Impact of adherence to antiretroviral therapy in HIV-1-infected patients at a university public service in Brazil

Long-term virological effectiveness with darunavir/ritonavir-based salvage therapy in people living with HIV/AIDS from São Paulo, Brazil

Even though darunavir/ritonavir (DRV/r) has high potency and a greater genetic barrier, there are few studies on the long-term effectiveness of DRV/r-based salvage therapy in people living with HIV (PLWH) in low and middle-income countries. This retrospective cohort study, from São Paulo, Brazil, included ART-experienced PLWH aged ≥18 years with virological failure (VF) who had started DRV/r plus an optimized background regimen (OBR) between 2008 and 2012. The proportion of patients with viral load (VL) <50 copies/mL, the improved mean CD4+ T cell count and the factors associated with VF during the 144-week follow-up were assessed. The study included 173 patients with the following characteristics [median (interquartile range)]: age 48 (42 -53) years; CD4+ T cell count, 229 (89 -376) cells/mm3; VL, 4.26 (3.70 -4.74) log10; 6 (4 -7) previous regimens; and 100 (38 -156) months of VF. After 144 weeks, 129 (75%) patients had VL< 50 copies/mL and a mean increase in the CD4+ T cell count of 190 cells/mm3. VL>100,000 copies/mL and poor adherence were associated with VF. DRV/r plus an OBR showed high long-term virological suppression and immunological recovery. VL>100,000 copies/mL and poor adherence were associated with VF at 144 weeks.

Adherence to combined Antiretroviral therapy (cART) among people living with HIV/AIDS in a Tertiary Hospital in Ilorin, Nigeria

Introduction

This study aims to assess the treatment adherence rate among People Living With HIV/AIDS (PLWHA) receiving treatment in a Nigerian tertiary Hospital.

Methods

This was a cross-sectional study that assessed self-reported treatment adherence among adults aged 18 years and above who were accessing drugs for the treatment of HIV. Systematic random sampling method was used to select 550 participants and data were collected by structured interviewer administered questionnaire.

Results

The mean age of respondents was 39.9±10 years. Adherence rate for HIV patients was 92.6%. Factors affecting adherence include lack of money for transportation to the hospital (75%), traveling (68.8%), forgetting (66.7%), avoiding side effects (66.7%), and avoiding being seen (63.6%).

Conclusion

The adherence rate was less than optimal despite advancements in treatment programmes. Adherence monitoring plans such as home visit and care should be sustained.

Is it possible to control HIV infection in a middle-income country through a multidisciplinary approach?

Despite the difficulties to follow and retain patients for a long time in the public health service, special programs may bring about increased chances of survival and better quality of life, as well as higher rates of retention in care; this is also true for middle-income developing countries such as Brazil. Our relatively small outpatient service (~500 HIV-infected patients) may not mirror the reality encountered in other settings, including São Paulo city, but retention and high quality of care may improve rates of virologic success, even in poorer settings. Furthermore, prevention of depression or anxiety, with discussion in groups of patients with the presence of a therapist, regular HIV RNA viral and CD4 cells counts, genotyping tests pre-HAART, and vigilance for drug failure, may explain this successful experience. We should also take into consideration that our cohort consists mostly of asymptomatic at-entry patients referred by the Blood Bank of São Paulo, located at the same Hospital, implying that they had a better immunological status at start than the more usual HIV population. Besides that, the degree of adherence to treatment in our service, in general, is quite high and the patients have a higher mean educational level; over 90% of the patients a high school or college education . Such features make this cohort a very specific and differentiated sample. In order to extend our findings, we intend to conduct similar studies in other HIV treatment centers, enabling comparisons of populations with different profiles.

Quality of life, anxiety and depression in patients with HIV/AIDS who present poor adherence to antiretroviral therapy: a cross-sectional study in Salvador, Brazil

The introduction of highly active antiretroviral therapy marked a major gain in efficacy of HIV/AIDS treatment and a reduction in morbidity and mortality of the infected patients. However, high levels of adherence are required to obtain virologic suppression. In Brazil, the policy of free and universal access to antiretroviral therapy has been in place since 1996, although there are reports of poor adherence.

Objective

To define the clinical, demographic and psychological characteristics, and quality of life of patients with HIV/AIDS who present poor adherence to highly active antiretroviral therapy.

Methods

This was a cross-sectional study. To be included in the study patients had to be 18 through 65 years old, diagnosed with HIV/AIDS, having the two previous viral loads above 500 copies, a surrogate for poor adherence to antiretrovirals. The following instruments were applied to all eligible patients: the sociodemographic questionnaire “Adherence Follow-up Questionnaire”, the Beck Depression Inventory (BDI-II), the Beck Anxiety Inventory (BAI), and the 36-Item Short Form Survey.

Results

47 patients were evaluated, 70.2% were female, mean age of 41.9 years (±10.5), 46.8% were single, 51.1% self-reported adherence ≥95%, 46.8% mentioned depression as the main reason for not taking the medication, 59.5% presented symptoms of moderate to severe depression, and 44.7% presented symptoms of moderate to severe anxiety. Finally, regarding health-related quality of life these patients obtained low scores in all dimensions, physical component summary of 43.96 (±9.64) and mental component summary of 33.19 (±13.35).

Conclusion

The psychological component is considered to be fundamental in the management of HIV/AIDS patients. Psychoeducation should be conducted at the initial evaluation to reduce negative beliefs regarding antiretroviral therapy Assessment of anxiety and depression symptoms should be done throughout therapy as both psycological conditions are associated with patient adherence, success of treatment, and ultimately with patients’ quality of life.

Alcohol use disorders among people living with HIV/AIDS in Southern Brazil: prevalence, risk factors and biological markers outcomes

BACKGROUND

Alcohol abuse is an important public health problem, frequently unrecognized among people living with HIV/AIDS (PLWHA), and requires investigation and intervention. It is usually associated with lower adherence to highly active antiretroviral therapy (HAART). It can also produce adverse clinical outcomes, such as changes in certain HIV markers, particularly CD4 cell counts and HIV viral loads (VLs). Thus, this study aimed to evaluate the prevalence of alcohol abuse among PLWHA, its associated risk factors and effects on CD4 cell counts and HIV VLs in southern Brazil.

METHODS

Between December 2012 and July 2013, 343 patients were interviewed at a reference hospital in southern Brazil. The instrument used was the Alcohol Use Disorder Identification Test (AUDIT), and a cutoff of eight points or more was applied. Socioeconomic, demographic, clinical and laboratory data were also collected. The statistical analysis included a Poisson regression to evaluate the factors associated with alcohol use disorder, and a linear regression was performed to assess the relationship between AUDIT scores and CD4 cell counts and HIV VLs.

RESULTS

Alcohol abuse was present in 28.6% of the respondents, and possible dependence was present in 5%. The risk factors identified included being male, mixed or black skin color, low education and the use of intravenous or inhaled drugs. A higher AUDIT score was associated with a lower CD4 cell count but was not associated with higher HIV VL values.

CONCLUSIONS

Our results show the importance of screening for alcohol abuse in this group. The prevalence of alcohol abuse was high, and it was associated with socioeconomic factors and the use of illicit drugs. Moreover, AUDIT score negatively affected CD4 cell counts as well.

Younger Age Predicts Failure to Achieve Viral Suppression and Virologic Rebound Among HIV-1-Infected Persons in Serodiscordant Partnerships

BACKGROUND

Antiretroviral therapy (ART) markedly reduces the risk of HIV-1 transmission in serodiscordant partnerships. We previously found that younger age and higher CD4 counts were associated with delayed initiation of ART by HIV-1-infected partners in serodiscordant partnerships. Among those initiating ART, we sought to explore whether those same factors were associated with failure to achieve viral suppression.

METHODS

In a prospective study of HIV-1-infected persons who had a known heterosexual HIV-1-uninfected partner in Kenya and Uganda [Partners Pre-Exposure Prophylaxis (PrEP) Study], we used Cox proportional hazards regression to evaluate correlates of viral nonsuppression (HIV-1 RNA >80 copies/ml).

RESULTS

Of 1,035 HIV-1-infected participants initiating ART, 867 (84%) achieved viral suppression: 77% by 6 months and 86% by 12 months. Younger age [adjusted hazard ratio (aHR) 1.05 for every 5 years younger; p = .006], lower pretreatment CD4 count (aHR 1.26; p = .009 for ≤250 compared with >250 cells/μl), and higher pretreatment HIV-1 RNA quantity (aHR 1.21 per log10; p < .001) independently predicted failure to achieve viral suppression. Following initial viral suppression, 8.8% (76/867) experienced virologic rebound (HIV-1 RNA >200 copies/ml): 6.3% and 11.5% by 6 and 12 months after initial suppression, respectively. Age was the only factor associated with increased risk of virologic rebound (aHR 1.33 for every 5 years younger; p = .005).

CONCLUSIONS

For HIV-1-infected persons in serodiscordant couples, younger age was associated with delayed ART initiation, failure to achieve viral suppression, and increased risk of virologic rebound. Motivating ART initiation and early adherence is a key to achieving and sustaining viral suppression.

The influence of depressive symptoms and substance use on adherence to antiretroviral therapy. A cross-sectional prevalence study

CONTEXT AND OBJECTIVE

Adherence to antiretroviral treatment (ART) is not a stable condition, but is dynamic, like mental conditions. The aim of this study was to examine whether non-adherence to ART is related to demographic and immunological variables, substance use and presence of depressive symptoms.

DESIGN AND SETTING

This was a cross-sectional prevalence study carried out at a public AIDS treatment center in the city of São Paulo, Brazil, between July 2006 and January 2007.

METHODS

438 patients on regular ART schedules with recent laboratory tests answered a demographic questionnaire, questions about substance use, the Hamilton Depression Rating Scale (HDRS) and the Simplified Medication Adherence Questionnaire (SMAQ).

RESULTS

The prevalence of non-adherence over the past three months (a pattern of treatment interruption) was 46.3%, and 27.2% also reported this in the past week (a pattern of missed doses). ART interruption was significantly related to older age, lower CD4+ cell count and homosexual/bisexual transmission. The pattern of missed doses was significantly related to younger age, higher HDRS scores and higher viral load of RNA HIV.

CONCLUSION

ART interruption may reflect recall errors and changes to the Brazilian demographic characteristics of HIV infection. The missed doses may reflect lifestyle characteristics of younger individuals. Attendance for HIV-positive individuals, particularly younger patients, should involve interventions and counseling in relation to the presence of depressive symptoms.

Alcohol use disorders negatively influence antiretroviral medication adherence among men who have sex with men in Peru

As international guidelines increase access to antiretroviral therapy (ART) globally, ART adherence becomes increasingly important to achieve HIV treatment as prevention (TasP) goals. In the concentrated HIV epidemic among men who have sex with men (MSM) and transgendered women (TGW) in Lima, Peru, the independent correlates of ART nonadherence were examined to inform treatment intervention priorities. Cross sectional survey of HIV-infected MSM and TGW who are engaged in clinical care in Lima, Peru. From June to August 2012, 302 HIV-infected Peruvian MSM/TGW from three clinical care sites were recruited using convenience sampling to participate in a cross-sectional computer-assisted adherence survey. Several standardized screening measures associated with ART nonadherence were examined in order to determine the independent correlates of optimal (≥90%) and perfect (100%) adherence, which were assessed using logistic regression. Of the 302 participants recruited, 263 (87.1%) were prescribed ART. Among those prescribed ART, 229 (87.1%) reported optimal and 146 (55.5%) reported perfect adherence. The prevalence of alcohol use disorders (AUD; 43.2%), alcohol dependence (5.3%), recent drug use (6.0%), and depression (44.5%) was high, and most participants had some evidence of neurocognitive impairment. Meeting criteria for having an AUD and depression were collinear (p < 0.001). On multivariate analysis, having an AUD was inversely related and the only independent correlate of optimal (AOR = 0.427; 95% CI = 0.187-0.976) and perfect (AOR = 0.552; 95% CI = 0.327-0.930) ART adherence. AUDs are highly prevalent among Peruvian HIV-infected MSM and contribute significantly to ART nonadherence. These findings support the need for screening and treating underlying AUDs. In order to meet HIV TasP goals, evidence-based strategies targeting AUDs are likely to directly improve ART adherence and indirectly improve overall individual health, HIV treatment engagement, and reduce transmission to sexual partners among this vulnerable and disproportionally affected population.

Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis

BACKGROUND

Adherence to combination antiretroviral therapy (ART) is a key predictor of the success of human immunodeficiency virus (HIV) treatment, and is potentially amenable to intervention. Insight into predictors or correlates of non-adherence to ART may help guide targets for the development of adherence-enhancing interventions. Our objective was to review evidence on predictors/correlates of adherence to ART, and to aggregate findings into quantitative estimates of their impact on adherence.

METHODS

We searched PubMed for original English-language papers, published between 1996 and June 2014, and the reference lists of all relevant articles found. Studies reporting on predictors/correlates of adherence of adults prescribed ART for chronic HIV infection were included without restriction to adherence assessment method, study design or geographical location. Two researchers independently extracted the data from the same papers. Random effects models with inverse variance weights were used to aggregate findings into pooled effects estimates with 95% confidence intervals. The standardized mean difference (SMD) was used as the common effect size. The impact of study design features (adherence assessment method, study design, and the United Nations Human Development Index (HDI) of the country in which the study was set) was investigated using categorical mixed effects meta-regression.

RESULTS

In total, 207 studies were included. The following predictors/correlates were most strongly associated with adherence: adherence self-efficacy (SMD = 0.603, P = 0.001), current substance use (SMD = -0.395, P = 0.001), concerns about ART (SMD = -0.388, P = 0.001), beliefs about the necessity/utility of ART (SMD = 0.357, P = 0.001), trust/satisfaction with the HIV care provider (SMD = 0.377, P = 0.001), depressive symptoms (SMD = -0.305, P = 0.001), stigma about HIV (SMD = -0.282, P = 0.001), and social support (SMD = 0.237, P = 0.001). Smaller but significant associations were observed for the following being prescribed a protease inhibitor-containing regimen (SMD = -0.196, P = 0.001), daily dosing frequency (SMD = -0.193, P = 0.001), financial constraints (SMD -0.187, P = 0.001) and pill burden (SMD = -0.124, P = 0.001). Higher trust/satisfaction with the HIV care provider, a lower daily dosing frequency, and fewer depressive symptoms were more strongly related with higher adherence in low and medium HDI countries than in high HDI countries.

CONCLUSIONS

These findings suggest that adherence-enhancing interventions should particularly target psychological factors such as self-efficacy and concerns/beliefs about the efficacy and safety of ART. Moreover, these findings suggest that simplification of regimens might have smaller but significant effects.

Predictors and correlates of adherence to combination antiretroviral therapy (ART) for chronic HIV infection: a meta-analysis

Background

Adherence to combination antiretroviral therapy (ART) is a key predictor of the success of human immunodeficiency virus (HIV) treatment, and is potentially amenable to intervention. Insight into predictors or correlates of non-adherence to ART may help guide targets for the development of adherence-enhancing interventions. Our objective was to review evidence on predictors/correlates of adherence to ART, and to aggregate findings into quantitative estimates of their impact on adherence.

Methods

We searched PubMed for original English-language papers, published between 1996 and June 2014, and the reference lists of all relevant articles found. Studies reporting on predictors/correlates of adherence of adults prescribed ART for chronic HIV infection were included without restriction to adherence assessment method, study design or geographical location. Two researchers independently extracted the data from the same papers. Random effects models with inverse variance weights were used to aggregate findings into pooled effects estimates with 95% confidence intervals. The standardized mean difference (SMD) was used as the common effect size. The impact of study design features (adherence assessment method, study design, and the United Nations Human Development Index (HDI) of the country in which the study was set) was investigated using categorical mixed effects meta-regression.

Results

In total, 207 studies were included. The following predictors/correlates were most strongly associated with adherence: adherence self-efficacy (SMD = 0.603, P = 0.001), current substance use (SMD = -0.395, P = 0.001), concerns about ART (SMD = -0.388, P = 0.001), beliefs about the necessity/utility of ART (SMD = 0.357, P = 0.001), trust/satisfaction with the HIV care provider (SMD = 0.377, P = 0.001), depressive symptoms (SMD = -0.305, P = 0.001), stigma about HIV (SMD = -0.282, P = 0.001), and social support (SMD = 0.237, P = 0.001). Smaller but significant associations were observed for the following being prescribed a protease inhibitor-containing regimen (SMD = -0.196, P = 0.001), daily dosing frequency (SMD = -0.193, P = 0.001), financial constraints (SMD -0.187, P = 0.001) and pill burden (SMD = -0.124, P = 0.001). Higher trust/satisfaction with the HIV care provider, a lower daily dosing frequency, and fewer depressive symptoms were more strongly related with higher adherence in low and medium HDI countries than in high HDI countries.

Conclusions

These findings suggest that adherence-enhancing interventions should particularly target psychological factors such as self-efficacy and concerns/beliefs about the efficacy and safety of ART. Moreover, these findings suggest that simplification of regimens might have smaller but significant effects.

Electronic supplementary material

The online version of this article (doi:10.1186/s12916-014-0142-1) contains supplementary material, which is available to authorized users.

Economic support to patients in HIV and TB grants in rounds 7 and 10 from the global fund to fight AIDS, tuberculosis and malaria

People with TB and/or HIV frequently experience severe economic barriers to health care, including out-of-pocket expenses related to diagnosis and treatment, as well as indirect costs due to loss of income. These barriers can both aggravate economic hardship and prevent or delay diagnosis, treatment and successful outcome, leading to increased transmission, morbidity and mortality. WHO, UNAIDS and the ILO argue that economic support of various kinds is essential to enable vulnerable people to protect themselves from infection, avoid delayed diagnosis and treatment, overcome barriers to adherence, and avert destitution. This paper analyses successful country proposals to the Global Fund to Fight AIDS, Tuberculosis and Malaria that include economic support in Rounds 7 and 10; 36 and 20 HIV and TB grants in Round 7 and 32 and 26, respectively, in Round 10. Of these, up to 84 percent included direct or indirect economic support for beneficiaries, although the amount constituted a very small proportion of the total grant. In TB grants, the objectives of economic support were generally clearly stated, and focused on mechanisms to improve treatment uptake and adherence, and the case was most clearly made for MDR-TB patients. In HIV grants, the objectives were much broader in scope, including mitigation of adverse economic and social effects of HIV and its treatment on both patients and families. The analysis shows that economic support is on the radar for countries developing Global Fund proposals, and a wide range of economic support activities are in place. In order to move forward in this area, the wealth of country experience that exists needs to be collated, assessed and disseminated. In addition to trials, operational research and programme evaluations, more precise guidance to countries is needed to inform evidence-based decision about activities that are cost-effective, affordable and feasible.

A preliminary RCT of CBT-AD for adherence and depression among HIV-positive Latinos on the U.S.-Mexico border: the Nuevo Día study

We conducted a preliminary RCT among 40 HIV-positive Latinos of Mexican descent on the U.S.-Mexico border who indicated imperfect adherence and depressive symptomatology. Participants were randomly assigned to culturally adapted cognitive-behavioral therapy for adherence and depression with an alarmed pillbox or usual care. Outcomes were depressive symptoms (self-report and blind clinician ratings), adherence (self-report and electronic pillbox), and biological markers. The intervention, delivered in English and Spanish, proved feasible and acceptable. Generalized estimating equations in intent-to-treat analyses showed some effects of "moderate" to "large" size, with maintenance over time. For example, intervention (vs. control) participants demonstrated at post-intervention a greater drop in BDI scores (OR = -3.64, p = 0.05) and greater adherence according to the electronic pillbox (OR = 3.78, p = 0.03). Biological markers indicated some relative improvement for CD4 count but not VL. The promising results suggest a larger trial to determine efficacy is warranted.

Individual and contextual factors of influence on adherence to antiretrovirals among people attending public clinics in Rio de Janeiro, Brazil

BACKGROUND

There are inconsistencies in the determinants of adherence to antiretrovirals (ARVs) across settings as well as a lack of studies that take into consideration factors beyond the individual level. This makes it necessary to examine factors holistically in multiple settings and populations while taking into consideration the particularities of each context, in order to understand the patterns of ARV adherence. This research explored ARV adherence and individual, relational and environmental-structural factors.

METHODS

A cross-sectional survey was conducted from August 2008 through July 2009 among participants currently on ARVs recruited from 6 public health clinics, selected to maximize diversity in terms of caseload and location, representing the range of clinics within Rio de Janeiro city, Brazil. Multivariate logistic regression analysis was used to assess the association between our multilevel factors with ARV adherence among participants with complete cases (n = 632).

RESULTS

Eighty-four percent of respondents reported adherence to all of their ARV doses in the last 4 days. Of the socio-demographic variables, those who had one child were positively associated with adherence (AOR 2.29 CI [1.33-3.94]). On the relational level, those with high social support (AOR 2.85 CI [1.50-5.41]) were positively associated with adherence to ARVs. On the environmental-structural level, we found gender was significant with women negatively associated with adherence to ARVs (AOR 0.58 CI [0.38-0.88]) while those with a high asset index (AOR 2.47 CI [1.79-3.40]) were positively associated with adherence to ARVs.

CONCLUSIONS

This research highlights the importance of examining the multiple levels of influence on ARV adherence. Intervention research in lower and middle-income settings should address and evaluate the impact of attending to both gender and economic inequalities to improve ARV adherence, as well as relational areas such as the provision of social support.

Retention in medical care and antiretroviral treatment according to skin color in southern Brazil

The aim of this study was to compare the retention in medical care and antiretroviral (ARV) treatment of individuals living with HIV and AIDS to antiretroviral therapy in southern Brazil according to their "race" or skin color. This study is part of a 225-day prospective trial, comprising 7 interviews, in which an intervention designed to improve adherence to treatment was tested. A convenience sample of 73 individuals living with HIV and/or AIDS enrolled in this follow-up procedure. The mean length of continuance in treatment was 161.5 (standard deviation [SD] = 18.6; 95% confidence interval [CI] = 125-198) and 138.4 (SD = 14.1; 95% C.I. = 111-166) days in the "nonwhite" and "white" categories, respectively. There was no significant difference between the 2 categories, χ(2)(1, n = 72) = 0.76, P = .38, which include similar levels of retention in medical care and treatment with ARV medications between groups of individuals categorized as white and nonwhite in this sample.

Current strategies for improving access and adherence to antiretroviral therapies in resource-limited settings

The rollout of antiretroviral therapy (ART) significantly reduced human immunodeficiency virus (HIV)-related morbidity and mortality, but good clinical outcomes depend on access and adherence to treatment. In resource-limited settings, where over 90% of the world's HIV-infected population resides, data on barriers to treatment are emerging that contribute to low rates of uptake in HIV testing, linkage to and retention in HIV care systems, and suboptimal adherence rates to therapy. A review of the literature reveals limited evidence to inform strategies to improve access and adherence with the majority of studies from sub-Saharan Africa. Data from observational studies and randomized controlled trials support home-based, mobile and antenatal care HIV testing, task-shifting from doctor-based to nurse-based and lower level provider care, and adherence support through education, counseling and mobile phone messaging services. Strategies with more limited evidence include targeted HIV testing for couples and family members of ART patients, decentralization of HIV care, including through home- and community-based ART programs, and adherence promotion through peer health workers, treatment supporters, and directly observed therapy. There is little evidence for improving access and adherence among vulnerable groups such as women, children and adolescents, and other high-risk populations and for addressing major barriers. Overall, studies are few in number and suffer from methodological issues. Recommendations for further research include health information technology, social-level factors like HIV stigma, and new research directions in cost-effectiveness, operations, and implementation. Findings from this review make a compelling case for more data to guide strategies to improve access and adherence to treatment in resource-limited settings.

HIV drug resistance early warning indicators in cohorts of individuals starting antiretroviral therapy between 2004 and 2009: World Health Organization global report from 50 countries

The World Health Organization developed a set of human immunodeficiency virus drug resistance (HIVDR) early warning indicators (EWIs) to assess antiretroviral therapy clinic and program factors associated with HIVDR. EWIs are monitored by abstracting data routinely recorded in clinical records, and the results enable clinics and program managers to identify problems that should be addressed to minimize preventable emergence of HIVDR in clinic populations. As of June 2011, 50 countries monitored EWIs, covering 131 686 patients initiating antiretroviral treatment between 2004 and 2009 at 2107 clinics. HIVDR prevention is associated with patient care (appropriate prescribing and patient monitoring), patient behavior (adherence), and clinic/program management efforts to reduce treatment interruptions (follow up, retention on first-line ART, procurement and supply management of antiretroviral drugs). EWIs measure these factors and the results have been used to optimize patient and population treatment outcomes.

A randomized controlled trial of a protocol of interviews designed to improve adherence to antiretroviral medications in southern Brazil

The aim of this study was to evaluate the efficacy of the Portuguese version of the Medication Adherence Training Instrument (MATI) for improving adherence to antiretroviral therapy (ART) in southern Brazil. Two different follow-up modalities were compared in this 225 days randomized controlled study: one based on the MATI protocol and a conventional (non-MATI) clinical follow-up. There were no differences between the groups with the exception of socioeconomic class ( P < 0.005). The mean length of continuance in treatment was 111.4 (SD = 13.9) and 137.6 (SD = 17.3) days in the MATI and non-MATI groups, respectively. A Mantel–Cox log-rank test revealed no significant difference between the two interventions ( P = 0.34). Despite the sample size limitation, the results from this study indicate that the Portuguese version of the MATI was not more efficacious than the regular follow-up intervention for improving adherence of outpatients to ART.

Women and vulnerability to HAART non-adherence: a literature review of treatment adherence by gender from 2000 to 2011

A literature review of original research articles on adherence to antiretroviral therapy (ART) in developed countries, covering January 2000 to June 2011, was conducted to determine if gender differences exist in the prevalence of nonadherence to ART. Of the 1,255 articles reviewed, only 189 included data on the proportion of the study population that was adherent and only 57 (30.2%) of these reported proportional adherence values by gender. While comparing articles was challenging because of varied reporting strategies, women generally exhibit poorer adherence than men. Thirty of the 44 articles (68.2%) that reported comparative data on adherence by gender found women to be less adherent than men. Ten articles (17.5%) reported significant differences in proportional adherence by gender, nine of which showed women to be less adherent than men. These findings suggest that in multiple studies from developed countries, female gender often predicts lower adherence. The unique circumstances of HIV-positive women require specialized care to increase adherence to ART.

Predictors of adherence to antiretroviral therapy among people living with HIV/AIDS in resource-limited setting of southwest ethiopia

BACKGROUND

Good adherence to antiretroviral therapy is necessary to achieve the best virological response, lower the risk that drug resistance will develop, and reduce morbidity and mortality. Little is known about the rate and predictors of adherence in Ethiopia. Therefore this study determines the magnitude and predictors of adherence to antiretroviral therapy among people living with HIV/AIDS in Southwest Ethiopia.

METHODS

A cross sectional study was carried out from January 1, 2009 to March 3, 2009 among 319 adult PLWHA (≥ 18 years) attending ART clinic at Jimma university Specialized Hospital (JUSH). Multiple Logistic regression models were constructed with adherence and independent variables to identify the predictors.

RESULTS

About 303(95%) of the study subjects were adherent based on self report of missed doses (dose adherence) in a one-week recall before the actual interview. The rate of self reported adherence in the study based on the combined indicator of the dose, time and food adherence measurement was 72.4%. Patients who got family support were 2 times [2.12(1.25-3.59)] more likely to adhere than those who didn't get family support as an independent predictor of overall adherence (dose, time and food). The reasons given for missing drugs were 9(27.3%) running out of medication/drug, 7(21.2%) being away from home and 7(21.2%) being busy with other things.

CONCLUSION

The adherence rate found in this study is similar to other resource limited setting and higher than the developed country. This study highlights emphasis should be given for income generating activities and social supports that helps to remember the patients for medication taking and management of opportunistic infections during the course of treatment.

Alcohol use and antiretroviral adherence: review and meta-analysis

BACKGROUND

Alcohol use is frequently implicated as a factor in nonadherence to highly active antiretroviral therapy (HAART). There have not been efforts to systematically evaluate findings across studies. This meta-analysis provides a quantitative evaluation of the alcohol-adherence association by aggregating findings across studies and examining potential moderators.

METHODS

Literature searches identified 40 qualifying studies totaling over 25,000 participants. Studies were coded on several methodological variables.

RESULTS

In the combined analysis, alcohol drinkers were approximately 50%-60% as likely to be classified as adherent [odds ratio (OR) = 0.548, 95% confidence interval (CI): 0.490 to 0.612] compared with abstainers (or those who drank relatively less). Effect sizes for problem drinking, defined as meeting the National Institute on Alcohol Abuse and Alcoholism criteria for at-risk drinking or criteria for an alcohol use disorder, were greater (OR = 0.474, 95% CI = 0.408 to 0.550) than those reflecting any or global drinking (OR = 0.604, 95% CI = 0.531 to 0.687). Several variables moderated the alcohol-adherence association.

CONCLUSIONS

Results support a significant and reliable association of alcohol use and medication nonadherence. Methodological variables seem to moderate this association and could contribute to inconsistent findings across studies. Future research would benefit from efforts to characterize theoretical mechanisms and mediators and moderators of the alcohol-adherence association.

The financial burden of HIV care, including antiretroviral therapy, on patients in three sites in Indonesia

This paper assesses the extent of the financial burden due to out-of-pocket payments for health care incurred by people living with HIV (PLHIV) and the effect of this burden on their financial capacity. Data were collected in a cross-sectional survey of 353 PLHIV from three cities in Indonesia (Jakarta, Jogjakarta and Merauke). Respondents in Jakarta were sampled from one hospital and one non-governmental organization working with PLHIV. In Jogjakarta and Merauke, all HIV patients on antiretroviral therapy (ART) who came to selected hospitals during the interview period were asked to participate in the survey. The survey collected data on the frequency and extent of payments for HIV-related care, with answers cross-checked against medical records. Results show that PLHIV had different burdens of payments in the different geographical areas. On average, respondents in Jogjakarta spent 68%, and PLHIV on ART in Jakarta spent 96%, of monthly expenditure for HIV-related care, indicating a substantial financial burden for many ART patients. These patients depended on several sources of finance to cover the costs of their care, with donations from their immediate family being the most common method, selling assets and payments from personal income being the second most common method in Jakarta and Jogjakarta, respectively. Most PLHIV in these two areas did not have insurance. In Merauke, there were little observed out-of-pocket payments because the government covers medical costs via the local budget and health insurance for the poor. The results of this study confirm previous findings that providing subsidized ART drugs alone does not ensure financial accessibility to HIV care. Thus, the government of Indonesia at central and local levels should consider covering HIV care additional to providing antiretroviral drugs free of charge. Social health insurance should also be encouraged.

Understanding the facilitators and barriers of antiretroviral adherence in Peru: a qualitative study

BACKGROUND

Antiretroviral scale-up is increasing in resource-constrained settings. To date, few studies have explored the barriers and facilitators of adherence to ART in these settings. Facilitators and barriers of antiretroviral adherence in Peru are not completely understood.

METHODS

At two clinics that serve a large number of HIV-positive individuals in Lima, Peru, 31 in-depth interviews were carried out in 2006 with adult HIV-positive individuals receiving ART. Purposive sampling was used to recruit the participants. Interviews were transcribed and coded using two Spanish-speaking researchers and a content analysis approach to identify themes in the data.

RESULTS

Among the participants, 28/31 (90%) were male, 25/31 (81%) were self-identified as mestizo, and 19/31 (61%) had an education above high school. The most frequently discussed barriers to adherence included side effects, simply forgetting, inconvenience, dietary requirements, being away from home, and fear of disclosure/stigma. The most frequently discussed facilitators to adherence included having a fixed routine, understanding the need for compliance, seeing positive results, treatment knowledge, and faith in treatment.

CONCLUSIONS

Overall, these findings were similar to the facilitators and challenges experienced by individuals on ART in other resource constrained settings. Further treatment support tools and networks should be developed to decrease the challenges of ART adherence for HIV-positive individuals in Lima, Peru.

Barriers to acceptance and adherence of antiretroviral therapy in urban Zambian women: a qualitative study

Sub-Saharan Africa contains over 60% of the world's HIV infections and Zambia is among the most severely affected countries in the region. As antiretroviral programs have been rapidly expanding, the long-term success of these programs depends on a good understanding of the behavioral determinants of acceptance and adherence to antiretroviral therapy (ART). The study used qualitative methods to gain local insight into potentially important factors affecting HIV-infected women's decision to accept or continue with ART. Some of the barriers identified by this study are consistent with factors cited in the existing adherence literature from both developed and developing nations such as side effects, hunger and stigma; other factors have not been previously reported. One major theme was unfamiliarity with the implications of having a chronic, potentially deadly disease. Other emerging themes from this study include the complicated effect of ART on interpersonal relationship, particularly between husbands and wives, the presence of depression and hopelessness, and lack of accurate information. The results suggest that the reasons for non-uptake of treatment include issues related to local cultural frameworks (e.g., illness ideology), mental and behavioral health (e.g., depression and/or interpersonal challenges), stigma, and motivating factors (e.g., values of church or marriage) of different cultures that affect the ability and willingness to take life-saving medicine for a long period of time. Qualitative studies are critical to better understand why ART eligible individuals are choosing not to initiate or continue treatment to achieve needed adherence levels.

Correlates of adherence to antiretroviral therapy in HIV-infected children in Lomé, Togo, West Africa

We assessed pediatric adherence to antiretroviral therapy (ART) and examined associated factors among children in Togo, West Africa. Structured interviews of caregivers of consecutively enrolled HIV-infected children receiving ART in three HIV/AIDS care centers in Lome, Togo were conducted. Child perfect adherence reflected caregivers' report of no antiretroviral drug doses missed neither in the past 4 days nor in the month before the interview. A total of 74 ART-treated children were included (median age 6 years). Of these, 42% of caregivers declared perfect adherence. In univariate analyses, the major factors relating to child non-adherence were: being female, living in an individual setting (vs. compound with enlarged family), receiving other ART than an NNRT-based regimen, drug regimens with six pills/spoons or more per day, caregiver other than biological parent, caregiver not declaring HIV-status, not participating to support groups and having perceived difficulty of antiretroviral (ARV) administration. In multivariate analysis, female gender, living in an individual setting, receiving other than NNRTI-based regimen and caregivers' perceived difficulty of ARV administration remained independently associated with the reported child's non-adherence. These data show low rates of perfect adherence to ART in children in West Africa, influenced by child and caregiver characteristics and suggest a need for counseling and education interventions as well as continuous psychological and social support.

The first ten years: achievements and challenges of the Brazilian program of universal access to HIV/AIDS comprehensive management and care, 1996-2006

A review was carried out of papers published between 1996 and 2006, documenting the introduction of highly active anti-retroviral therapy (HAART) in Brazil. Papers indexed in the MEDLINE and SciELO databases were retrieved using different combinations of keywords related to the management and care of AIDS in the post-HAART era: opportunistic diseases and co-infections, adherence to therapy, survival in the pre- and post-HAART eras, adverse events and side-effects, emergence and possible transmission of resistant viral strains, metabolic and cardiovascular disorders, and issues related to access to care and equity. The review documents the dramatic changes in HIV/AIDS disease progression in the post-HAART era, including an increase in survival and quality of life and a pronounced decrease in the episodes of opportunistic diseases. Notwithstanding such major achievements, new challenges have emerged, including slow evolving co-infections (such as hepatitis C, metabolic and cardiovascular disorders), the emergence of viral resistance, with consequences at the individual level (virological failure) and the community level (primary/secondary resistance at the population level), and impacts on the cost of new therapeutic regimens.

100% adherence study: educational workshops vs. video sessions to improve adherence among ART-naïve patients in Salvador, Brazil

We conducted a randomized trial to test an intervention aimed at increasing adherence to antiretroviral therapy (ART) among HIV-positive, ART-naïve patients in Salvador, Brazil. Participants (N = 107) were randomized to either educational workshops based on the information-motivation-behavioral skills model (n = 52) or a control video session (n = 55). Changes in self-reported ART adherence, viral load, CD4 cell counts and ART pharmacy records were measured periodically over 12 months. After 3-6 months, ART adherence (> or = 95%) was 77.8% in the workshop group and 85.7% in video group (as treated) and 53.8% and 65.5%, respectively, using intention-to-treat (ITT) analysis (both P > 0.05) At 9-12 months, ART adherence decreased to 73.7% in the workshop group and 79.1% in the video group (as treated) and 53.8% and 61.8% using ITT, respectively. No differences were found in self-reported adherence, viral load or pharmacy records between groups. We found that the educational workshop intervention does not increase adherence to ART.

Influence of prior antiretroviral experience on adherence and responses to new highly active antiretroviral therapy regimens

The impact of prior antiretroviral experience on adherence and clinical outcomes in patients initiating a new highly active antiretroviral therapy (HAART) regimen is not well defined. We performed an observational cohort analysis of antiretroviral-experienced or -naive HIV-infected patients prescribed a new HAART regimen (3538 patients) and enrolled in Kaiser Permanente Northern California from 1997 through 2002. Outcomes evaluated were HAART adherence and changes in HIV RNA level and CD4 T-cell counts over 12 and 24 months. The antiretroviral-naive group had a significantly greater odds of achieving >/=95% adherence to the HAART regimen over 12 months (adjusted odds ratio [OR] = 1.88, p < 0.001) and over 24 months (OR = 1.66, p < 0.001). The odds of achieving HIV RNA levels below limits of quantification also was higher among patients who were antiretroviral naive; over 24 months OR = 6.88, p < 0.001. Adjusted change in CD4 T-cell count was also greater among naive patients over 24 months (+67 cells/muL, p < 0.001), compared to antiretroviral-experienced patients. Years of antiretroviral experience did not affect adherence or any outcome measure. Adjusting for HAART adherence did not significantly affect HIV RNA results but did lessen CD4 T-cell count differences between antiretroviral-naive and -experienced patients. Thus, antiretroviral naive patients have improved HAART adherence, HIV RNA control, and CD4 T-cell count increases compared to antiretroviral-experienced patients regardless of years of antiretroviral experience. These findings should help direct HAART adherence efforts in HIV care clinics.

Adherence to antiretroviral therapy in a context of universal access, in Rio de Janeiro, Brazil

Adherence is integral to improving and maintaining the health and quality of life of people living with HIV. Two-hundred HIV-positive adults recruited from teaching hospitals and non-governmental organizations (NGOs) in Rio de Janeiro City were assessed on socio-demographic factors, adherence to antiretroviral therapy (ART) and psychosocial factors hypothesized to be associated with ART. Predictors of non-adherence were analyzed using bivariate and multivariate analyses. Self-reported medication adherence was high (82% had adherence >90%). Non-adherence was associated with personal factors (i.e. sexual orientation, self-efficacy), physical factors (i.e. loss of appetite) and interpersonal factors (i.e. doctor-patient relationship). Adherence in Brazil is as good, if not better, than that seen in the US and western Europe, which is noteworthy since the sample was derived predominantly from public healthcare settings. It is possible that the connection to NGOs in Rio de Janeiro City played a helpful role in achieving high levels of adherence in this sample of people living with HIV and AIDS. Recommendations, based on study findings, include enhancing and sustaining supportive services for NGOs, promoting patient self-efficacy and behavioral skills for adherence, increasing social network support and having healthcare providers directly address patients' medication beliefs, attitudes and experience with side effects.

Evaluation of the consistency of refills for antiretroviral medications in two hospitals in the state of Rio de Janeiro, Brazil

We conducted a retrospective cohort study using pharmacy records to assess the frequency of delay in picking up antiretroviral (ARV) medication refills from the pharmacy and to identify determinants of delay among HIV-infected patients at two Brazilian hospitals. We selected patients who were on ARV therapy before January 2001 at Nova Iguaçu Hospital (NIPRH) (N = 265) and Evandro Chagas (N=424) Clinical Research Institute. We abstracted medical records and pharmacy data using standardised forms and analysed potential associations between delay in refilling medications and patients' demographic characteristics, type of ARV drug regimen and evolution of HIV disease. Sixty-nine patients (26%) had delays in medication refills >1 month at least once in 2001 at NIPRH compared with 140 (33%) patients at IPEC (p=0.052). No factor was found to be associated with having a delay in medication refill >1 month at NIPRH. At IPEC, delays in medication refill >1 month were associated with a median CD4+ T cell count <200/mm(3) versus >500/mm(3) (adjusted odds ratio (AOR) = 3.8; 95% confidence interval (CI) =1.6-8.9) and with dual protease inhibitor-based ARV regimens versus other regimens (AOR = 4.3; 95% CI = 1.9-9.4). In conclusion, rates of delay in medication refills were similar to rates of adherence to ARV therapy found in other studies in Brazil, suggesting that delay in medication refills could be used as a surrogate for adherence. Analysing ARV medication refills can complement self-reported information on adherence.

Drug resistance among chronic HIV-1-infected patients naïve for use of anti-retroviral therapy in Sao Paulo city

Primary infection with drug-resistant HIV appears to be increasing in the regions where HAART is widely available, which may reduce efficacy of first-line antiretroviral therapy. To determine prevalence of antiretroviral drug-resistant mutations in newly diagnosed subjects in a clinical setting where HAART has been widely used since 1997. One hundred and thirty-six HIV-1-infected adult patients were diagnosed with HIV infection between January 2000 and December 2006 in the HIV out-clinic at the HC/FMUSP, Sao Paulo city. These antiretroviral naïve patients were mainly referred from the blood bank, situated in the same building or elsewhere in the city. The samples were genotyped to provide HIV protease and reverse transcriptase sequence data. Major antiretroviral drug resistance mutations were classified according to Shafer et al. [Shafer, R.W., Rhee, S.Y., Pillay, D., et al., 2007. HIV-1 protease and reverse transcriptase mutations for drug resistance surveillance. AIDS 21, 215-223]. Thirteen cases had no DNA amplification, and 123 patients were successfully analyzed, with a mean age of 37 years and 89 (72%) were males. Antiretroviral drug resistance mutations were detected in 8/123 patients (6.5%), all eight were heterosexuals and HIV asymptomatic, the mean of the CD4 cells count was 323 cells/mm(3), and the RNA plasma viral load was 4.7 log(10)/mL. We found NRTI (n=2, 1.6%), NNRTI-resistant (n=2, 1.6%) mutations, and one cases with PI mutation (0.8%). Three cases (2.4%) showed mutations for NRTI, NNRTI or PI, simultaneously. Eighty-two percent were HIV-1 B subtype, and HIV-1 F (6.5%), HIV-1 C (5.7%) and recombinant viruses (5.8%) were observed. In an unselected cohort, primary drug resistance was seen in 6.5% of the naïve for drug ART use. These results indicate that HIV drug resistance testing should be a practical approach in monitoring first-line ART. In addition, HIV-1 C seems to be emerging in Sao Paulo city.

Estimating the impact of alcohol consumption on survival for HIV+ individuals

Alcohol consumption is associated with decreased antiretroviral adherence, and decreased adherence results in poorer outcomes. However the magnitude of alcohol's impact on survival is unknown. Our objective was to use a calibrated and validated simulation of HIV disease to estimate the impact of alcohol on survival. We incorporated clinical data describing the temporal and dose-response relationships between alcohol consumption and adherence in a large observational cohort (N=2,702). Individuals were categorized as nondrinkers (no alcohol consumption), hazardous drinkers (consume > or =5 standard drinks on drinking days), and nonhazardous drinkers (consume <5 standard drinks on drinking days). Our results showed that nonhazardous alcohol consumption decreased survival by more than 1 year if the frequency of consumption was once per week or greater, and by 3.3 years (from 21.7 years to 18.4 years) with daily consumption. Hazardous alcohol consumption decreased overall survival by more than 3 years if frequency of consumption was once per week or greater, and by 6.4 years (From 16.1 years to 9.7 years) with daily consumption. Our results suggest that alcohol is an underappreciated yet modifiable risk factor for poor survival among individuals with HIV.

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

BACKGROUND

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

METHODS AND FINDINGS

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

CONCLUSIONS

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

Self-report measures of antiretroviral therapy adherence: A review with recommendations for HIV research and clinical management

A review of 77 studies employing self-report measures of antiretroviral adherence published 1/1996 through 8/2004 revealed great variety in adherence assessment item content, format, and response options. Recall periods ranged from 2 to 365 days (mode = 7 days). The most common cutoff for optimal adherence was 100% (21/48 studies, or 44%). In 27 of 34 recall periods (79%), self-reported adherence was associated with adherence as assessed with other indirect measures. Data from 57 of 67 recall periods (84%) indicated self-reported adherence was significantly associated with HIV-1 RNA viral load; in 16 of 26 (62%), it was associated with CD4 count. Clearly, the field would benefit from item standardization and a priori definitions and operationalizations of adherence. We conclude that even brief self-report measures of antiretroviral adherence can be robust, and recommend items and strategies for HIV research and clinical management.

Pesquisas brasileiras biomédicas e epidemiológicas face às metas da UNGASS

O foco do estudo é a resposta brasileira em Ciência, Tecnologia e Inovação às metas formuladas no documento da UNGASS. Foram analisados os itens 70-73 que integram o documento Draft Declaration of Commitment for the UNGASS on HIV/AIDS, 2001, que definem metas para a Ciência, Tecnologia e Inovação em HIV/Aids. Os principais tópicos listados nesses itens foram operacionalizados sob a forma de "palavras-chave", de modo a orientar buscas sistemáticas nos bancos de dados padrão em biomedicina, incluindo ainda o Web of Science, nas suas subdivisões referentes às ciências naturais e sociais. O sucesso da pesquisa brasileira no âmbito da caracterização e isolamento do HIV-1 é inegável. Estudos vacinais fases II/III têm sido desenvolvidos no Rio de Janeiro, Belo Horizonte e São Paulo. O monitoramento da resistência primária teve estudos empíricos desenvolvidos em populações específicas, por meio da "Rede Brasileira em Monitoramento da Resistência do HIV". No âmbito do monitoramento da resistência secundária, destacaram-se iniciativas como a Rede Nacional de Genotipagem. Dois sistemas nacionais, o Sistema de Informações de Mortalidade e o Sistema de Informações de Agravos de Notificação - Aids e alguns estudos de maior abrangência têm dado origem a trabalhos sobre tendências da epidemia. A produção de medicamentos genéricos de qualidade e sua distribuição gratuita aos pacientes foram destacadas. O Brasil tem implementado uma resposta consistente e diversificada no âmbito do HIV/Aids, com estudos referentes ao desenvolvimento de vacinas, novos medicamentos e monitoramento da epidemia.

Antiretroviral adherence in a resource-poor setting

Adherence is key to successful antiretroviral therapy (ART). Many countries with increased HIV prevalence and the greatest need for ART have limited health resources. Recent assumptions that the adherence required for successful ART will not be achieved in resource-poor settings have led to calls for caution in expanded access programs. New studies from Africa refute this, showing excellent adherence and virologic outcomes. Major factors contributing to adherence or nonadherence are whether the drug is accessed for free or is self-funded, patient preparedness for use of ART, stigmatization related to being HIV-positive, and ease of use of regimen.

A temporal and dose-response association between alcohol consumption and medication adherence among veterans in care

BACKGROUND

Previous studies have shown that alcohol consumption is associated with decreased medication adherence, but this association may be confounded by characteristics common among those who drink heavily and those who fail to adhere (e.g., illicit drug use). Our objective was to determine whether there are temporal and dose-response relationships between alcohol consumption and poor adherence.

METHODS

We administered telephone interview surveys to participants in the Veterans Aging Cohort Study, an eight-site observational study of HIV+ and matched HIV- veterans in care, to determine whether alcohol consumption on a particular day was associated with nonadherence to prescribed medications on that same day. We used the Time Line Follow Back to measure alcohol consumption and the Time Line Follow Back Modified for Adherence to measure adherence. Individuals were categorized as abstainers (no alcohol in past 30 days), nonbinge drinkers (alcohol in past 30 days but < or =four standard drinks on each day), or binge drinkers (> or =five standard drinks on at least one day).

RESULTS

Among 2702 respondents, 1582 (56.6%) were abstainers, 931 (34.5%) were nonbinge drinkers, and 239 (8.9%) were binge drinkers. Abstainers missed medication doses on 2.4% of surveyed days. Nonbinge drinkers missed doses on 3.5% of drinking days, 3.1% of postdrinking days, and 2.1% of nondrinking days (p < 0.001 for trend), and this trend was more pronounced among HIV+ individuals than HIV- individuals. Binge drinkers missed doses on 11.0% of drinking days, 7.0% of postdrinking days, and 4.1% of nondrinking days (p < 0.001 for trend), and this trend was comparably strong for HIV+ and HIV- individuals.

CONCLUSIONS

Among veterans in care, self-reported alcohol consumption demonstrates a temporal and dose-response relationship to poor adherence. HIV+ individuals may be particularly sensitive to alcohol consumption.

Induction With Abacavir/Lamivudine/Zidovudine Plus Efavirenz for 48 Weeks Followed by 48-Week Maintenance With Abacavir/Lamivudine/Zidovudine Alone in Antiretroviral-Naive HIV-1-Infected Patients

BACKGROUND

The ESS40013 study tested 4-drug induction followed by 3-drug maintenance as initial antiretroviral therapy (ART) to reduce HIV RNA rapidly and then to simplify to an effective yet more convenient and tolerable regimen.

METHODS

Four hundred forty-eight antiretroviral-naive adults were treated with abacavir/lamivudine/zidovudine (ABC/3TC/ZDV) and efavirenz (EFV) for the 48-week induction phase. Two hundred eighty-two patients were randomized in a 1:1 ratio to continue ABC/3TC/ZDV+EFV or to simplify to ABC/3TC/ZDV for the 48-week maintenance phase.

RESULTS

The baseline median HIV RNA level and CD4 cell count were 5.08 log10 copies/mL (56%>or=100,000 copies/mL) and 210 cells/mm (48% <200 cells/mm), respectively. No significant differences were noted between ABC/3TC/ZDV+EFV and ABC/3TC/ZDV for an HIV RNA level <50 copies/mL (79% vs. 77% [intent to treat (ITT), missing=failure]; P=0.697) or time to treatment failure (P=0.75) at week 96. Drug-related adverse events were more commonly reported for ABC/3TC/ZDV+EFV than for ABC/3TC/ZDV (15% vs. 6%). Improvements in total cholesterol, low-density lipoprotein cholesterol, and triglycerides were observed in the ABC/3TC/ZDV group. Virologic failure occurred in 22 patients during induction and in 24 patients (16 in ABC/3TC/ZDV group and 8 in ABC/3TC/ZDV+EFV group; P=0.134) during maintenance. A greater proportion of patients receiving ABC/3TC/ZDV than ABC/3TC/ZDV+EFV reported perfect adherence at week 96 (88.8% vs. 79.6%; P=0.057).

CONCLUSIONS

After induction with ABC/3TC/ZDV+EFV, simplification to ABC/3TC/ZDV alone maintained virologic control and immunologic response, reduced fasting lipids and ART-associated adverse events, and improved adherence.

The role of integrated home-based care in patient adherence to antiretroviral therapy

Non-adherence is one of the primary obstacles to successful antiretroviral therapy in HIV+ patients worldwide. In Brazil, the Domiciliary Therapeutic Assistance is a multidisciplinary and integrated home-based assistance program provided for HIV+ patients confined in their homes due to physical deficiency. This study investigated ADT's ability to monitor and promote appropriate adherence to ARV therapy. Fifty-six individuals were recruited from three study groups: Group 1 - patients currently in the ADT program, Group 2 - 21 patients previously treated by the ADT program, and Group 3 - 20 patients who have always been treated using conventional ambulatory care. Using multivariable self-reporting to evaluate adherence, patients in the ADT program had significantly better adherence than patients in ambulatory care (F = 6.66, p = 0.003). This effect was independent of demographic and socioeconomic characteristics as well as medical history. Patients in the ADT program also showed a trend towards greater therapeutic success than ambulatory patients. These results suggest the incorporation of characteristics of ADT in conventional ambulatory care as a strategy to increase adherence to ARV therapy.

CD4+ T-cell recovery and clinical outcome in HIV-1-infected patients exposed to multiple antiretroviral regimens: partial control of viremia is associated with favorable outcome

The goal of antiretroviral therapy is clinical benefit through the suppression of viral replication and the immunologic reconstitution of HIV-1-infected patients. In spite of the availability of different highly active antiretroviral therapy only some patients sustain undetectable plasma viremia. We performed an observational study from October 1987 to February 2001 on immunologic and clinical outcome of 148 HIV-1-infected patients from an open clinical cohort at São Paulo University, Brazil. The median T CD4+ at starting first monitored regimen was 227 cells per microliter, with 65% of patients previously exposed to antiretroviral regimens, mostly dual therapy. Virologic response to antiretroviral therapy, after a median period of 179 weeks of monitored treatment, allowed classifying patients as aviremic (RNA plasma viremia below 500 copies per milliliter); viremic (current viral load at historic levels), and viremic-attenuated groups (detectable viremia, but > 1 log viral suppression). HIV RNA viral load, T CD4+ cells count, HIV-1 pol sequencing, inflammatory parameters, and clinical events were documented during a median follow-up of 251 weeks. This study observed better clinical and immunologic responses in the aviremic group, but the viremic-attenuated group showed a significant gain in CD4+ cells (p < 0.013) and a decreased number of cases progressing to an AIDS-defining clinical condition (p < 0.001) compared to the viremic group.

Human immunodeficiency virus type 1 Brazilian subtype B variant showed an increasing avidity of the anti-V3 antibodies over time compared to the subtype B US/European strain in São Paulo, Brazil

The Brazilian variant of human immunodeficiency virus type 1 (HIV-1) subtype B, (serotype B"-GWGR), has a tryptophan replacing the proline in position 328 the HIV-1 envelope. A longer median time period from infection to acquired immunodeficiency syndrome (AIDS) for serotype B (B"-GWGR) infected subjects compared to the B-GPGR US/European strain was reported. In a cohort study, in São Paulo city, 10 B"-GWGR patients had a statistically significant increased avidity of the anti-V3 antibodies, from 79% +/- 33% to 85% +/- 75%, versus from 48% +/- 59% to 32% +/- 17% for the 10 B-GPGR subjects (p = 0.02). The T CD4+ cells showed a mean increase of + 0.45 cells/month for the B-GPGR subjects and for B"-GWGR the slope was + 1.24 cells/month (p = 0.06), for 62 and 55 months of follow up, respectively. RNA plasma viral load decreased from 3.98 +/- 1.75 to 2.16 +/- 1.54 log10 in the B"-GWGR group while B-GPGR patients showed one log10 reduction in viral load from 4.09 +/- 0.38 to 3.17 +/- 1.47 log10 over time (p = 0.23), with a decreasing slope of 0.0042 +/- log10,/month and 0.0080 +/- log10/month, for B-GPGR and B"-GWGR patients, respectively (p = 0.53). Neither group presented any AIDS defining events during the study, according to Center for Diseases Control criteria. Although the sample size is small, these results may indicate that differences in the pathogenicity of the 2 HIV-1 B serotypes which co-circulate in Brazil may be correlated to the avidity of anti-V3 antibodies.

Assessment of Readiness for Adherence by HIV-Positive Males Who Had Previously Failed Treatment

The purpose of this prospective pilot study was to examine the relationship between the level of readiness for health behavior change and adherence by HIV-positive males (n = 19) who had previously failed treatment due to nonadherence. Participants completed the Index of Readiness (IR), an instrument measuring readiness to initiate health behavior change, prior to beginning new antiretroviral medications. After 6 months, participants were divided into two mutually exclusive groups: those who reached and sustained viral suppression and those who did not. Participants who experienced and sustained viral suppression had statistically significantly higher scores on the Identification of Barriers/Creating Strategies subscale of the IR compared to participants who did not reach viral suppression. Results from this preliminary study indicate that readiness may be a key component in successful adherence and that the IR may be a useful tool in assessing readiness for adherence to antiretroviral medications.

Factors that influence the medication decision making of persons with HIV/AIDS: a taxonomic exploration

It is well known that patients often alter their medication regimens and that these changes may have profound consequences for their health outcomes. Not so well known are the factors that influence the medication decision making of persons managing their own treatment in their day-to-day home situations. In this study, persons living with HIV/AIDS (PLWH) were asked about factors that affected the taking of their medications. Using semistructured interviews in this study of 57 PLWH, the authors used intensive analysis of the narratives to create taxonomies of the barriers and facilitators to taking HIV medications and the decisions that were involved. Categories of identified facilitators included motivation, factors of faith, routines, and others' influences. Categories of identified barriers included perceptions, psycho-emotional issues, provider/clinic issues, interpersonal factors, and disease and treatment factors. This study showed medication decision making to be a complex process, influenced by often-competing life and treatment issues and affected by participants' beliefs and values. These findings call for research into the everyday selfcare of PLWH to understand the reasoned decision-making that PLWH use in managing not only their medications but also their lives.

Self-reported adherence to antiretroviral treatment and degree of sense of coherence in a group of HIV-infected patients

The goal of this study was to explore the relation between self-reported adherence to antiretroviral treatment and degree of sense of coherence in a group of human immunodeficiency virus (HIV)-infected patients. Ninety-nine patients from an outpatient clinic, all undergoing antiretroviral therapy, participated. Questionnaires were answered twice at a 12-month interval. The 29-item Sense of Coherence (SOC) Scale was used for measuring the ability to cope with stressful life situations. Medication adherence was assessed with self-reported measurements. Clinical characteristics and background variables were collected from the medical records. Results from variables measured with the 12-month interval show a significant concordance with disease stage (p < or = 0.0001), and in HIV-RNA copies per milliliter (p < or = 0.0001) and an increase in CD4 cell count/mm3 (p = < 0.0001). Univariate analysis showed significant differences between nonadherent patients (n = 19) and adherent patients (n = 80) at the last measurement (i.e., the nonadherent group had lower CD4 cell count/mm3 [p = 0.004], higher HIV-1 RNA levels [p 50.029], and lower SOC [p = 0.04] than the adherent group). Finally, multiple regression analyses showed that at measurement 2 the SOC predicted nonadherence, the lower SOC the more missed doses (p < or = 0.01). Because SOC seems to play an important role in this group of patients managing their disease, a caring patient-provider relationship should be developed to minimize nonadherent behaviour. For this reason SOC scale might be of great clinical value to identify patients needing the most support for successful treatment.