Measuring adherence to treatment of paediatric HIV/AIDS

Adolescent human immunodeficiency virus self-management: Associations with treatment adherence, viral suppression, sexual risk behaviours and health-related quality of life

Background

With the advent of access to antiretroviral treatment (ART), human immunodeficiency virus (HIV) has become a chronic disease and self-management is an important component of its care. Research to date has not explored associations between adolescent HIV self-management and treatment adherence, viral suppression, sexual risk behaviour and health-related quality of life (HRQoL).

Objectives

To explore the associations between adolescent HIV self-management and treatment adherence, viral suppression, sexual risk behaviour and HRQoL.

Methods

A quantitative cross-sectional study of 385 adolescents living with HIV (ALHIV) aged 13–18 years, who were recruited from 11 healthcare facilities between March and August 2017 in the Cape Metropole of the Western Cape, South Africa, provided the data that were examined in this self-completed questionnaire. Validated scales were used to measure key variables. The most recent viral load (VL) was obtained from the participants’ clinic folder, taking into account that VL is done annually.

Results

Adolescents who reported higher HIV self-management were more likely to be adherent to treatment (t = 4.435 [336], p < 0.01), virally suppressed (t = 2.376 [305], p = 0.02) and to practise consistent condom use (t = 1.947 [95], p = 0.54). Structural equation modelling (SEM) indicated a significant relationship between self-management and HRQoL (r = 0.43, p < 0.01), whilst non-adherent treatment taking behaviour, correlated with elevated VL log values. No significant correlation was found between self-management and sexual risk behaviour.

Conclusion

Targeting adolescents’ skills related to HIV self-management in the clinical setting may improve adolescents’ treatment taking behaviour, viral suppression rates and their HRQoL.

Using Lopinavir Concentrations in Hair Samples to Assess Treatment Outcomes on Second-Line Regimens Among Asian Children

We conducted a prospective monitoring study to determine whether antiretroviral (ARV) levels in hair of Asian children on second-line protease inhibitor-based ARV therapy (ART) are associated with virologic failure (VF), compared to plasma drug levels and self-reported adherence. HIV-infected Asian children on second-line ART regimens were enrolled into a longitudinal cohort. Traditional adherence measures, plasma, and hair samples were collected 24 weeks after study enrollment. Hair ARV levels were determined via liquid chromatography/tandem mass spectrometry. Among 149 children on lopinavir/ritonavir-based regimens, 47% were female; the median [interquartile range (IQR)] age was 10.3 (7.9-13.3) years. The median CD4% was 26% (IQR 21.7-32.1%) and the median CD4 cell count 754 (IQR 596-1,013) cells/mm(3). The median duration of lopinavir-based ART prior to week 24 of the study was 2.9 (IQR 1.6-4.2) years. Adherence was >95% in 91% (135/148) by visual analogue scale and 89% (129/145) by pill count. The median lopinavir hair concentrations were 5.43 (IQR 3.21-9.01) ng/mg in children with HIV RNA >1,000 copies/ml and 9.96 (IQR 6.51-12.31) ng/mg in children with HIV RNA <1,000 copies/ml (p = 0.003). Plasma trough and lopinavir hair concentrations were not statistically significantly correlated (Pearson's correlation coefficient 0.20; p = 0.13). Increasing lopinavir hair concentrations in quartiles were strongly associated with virologic success (odds ratios ≥4.0, overall p = 0.02), while self-reported adherence, pill count, and plasma lopinavir levels were not. Based on this first report of hair ARV concentrations and virologic outcomes in children, ARV hair concentrations, representing longer-term adherence, may be useful to identify children at risk for VF.

Evaluation of adherence measures of antiretroviral prophylaxis in HIV exposed infants in the first 6 weeks of life

BACKGROUND

Adherence to an antiretroviral regimen is imperative for treatment success in both HIV infected adults and children. Likewise, adherence to antiretroviral prophylaxis is critical in HIV prevention. Studies on pediatric adherence are limited, particularly the prophylactic use of antiretroviral drugs and treatment adherence in very young infants. The HIV Prevention Trials Network (HPTN) 046 study (Clinical Trial Registration NCT00074412) determined the safety and efficacy of an extended regimen of nevirapine suspension in infants born to HIV-1 infected women for the prevention of vertical HIV transmission during breastfeeding. As per protocol, adherence to nevirapine prophylaxis was measured by maternal verbal reports. In addition, the pharmacy assessed the unused returned suspension. The aim of this sub-study was to determine the reliability of maternal verbal reports in measuring adherence to antiretroviral prophylaxis in infants in the first 6 weeks of life and evaluating the unused returned nevirapine as an alternative method of measuring adherence.

METHODS

Maternal verbal reports and pharmacy returns indicative of "missed < 2 doses" were evaluated against a plasma nevirapine concentration of >100 ng/ml in a subgroup of infants at 2, 5 and 6 weeks of age. Plasma nevirapine concentration of >100 ng/ml was used as a marker of adherence (10 times the in vitro IC50 against HIV).

RESULTS

Adherence was 87.7% (maternal verbal report) and 71.3% (unused returned medication), as compared to 85.6% by plasma nevirapine concentration. Evaluated against plasma nevirapine concentration <100 ng/ml, the sensitivity and specificity of maternal verbal reports to detect a missed dose in the last 3 days were 75% and 78% (p = 0.03) respectively. Overall, among infants who were classified as adherent based on missed doses by maternal verbal reports and unused returned medication, 88.4% and 87.4% of infants attained a nevirapine concentration above 100 ng/ml respectively.

CONCLUSION

Maternal verbal reports are a reliable measure of adherence to infant antiretroviral prophylaxis in the first 6 weeks of life and could be useful in assessing adherence to antiretroviral treatment in infants younger than 6 weeks. In the absence of resources or expertise to determine plasma drug concentration, we would recommend random assessments of unused returned medication.

Assessment of HIV antiretroviral therapy adherence by measuring drug concentrations in hair among children in rural Uganda

Current tools for measuring medication adherence have significant limitations, especially among pediatric populations. We conducted a prospective observational study to assess the use of antiretroviral (ARV) drug levels in hair for evaluating antiretroviral therapy (ART) adherence among HIV-infected children in rural Uganda. Three-day caregiver recall, 30-day visual analog scale (VAS), Medication Event Monitoring System (MEMS), and unannounced pill counts and liquid formulation weights (UPC) were collected monthly over a one-year period. Hair samples were collected quarterly and analyzed for nevirapine (NVP) levels, and plasma HIV RNA levels were collected every six months. Among children with at least one hair sample collected, we used univariable random intercept linear regression models to compare log transformed NVP concentrations with each adherence measure, and the child's age, sex, and CD4 count percentage (CD4%). One hundred and twenty-one children aged 2-10 years were enrolled in the study; 74 (61%) provided at least one hair sample, and the mean number of hair samples collected per child was 1.9 (standard deviation [SD] 1.0). Three-day caregiver recall, VAS, and MEMS were found to be positively associated with increasing NVP concentration in hair, although associations were not statistically significant. UPC was found to have a nonsignificant negative association with increasing hair NVP concentration. In conclusion, NVP drug concentrations in hair were found to have nonsignificant, although generally positive, associations with other adherence measures in a cohort of HIV-infected children in Uganda. Hair collection in this population proved challenging, suggesting the need for community education and buy-in with the introduction of novel methodologies.

A meta-analysis of adherence to antiretroviral therapy and virologic responses in HIV-infected children, adolescents, and young adults

The relationship between adherence to antiretroviral therapy (ART) and virologic outcomes in HIV+ children, adolescents, and young adults has been notably understudied, with much of the extant research focused on specific sub-literatures, such as resource-limited regions, specific clinical outcomes and time frames. The authors sought to better characterize the relationship between adherence to ART and virologic functioning along various sample and methodological factors. The authors conducted a meta-analysis of thirty-seven studies and utilized a random effects model to generate weighted mean effect sizes. In addition, the authors conducted meta-ANOVAs to examine potential factors influencing the relationship between adherence and three categories of clinical outcomes, specifically Viral Load (VL) <100, VL < 400, and continuously measured VL. The analyses included 5,344 HIV+ children, adolescents, and young adults. The relationship between adherence behaviors and virologic outcomes varied across different methods of measurement and analysis. The relationship between adherence and continuously measured VL was significantly larger than for dichotomously-coded VL < 400 at Qb (20.69(1), p < .0005). Caregiver self-report indices elicited very small to small magnitude effects across both VL < 100 and VL < 400 outcomes and combined informant reporting (youth/adolescent and parent) produced significantly larger effects than caregiver report alone with adherence and VL < 400 outcomes at Qb (9.28(1), p < .005). More recently published trials reported smaller relationships between adherence and categorical clinical outcomes, such that year of publication significantly negatively correlated with VL < 100 (r = -.71(14), p < .005) and VL < 400 (r = -.43(26), p < .02). The data suggest that the magnitude of the relationship between ART adherence and virologic outcomes among heterogeneous samples of HIV+ children, adolescents and young adults varies across virologic outcomes and may be affected by moderating sample and methodological factors. Methodological and research recommendations for the interpretation of the current findings as well as for future HIV adherence related research are presented.

The effect of different intervention programs on treatment adherence of HIV-infected children, a retrospective study

In HIV-infected children, long-term adherence to combination anti-retroviral therapy (cART) is difficult. In this retrospective study, we evaluated the effect of two different treatment adherence programs on treatment adherence (as indicated by cART failures) and the need for additional supportive care measures in a cohort of 31 HIV-infected children between 3 and 18 years of age. In a follow-up period of 6 years, we evaluated the treatment adherence at baseline (before introduction of any treatment adherence program in 2004) and compared this to cART failures during two treatment adherence programs (in respectively 2006 and 2009). The need for additional supportive care measures (the frequency of hospitalizations, daily observed treatment, use of child protection service, attendance of special schools, and placement in foster homes) was also evaluated at these three time points. The first treatment adherence program focused on increasing patient's obedience by imposing negative measures in case of treatment failure, whereas the second program aimed to increase treatment adherence by rewarding optimal medication intake. Prior to start of any treatment adherence intervention program, cART failures were observed in 29% of the pediatric patients. After introduction of the first treatment adherence program, cART failures decreased to 6%. During the second treatment adherence program, the cART failures remained equally low (10%), but the need for some specific additional supportive care measures (the frequency of hospitalizations and placement in foster homes) was importantly reduced. Treatment adherence programs are effective in increasing treatment adherence to cART in HIV-infected children. A novel reward treatment interventional program as an addition to social supportive care programs is a promising new positive enforcement program and can reduce the need for additional supportive care programs. Further prospective studies are needed to evaluate the long-term effect of this new treatment intervention program.

Multisystemic therapy for poorly adherent youth with HIV: results from a pilot randomized controlled trial

Adherence to antiretroviral medication for the treatment of HIV is a significant predictor of virologic suppression and is associated with dramatic reductions in mortality and morbidity and other improved clinical outcomes for pediatric patient populations. Effective strategies for addressing adherence problems in youth infected with HIV are needed and require significant attention to the complex interplay of multiple, interacting causal risk factors that lead to poor self-care. Within the context of a pilot randomized trial, we evaluated the feasibility and initial efficacy of a multisystemic therapy (MST) intervention adapted to address HIV medication adherence problems against a usual care condition that was bolstered with a single session of motivational interviewing (MI). For 34 participating youth, health outcomes (viral load [VL] and CD4 count) were obtained from approximately 10 months pre-baseline through approximately 6 months post-baseline and self-reported medication adherence outcomes were obtained quarterly from baseline through 9 months post-baseline. Using mixed-effects regression models we examined within- and between-groups differences in the slopes of these outcomes. Feasibility was supported, with a 77% recruitment rate and near-maximal treatment and research retention and completion rates. Initial efficacy also was supported, with the MST condition but not the MI condition demonstrating statistically and clinically significant VL reductions following the start of treatment. There was also some support for improved CD4 count and self-reported medication adherence for the MST but not the MI condition. MST was successfully adapted to improve the health outcomes of youth poorly adherent to antiretroviral medications. Replication trials and studies designed to identify the mechanisms of action are important next steps.

Adherence to antiretroviral therapy in pediatric patients with human immunodeficiency virus (HIV-1)

The evaluation of HIV treatment adherence is essential to manage the development of resistant mutations, treatment failure, and disease progression in patients with HIV-1 infection; however, none of the commonly used measures of treatment adherence have been found to be accurate. The objective of this study was to evaluate three treatment adherence measures (caregiver reports, pharmacy refill, and appointment maintenance data) in association with viral load suppression in pediatric patients with HIV-1 infection. Although viral suppression was not found to be significantly associated with adherence defined by any single measure, treatment adherence could be predicted if all three measures were in agreement.

Medication adherence in adolescents with behaviorally-acquired HIV: evidence for using a multimethod assessment protocol

PURPOSE

The present study investigated medication adherence in an understudied population, adolescents with behaviorally acquired HIV, to improve upon prior methodological limitations using concurrent collection of HIV health status markers (viral load [VL]; percentage CD4 count [CD4%]) and multimethod adherence assessment (pill count, missed doses, off-schedule dosing).

PARTICIPANTS

A total of 60 youth with behaviorally acquired HIV receiving routine care in a multidisciplinary specialty clinic in the Mid-Southern United States. Adherence was assessed by routine pharmacy pill count and self-reported 3-day recall of doses missed and doses taken off-schedule, collected concurrently with clinically obtained VL and CD4% indicators. Adherence measures were evaluated as predictors of VL and CD4% using logistic regression analyses.

RESULTS

Adherence difficulties were detected by all assessment methods, with off-schedule dosing appearing the most problematic (29.4% taken off-schedule). Self-report of doses missed (p = .038) and off-schedule dosing (p = .021) significantly predicted detectable VL. For each percent increase in nonadherence by off-schedule dosing, there was a 2% increased likelihood of detectable VL. No adherence measure significantly correlated with CD4%; pharmacy pill count did not relate to either health status marker.

CONCLUSIONS

This study is the first to document multimethod medication adherence measurement in a defined sample of adolescents with behaviorally acquired HIV, using imposed concurrent collection of CD4% and VL. Adherence difficulties were detected regardless of assessment strategy, with off-schedule dosing representing the greatest nonadherence behavior. Both 3-day recall methods predicted VL. Further investigation of adherence in larger samples of youth with behaviorally acquired HIV is needed to better understand the relationship to CD4% suppression.

Multimethod adherence assessment in children with perinatally acquired HIV-1: the influence of off-schedule dosing in predicting biological markers

To improve upon adherence assessment in children with HIV, multimethod adherence strategies (pill count, missed doses, off-schedule dosing) were conducted concurrent with viral load and CD4% biomarker assays. Off-schedule dosing predicted both health status markers, while the more common strategies did not. Findings support inclusion of off-schedule dosing concurrent with collection of biomarkers to assess adherence in children with HIV.

Assessment of adherence to antiretroviral therapy in perinatally HIV-infected children and youth using self-report measures and pill count

BACKGROUND

Parent/caregiver or child/youth self-report and pill counts are commonly used methods for assessing adherence to antiretroviral therapy among children and youth with HIV. The purpose of this study was to compare these different methods with one another and with viral load.

METHODS

Randomly selected parent/caregiver and child/youth dyads were interviewed using several adherence self-report measures and an announced pill count was performed. Adherence assessment methods were compared with one another and their relative validity was assessed by comparison with the child's viral load close to the time of the interview or pill count, adjusting for primary caregiver, child age, and child disclosure of the diagnosis.

RESULTS

There were 151 evaluable participants. Adherence rate by pill count was >or=90% in 52% of participants, was significantly associated with log(RNA) viral load (p = .032), and had significant agreement with viral load <400 copies/mL. However, pill count data were incomplete for 26% of participants. With similar proportions considered adherent, a variety of self-report adherence assessment methods also were associated with log(RNA) viral load including: "no dose missed within the past 1 month" (p = .054 child/youth interview, p = .004 parent/caregiver interview), and no barrier to adherence identified (p = .085 child/youth interview, p = .015 parent/caregiver interview). Within-rater and inter-rater agreement was high among self-report methods. Three day recall of missed doses was not associated with viral load.

CONCLUSION

Findings demonstrate the validity of adherence assessment strategies that allow the parent/caregiver or child/youth to report on adherence over a longer period of time and to identify adherence barriers. Adherence assessed by announced pill count was robustly associated with viral load, but there was incomplete data for many participants.

Evidence-based assessment of adherence to medical treatments in pediatric psychology

OBJECTIVES

Adherence to medical regimens for children and adolescents with chronic conditions is generally below 50% and is considered the single, greatest cause of treatment failure. As the prevalence of chronic illnesses in pediatric populations increases and awareness of the negative consequences of poor adherence become clearer, the need for reliable and valid measures of adherence has grown.

METHODS

This review evaluated empirical evidence for 18 measures utilizing three assessment methods: (a) self-report or structured interviews, (b) daily diary methods, and (c) electronic monitors.

RESULTS

Ten measures met the "well-established" evidence-based (EBA) criteria.

CONCLUSIONS

Several recommendations for improving adherence assessment were made. In particular, consideration should be given to the use of innovative technologies that provide a window into the "real time" behaviors of patients and families. Providing written treatment plans, identifying barriers to good adherence, and examining racial and ethnic differences in attitudes, beliefs and behaviors affecting adherence were strongly recommended.

A systematic review of pediatric adherence to antiretroviral therapy in low- and middle-income countries

BACKGROUND

Sustaining antiretroviral therapy (ART) adherence requires accurate, consistent monitoring, a particular challenge for low-income countries. The optimal strategy to measure pediatric adherence remains unclear.

OBJECTIVE

To conduct a systematic review of pediatric ART adherence measurement techniques, adherence estimates, and clinical correlates in low- and middle-income countries to inform ART adherence monitoring.

METHODS

We searched online bibliographic databases, including MEDLINE and EMBASE, using systematic criteria. Two reviewers selected all descriptive or interventional studies involving nonpregnant, HIV-positive individuals < or =18 years old that measured ART adherence in low- or middle-income countries as defined by World Bank criteria. Data were extracted regarding sample characteristics, study setting, measurement strategy, adherence estimate, and adherence correlates.

RESULTS

The search yielded 1566 titles, of which 17 met selection criteria. Adherence measurement strategies included self- or proxy-report measures (14 studies), pill counts (4 studies), pharmacy records, drug levels, clinic adherence, and directly observed therapy (1 study each). The self- or proxy-report measures were heterogeneous, and few employed validation strategies. Caregiver-reported adherence was generally higher than self-report estimates. Pill counts revealed lower adherence estimates. Estimates of ART adherence ranged from 49% to 100%, with 76% of articles reporting >75% adherence. Factors related to family structure, socioeconomic status, disclosure, and medication regimen were all significantly associated with ART adherence.

CONCLUSIONS

Pediatric HIV care programs in low- and middle-income countries use heterogeneous methods to measure ART adherence. Adherence estimates vary substantially, but most studies from low- and middle-income countries report >75% adherence, whereas most studies from high-income countries report <75% adherence.

Adherence to antiretroviral therapy for pediatric HIV infection: a qualitative systematic review with recommendations for research and clinical management

Although nonadherence to prescribed therapies is widespread, it is particularly problematic with highly active antiretroviral therapy for HIV infection. This review of >50 studies in the area of pediatric HIV infection revealed varying methods for assessing antiretroviral adherence with a wide range of estimates of adherence. Correlates of adherence could be grouped as those relating to the medication, the patient, and the caregiver/family, with many conflicting findings and a lack of theory guiding the research. Only 8 studies, mainly small feasibility or pilot investigations, evaluated highly active antiretroviral therapy adherence interventions in pediatric populations. We conclude with specific recommendations for assessment and clinical management of adherence and discuss directions for future research in this area.

Health risk behaviors among HIV-infected youth in Bangkok, Thailand

PURPOSE

To describe health risk behaviors, including sexual risk, alcohol/substance use, and medication adherence in HIV-infected youth in Bangkok. Despite the high burden of HIV in developing countries compared with developed countries, considerably more information is available in the latter compared with the former regarding adolescent health risk behaviors. Currently there is no information on health risk behaviors among HIV-infected youth in Thailand.

METHODS

HIV-infected Thai youth 16-25 years of age were enrolled. Participants were seen at a baseline visit and a 3-month visit to assess health risk behaviors. The interviews were completed at both visits.

RESULTS

There were 29 men and 41 women. Twenty-eight participants (40%) were on antiretroviral therapy at baseline visit. Mean adherence was 94.3-98.2% over the past month and 90.9-96.3% over the past 3 months, though up to one-third reported less than 95% adherence. The proportion of youth with consistent condom use in the previous 30 days at baseline (55.6%) was comparable to the proportion at 3-month visit (58.3%) (p = 1.0). Men were more likely to have a partner with unknown human immunodeficiency virus (HIV) status and were less likely to disclose HIV status to their partners. Forty-nine youth (70.0%) had used alcohol in the past 12 months; nine (12.9%) had used more than 20 times. Approximately 1/4 had used alcohol in the previous 30 days at baseline and at 3-month visit. Substance use besides cigarettes was uncommon.

CONCLUSION

Levels of treatment adherence were high among Thai youth receiving antiretroviral therapy. Alcohol use was prevalent, though other drug use was not. Sexual acts without a condom in both genders and nondisclosure among males were concerning. Interventions focusing on sexual risk reduction for HIV-infected youth are needed and must be scaled up in Thailand.

Brief report: assessing adherence to pediatric antiretroviral regimens using the 24-hour recall interview

OBJECTIVE

Examine the 24-hr Recall Interview (24RI) for assessing children's antiretroviral medication adherence.

METHODS

Caregivers of 54 children with HIV (aged 2-12 years) completed a clinical adherence interview and the 24RI by telephone. Children's viral load and 3-month pharmacy records were obtained.

RESULTS

Thirty-seven percent of children missed > or = 1 dose of medicine over 3 days. In 22% of the samples, adherence varied across medications. The 24RI adherence scores (Frequency, Interval, and Dietary Adherence) were moderately reliable across the three interviews. Pharmacy refill rates were significantly related to viral load, and 24RI barriers were marginally significantly related to viral load.

CONCLUSIONS

The 24RI, with its systematic, cued recall, and decreased focus on adherence, may reduce socially desirable responding compared to other self-report methods, and reporting adherence barriers may indicate adherence difficulty. However, the validity of the 24RI must be improved to make it a useful measure to include in an adherence assessment battery.

Use of multisystemic therapy to improve antiretroviral adherence and health outcomes in HIV-infected pediatric patients: evaluation of a pilot program

The purpose of the current study was to evaluate a clinical program that used multisystemic therapy (MST) to improve regimen adherence and health outcomes among children with perinatally acquired HIV who exhibited high viral loads in the absence of viral resistance. MST is an intensive, home-based family therapy previously used for the treatment of serious antisocial behavior. Goals of the study were to assess the feasibility of the MST program and its effectiveness for improving health outcomes among children who were treated. The study was conducted by retrospective chart review. Ninety percent of children and families referred to the program accepted the referral and 95% received a full dose of treatment, suggesting high program feasibility. Nineteen children participated in the program. General HIV knowledge on the part of caregivers improved significantly over the course of treatment. Although caregiver-reported adherence did not change, viral loads were found to significantly decrease from referral to the end of MST treatment, with the mean change reflecting a greater than 1 log10 decrease. The majority of children maintained these improvements during the 3 months after treatment termination. Results suggest that MST holds promise as an intervention for improving health outcomes among pediatric patients with HIV.

Evaluation of a peer support group therapy for HIV-infected adolescents

OBJECTIVE

To assess the effects of a peer support group therapy on HIV-infected adolescents.

DESIGN

A prospective study of a cohort of HIV-infected adolescents participating or not participating in a psychodynamic oriented, emotional support group.

METHODS

From a group of 30 perinatally HIV-infected adolescents who attended an outpatient clinic, 10 agreed to participate in the peer support group (group 1), 10 declined (group 2) and 10 others who lived too far from the clinic were not invited to participate (group 3). The three groups were compared at baseline and 2 years later using the outcome measures: perceived illness experience scale, perceived treatment inventory, self-esteem inventory.

RESULTS

At baseline, the three groups had similar characteristics overall. The adolescents' self-esteem was in the normal range. After 2 years, worries about illness had decreased in group 1, whereas the scores had increased or remained the same for the other adolescents (P = 0.026). The adolescents in group 1 had less negative perception of treatment at 2 years than those in groups 2 and 3 (P = 0.030). After intervention, the percentage of adolescents with an undetectable viral load had increased in group 1 from 30 to 80% (P = 0.063) but was unchanged in groups 2 and 3. Considering the three groups altogether, the decrease in the viral load correlated with improvement of the perceived treatment inventory (Spearman R = 0.482 P = 0.015).

CONCLUSIONS

: This pilot study suggests that a peer support group intervention is associated with an improvement in adolescents' emotional well being, and that this can have a positive influence on medical outcomes.