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Non-adherence to Medications in Pregnant Ulcerative Colitis Patients Contributes to Disease Flares and Adverse Pregnancy Outcomes. Dig Dis Sci 2021; 66:577-586. [PMID: 32249373 DOI: 10.1007/s10620-020-06221-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Accepted: 03/18/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Adherence to medications is important to maintain disease under control and to prevent complications in pregnant patients with ulcerative colitis (UC). To evaluate the incidence of non-adherence during pregnancy and its effect on relapse and pregnancy outcomes, we conducted a multicenter prospective study using a patient self-reporting system without physician interference. METHODS Sixty-eight pregnant UC women were recruited from 17 institutions between 2013 and 2019. During the course of pregnancy, questionnaires were collected separately from patients and physicians, to investigate the true adherence to medications, disease activity, and birth outcomes. Multivariable logistic regression analysis was performed to identify the risk factors for the relapse or adverse pregnancy outcomes. RESULTS Of 68 pregnancy, 15 adverse pregnancy outcomes occurred in 13 patients. The rate of self-reported non-adherence was the greatest to mesalamines in the first trimester, which was significantly higher than physicians' estimate (p = 0.0116), and discontinuation was observed in 42.1% of non-adherent group. Logistic regression analysis revealed non-adherence as an independent risk factor for relapse [odds ratio (OR) 7.659, 95% CI 1.928-30.427, p = 0.038], and possibly for adverse pregnancy outcome (OR 8.378, 95% CI 1.350-51.994, p = 0.023). Among the subgroup of patients treated with oral mesalamine alone, the non-adherence was confirmed to be an independent risk factor for relapse (p = 0.002). CONCLUSION Non-adherence to mesalamine was underestimated by physicians in pregnant UC patients and contributed to disease relapse and possibly on pregnancy outcomes. Preconceptional education regarding safety of medications and risk of self-discontinuation is warranted.
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Shanmukhappa SC, Abraham RR, Huilgol P, Godbole R, Anand AK, Prasad R, Shridhar V, Bhrushundi M. What influences adherence among HIV patients presenting with first-line antiretroviral therapy failure (ART failure)? A retrospective, cross-sectional study from a private clinic in Nagpur, India. J Family Med Prim Care 2020; 9:6217-6223. [PMID: 33681067 PMCID: PMC7928081 DOI: 10.4103/jfmpc.jfmpc_1155_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 09/08/2020] [Accepted: 09/25/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Multiple reports show increasing occurrences of ART failure in India. Despite the fact that a significant volume of outpatient and on-going healthcare occurs in private clinics, there are very few studies on adherence from private clinics in India. Objective: To evaluate the factors influencing adherence to ART in patients with first-line ART failure. Materials and Methods: Data were collected from a convenience sample of 139 individuals diagnosed with clinical, immunological or virologic failure from a private HIV clinic in Nagpur, India. A retrospective cross-sectional study was undertaken and data were statistically analysed. Results: Of the 139 patients, 118 (84.9%) were male and 21 (15.1%) were female. 64 (46%) had received pre-treatment and adherence counselling. 81 (58.3%) were not told about the side effects of ART medications and 65 (46.8%) avoided friends and family. Most common reasons for suboptimal adherence by stopping treatment were high cost, alcoholism, choosing non-allopathic medications and depression. Reasons cited for suboptimal adherence due to missed doses included feeling healthy, depression, forgetfulness and busy schedule. A significant association was found between pre-treatment counselling, adherence counselling and being told the importance of lifelong treatment and decreased occurrence of complete stoppage of treatment. Conclusion: This study brings to light some of the predictors of ART failure. Counselling, having a strong support system as well as early identification and tackling of reasons for suboptimal adherence plays an important role in preventing ART failure.
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Affiliation(s)
- Sanjana Chetana Shanmukhappa
- Visiting Research Scholar, AFPI National Center for Primary Care Research and Policy, Bangalore, Karnataka, India
| | - Rahul R Abraham
- Visiting Research Scholar, AFPI National Center for Primary Care Research and Policy, Bangalore, Karnataka, India
| | - Poorva Huilgol
- Laboratory Technician, Molecular Solutions Care Health, Bangalore, Karnataka, India
| | - Rekha Godbole
- Chief of Genotyping Services, Molecular Solutions Care Health, Bangalore, Karnataka, India
| | - Ashoojit K Anand
- Clinical Director, PCMH Restore Health Center, Bangalore, Karnataka, India
| | - Ramakrishna Prasad
- Executive Director, PCMH Restore Health Center, Bangalore, Karnataka, India
| | - Varsha Shridhar
- Director and Co-founder, Molecular Solutions Care Health, Bangalore, Karnataka, India
| | - Milind Bhrushundi
- Central Indian Institute of Infectious Diseases and Lata Mangeshkar Hospital, Nagpur, Maharashtra, India
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A Behavioral Adherence Intervention Improves Rates of Viral Suppression Among Adherence-Challenged People Living with HIV in South India. AIDS Behav 2020; 24:2195-2205. [PMID: 31933020 DOI: 10.1007/s10461-020-02785-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
The success of antiretroviral therapy (ART) has led to both extended life expectancy and improved quality of life among people living with HIV (PLWH). To maximize the efficacy of first line ART regimens in low- and middle-income countries (LMIC), we need culturally-relevant interventions that empower participants to reduce barriers to long-term uninterrupted adherence. The Chetana adherence intervention trial was designed in collaboration with local community groups as a comprehensive wellness program for adherence-challenged PLWH and included peer-led adherence support, yoga, nutrition, information about local resources, and individual counseling using motivational interviewing techniques. Intervention arm participants were almost twice as likely to be virally suppressed at their 12-month follow-up visit (AOR = 1.98; 95% CI [1.2, 3.23]) as were participants in the active control arm. They were also about twice as likely as control arm participants to self-report ≥ 95% adherence (AOR = 1.86, 95% CI [1.09, 3.15]), and as having eliminated individual adherence barriers (AOR = 2.33, 95% CI [1.51, 3.62]) and clinic attendance barriers (AOR = 2.01, 95% CI [1.20, 3.38]) These low-cost strategies can be implemented by local NGOs, making it both scalable and sustainable in this and similar settings.
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Chakraborty A, Hershow RC, Qato DM, Stayner L, Dworkin MS. Adherence to Antiretroviral Therapy Among HIV Patients in India: A Systematic Review and Meta-analysis. AIDS Behav 2020; 24:2130-2148. [PMID: 31933019 DOI: 10.1007/s10461-020-02779-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We conducted a systematic review and meta-analysis to estimate the prevalence of adherence to antiretroviral therapy (ART) in India, the third largest HIV epidemic in the world. We identified peer reviewed literature published between 2007 and 2017 to extract data on ART adherence. We estimated pooled prevalence of adherence to ART using a random-effects model. Thirty-two eligible studies (n = 11,543) were included in the meta-analysis. Studies were mostly clustered in the southern and western Indian states. Overall, 77% (95% Confidence Interval 73-82; I2 = 96.80%) of patients had optimum adherence to ART. Women had higher prevalence of optimum adherence compared to men. Depression or anxiety were significant risk factors in seven of the fifteen studies reporting determinants of nonadherence. Studies should be performed to explore the reasons for gender gap in ART adherence and HIV program in India should prioritize mental health issues among HIV patients to improve ART adherence.
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Affiliation(s)
- Apurba Chakraborty
- Division of Epidemiology and Biostatistics, University of Illinois At Chicago School of Public Health, 1603 W. Taylor Street, MC 923, Chicago, IL, 60612, USA.
| | - Ronald C Hershow
- Division of Epidemiology and Biostatistics, University of Illinois At Chicago School of Public Health, 1603 W. Taylor Street, MC 923, Chicago, IL, 60612, USA
| | - Dima M Qato
- University of Illinois At Chicago College of Pharmacy, 833 S. Wood St, Chicago, IL, 60612, USA
| | - Leslie Stayner
- Division of Epidemiology and Biostatistics, University of Illinois At Chicago School of Public Health, 1603 W. Taylor Street, MC 923, Chicago, IL, 60612, USA
| | - Mark S Dworkin
- Division of Epidemiology and Biostatistics, University of Illinois At Chicago School of Public Health, 1603 W. Taylor Street, MC 923, Chicago, IL, 60612, USA
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Heylen E, Chandy S, Shamsundar R, Nair S, Ravi Kumar BN, Ekstrand ML. Correlates of and barriers to ART adherence among adherence-challenged people living with HIV in southern India. AIDS Care 2020; 33:486-493. [PMID: 32172599 DOI: 10.1080/09540121.2020.1742862] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Suboptimal adherence to Antiretroviral Therapy (ART) regimens can lead to the development of drug resistance, virologic and clinical failure, and, on the community level, the spread of drug-resistant HIV. To design effective interventions, it is crucial to understand locally specific barriers to optimal adherence. Self-report data from a cross-sectional sample of 527 adherence-challenged people living with HIV (PLWH) in the South-Indian state of Karnataka showed that they took on average 68% of prescribed doses in the past month. Large majorities of participants encountered individual (95%), social/structural (88%), and clinic/regimen (80%) adherence barriers. Multivariate linear regression analyses of past month adherence showed that disclosure to all adults in the household was positively related to adherence, as was employing a larger number of adherence strategies, perceiving more benefits of ART, and having been on ART for longer. Fears of stigmatization upon disclosure of HIV-status to friends and people at work were negatively related to adherence. These results suggest that some barriers, especially individual-level barriers like forgetfulness are very common and can be targeted with relatively simple individual-level strategies. Other barriers, related to fear of stigma and lack of disclosure may require family- or community-level interventions.
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Affiliation(s)
- Elsa Heylen
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sara Chandy
- Department of Medicine, St. John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - Ranjani Shamsundar
- Department of Microbiology, St. John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - Shoba Nair
- Department of Pain and Palliative Medicine, St John's Medical College, St John's National Academy of Health Sciences, Bangalore, India
| | - B N Ravi Kumar
- Karnataka State AIDS Prevention Society, Bangalore, India
| | - Maria L Ekstrand
- Center for AIDS Prevention Studies, Department of Medicine, University of California San Francisco, San Francisco, CA, USA.,St. John's Research Institute, St John's National Academy of Health Sciences, Bangalore, India
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Ekstrand ML, Heylen E, Mazur A, Steward WT, Carpenter C, Yadav K, Sinha S, Nyamathi A. The Role of HIV Stigma in ART Adherence and Quality of Life Among Rural Women Living with HIV in India. AIDS Behav 2018; 22:3859-3868. [PMID: 29789984 DOI: 10.1007/s10461-018-2157-7] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
HIV stigma continues to be a barrier to physical and mental health among people living with HIV globally, especially in vulnerable populations. We examined how stigma is associated with health outcomes and quality of life among rural women living with HIV in South India (N = 600). Interviewer-administered measures assessed multiple dimensions of stigma, as well as loneliness, social support, ART adherence, time since diagnosis, and quality of life. Internalized stigma and a lack of social support were associated with a lower quality of life, while the association between internalized stigma and adherence was mediated by the use of stigma-avoidant coping strategies, suggesting that keeping one's diagnosis a secret may make it more difficult to take one's medications. These findings suggest that these women constitute a vulnerable population who need additional services to optimize their health and who might benefit from peer support interventions and stigma-reduction programs for family and community members.
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Affiliation(s)
- Maria L Ekstrand
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA.
- St John's Research Institute, Bangalore, India.
| | - Elsa Heylen
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | - Amanda Mazur
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | - Wayne T Steward
- University of California, San Francisco, 550 16th St, 3rd floor, San Francisco, CA, 94158, USA
| | | | | | - Sanjeev Sinha
- All India Institute of Medical Sciences, New Delhi, India
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Nyamathi A, Ekstrand M, Heylen E, Ramakrishna P, Yadav K, Sinha S, Hudson A, Carpenter CL, Arab L. Relationships Among Adherence and Physical and Mental Health Among Women Living with HIV in Rural India. AIDS Behav 2018; 22:867-876. [PMID: 27990577 PMCID: PMC5476510 DOI: 10.1007/s10461-016-1631-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
We conducted a cross-sectional examination of the physical and psychological factors related to ART adherence among a sample of 400 women living with HIV/AIDS in rural India. Interviewer-administered measures assessed adherence, internalized stigma, depressive symptoms, quality of life, food insecurity, health history and sociodemographic information. CD4 counts were measured using blood collected at screening. Findings revealed that adherence to ART was generally low, with 94% of women taking 50% or less of prescribed medication in past month. Multivariate analyses showed a non-linear association between numbers of self-reported opportunistic infections (OIs) in past 6 months (p = 0.016) and adherence, with adherence decreasing with each additional OI for 0-5 OIs. For those reporting more than 5 OIs, the association reversed direction, with increasing OIs beyond 5 associated with greater adherence.
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Affiliation(s)
- Adeline Nyamathi
- School of Nursing, University of California, Room 2-250, Factor Building, Los Angeles, CA, 90095-1702, USA.
| | - Maria Ekstrand
- Center for AIDS Prevention Studies, University of California, San Francisco, USA
| | - Elsa Heylen
- Center for AIDS Prevention Studies, University of California, San Francisco, USA
| | | | - Kartik Yadav
- School of Nursing, University of California, Room 2-250, Factor Building, Los Angeles, CA, 90095-1702, USA
| | - Sanjeev Sinha
- Department of Medicine, All India Institute of Medical Sciences (AIIMS), New Delhi, India
| | - Angela Hudson
- School of Medicine, Cal State University, Los Angeles, USA
| | - Catherine L Carpenter
- School of Nursing, University of California, Room 2-250, Factor Building, Los Angeles, CA, 90095-1702, USA
| | - Lenore Arab
- School of Medicine, University of California, Los Angeles, USA
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Nyamathi AM, Ekstrand M, Yadav K, Ramakrishna P, Heylen E, Carpenter C, Wall S, Oleskowicz T, Arab L, Sinha S. Quality of Life Among Women Living With HIV in Rural India. J Assoc Nurses AIDS Care 2017; 28:575-586. [PMID: 28473182 DOI: 10.1016/j.jana.2017.03.004] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Accepted: 03/15/2017] [Indexed: 01/20/2023]
Abstract
A cross-sectional examination was conducted on quality of life (QOL) among women living with HIV (WLWH) in rural Andhra Pradesh, India. Baseline data were collected from 400 WLWH and their children. QOL was measured with 10 items from the Quality of Life Enjoyment and Satisfaction Questionnaire. Findings revealed low QOL scores; on a scale from 0 to 3, the mean QOL score was 0.38 (SD = 0.30). Depression symptoms were reported by 25.5%, internalized stigma was high, and most reported little to no social support. Multivariable analysis revealed positive associations between QOL and CD4+ T cells (b = .0011, p = .021) and social support (b = .260, p < .0001), and a negative relationship between QOL and internalized stigma (b = -.232, p < .0001). Interventions focused on improving QOL for WLWH should incorporate strategies to improve social support and adherence to antiretroviral therapy, while mitigating internalized stigma.
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Sweeney SM, Vanable PA. The Association of HIV-Related Stigma to HIV Medication Adherence: A Systematic Review and Synthesis of the Literature. AIDS Behav 2016; 20:29-50. [PMID: 26303196 DOI: 10.1007/s10461-015-1164-1] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
This paper provides a review of the quantitative literature on HIV-related stigma and medication adherence, including: (1) synthesis of the empirical evidence linking stigma to adherence, (2) examination of proposed causal mechanisms of the stigma and adherence relationship, and (3) methodological critique and guidance for future research. We reviewed 38 studies reporting either cross-sectional or prospective analyses of the association of HIV-related stigma to medication adherence since the introduction of antiretroviral therapies (ART). Although there is substantial empirical evidence linking stigma to adherence difficulties, few studies provided data on psychosocial mechanisms that may account for this relationship. Proposed mechanisms include: (a) enhanced vulnerability to mental health difficulties, (b) reduction in self-efficacy, and (c) concerns about inadvertent disclosure of HIV status. Future research should strive to assess the multiple domains of stigma, use standardized measures of adherence, and include prospective analyses to test mediating variables.
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Affiliation(s)
- Shannon M Sweeney
- Department of Psychology, Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244-2340, USA.
| | - Peter A Vanable
- Department of Psychology, Syracuse University, 430 Huntington Hall, Syracuse, NY, 13244-2340, USA.
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Sweeney SM, Mitzel LD, Vanable PA. Impact of HIV-related stigma on medication adherence among persons living with HIV. Curr Opin Psychol 2015. [DOI: 10.1016/j.copsyc.2015.06.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Association of individual and systemic barriers to optimal medical care in people living with HIV/AIDS in Miami-Dade County. J Acquir Immune Defic Syndr 2015; 69 Suppl 1:S63-72. [PMID: 25867780 DOI: 10.1097/qai.0000000000000572] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Barriers to retention in HIV care are detrimental to patients' progress along the HIV continuum of care. Previous literature has focused on individual, client-level barriers, and interventions to address them. In contrast, less work has examined the role of system-level barriers on HIV care outcomes. This study seeks to understand how individual and systemic barriers individually are associated with clinic appointment attendance and virologic suppression in HIV-infected patients attending the largest HIV clinic in Miami-Dade, FL. In addition, we examined the synergistic effects of these barriers as potential syndemic factors on these health outcomes. Barriers to clinic attendance were determined in a face-to-face study interview with 444 HIV-infected outpatients (187 regular attenders, 191 irregular attenders, and 66 nonattenders) identified from electronic medical records. Compared with the other attendance groups, nonattenders had higher viral loads, were less likely to be virologically suppressed, had lower CD4 counts, had higher depressive symptoms, life chaos, lower quality of life, and higher rates of food insecurity, and recent drug use. Additionally, nonattenders compared with regular attenders had lower physician relationship ratings, had lower medical information clarity and more often reported transportation as a barrier to clinic attendance. When viewed as a syndemic, compared with patients not reporting any barriers, patients with 3 or more individual-level barriers were more likely to have a detectable viral load (odds ratio = 3.60, 95% CI: 1.71 to 7.61). Our findings suggest that patients presenting to the clinic with multiple barriers should be prioritized for assistance and future interventions to improve retention in care. Interventions should address multiple individual and system-level barriers simultaneously with particular attention to addressing depressive symptoms, organizational skills, relationship with the physician, and HIV-related health education.
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