Barriers to antiretroviral therapy adherence in developed countries: a qualitative synthesis to develop a conceptual framework for a new patient-reported outcome measure

The first AI-based Chatbot to promote HIV self-management: A mixed methods usability study

BACKGROUND

We developed MARVIN, an artificial intelligence (AI)-based chatbot that provides 24/7 expert-validated information on self-management-related topics for people with HIV. This study assessed (1) the feasibility of using MARVIN, (2) its usability and acceptability, and (3) four usability subconstructs (perceived ease of use, perceived usefulness, attitude towards use, and behavioural intention to use).

METHODS

In a mixed-methods study conducted at the McGill University Health Centre, enrolled participants were asked to have 20 conversations within 3 weeks with MARVIN on predetermined topics and to complete a usability questionnaire. Feasibility, usability, acceptability, and usability subconstructs were examined against predetermined success thresholds. Qualitatively, randomly selected participants were invited to semi-structured focus groups/interviews to discuss their experiences with MARVIN. Barriers and facilitators were identified according to the four usability subconstructs.

RESULTS

From March 2021 to April 2022, 28 participants were surveyed after a 3-week testing period, and nine were interviewed. Study retention was 70% (28/40). Mean usability exceeded the threshold (69.9/68), whereas mean acceptability was very close to target (23.8/24). Ratings of attitude towards MARVIN's use were positive (+14%), with the remaining subconstructs exceeding the target (5/7). Facilitators included MARVIN's reliable and useful real-time information support, its easy accessibility, provision of convivial conversations, confidentiality, and perception as being emotionally safe. However, MARVIN's limited comprehension and the use of Facebook as an implementation platform were identified as barriers, along with the need for more conversation topics and new features (e.g., memorization).

CONCLUSIONS

The study demonstrated MARVIN's global usability. Our findings show its potential for HIV self-management and provide direction for further development.

Barriers to adherence to antiretroviral therapy: identifying priority areas for people with HIV and healthcare professionals

BACKGROUND

Challenges to antiretroviral therapy adherence are well-known and continue to be a major hurdle in HIV care. The objective of this paper is to identify barriers to antiretroviral therapy (ART) adherence that are relevant to HIV care from the perspective of people living with HIV and healthcare and social service professionals.

METHODS

This study used an online survey design to collect information from the two groups. A total of 100 areas that covered six domains and 20 subdomains were administered to people living with HIV and care professionals in Canada and France. The survey asked participants to rate the importance of each area for HIV care on a four-point Likert scale. Any areas rated 3 or 4 were considered important and ranked. A Chi-square test was conducted for the difference between the groups, people living with HIV and professionals, and between women and men.

RESULTS

A response rate of 87% (58/66) in Canada and 65% (38/58) was achieved. 15 of 43 (35%) areas were endorsed as important barriers by both groups, across countries and sex-covering subdomains - drug cost coverage, challenging material circumstances, HIV stigma, and privacy concerns, affect, motivation, beliefs, acceptance of HIV, comorbidity, side effects, and demands and organisation of daily life. People living with HIV identified two, and care professionals identified nine, additional areas as important barriers to HIV care across different domains and subdomains.

CONCLUSION

The study identified some common and distinct barriers to ART from the perspective of the people living with HIV and care professionals.

Barriers, opportunities, and potential costs of expanding HIV support services

Experiencing housing instability, food insecurity, and financial stress can negatively impact retention in care and treatment adherence for people living with HIV. Expanding services that support socioeconomic needs could help improve HIV outcomes. Our objective was to investigate barriers, opportunities, and costs of expanding socioeconomic support programs. Semi-structured interviews were conducted with organizations serving U.S. Ryan White HIV/AIDS Program clients. Costs were estimated from interviews, organization documents, and city-specific wages. Organizations reported complex patient, organization, program, and system challenges as well as several opportunities for expansion. The average one-year per-person cost for engaging new clients was $196 for transportation, $612 for financial aid, $650 for food aid, and $2498 for short-term housing (2020 USD). Understanding potential expansion costs is important for funders and local stakeholders. This study provides a sense of magnitude for costs to scale-up programs to better meet socioeconomic needs of low-income patients living with HIV.

Differences in Antiretroviral Adherence Behaviors, Treatment Success, and Eligibility for Long-Acting Injectable Treatment between Patients Who Acquired HIV in Childhood vs. Those Who Acquired It in Adolescence/Early Adulthood

This study investigates the impact of the age at which HIV was acquired on adherence. There was no difference in adherence between patients who acquired HIV in childhood vs. those who acquired it in adolescence/early adulthood (83% vs. 90%; p = 0.24), but achievement of virological/immunological efficacy (78.8% vs. 93.5%, p = 0.02) was less likely in patients who had acquired HIV in childhood. On the basis of resistance, patients who acquired HIV in adolescence/early adulthood tended to be more eligible for cabotegravir/rilpivirine treatment (90.3% vs. 80.3%; p = 0.11).

Traditional Human Immunodeficiency Virus treatment and family and social influence as barriers to accessing HIV care services in Belu, Indonesia

Access to HIV care services, including antiretroviral therapy (ART), is essential for improving health outcomes of people living with HIV (PLHIV) and reducing HIV transmission and AIDS-related deaths. As a part of a qualitative study in Belu, this paper describes the use of traditional medicines for HIV treatment and family and social influence as barriers to access to HIV care services among PLHIV. One-on-one in-depth interviews were employed to collect data from 46 PLHIV (26 women and 20 men) and 10 healthcare professionals. They were recruited using the snowball sampling technique. The study information sheets were initially posted on information boards in healthcare facilities. Potential participants who contacted to confirm their participation were recruited for an interview and then asked for help to distribute the information sheets to their eligible colleagues who might be willing to participate. Data analysis was performed using NVivo 12 software and guided by a qualitative data analysis framework. The findings showed that the use of traditional medicines, a well-known cultural practice in Belu, was a barrier to access to HIV care services among PLHIV. The influence of family in determining the use of traditional medicines for HIV treatment, supported by the lack of knowledge of ART, effectiveness of traditional medicines in treating other health issues, and social influence of relatives, neighbours, and friends, were also significant barriers to PLHIV’s access to HIV care services. The findings indicate the need for dissemination of HIV care-related information for PLHIV, family, and community members to increase their knowledge of the service, ART and its function, and to support and improve access to HIV care services especially ART by PLHIV.

Content validation of a new measure of patient-reported barriers to antiretroviral therapy adherence, the I-Score: results from a Delphi study

Background

Over a third of people living with HIV (PLHIV) have suboptimal adherence to antiretroviral therapy (ART). Measures of barriers to ART adherence often lack comprehensiveness. To help manage ART adherence barriers in HIV care, we are developing a new patient-reported outcome measure (PROM) of these barriers (the I-Score).

Methods

We assessed the content validity of 100 items (distinct barriers) to retain only those most relevant to both PLHIV and HIV health/social service providers. A web-based Delphi was conducted in Canada and France, collecting data from December 2018 to October 2019. Items were evaluated on relevance (the combined rated importance and actionability for HIV care of items among both PLHIV and providers); comprehensibility (rated item clarity); comprehensiveness (examined against our conceptual framework); cross-cultural equivalence (based on comparisons by questionnaire language (English, French) and country of residence). Pearson’s chi-square tests were used for comparisons by language, country, gender, and stakeholder group (PLHIV, providers).

Results

Panelists included 40 PLHIV and 57 providers (66% response rate). Thirty-one items were retained based on consensus thresholds for relevance (minimum: 50% for PLHIV, 60% for providers) and showed good comprehensibility and comprehensiveness, when compared to our conceptual framework (representation of: 6/6 domains, 15/20 subdomains). No significant difference in relevance based on language or country was found among retained items, suggestive of cross-cultural equivalence. Among all 100 items, only 6 significant differences on relevance were observed for gender. For 62 items, the relevance ratings of PLHIV and providers differed significantly, with providers showing greater endorsement of all items but one.

Discussion

The Delphi led to a much-needed item reduction. Remaining items highlight the panel’s multidimensional priorities for the PROM on ART adherence barriers, with few, if any, differences by language, country, and gender. While the analyses may lack generalizability and power, the sample size is considered adequate for a PROM validation study.

Conclusion

Retained items showed good content validity. The different patterns of item endorsement observed underscore the utility of engaging multiple stakeholder groups in PROM development for use in clinical practice. The greater endorsement of items by providers versus patients merits further investigation, including the implications of such differentials for measure development.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-022-00435-0.

A conceptual model of alcohol use and adherence to antiretroviral therapy: systematic review and theoretical implications for mechanisms of action

Alcohol consumption is one of the most prevalent correlates of antiretroviral therapy (ART) adherence, yet causal processes underlying this association remain largely unexplored. The goal of this systematic review was to develop a conceptual model that describes the causal effect of alcohol consumption on ART nonadherence. We reviewed 230 studies that examined the association between alcohol consumption and ART adherence with three primary aims: (1) to replicate and extend previous reviews of the literature, (2) to summarize and critique study designs capable of answering questions about temporal overlap and (3) to summarize potential mechanisms of action. A model of alcohol-associated ART nonadherence was proposed to guide future work, integrating general theories of ART adherence and theory on the psychological and behavioral effects of alcohol intoxication. The conceptual model describes two mechanistic processes-prospective memory impairment and interactive toxicity beliefs/avoidance behaviors-involved in alcohol-associated intentional and unintentional nonadherence, respectively. This model can be used to guide future research on the causal processes involved in the frequently observed correlation between alcohol consumption and adherence.

Barriers and facilitators of adherence to antiretroviral treatment at a public health facility in Ghana: a mixed method study

BACKGROUND

HIV/AIDS is a disease of global public health concern with high morbidity and mortality rates. Poor adherence to antiretroviral therapy (ART) increases the risk of viral drug resistance and reduces treatment effectiveness towards viral suppression leading to disease progression, greater risk of death and increased risk of viral transmission. The study sought to assess current adherence levels to ART among patients in Ghana, exploring barriers and enablers of adherence to it, to provide future guidance to all key stakeholder groups.

METHOD

A mixed method approach was used comprising of a cross-sectional survey of patients followed by a focused group discussion with patients and an in-depth interview of four key health professionals working in the ART clinic of Atua Government Hospital, a primary care health facility in the Eastern Region of Ghana. A structured questionnaire was used to assess current adherence levels and their determinants among 231 randomly selected patients attending the clinic between July to September, 2019. Quantitative data were analysed using bivariate and multivariate methods while qualitative data were analysed using thematic framework approach.

RESULTS

Adherence levels was found to be 42.9% among our study population. Lower adherence to ART was associated with patients' belief in herbal medicine (aOR =0.34 CI: 0.19-0.61). Other barriers identified from the qualitative analysis included low motivation arising from pill fatigue, forgetfulness, frequent stock out of medicines, long waiting times and worrying side-effects; while enablers, on the other hand, included measures that ensure improved assessment of adherence and health facility-related activities that improve patient satisfaction with ART services. Conclusion: Adherence to ART among patients living with HIV was sub-optimal in our study population. Understanding of the barriers and factors that enable adherence to ART is a key step to developing evidence-based adherence improvement strategies to enhance clinical outcomes.

Implementation of an electronic patient-reported measure of barriers to antiretroviral therapy adherence with the Opal patient portal: Protocol for a mixed method type 3 hybrid pilot study at a large Montreal HIV clinic

BACKGROUND

Adherence to antiretroviral therapy (ART) remains problematic. Regular monitoring of its barriers is clinically recommended, however, patient-provider communication around adherence is often inadequate. Our team thus decided to develop a new electronically administered patient-reported outcome measure (PROM) of barriers to ART adherence (the I-Score) to systematically capture this data for physician consideration in routine HIV care. To prepare for a controlled definitive trial to test the I-Score intervention, a pilot study was designed. Its primary objectives are to evaluate patient and physician perceptions of the I-Score intervention and its implementation strategy.

METHODS

This one-arm, 6-month study will adopt a mixed method type 3 implementation-effectiveness hybrid design and be conducted at the Chronic Viral Illness Service of the McGill University Health Centre (Montreal, Canada). Four HIV physicians and 32 of their HIV patients with known or suspected adherence problems will participate. The intervention will involve having patients complete the I-Score through a smartphone application (Opal), before meeting with their physician. Both patients and physicians will have access to the I-Score results, for consideration during the clinic visits at Times 1, 2 (3 months), and 3 (6 months). The implementation strategy will focus on stakeholder involvement, education, and training; promoting the intervention's adaptability; and hiring an Application Manager to facilitate implementation. Implementation, patient, and service outcomes will be collected (Times 1-2-3). The primary outcome is the intervention's acceptability to patients and physicians. Qualitative data obtained, in part, through physician focus groups (Times 2-3) and patient interviews (Times 2-3) will help evaluate the implementation strategy and inform any methodological adaptations.

DISCUSSION

This study will help plan a definitive trial to test the efficacy of the I-Score intervention. It will generate needed data on electronic PROM interventions in routine HIV care that will help improve understanding of conditions for their successful implementation.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04702412; https://clinicaltrials.gov/.

Study protocol: Strengthening understanding of effective adherence strategies for first-line and second-line antiretroviral therapy (ART) in selected rural and urban communities in South Africa

Multiple factors make adherence to antiretroviral therapy (ART) a complex process. This study aims to describe the barriers and facilitators to adherence for patients receiving first-line and second-line ART, identify different adherence strategies utilized and make recommendations for an improved adherence strategy. This mixed method parallel convergent study will be conducted in seven high volume public health facilities in Gauteng and one in Limpopo province in South Africa. The study consists of four phases; a retrospective secondary data analysis of a large cohort of patients on ART (using TIER.Net, an ART patient and data management system for recording and monitoring patients on ART and tuberculosis (TB)) from seven Johannesburg inner-city public health facilities (Gauteng province); a secondary data analysis of the Intensified Treatment Monitoring Accumulation (ITREMA) trial (a randomized control trial which ran from June 2015 to January 2019) conducted at the Ndlovu Medical Center (Limpopo province); in-depth interviews with people living with Human Immunodeficiency Virus (PLHIV) who are taking ART (in both urban and rural settings); and a systematic review of the impact of treatment adherence interventions for chronic conditions in sub-Saharan Africa. Data will be collected on demographics, socio-economic status, treatment support, retention in care status, disclosure, stigma, clinical markers (CD4 count and viral load (VL)), self-reported adherence information, intrapersonal, and interpersonal factors, community networks, and policy level factors. The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting and Population, Interventions, Comparisons and Outcomes (PICO) criteria. Analyses will involve tests of association (Chi-square and t-test), thematic analysis (deductive and inductive approaches) and network meta-analysis. Using an integrated multilevel socio-ecological framework this study will describe the factors associated with adherence for PLHIV who are taking first-line or second-line ART. Implementing evidence-based adherence approaches, when taken up, will improve patient's overall health outcomes. Our study results will provide guidance regarding context-specific intervention strategies to improve ART adherence.

Social Networks and Barriers to ART Adherence Among Young Adults (18-24 years) Living with HIV at Selected Primary Health Facilities of South-Western Uganda: A Qualitative Study

Background

Young adults living with HIV (YALWH) struggle to maintain high levels of adherence to antiretroviral therapy (ART) because of numerous barriers. This study describes the social networks of YALWH (18–24 years), their barriers to ART adherence, and the perceived role of social networks in overcoming those barriers.

Methods

This study used a qualitative descriptive research design. Twenty-three (23) YALWH who were on ART for a period of greater than one (1) month and had consented to participate in the study were purposively selected from two primary health care facilities in southwestern Uganda. We held four (4) focus group discussions with the YALWH over 5 weeks between the 24th of July and 7th September 2020. Data were audio recorded, transcribed, and entered in Microsoft word 2010. Using the content analysis techniques, data were inductively coded and categories or themes developed.

Results

Most YALWH belonged to bonding (family, friends, and neighbors), followed by bridging (informal groups), and linking (health professionals) social networks, respectively. Most YALWH, irrespective of gender, had close connections with their mothers or elder sisters. The commonest form of bridging networks was informal community groups that provided financial services, whereas the linking ones comprised health professionals’ directly involved in HIV patient care such as nurses, counselors, and their affiliates (expert clients or clinic based peer supporters), who occasionally acted as bonding networks. Structural barriers to ART adherence (eg, stigma) were the most cited, followed by medication- (eg, pill burden), and patient-related barriers (eg, non-disclosure of HIV status). Bonding networks were perceived to help overcome patient, medication, and structural barriers to ART adherence. Bridging networks overcame structural and medication-related barriers to ART adherence. Linking networks were perceived to help overcome some health systems and medication-related barriers to ART adherence.

Conclusion

Bonding social networks seem to play a prominent role in overcoming numerous barriers to ART adherence compared with bridging and linking social networks.

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.

Stakeholder efforts to mitigate antiretroviral therapy interruption among people living with HIV during the COVID-19 pandemic in China: a qualitative study

Introduction

The COVID‐19 pandemic has affected antiretroviral therapy (ART) continuity among people living with HIV (PLHIV) worldwide. We conducted a qualitative study to explore barriers to ART maintenance and solutions to ART interruption when stringent COVID‐19 control measures were implemented in China, from the perspective of PLHIV and relevant key stakeholders.

Methods

Between 11 February and 15 February 2020, we interviewed PLHIV, community‐based organization (CBO) workers, staff from centres for disease control and prevention (CDC) at various levels whose work is relevant to HIV care (CDC staff), HIV doctors and nurses and drug vendors from various regions in China. Semi‐structured interviews were conducted using a messaging and social media app. Challenges and responses relevant to ART continuity during the COVID‐19 pandemic were discussed. Themes were identified by transcript coding and mindmaps.

Results

Sixty‐four stakeholders were recruited, including 16 PLHIV, 17 CBO workers, 15 CDC staff, 14 HIV doctors and nurses and two drug vendors. Many CDC staff, HIV doctors and nurses responsible for ART delivery and HIV care were shifted to COVID‐19 response efforts. Barriers to ART maintenance were (a) travel restrictions, (b) inadequate communication and bureaucratic obstacles, (c) shortage in personnel, (d) privacy concerns, and (e) insufficient ART reserve. CBO helped PLHIV maintain access to ART through five solutions identified from thematic analysis: (a) coordination to refill ART from local CDC clinics or hospitals, (b) delivery of ART by mail, (c) privacy protection measures, (d) mental health counselling, and (e) providing connections to alternative sources of ART. Drug vendors contributed to ART maintenance by selling out‐of‐pocket ART.

Conclusions

Social and institutional disruption from COVID‐19 contributed to increased risk of ART interruption among PLHIV in China. Collaboration among key stakeholders was needed to maintain access to ART, with CBO playing an important role. Other countries facing ART interruption during current or future public health emergencies may learn from the solutions employed in China.

An Adaptable Framework for Factors Contributing to Medication Adherence: Results from a Systematic Review of 102 Conceptual Frameworks

OBJECTIVE

To summarize the available conceptual models for factors contributing to medication adherence based on the World Health Organization (WHO)'s five dimensions of medication adherence via a systematic review, identify the patient groups described in available conceptual models, and present an adaptable conceptual model that describes the factors contributing to medication adherence in the identified patient groups.

METHODS

We searched PubMed®, Embase®, CINAHL®, and PsycINFO® for English language articles published from inception until 31 March 2020. Full-text original publications in English that presented theoretical or conceptual models for factors contributing to medication adherence were included. Studies that presented statistical models were excluded. Two authors independently extracted the data.

RESULTS

We identified 102 conceptual models, and classified the factors contributing to medication adherence using the WHO's five dimensions of medication adherence, namely patient-related, medication-related, condition-related, healthcare system/healthcare provider-related, and socioeconomic factors. Eight patient groups were identified based on age and disease condition. The most universally addressed factors were patient-related factors. Medication-related, condition-related, healthcare system-related, and socioeconomic factors were represented to various extents depending on the patient group. By systematically examining how the WHO's five dimensions of medication adherence were applied differently across the eight different patient groups, we present a conceptual model that can be adapted to summarize the common factors contributing to medication adherence in different patient groups.

CONCLUSION

Our conceptual models can be utilized as a guide for clinicians and researchers in identifying the facilitators and barriers to medication adherence and developing future interventions to improve medication adherence.

PROTOCOL REGISTRATION

PROSPERO Identifier: CRD42020181316.

Acceptability of a Patient Portal (Opal) in HIV Clinical Care: A Feasibility Study

Opal (opalmedapps.com), a patient portal in use at the Cedars Cancer Centre of the McGill University Health Centre (MUHC) (Montreal, Canada), gives cancer patients access to their medical records, collects information on patient-reported outcome measures (PROMs), and has demonstrated patient satisfaction with care. This feasibility study aims to evaluate Opal's potential acceptability in the context of HIV care. People living with HIV (PLWH) and their healthcare providers (HCPs) completed cross-sectional surveys from August 2019 to February 2020 at large HIV centers, including the Chronic Viral Illness Service of the MUHC, and other HIV clinical sites in Montreal and Paris, France. This study comprised 114 PLWH (mean age 48 years old, SD = 12.4), including 74% men, 24% women, and 2% transgender or other; and 31 HCPs (mean age 46.5 years old, SD = 11.4), including 32% men, 65% women, and 3% other. Ownership of smartphones and tablets was high (93% PLWH, 96% HCPs), and participants were willing to use Opal (74% PLWH, 68% HCPs). Participants were interested in most Opal functions and PROMs, particularly PROMs capturing quality of life (89% PLWH, 77% HCPs), experience of healthcare (86% PLWH, 97% HCPs), and HIV self-management (92% PLWH, 97% HCPs). This study suggests Opal has high acceptability and potential usefulness as perceived by PLWH and HCPs.

A mega-aggregation framework synthesis of the barriers and facilitators to linkage, adherence to ART and retention in care among people living with HIV

BACKGROUND

People living with human immunodeficiency virus (PLHIV) struggle with the challenges of living with a chronic disease and integrating antiretroviral treatment (ART) and care into their daily lives. The aims of this study were as follows: (1) to undertake the first mega-aggregation of qualitative evidence syntheses using the methods of framework synthesis and (2) make sense of existing qualitative evidence syntheses that explore the barriers and facilitators of adherence to antiretroviral treatment, linkage to care and retention in care for PLHIV to identify research gaps.

METHODS

We conducted a comprehensive search and did all screening, data extraction and critical appraisal independently and in duplicate. We used the Kaufman HIV Behaviour Change model (Kaufman et al., 2014) as a framework to synthesise the findings using the mega-aggregative framework synthesis approach, which consists of 8 steps: (1) identify a clearly defined review question and objectives, (2) identify a theoretical framework or model, (3) decide on criteria for considering reviews for inclusion, (4) conduct searching and screening, (5) conduct quality appraisal of the included studies, (6) data extraction and categorisation, (7) present and synthesise the findings, and (8) transparent reporting. We evaluated systematic reviews up to July 2018 and assessed methodological quality, across reviews, using the Joanna Briggs Institute Critical Appraisal Checklist for Systematic Reviews.

RESULTS

We included 33 systematic reviews from low, middle- and high-income countries, which reported on 1,111,964 PLHIV. The methodological quality of included reviews varied considerably. We identified 544 unique third-order concepts from the included systematic reviews, which were reclassified into 45 fourth-order themes within the individual, interpersonal, community, institutional and structural levels of the Kaufman HIV Behaviour Change model. We found that the main influencers of linkage, adherence and retention behaviours were psychosocial and personal characteristics-perceptions of ART, desires, fears, experiences of HIV and ART, coping strategies and mental health issues-interwoven with other factors on the interpersonal, community, institutional and structural level. Using this approach, we found interdependence between factors influencing ART linkage, retention and adherence and identified the need for qualitative evidence that explores, in greater depth, the complex relationships between structural factors and adherence, sociodemographic factors such as community violence and retention, and the experiences of growing up with HIV in low- and middle-income countries-specifically in children, youth, women and key populations.

CONCLUSIONS

This is the first mega-aggregation framework synthesis, or synthesis of qualitative evidence syntheses using the methods of framework synthesis at the overview level. We found the novel method to be a transparent and efficient method for assessing the quality and making sense of existing qualitative systematic reviews.

SYSTEMATIC REVIEW REGISTRATION

The protocol of this overview was registered on PROSPERO ( CRD42017078155 ) on 17 December 2017.

Forecasting future HIV infection cases: evidence from Indonesia

Countries throughout the world, including Indonesia, are facing a complex problem with regards to HIV infection incidences and its prevalence. This is despite some local governments in some provinces of Indonesia working together with the Social Ministry of Indonesia to eradicate prostitution. There are high numbers of HIV sub-types in Indonesia such as HIV-1 (CRF01_AE and B). The forecast was conducted with the Autoregressive Integrated Moving Average model. The ARMA (1,1) was observed to be the best model for forecasting the number of HIV patients in Indonesia. This forecasting has been done since March 2019. Based on its dynamic forecasting with ARMA (1,1), this study proved the number of HIV-positive patients, from 2019 to 2030, had increased from 22,679 to 36,255, by almost 37% within 12 years. Indonesia is facing a growing trend in the number of new HIV cases, until 2030 which caused by stopped their follow-up treatments or they have ceased in consuming the Antiretroviral drugs even though the Indonesian government was provided national health insurance which covers the Antiretroviral drug and a limited number of health-care services providing the Antiretroviral therapy. Therefore, investigations focusing on estimate the number of HIV patients in Indonesia is an important finding. The information can be used as a resource for policy and decision making for plans and programs.

Patient-reported outcomes in HIV clinical trials evaluating antiretroviral treatment: a systematic review

We aimed to assess patterns of patient-reported outcomes (PRO) instruments' utilization in HIV clinical trials in relation to antiretroviral therapy (ART). PubMed/MEDLINE, Scopus, and EMBASE were searched using the terms "Patient-Reported Outcomes" and "HIV/AIDS" or "Antiretroviral Treatment" or "ART" or "Antiretroviral Therapy" from 1 January 1990 until 1 December 2019. In total, 173 studies were identified and 26 were directly related to ART. Study population included treatment-naïve patients (n = 4), treatment-experienced (n = 20), or both (n = 2). Instruments were implemented to assess general experience with ART (n = 3), single-tablet regimens (STR) (n = 2), monotherapy (n = 4), regimen switch (n = 9), or regimen comparison (n = 8). The most commonly used instruments were Medical Outcomes Study-HIV Health Survey (MOS-HIV, n = 8), HIV Symptom Index (HIV-SI, n = 7) and unstructured self-reports (n = 5) followed by others. MOS-HIV was used mainly in comparative (n = 4) and monotherapy (n = 3) trials, HIV-SI in switch (n = 4) and STR (n = 2) trials, and self-reports in comparative trials (n = 3). Even though, the implementation of PRO tools is increasing with time, reporting of PRO in HIV clinical trials remains limited.

Barriers and facilitators systematic reviews in health: A methodological review and recommendations for reviewers

BACKGROUND

Systematic reviews cataloguing the barriers to and facilitators of various outcomes are increasingly popular, despite criticisms of this type of review on philosophical, methodological, and practical grounds. The aims of this review are to appraise, analyze, and discuss the reporting and synthesis practices used in recently published barriers and facilitators reviews in health services research.

METHODS

All English-language peer-reviewed systematic reviews that synthesized research on barriers and facilitators in a health services context were eligible for inclusion. We searched 11 databases over a 13-month period (1 November 2017-30 November 2018) using an exhaustive list of search terms for "barrier(s)," "facilitator(s)," and "systematic review."

RESULTS

One hundred reviews were included. We found a high degree of variation in the synthesis practices used in these reviews, with the majority employing aggregative (rather than interpretive) approaches. The findings echo common critiques of this review type, including concerns about the reduction of complex phenomena to simplified, discrete factors. Although several reviews highlighted the "complexity" of barriers and facilitators, this was usually not analyzed systematically. Analysis of the subsample of reviews that explicitly discussed the barriers and facilitators approach revealed some common issues. These tended to be either conceptual/definitional (eg, ideas about interrelationships and overlap between factors) and methodological/practical (eg, challenges related to aggregating heterogeneous research).

CONCLUSION

Barriers and facilitators reviews should (a) clearly operationally define "barrier" and "facilitator," (b) explicitly describe how factors are extracted and subsequently synthesized, and (c) provide critical reflection on the contextual variability and reliability of identified factors.

Patient-reported outcomes to enhance person-centred HIV care

Quality of life has been proposed as the fourth 90 to complement the UNAIDS 90-90-90 targets to monitor the global HIV response, highlighting a need to address the holistic needs of people living with HIV beyond viral suppression. This proposal has instigated a wider discussion about the use of patient-reported outcomes (PROs) to improve the treatment and care of an ageing HIV population with increasing comorbidities and a disproportionate burden of social problems. PROs can provide a first-hand assessment of the impact of HIV treatment and care on patients' quality of life, including symptoms. The field of PRO measures is rapidly expanding but still no gold standard exists, raising concerns about tool selection. Challenges also remain in the collection, interpretation, and use of PRO data to improve the performance of the health system. An emerging concern is how to adapt PROs to different sociocultural and geographical settings.

Assessing the Content Validity of a New Patient-Reported Measure of Barriers to Antiretroviral Therapy Adherence for Electronic Administration in Routine HIV Care: Proposal for a Web-Based Delphi Study

Background

Adherence to lifesaving antiretroviral therapy (ART) for HIV infection remains a challenge for many patients. Routine screening for barriers to ART adherence could help make HIV care more patient-centered and prevent virologic rebound or failure. Our team is currently developing a new HIV-specific patient-reported outcome measure (PROM) of these barriers for use in Canada and France along with a digital app for its electronic administration. In our previous work, we developed the PROM’s multidimensional conceptual framework and generated 100 English items, which have been translated to French.

Objective

This study aims to use a Web-based Delphi to help validate and select the content of this new HIV-specific PROM, based on the perspective of anglophone and francophone patients and providers in Canada and France. Here, we present the proposal for this Delphi.

Methods

This modified Delphi will involve a diverse panel of patients (n=32) and providers (n=52) recruited especially from the 9 sites of the PROM development study (site locations in Canada: Montreal, Toronto, Vancouver; in France: Paris, Nantes, Clermont-Ferrand, Saint-Martin, Cayenne). Overall, 2 rounds of Web-based questionnaires will be conducted. The threshold for consensus is set at 60% and will determine which items are carried forward to the second round. Per item, 3 aspects will be rated: importance as a barrier to ART adherence, relevance for HIV care, and clarity. In both rounds, space will be available for free text comments. Overall comprehensiveness will be assessed in the second round.

Results

This study has undergone a methodological review by experts in patient-oriented research. It has received approval from a research ethics board of the McGill University Health Centre. It is financially supported, in part, by the Canadian Institutes of Health Research’s Strategy for Patient-Oriented Research-Quebec Support Unit (M006). As of May 21, 2019, 15 people living with HIV and 25 providers completed the first round of the Delphi (24 from Canada and 16 from France).

Conclusions

To our knowledge, this is the first Delphi to seek consensus on the most relevant and clinically actionable barriers to ART adherence, collecting opinions on an extensive list of barriers. Drawing on a relatively large and diverse panel of HIV patients and providers, it essentially engages key stakeholders in decision making about the PROM’s final content, helping to ensure its utility and adoption.

International Registered Report Identifier (IRRID)

PRR1-10.2196/12836

Beyond HIV prevention: a qualitative study of patient-reported outcomes of PrEP among MSM patients in two public STD clinics in Baltimore

Pre-exposure prophylaxis (PrEP) could have a substantial impact on the HIV epidemic within the US. However, the implementation of PrEP interventions outside of clinical trials has been slow and faces considerable barriers. The aim of the current study was to qualitatively explore PrEP-related patient-reported outcomes (PRO) among MSM patients who enrolled in a PrEP program at two public STD clinics in Baltimore. We conducted in-depth interviews with 18 PrEP patients who self-identified as MSM at two Baltimore City Health Department STD clinics between March and November, 2017. A codebook was developed using an iterative process. During analysis, the study team identified various biomedical and psychosocial PrEP-related PRO among MSM PrEP patients. In addition to HIV prevention, PrEP-related PRO included greater peace of mind, better continuity in care and awareness about health and well-being, relationship solidarity with serodiscordant partners, and access to social services. These findings on PrEP-related PRO can potentially contribute to improving patient-provider communication, leading to increased engagement in care and uptake of PrEP by MSM.

Evaluation of a project to engage patients in the development of a patient-reported measure for HIV care (the I-Score Study)

BACKGROUND

Patient engagement (PE), patients' meaningful involvement in research through partnerships and sensitivity to their expertise, is receiving attention. However, PE initiatives are poorly reported and little is known about patients' perspective on PE.

OBJECTIVE

To document and evaluate the first phase (22 months) of a PE Project for the I-Score Study which is developing a patient-reported measure of HIV treatment adherence barriers, we describe the nature of PE conducted, determine the level of PE achieved and present its impacts from the engaged patients' perspective.

SETTING AND PARTICIPANTS

A Montreal-based committee of ten people with HIV was recruited from community and clinical settings and participated in: I-Score study decision making, knowledge dissemination, research on the experience of people with HIV and the PE project's evaluation.

METHODS

The evaluation followed a convergent parallel mixed-methods design. Data collection included participant observation, a satisfaction survey and meeting minutes/transcriptions. Analysis entailed reporting PE activities, generating descriptive statistics and thematically analysing qualitative material.

RESULTS

PE consisted of twelve meetings, including two focus groups (needs assessment), in addition to four knowledge dissemination activities. PE levels showed an increase: the first four regular meetings entailed information/consultation, while subsequent meetings reached implication/collaboration. Regarding impacts, patients indicated high and stable satisfaction rates (M = 4.4/5; SD = 0.76). Furthermore, thematic analysis identified "positive interactions," "co-learning," "self-determination," and "the collective management of confidentiality" as important PE impacts for engaged patients.

CONCLUSION

This PE Project evaluation highlighted growing engagement levels, high satisfaction rates and the importance of a patient-centric approach to PE.