroviral therapy

Although parents and caregivers may have primary responsibility for their children's medication- taking, surprisingly few studies have examined caregiver psychosocial correlates of children's adherence to antiretroviral therapy (ART). This cross-sectional, descriptive study examined the relationship between caregiver psychosocial characteristics and medication adherence among children with HIV. Fifty-four caregivers of children with HIV completed a demographic questionnaire, the Parenting Stress Index, the Brief Symptom Inventory, the Family Support Scale, and the Support Functions Scale. Adherence to ART was measured with children's 6-month pharmacy refill histories. Children and caregivers were primarily African American, urban, and poor (63% reported <$15,000 annual household income). Univariate analyses showed that an adherent classification (>/= 80% refill rate) was associated with shorter duration of highly active antiretroviral therapy (HAART) treatment, nondisclosure of the HIV diagnosis to the child, lower caregiver income level, having a nonbiologically related caregiver, and less caregiver psychiatric distress. In a multivariate logistic regression, duration of child's HAART treatment, child HIV disclosure status, caregiver income, and caregiver psychiatric distress accounted for 63% of the variance in adherence. Findings highlight the complexity of children's adherence to ART and the need for multicenter studies with greater sample sizes to explore in more detail the effects of caregiver psychological distress and child HIV disclosure status on adherence as well as the ways in which regimen fatigue and adherence fluctuate over time.