Long-term adherence to first-line highly active antiretroviral therapy in a hospital-based cohort: predictors and impact on virologic response and relapse

Cocaine-Induced DNA-Dependent Protein Kinase Relieves RNAP II Pausing by Promoting TRIM28 Phosphorylation and RNAP II Hyperphosphorylation to Enhance HIV Transcription

Drug abuse continues to pose a significant challenge in HIV control efforts. In our investigation, we discovered that cocaine not only upregulates the expression of the DNA-dependent protein kinase (DNA-PK) but also augments DNA-PK activation by enhancing its phosphorylation at S2056. Moreover, DNA-PK phosphorylation triggers the higher localization of the DNA-PK into the nucleus. The finding that cocaine increases the nuclear localization of the DNA-PK provides further support to our observation of enhanced DNA-PK recruitment at the HIV long terminal repeat (LTR) following cocaine exposure. By activating and facilitating the nuclear localization of the DNA-PK, cocaine effectively orchestrates multiple stages of HIV transcription, thereby promoting HIV replication. Additionally, our study demonstrates that the cocaine-induced DNA-PK promotes the hyper-phosphorylation of the RNA polymerase II (RNAP II) carboxyl-terminal domain (CTD) at Ser5 and Ser2 sites, enhancing both the initiation and elongation phases, respectively, of HIV transcription. The cocaine-mediated enhancement of transcriptional initiation is supported by its activation of cyclin-dependent kinase 7 (CDK7). Additionally, the induction of transcriptional elongation is marked by higher LTR recruitment and the increased phosphorylation of CDK9, which indicates the stimulation of positive transcriptional elongation factor b (P-TEFb). We demonstrate for the first time that cocaine, through DNA-PK activation, promotes the specific phosphorylation of TRIM28 at serine 824 (p-TRIM28, S824). This modification converts TRIM28 from a transcriptional inhibitor to a transactivator for HIV transcription. Additionally, we observed that the phosphorylation of TRIM28 (p-TRIM28, S824) promotes the transition from the pausing phase to the elongation phase of HIV transcription, thereby facilitating the production of full-length HIV genomic transcripts. This finding corroborates the previously observed enhanced RNAP II CTD phosphorylation at Ser2, a marker of transcriptional elongation, following cocaine exposure. Accordingly, upon cocaine treatment, we observed the elevated recruitment of p-TRIM28-(S824) at the HIV LTR. Overall, our results unravel the intricate molecular mechanisms underlying cocaine-induced HIV transcription and gene expression. These findings hold promise for the development of highly targeted therapeutics aimed at mitigating the detrimental effects of cocaine in individuals living with HIV.

Cocaine-induced DNA-PK relieves RNAP II pausing by promoting TRIM28 phosphorylation

Drug abuse continues to pose a significant challenge in HIV control efforts. In our investigation, we discovered that cocaine not only upregulates the expression of DNA-dependent protein kinase (DNA-PK) but also augments DNA-PK activation by enhancing its phosphorylation at S2056. Moreover, DNA-PK phosphorylation triggers the translocation of DNA-PK into the nucleus. The finding that cocaine promotes nuclear translocation of DNA-PK further validates our observation of enhanced DNA-PK recruitment at the HIV long terminal repeat (LTR) following cocaine exposure. By activating and facilitating the nuclear translocation of DNA-PK, cocaine effectively orchestrates multiple stages of HIV transcription, thereby promoting HIV replication. Additionally, our study indicates that cocaine-induced DNA-PK promotes hyper-phosphorylation of RNA polymerase II (RNAP II) carboxyl-terminal domain (CTD) at Ser5 and Ser2 sites, enhancing both initiation and elongation phases, respectively, of HIV transcription. Cocaine's enhancement of transcription initiation and elongation is further supported by its activation of cyclin-dependent kinase 7 (CDK7) and subsequent phosphorylation of CDK9, thereby promoting positive transcriptional elongation factor b (P-TEFb) activity. We demonstrate for the first time that cocaine, through DNA-PK activation, promotes the specific phosphorylation of TRIM28 at Serine 824 (p-TRIM28, S824). This modification converts TRIM28 from a transcriptional inhibitor to a transactivator for HIV transcription. Additionally, we observe that phosphorylation of TRIM28 (p-TRIM28, S824) promotes the transition from the pausing phase to the elongation phase of HIV transcription, thereby facilitating the production of full-length HIV genomic transcripts. This finding corroborates the observed enhanced RNAP II CTD phosphorylation at Ser2, a marker of transcriptional elongation, following cocaine exposure. Accordingly, upon cocaine treatment, we observed elevated recruitment of p-TRIM28-(S824) at the HIV LTR. Overall, our results have unraveled the intricate molecular mechanisms underlying cocaine-induced HIV transcription and gene expression. These findings hold promise for the development of highly targeted therapeutics aimed at mitigating the detrimental effects of cocaine in individuals living with HIV.

Impact of antiretroviral therapy (ART) duration on ART adherence among men who have sex with men (MSM) living with HIV in Jinan of China

Background

Consistent and complete adherence is considered an essential requirement for patients on antiretroviral therapy (ART). This study aimed to evaluate the impact of ART duration on ART adherence, identify the trend of complete adherence, and compare the factors associated with ART adherence between short-term and long-term ART group among men who have sex with men (MSM) living with HIV in Jinan of China.

Methods

MSM living with HIV aged 18 or above and currently on ART were recruited from October to December 2020 using convenience sampling. Univariate and multivariable logistic regressions were used to evaluate the impact of ART duration on adherence and compare factors associated with ART adherence between subgroups. The Mann–Kendall test was used to identify the trend of complete adherence.

Results

A total of 585 participants were included in analysis, consisting of 352 on short-term ART (ART initiation ≤ 3 years) and 233 on long-term ART (ART initiation > 3 years). Significant difference of complete ART adherence between short-term and long-term ART group was detected (79.8% vs. 69.1%, P = 0.003). Multivariable analysis showed that men with longer ART duration were less likely to report complete ART adherence (AOR = 0.88, 95% CI 0.81–0.95). A descending trend of complete adherence was identified (Z = 1.787, P = 0.037). Alcohol use and lack of medication reminders were barriers to complete adherence for both of the subgroups.

Conclusions

Sustained efforts to encourage maintaining adherence for a lifetime are necessary, especially for those on long-term ART. Future interventions should be tailored to subgroups with different ART duration and individuals with specific characteristics.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12981-022-00482-z.

A differentiated digital intervention to improve antiretroviral therapy adherence among men who have sex with men living with HIV in China: a randomized controlled trial

BACKGROUND

Antiretroviral therapy (ART) adherence is still suboptimal among some key populations, highlighting the need for innovative tailored strategies. This randomized controlled trial (RCT) aimed to evaluate the effect of a differentiated digital intervention on ART adherence among men who have sex with men (MSM) living with HIV in China.

METHODS

The two-armed parallel RCT was conducted at one HIV clinic in Jinan of China from October 19, 2020, to June 31, 2021. Men were referred by health providers to join the study and then choose one of three digital strategies-text message, only instant message, or instant message plus social media. They were assigned in a 1:1 ratio to the intervention arm or control arm using block randomization, and inside each arm, there were three groups depending on the type of delivering the message. The groups were divided according to participants' preferred digital strategies. The intervention arm received ART medication messages, medication reminders, peer education, and involved in online discussion. The control arm received messages on health behavior and nutrition. The primary outcome was self-reported optimal ART adherence, defined as not missing any doses and not having any delayed doses within a one-month period. Secondary outcomes included CD4 T cell counts, viral suppression, HIV treatment adherence self-efficacy, and quality of life. Intention-to-treat analysis with generalized linear mixed models was used to evaluate the intervention's effect.

RESULTS

A total of 576 participants were enrolled, including 288 participants assigned in the intervention arm and 288 assigned in the control arm. Most were ≤ 40 years old (79.9%) and initiated ART ≤ 3 years (60.4%). After intervention, the proportion of participants achieving optimal ART adherence in the intervention arm was higher than in the control arm (82.9% vs 71.1%). The differentiated digital intervention significantly improved ART adherence (RR = 1.74, 95%CI 1.21-2.50). Subgroup analysis showed one-to-one instant message-based intervention significantly improved ART adherence (RR = 2.40, 95% CI 1.39-4.17).

CONCLUSIONS

The differentiated digital intervention improved ART adherence among MSM living with HIV in China, which could be integrated into people living with HIV (PLWH) management and further promoted in areas where PLWH can access text messaging and instant messaging services.

TRIAL REGISTRATION

ChiCTR2000041282. Retrospectively registered on 23 December 2020.

Influence of Material Deprivation on Clinical Outcomes Among People Living with HIV in High-Income Countries: A Systematic Review and Meta-analysis

Despite developments in HIV treatment and care, disparities persist with some not fully benefiting from improvements in the HIV care continuum. We conducted a systematic review to explore associations between social determinants and HIV treatment outcomes (viral suppression and treatment adherence) in high-income countries. A random effects meta-analysis was performed where there were consistent measurements of exposures. We identified 83 observational studies eligible for inclusion. Social determinants linked to material deprivation were identified as education, employment, food security, housing, income, poverty/deprivation, socioeconomic status/position, and social class; however, their measurement and definition varied across studies. Our review suggests a social gradient of health persists in the HIV care continuum; people living with HIV who reported material deprivation were less likely to be virologically suppressed or adherent to antiretrovirals. Future research should use an ecosocial approach to explore these interactions across the lifecourse to help propose a causal pathway.

HIV care continuum characteristics among people with opioid use disorder and HIV in Vietnam: baseline results from the BRAVO study

BACKGROUND

Little is known about patient characteristics that contribute to initiating antiretroviral therapy (ART) and achieving viral suppression among HIV people with opioid use disorder in Vietnam. The primary objective of this analysis was to evaluate associations between participant characteristics and the critical steps in the HIV care continuum of ART initiation and HIV viral suppression among people with opioid use disorder and HIV in Vietnam.

METHODS

We assessed baseline participant characteristics, ART status, and HIV viral suppression (HIV RNA PCR < 200 copies/mL) enrolled in a clinical trial of HIV clinic-based buprenorphine versus referral for methadone among people with opioid use disorder in Vietnam. We developed logistic regression models to identify characteristics associated with ART status and HIV viral suppression.

RESULTS

Among 283 study participants, 191 (67.5%) were prescribed ART at baseline, and 168 of those on ART (90%) were virally suppressed. Years since HIV diagnosis (aOR = 1.12, 95% CI 1.06, 1.19) and being married (aOR = 2.83, 95% CI 1.51, 5.34) were associated with an increased likelihood of current prescription for ART at baseline. Greater depression symptoms were negatively associated with receipt of ART (aOR = 0.97, 95% CI = (0.94, 0.9963)). In the HIV suppression model, once adjusting for all included covariates, only receipt of ART was associated with viral suppression (aOR = 25.9, 95% CI = (12.5, 53.8). In bivariate analyses, methamphetamine was negatively correlated with ART prescription (p = 0.07) and viral suppression (p = 0.08).

CONCLUSION

While fewer than 90% of participants had received ART, 90% of those on ART had achieved HIV viral suppression at baseline, suggesting that interventions to improve uptake of ART in Vietnam are essential for achieving UNAIDS 90-90-90 goals in people who use heroin in Vietnam. Social determinants of health associated with ART and HIV viral suppression suggest that social support may be a key to facilitating both of these steps in the HIV care continuum.

Long-term adherence to antiretroviral therapy in a South African adult patient cohort: a retrospective study

Background

South Africa has the highest HIV prevalence and supports the largest antiretroviral therapy (ART) programme globally. With the introduction of a test and treat policy, ensuring long term optimal adherence to ART (≥95%) is essential for successful patient and public health outcomes. The aim of this study was to assess long-term ART adherence to inform best practices for chronic HIV care.

Method

Long-term ART adherence was retrospectively analysed over a median duration of 5 years (interquartile range [IQR]: 5.3–6.5) in patients initially enrolled in a randomised controlled trial assessing tuberculosis and HIV treatment integration and subsequently followed post-trial in an observational cohort study in Durban, South Africa. The association between baseline patient characteristics and adherence over time was estimated using generalized estimating equations (GEE). Adherence was assessed using pharmacy pill counts conducted at each study visit and compared to 6 monthly viral load measurements. A Kaplan Meier survival analysis was used to estimate time to treatment failure. The McNemar test (with exact p-values) was used to determine the effect of pill burden and concurrent ART and tuberculosis treatment on adherence.

Results

Of the 270 patients included in the analysis; 54.8% were female, median age was 34 years (IQR:29–40) and median time on ART was 70 months (IQR = 64–78). Mean adherence was ≥95% for each year on ART. Stable patients provided with an extended 3-month ART supply maintained adherence > 99%. At study end, 96 and 94% of patients were optimally adherent and virologically suppressed, respectively. Time since ART initiation, female gender and primary breadwinner status were significantly associated with ≥95% adherence to ART. The cumulative probability of treatment failure was 10.7% at 5 years after ART initiation. Concurrent ART and tuberculosis treatment, or switching to a second line ART regimen with higher pill burden, did not impair ART adherence.

Conclusion

Optimal long-term adherence with successful treatment outcomes are possible within a structured ART programme with close adherence monitoring. This adherence support approach is relevant to a resource limited setting adopting a test and treat strategy.

The Impact of Comorbid Mental Health Disorders on Complications Following Cervical Spine Surgery With Minimum 2-Year Surveillance

STUDY DESIGN

Retrospective analysis.

OBJECTIVE

To improve understanding of the impact of comorbid mental health disorders (MHDs) on long-term outcomes following cervical spinal fusion in cervical radiculopathy (CR) or cervical myelopathy (CM) patients.

SUMMARY OF BACKGROUND DATA

Subsets of patients with CR and CM have MHDs, and their impact on surgical complications is poorly understood.

METHODS

Patients admitted from 2009 to 2013 with CR or CM diagnoses who underwent cervical surgery with minimum 2-year surveillance were retrospectively reviewed using New York State's Statewide Planning and Research Cooperative System. Patients with a comorbid MHD were compared against those without (no-MHD). Univariate analysis compared demographics, complications, readmissions, and revisions between MHD and no-MHD cohorts. Multivariate binary logistic regression models identified independent predictors of outcomes (covariates: age, sex, Charlson/Deyo score, and surgical approach).

RESULTS

A total of 20,342 patients (MHD: n = 4819; no-MHD: n = 15,523) were included. MHDs identified: depressive (57.8%), anxiety (28.1%), sleep (25.2%), and stress (2.9%). CR patients had greater prevalence of comorbid MHD than CM patients (P = 0.015). Two years postoperatively, all patients with MHD had significantly higher rates of complications (specifically: device-related, infection), readmission for any indication, and revision surgery (all P < 0.05); regression modeling corroborated these findings and revealed combined surgical approach as the strongest predictor for any complication (CR, odds ratio [OR]: 3.945, P < 0.001; CM, OR: 2.828, P < 0.001) and MHD as the strongest predictor for future revision (CR, OR: 1.269, P = 0.001; CM, OR: 1.248, P = 0.008) in both CR and CM cohorts.

CONCLUSION

Nearly 25% of patients admitted for CR and CM carried comorbid MHD and experienced greater rates of any complication, readmission, or revision, at minimum, 2 years after cervical spine surgery. Results must be confirmed with retrospective studies utilizing larger national databases and with prospective cohort studies. Patient counseling and psychological screening/support are recommended to complement surgical treatment.

LEVEL OF EVIDENCE

3.

A New Era of HIV Risk: It's Not What You Know, It's Who You Know (and How Infectious)

HIV is transmitted in social and sexual relationships, and HIV transmission risks, as well as protective actions, are evolving as HIV epidemics unfold. The current focus of HIV prevention is centered on antiretroviral medications used to reduce HIV infectiousness in persons already infected with HIV [treatment as prevention (TasP)]. The same medications used to treat infected persons can also be used by uninfected persons as pre-exposure prophylaxis (PrEP) to reduce the infectivity of HIV. Both PrEP and TasP are effective when adherence is high and individuals do not have co-occurring sexually transmitted infections. HIV prevention is most effective and efficient when delivered within sexual networks with high HIV prevalence. Specific network characteristics are recognized as important facilitators of HIV transmission; these characteristics include the degree of similarity among network members (homophily), gender role norms, and belief systems. Since 2011, HIV risk has been redefined based on infectiousness and infectivity, ushering in a new era of HIV prevention with the potential to end HIV epidemics.

Why it Worked: Participants' Insights into an mHealth Antiretroviral Therapy Adherence Intervention in China

Background:

Few Antiretroviral Therapy (ART) adherence trials investigate the reasons for intervention success or failure among HIV-positive individuals.

Objectives:

To conduct qualitative research to explore the reasons for effectiveness of a 6-month mHealth (mobile health) trial that improved adherence among ART patients in China. The intervention utilized Wireless Pill Containers (WPCs) to provide, real-time SMS reminders, WPC-generated adherence reports, and report-informed counseling.

Methods:

We conducted in-depth interviews with 20 intervention-arm participants immediately following the trial. Sampling was purposeful to ensure inclusion of participants with varied adherence histories. Questions covered adherence barriers and facilitators, and intervention experiences. We analyzed data in nVivo using a thematic approach.

Results:

Of participants, 14 (70%) were male; 7 (35%) had used injectable drugs. Pre-intervention, 11 were optimal adherers and 9 were suboptimal adherers, using a 95% threshold. In the final intervention month, all but 3 (85%) attained optimal adherence. Participants identified a range of adherence barriers and facilitators, and described various mechanisms for intervention success. Optimal adherers at baseline were motivated by positive adherence reports at monthly clinic visits-similar to receiving A+ grades. For suboptimal adherers, reminders facilitated the establishment of adherence-promoting routines; data-guided counseling helped identify strategies to overcome specific barriers.

Conclusion:

Different behavioral mechanisms appear to explain the success of an mHealth adherence intervention among patients with varying adherence histories. Positive reinforcement was effective for optimal adherers, while struggling patients benefitted from reminders and data-informed counseling. These findings are relevant for the design and scalability of mHealth interventions and warrant further investigation.

Adherence to antiretroviral therapy, stigma and behavioral risk factors in HIV-infected adolescents in Asia

We studied behavioral risks among HIV-infected and uninfected adolescents using an audio computer-assisted self-interview. A prospective cohort study was initiated between 2013 and 2014 in Malaysia, Thailand, and Vietnam. HIV-infected adolescents were matched to uninfected adolescents (4:1) by sex and age group (12-14 and 15-18 years). We enrolled 250 HIV-infected (48% male; median age 14.5 years; 93% perinatally infected) and 59 uninfected (51% male; median age 14.1 years) adolescents. At enrollment, HIV-infected adolescents were on antiretroviral therapy (ART) for a median (IQR) of 7.5 (4.7-10.2) years, and 14% had HIV-RNA >1000 copies/mL; 19% reported adherence <80%. Eighty-four (34%) HIV-infected and 26 (44%) uninfected adolescents reported having ever smoked cigarettes or drunk alcohol (p = 0.13); 10% of HIV-infected and 17% of uninfected adolescents reported having initiated sexual activity; 6 of the HIV-infected adolescents had HIV-RNA >1000 copies/mL. Risk behaviors were common among adolescents, with few differences between those with and without HIV.

Barriers to HIV Medication Adherence as a Function of Regimen Simplification

BACKGROUND

Barriers to HIV medication adherence may differ by levels of dosing schedules.

PURPOSE

The current study examined adherence barriers associated with medication regimen complexity and simplification.

METHODS

A total of 755 people living with HIV currently taking anti-retroviral therapy were recruited from community services in Atlanta, Georgia. Participants completed audio-computer-assisted self-interviews that assessed demographic and behavioral characteristics, provided their HIV viral load obtained from their health care provider, and completed unannounced phone-based pill counts to monitor medication adherence over 1 month.

RESULTS

Participants taking a single-tablet regimen (STR) were more likely to be adherent than those taking multi-tablets in a single-dose regimen (single-dose MTR) and those taking multi-tablets in a multi-dose regimen (multi-dose MTR), with no difference between the latter two. Regarding barriers to adherence, individuals taking STR were least likely to report scheduling issues and confusion as reasons for missing doses, but they were equally likely to report multiple lifestyle and logistical barriers to adherence.

CONCLUSIONS

Adherence interventions may need tailoring to address barriers that are specific to dosing regimens.

Exploring the Healthcare Environment and Associations with Clinical Outcomes of People Living with HIV/AIDS

Despite three decades of dramatic treatment breakthroughs in antiretroviral regimens, clinical outcomes for people living with HIV vary greatly. The HIV treatment cascade models the stages of care that people living with HIV go through toward the goal of viral suppression and demonstrates that <30% of those living with HIV/AIDS in the United States have met this goal. Although some research has focused on the ways that patient characteristics and patient-provider relationships contribute to clinical adherence and treatment success, few studies to date have examined the ways that contextual factors of care and the healthcare environment contribute to patient outcomes. Here, we present qualitative findings from a mixed-methods study to describe contextual and healthcare environment factors in a Ryan White Part C clinic that are associated with patients' abilities to achieve viral suppression. We propose a modification of Andersen's Behavioral Model of Health Services Utilization, and its more recent adaptation developed by Ulett et al., to describe the ways that clinic, system, and provider factors merge to create a system of care in which more than 86% of the patient population is virally suppressed.

Psychosocial Characteristics Associated with Both Antiretroviral Therapy Adherence and Risk Behaviors in Women Living with HIV

The purpose of this study was to identify key psychosocial characteristics of HIV-infected women who exhibit different levels of both ART adherence and risk behaviors. We analyzed baseline data from 193 predominately African American HIV-infected women participating in a behavioral clinical trial. Women were categorized into high/low groups based on levels of adherence and risky behaviors. There was a significant interaction effect for internal motivation for adherence. Women at high risk for poor health and transmitting HIV (low adherence/high risk group) had the lowest levels of internal motivation and also reported more difficult life circumstances. Gender roles, caretaking and reliance on men for economic and other support may promote external versus internal motivation as well as riskier behaviors in this group. The highest levels of internal motivation were found in those with High Adherence/High Risk behaviors. This group was highly knowledgeable about HIV and had the lowest VL. Compared to others, this group seems to tolerate risky behaviors given their high level of adherence. Adherence and risk reduction behaviors are key to individual and public health. Motivation and risk compensation should be addressed when providing interventions to women living with HIV.

Housing Status, Medical Care, and Health Outcomes Among People Living With HIV/AIDS: A Systematic Review

BACKGROUND

Accumulating evidence suggests responses to HIV that combine individual-level interventions with those that address structural or contextual factors that influence risks and health outcomes of infection. Housing is such a factor. Housing occupies a strategic position as an intermediate structural factor, linking "upstream" economic, social, and cultural determinants to the more immediate physical and social environments in which everyday life is lived. The importance of housing status for HIV prevention and care has been recognized, but much of this attention has focused on homeless individuals as a special risk group. Analyses have less often addressed community housing availability and conditions as factors influencing population health or unstable, inadequate, or unaffordable housing as a situation or temporary state. A focus on individual-level characteristics associated with literal homelessness glosses over social, economic, and policy drivers operating largely outside any specific individual's control that affect housing and residential environments and the health resources or risk exposures such contexts provide.

OBJECTIVES

We examined the available empirical evidence on the association between housing status (broadly defined), medical care, and health outcomes among people with HIV and analyzed results to inform future research, program development, and policy implementation.

SEARCH METHODS

We searched 8 electronic health and social science databases from January 1, 1996, through March 31, 2014, using search terms related to housing, dwelling, and living arrangements and HIV and AIDS. We contacted experts for additional literature.

SELECTION CRITERIA

We selected articles if they were quantitative analyses published in English, French, or Spanish that included at least 1 measure of housing status as an independent variable and at least 1 health status, health care, treatment adherence, or risk behavior outcome among people with HIV in high-income countries. We defined housing status to include consideration of material or social dimensions of housing adequacy, stability, and security of tenure.

DATA COLLECTION AND ANALYSIS

Two independent reviewers performed data extraction and quality appraisal. We used the Cochrane Risk of Bias Tool for randomized controlled trials and a modified version of the Newcastle Ottawa Quality Appraisal Tool for nonintervention studies. In our quality appraisal, we focused on issues of quality for observational studies: appropriate methods for determining exposure and measuring outcomes and methods to control confounding.

RESULTS

Searches yielded 5528 references from which we included 152 studies, representing 139,757 HIV-positive participants. Most studies were conducted in the United States and Canada. Studies examined access and utilization of HIV medical care, adherence to antiretroviral medications, HIV clinical outcomes, other health outcomes, emergency department and inpatient utilization, and sex and drug risk behaviors. With rare exceptions, across studies in all domains, worse housing status was independently associated with worse outcomes, controlling for a range of individual patient and care system characteristics.

CONCLUSIONS

Lack of stable, secure, adequate housing is a significant barrier to consistent and appropriate HIV medical care, access and adherence to antiretroviral medications, sustained viral suppression, and risk of forward transmission. Studies that examined the history of homelessness or problematic housing years before outcome assessment were least likely to find negative outcomes, homelessness being a potentially modifiable contextual factor. Randomized controlled trials and observational studies indicate an independent effect of housing assistance on improved outcomes for formerly homeless or inadequately housed people with HIV. Housing challenges result from complex interactions between individual vulnerabilities and broader economic, political, and legal structural determinants of health. The broad structural processes sustaining social exclusion and inequality seem beyond the immediate reach of HIV interventions, but changing housing and residential environments is both possible and promising.

Antiretroviral therapy adherence strategies used by patients of a large HIV clinic in Lesotho

A high degree of adherence to antiretroviral therapy (ART) in patients infected with human immunodeficiency virus (HIV) is necessary for long term treatment effects. This study explores the role of timing of ART intake, the information patients received from health workers, local adherence patterns, barriers to and facilitators of ART among 28 HIV-positive adults at the Senkatana HIV Clinic in Maseru, Lesotho. This qualitative, semi-structured interview study was carried out during February and March of 2011 and responses were analyzed inspired by the Grounded Theory method. Results were then compared and discussed between the authors and the main themes that emerged were categorized. The majority of the respondents reported having missed one or more doses of medicine in the past and it was a widespread belief among patients that they were required to skip the dose of ART if they were "late". The main barriers to adherence were interruptions of daily routines or leaving the house without sufficient medicine. The use of mobile phone alarms, phone clocks and support from family and friends were major facilitators of adherence. None of the patients reported to have been counseled on family support or the use of mobile phones as helpful methods in maintaining or improving adherence to ART. Being on-time with ART was emphasized during counseling by health workers. In conclusion, patients should be advised to take the dose as soon as they remember instead of skipping the dose completely when they are late. Mobile phones and family support could be subjects to focus on during future counseling particularly with the growing numbers of mobile phones in Africa and the current focus on telemedicine.

Medication adherence challenges among patients experiencing homelessness in a behavioral health clinic

BACKGROUND

Behavioral health medication nonadherence is associated with poor health outcomes and increased healthcare costs. Little is known about reasons for nonadherence with behavioral health medications among homeless people.

OBJECTIVES

To identify reasons for medication nonadherence including the sociodemographic, health-related factors, and behavioral health conditions associated with medication nonadherence among behavioral health patients served by a Health Care for the Homeless center (HCH) in Virginia.

METHODS

The study sample was selected from an existing database that included sociodemographic, health-related information, and medication-related problems identified during a pharmacist-provided medication review conducted during October 2008-September 2009. Patients experiencing or at risk of homelessness who were ≥18 years old with at least one behavioral health condition who had a medication review were eligible for the study. A qualitative content analysis of the pharmacist documentation describing the patient's reason(s) for medication nonadherence was conducted. The Behavioral Model for Vulnerable Populations was the theoretical framework. The outcome variable was self-reported medication nonadherence. Descriptive and multivariate (logistic regression) statistics were used.

RESULTS

A total of 426 individuals met study criteria. The mean age was 44.7 ± 10.2 years. Most patients were African-American (60.5%) and female (51.6%). The content analysis identified patient-related factors (74.8%), therapy-related factors (11.8%), and social or economic factors (8.8%) as the most common reasons for patients' medication nonadherence. Patients with post-traumatic stress disorder (PTSD) (adjusted odds ratio: 0.4; 95% CI: 0.19-0.87) were less likely to have a medication adherence problem identified during the medication review.

CONCLUSIONS

The content analysis identified patient-related factors as the most common reason for nonadherence with behavioral health medications. In the quantitative analysis, patients with a PTSD diagnosis were less likely to have nonadherence identified which may be related to their reluctance to self-report nonadherence and their diagnosis, which warrants further study.

Estimating the range of potential epidemiological impact of pre-exposure prophylaxis: run-away success or run-away failure?

OBJECTIVE

To investigate the influence of potential interactions between key aspects of a pre-exposure prophylaxis (PrEP) intervention on projections of epidemiological impact and cost-effectiveness.

METHODS

A mathematical model representing the HIV epidemic and intervention context in Nyanza province in Kenya was developed. We consider a scenario whereby a fixed annual budget is allocated to a PrEP intervention. A standard projection of impact is generated, assuming that the unit cost of PrEP, adherence to PrEP and the ability of the programme to direct PrEP to those at high risk, all stay constant. The influence of dynamic assumptions and possible interactions between PrEP intervention assumptions is then assessed in comparison.

RESULTS

The cumulative impact of a PrEP intervention could be increased approximately two-fold, relative to the standard projection, if positive interactions (between coverage and cost, coverage and adherence, prioritization and time) are assumed, whereas negative interactions between these factors could almost entirely negate the preventive benefit of the PrEP intervention. The corresponding estimates of cost per infection averted span a wide range from $2060 to $36360.

CONCLUSIONS

Multiple potentially interacting factors will determine the impact of PrEP. Model forecasts should reflect that uncertainty and programmes should focus on these factors and measure them, to maximize the impact of programmes.

Incomplete adherence among treatment-experienced adults on antiretroviral therapy in Tanzania, Uganda and Zambia

OBJECTIVES

To characterize antiretroviral therapy (ART) adherence across different programmes and examine the relationship between individual and programme characteristics and incomplete adherence among ART clients in sub-Saharan Africa.

DESIGN

A cross-sectional study.

METHODS

Systematically selected ART clients (≥18 years; on ART ≥6 months) attending 18 facilities in three countries (250 clients/facility) were interviewed. Client self-reports (3-day, 30-day, Case Index ≥48 consecutive hours of missed ART), healthcare provider estimates and the pharmacy medication possession ratio (MPR) were used to estimate ART adherence. Participants from two facilities per country underwent HIV RNA testing. Optimal adherence measures were selected on the basis of degree of association with concurrent HIV RNA dichotomized at less than or greater/equal to 1000 copies/ml. Multivariate regression analysis, adjusted for site-level clustering, assessed associations between incomplete adherence and individual and programme factors.

RESULTS

A total of 4489 participants were included, of whom 1498 underwent HIV RNA testing. Nonadherence ranged from 3.2% missing at least 48 consecutive hours to 40.1% having an MPR of less than 90%. The percentage with HIV RNA at least 1000 copies/ml ranged from 7.2 to 17.2% across study sites (mean = 9.9%). Having at least 48 consecutive hours of missed ART was the adherence measure most strongly related to virologic failure. Factors significantly related to incomplete adherence included visiting a traditional healer, screening positive for alcohol abuse, experiencing more HIV symptoms, having an ART regimen without nevirapine and greater levels of internalized stigma.

CONCLUSION

Results support more in-depth investigations of the role of traditional healers, and the development of interventions to address alcohol abuse and internalized stigma among treatment-experienced adult ART patients.

Patterns of adherence to antiretroviral therapy and HIV drug resistance over time in the Stratall ANRS 12110/ESTHER trial in Cameroon

OBJECTIVES

The emergence of HIV drug resistance is a crucial issue in Africa, where second-line antiretroviral therapy (ART) is limited, expensive and complex. We assessed the association between adherence patterns and resistance emergence over time, using an adherence measure that distinguishes low adherence from treatment interruptions, in rural Cameroon.

METHODS

We performed a cohort study among patients receiving nonnucleoside reverse transcriptase inhibitor (NNRTI)-based ART in nine district hospitals, using data from the Stratall trial (2006-2010). Genotypic mutations associated with antiretroviral drug resistance were assessed when 6-monthly HIV viral loads were > 5000 HIV-1 RNA copies/mL. ART adherence data were collected using face-to-face questionnaires. Combined indicators of early (1-3 months) and late (6 months to t - 1; t is the time point when the resistance had been detected) adherence were constructed. Multivariate logistic regression and Cox models were used to assess the association between adherence patterns and early (at 6 months) and late (after 6 months) resistance emergence, respectively.

RESULTS

Among 456 participants (71% women; median age 37 years), 45 developed HIV drug resistance (18 early and 27 late). Early low adherence (< 80%) and treatment interruptions (> 2 days) were associated with early resistance [adjusted odds ratio (95% confidence interval) 8.51 (1.30-55.61) and 5.25 (1.45-18.95), respectively]. Early treatment interruptions were also associated with late resistance [adjusted hazard ratio (95% confidence interval) 3.72 (1.27-10.92)].

CONCLUSIONS

The emergence of HIV drug resistance on first-line NNRTI-based regimens was associated with different patterns of adherence over time. Ensuring optimal early adherence through specific interventions, adequate management of drug stocks, and viral load monitoring is a clinical and public health priority in Africa.

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.

Adherence to antiretroviral therapy and its determinants in children with HIV infection - Experience from Paediatric Centre of Excellence in HIV Care in North India

The objective of this study is to assess adherence to antiretroviral therapy (ART) in HIV-infected children using the pill count method, and determine factors leading to adherence failure. Records of 106 children living with HIV (CLHIV) age <15 years and on ART for >6 months were reviewed. Average adherence to ART by pill count method over preceding six months was calculated and re-assessed by 3-day recall method. The caregivers of 105 children and one child himself were interviewed about the problems encountered while giving ART. Median age of enrolled children was 104 (inter-quartile range [IQR] 77.3-133.8) months. Median duration of ART was 25 (IQR 16-35) months. The desired adherence level of >95% during six months of review assessed by pill count was achieved in 95.3% children. The 3-day recall method yielded >95% adherence in 99% children (p ≤ .001). Caregivers of 59 children (56.2%) reported multiple problems while administering drugs. In most instances, problems encountered were related to family/caregivers, the commonest being multiple caregivers, job constraints and death/illness in the family. In conclusion, we found a very high level of adherence to ART in CLHIV. Poor adherence was mainly associated with issues related to the family/caregivers.

The association of pharmacy drug-delivery services with adherence in an urban HIV population†

Objective

The aim of this study was to examine the effect of drug-distribution methods on antiretroviral medication adherence in HIV-positive patients.

Methods

This was a longitudinal, retrospective study of an independent retail pharmacy providing complementary delivery services. Patients of 18 years of age or older receiving antiretroviral therapy were evaluated from 1 January to 30 June 2004. Patients were included if they had a minimum of one prescription claim for any antiretroviral medication during the study period and received state medication assistance. Using data obtained from computerized pharmacy records a medication possession ratio was calculated to assess adherence measured by pharmacy refill history over 6 months. To assess the consistency of adherence over time a modified medication possession ratio, termed the compliance/non-compliance index (CNI) at each refill, was developed and compared between each group.

Key findings

Of the 181 patients included in the study, those who had medications delivered had significantly better adherence (90.3% compared with 82.6%, P = 0.001) and CNI value (73.5% compared with 57.9%, P = 0.001) in comparison with those who picked up their medications. After controlling for age, gender, drug class, insurance type and time and distance from the pharmacy, use of medication-delivery services was significantly associated with adherence (P &lt; 0.0001) and CNI score (P = 0.012).

Conclusion

Complementary medication-delivery services by pharmacies significantly increased adherence at each refill for antiretroviral therapy in HIV-positive patients. Further research is needed on how medication-distribution strategies can be implemented universally and the economic impact on cost of care to increase medication adherence in this high-risk population.

Tenofovir in second-line ART in Zambia and South Africa: collaborative analysis of cohort studies

OBJECTIVES

Tenofovir (TDF) is increasingly used in second-line antiretroviral treatment (ART) in sub-Saharan Africa. We compared outcomes of second-line ART containing and not containing TDF in cohort studies from Zambia and the Republic of South Africa (RSA).

METHODS

Patients aged 16 years and older starting protease-inhibitor-based second-line ART in Zambia (1 cohort) and RSA (5 cohorts) were included. We compared mortality, immunological failure (all cohorts), and virological failure (RSA only) between patients receiving and not receiving TDF. Competing risk models and Cox models adjusted for age, sex, CD4 count, time on first-line ART, and calendar year were used to analyze mortality and treatment failure, respectively. Hazard ratios (HRs) were combined in fixed-effects meta-analysis.

FINDINGS

1687 patients from Zambia and 1556 patients from RSA, including 1350 (80.0%) and 206 (13.2%) patients starting TDF, were followed over 4471 person-years. Patients on TDF were more likely to have started second-line ART in recent years and had slightly higher baseline CD4 counts than patients not on TDF. Overall, 127 patients died, 532 were lost to follow-up, and 240 patients developed immunological failure. In RSA, 94 patients had virologic failure. Combined HRs comparing TDF with other regimens were 0.60 (95% confidence interval [CI]: 0.41 to 0.87) for immunologic failure and 0.63 (0.38-1.05) for mortality. The HR for virologic failure in RSA was 0.28 (0.09-0.90).

CONCLUSIONS

In this observational study, patients on TDF-containing second-line ART were less likely to develop treatment failure than patients on other regimens. TDF seems to be an effective component of second-line ART in southern Africa.

Sex differences in adherence to highly active antiretroviral therapy: a meta-analysis

Observational studies have found that women tend to have lower adherence to highly active antiretroviral therapy (HAART) than men do, though no meta-analysis has yet investigated this trend. The aims of the current meta-analysis are to determine if and to what degree the percentage of men versus women maintaining ≥90% adherence to prescribed HAART differs, and if the external variables moderating adherence differs by gender. Eight electronic databases were searched to locate all relevant studies available by May 2011. Fifty-six observational studies were eligible for inclusion in the meta-analysis. A random effect model was assumed for the global percentage estimation and to explain the heterogeneity. Across these studies, the difference between men and women in the proportion of individuals with ≥90% adherence to HAART was marginally significant (p<0.1; 67% and 62%, respectively). A greater proportion of men maintaining ≥90% adherence to HAART was more likely in studies with higher proportions of men who have sex with men (MSM), lower proportions of male alcohol users or lower proportions of men in a methadone program. In women, higher rates of adherence were found in studies conducted in Africa, Asia, and South America, when the sample included more widows or when the sample had a lower basal CD4 count. That both the percentage of adherent individuals and the variables associated with such adherence differ between men and women are suggestive of the need for improving gender-tailored interventions for adherence to HAART.

Substance use: impact on adherence and HIV medical treatment

Substance use is highly prevalent among people living with HIV/AIDS, is often comorbid with other mental health problems, related to poor HIV medical outcomes, and, is associated with poor medication and treatment adherence. The current review reports on the recent state of the literature in terms of substance use and its relation to HIV medication and treatment adherence, and offers recommendations for advancing treatment and secondary HIV prevention efforts. Identifying substance users within HIV primary care and developing, evaluating, and refining integrative substance use-mental health-adherence interventions may be clinically important targets for effective disease management and may contribute to secondary HIV prevention efforts.

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.

Homelessness as a structural barrier to effective antiretroviral therapy among HIV-seropositive illicit drug users in a Canadian setting

Despite the advent of effective antiretroviral therapy (ART), HIV-seropositive injection drug users (IDU) continue to suffer from elevated levels of morbidity and mortality. Evidence is needed to identify social- and structural-level barriers to effective ART. We investigated the impact of homelessness on plasma HIV RNA response among illicit drug users initiating ART in a setting with free and universal access to HIV care. We accessed data from a long-running prospective cohort of community-recruited IDU linked to comprehensive HIV clinical monitoring and ART dispensation records. Using Cox proportional hazards with recurrent events modeling, we estimated the independent effect of homelessness on time to plasma HIV viral load suppression. Between May 1996 and September 2009, 247 antiretroviral naïve individuals initiated ART and contributed 1755 person-years of follow-up. Among these individuals, the incidence density of plasma HIV RNA suppression less than 500 copies/mm(3) was 56.7 (95% confidence interval [CI]: 46.9-66.0) per 100 person-years. In unadjusted analyses, homelessness was strongly associated with lower rates suppression (hazard ratio = 0.56, 95% CI: 0.40-0.78, p = 0.001), however, after adjustment for adherence this association was no longer significant (adjusted hazard ratio = 0.79, 95% CI: 0.56-1.11, p = 0.177). Homelessness poses a significant structural barrier to effective HIV treatment. However, since this relationship appears to be mediated by lower levels of ART adherence, interventions to improve adherence among members of this vulnerable population are needed.

Sticking to it: the effect of maximally assisted therapy on antiretroviral treatment adherence among individuals living with HIV who are unstably housed

Housing is a known determinant of health behaviors, which includes adherence to Antiretroviral Therapy (ART). Within the Longitudinal Investigations into Supportive and Ancillary Health Services (LISA) study, unstable housing is inversely associated with adherence. Several comprehensive adherence support services have emerged to improve adherence for unstably housed or otherwise vulnerable populations. The Maximally Assisted Therapy (MAT) program in Vancouver, British Columbia uses a multidisciplinary approach to support HIV-positive clients with a history of addictions or mental illness, many of whom also experience episodic homelessness. This study investigated the association between antiretroviral adherence and use of support services, including the MAT program, amongst people living with HIV and AIDS who are unstably housed in the LISA sample. Of the 212 unstably housed participants, those who attended the MAT program were 4.76 times more likely to be ≥95% adherent (95% CI 1.72-13.13; P = 0.003) than those who did not. The findings suggest that in the absence of sustainable housing solutions, programs such as MAT play an important role in supporting treatment adherence in this population.

Interventions to increase antiretroviral adherence in sub-Saharan Africa: a systematic review of evaluation studies

The success of potent antiretroviral treatment for HIV infection is primarily determined by adherence. We systematically review the evidence of effectiveness of interventions to increase adherence to antiretroviral treatment in sub-Saharan Africa. We identified 27 relevant reports from 26 studies of behavioural, cognitive, biological, structural, and combination interventions done between 2003 and 2010. Despite study diversity and limitations, evidence suggests that treatment supporters, directly observed therapy, mobile-phone text messages, diary cards, and food rations can effectively increase adherence in sub-Saharan Africa. However, some interventions are unlikely to have large or lasting effects, and others are effective only in specific settings. These findings emphasise the need for more research, particularly for randomised controlled trials, to examine the effect of context and specific features of intervention content on effectiveness. Future work should assess intervention targeting and selection of interventions based on behavioural theories relevant to sub-Saharan Africa.

Adherence to highly active antiretroviral therapy (HAART): a meta-analysis

This meta-analysis synthesizes eighty-four observational studies, conducted across twenty countries, to determine the mean proportion of people who reported ≥90% adherence to prescribed highly active antiretroviral therapy (HAART) and to identify the factors associated with high levels of adherence. Eight electronic databases were searched to locate all relevant studies available by January 2010, which were then coded for sample characteristics and adherence levels. The average rate of reporting ≥90% adherent HAART adherence is 62%. However, this proportion varies greatly across studies. In particular, a greater proportion of individuals maintaining ≥90% adherence to HAART is more likely in studies with higher proportions of men who have sex with men (MSM) and lower proportions of injection drug users (IDU), with participants in an earlier stage of infection, and in studies conducted in countries characterized by lower Human Development Index (HDI) scores.

Self-report of current and prior antiretroviral drug use in comparison to the medical record among HIV-infected patients receiving primary HIV care

OBJECTIVE

Patient antiretroviral (ARV) therapy knowledge is essential for regimen adherence, successful therapeutic response, and minimization of resistance evolution. Moreover, a complete and accurate patient ARV history is needed to construct efficacious and tolerable future regimens. In this study we assessed the ability of HIV-infected patients receiving care in a university infectious diseases clinic to accurately recall current and past ARVs.

METHODS

A convenience sample (n = 205) of UNC HIV Clinical Cohort participants (n = 1840) completed a comprehensive in-person interview. Patients were asked about current and ever ARV use and were provided proprietary and generic ARV names and photographs. Self-reported sensitivity for current and ever ARV use (proportion that correctly identified all recorded ARVs), was calculated using the medical record as the gold standard.

RESULTS

One hundred and eighty-five patients had received ARVs at some point after enrollment in the cohort study (ever users). For current ARV use (n = 138), self-reported sensitivity was 63% (95% CI: 54-71). For ever use (n = 185), sensitivity was 18% (95% CI: 13-24).

CONCLUSION

Self-reported cumulative ARV use is not accurate. Since HIV-infected patients are prescribed a number of medications over their treatment course, it is necessary to develop new medication reconciliation techniques that are not dependent on patient memory or knowledge in order to improve patient outcomes.

Adherence to antiretroviral therapy in an urban, free-care HIV clinic in Guatemala City, Guatemala

BACKGROUND

Numerous studies have demonstrated that, in addition to inherent qualities of antiretroviral (ARV) medications, adherence is affected by demographic, socioeconomic, and psychological factors. There are limited data about factors affecting adherence to antiretroviral therapy (ART) among HIV-infected persons in urban Guatemalan HIV care centers.

METHODS

Participants were patients at an urban, free-care public clinic in Guatemala City and obtained medications from a closed-pharmacy system. Nonpregnant patients ≥18 years who received medications from the Global Fund to Fight AIDS, Tuberculosis & Malaria, who had taken ARV medications for ≥12 weeks, who arrived for an appointment at the clinic, and who provided informed consent were interviewed. Adherence was measured using pharmacy pill counts and patient self-reports. Recent biological markers for each patient were collected from the clinic's database, and χ( 2) and descriptive statistics were used to analyze results.

RESULTS

Among 122 patients interviewed, mean adherence by pill count was 97%. A total of 110 patients (90%) had adherence ≥95% using pharmacy pill counts, and 108 (89%) had adherence ≥95% using self-reports. Virologic failure (viral load [VL] ≥500 copies/mL) was significantly less common among patients with ≥95% adherence (P = .02). Family and spousal support for treatment were significantly associated with ≥95% adherence (P = .01 and .003, respectively). The presence of stavudine (d4T) in a patient's regimen was significantly associated with <95% adherence according to self-reports (P < .01). The most common self-reported cause for missing medications was forgetfulness, followed by leaving medications at home. Inability to travel to the clinic was a major cause of missing medications, and only 51 patients (41.8%) reported always having sufficient economic resources to reach the clinic for appointments and to refill prescriptions.

CONCLUSIONS

In this urban Central American population, high levels of adherence were measured by both self-report and pharmacy pill count. Socioeconomic and demographic conditions associated with adherence and specific reasons for missing medications were identified.

Prevalence of transmitted drug resistance and impact of transmitted resistance on treatment success in the German HIV-1 Seroconverter Cohort

BACKGROUND

The aim of this study is to analyse the prevalence of transmitted drug resistance, TDR, and the impact of TDR on treatment success in the German HIV-1 Seroconverter Cohort.

METHODS

Genotypic resistance analysis was performed in treatment-naïve study patients whose sample was available 1,312/1,564 (83.9% October 2008). A genotypic resistance result was obtained for 1,276/1,312 (97.3%). The resistance associated mutations were identified according to the surveillance drug resistance mutations list recommended for drug-naïve patients. Treatment success was determined as viral suppression below 500 copies/ml.

RESULTS

Prevalence of TDR was stable at a high level between 1996 and 2007 in the German HIV-1 Seroconverter Cohort (N = 158/1,276; 12.4%; CI(wilson) 10.7-14.3; p(for trend) = 0.25). NRTI resistance was predominant (7.5%) but decreased significantly over time (CI(Wilson): 6.2-9.1, p(for trend) = 0.02). NNRTI resistance tended to increase over time (NNRTI: 3.5%; CI(Wilson): 2.6-4.6; p(for trend)= 0.07), whereas PI resistance remained stable (PI: 3.0%; CI(Wilson): 2.1-4.0; p(for trend) = 0.24). Resistance to all drug classes was frequently caused by singleton resistance mutations (NRTI 55.6%, PI 68.4%, NNRTI 99.1%). The majority of NRTI-resistant strains (79.8%) carried resistance-associated mutations selected by the thymidine analogues zidovudine and stavudine. Preferably 2NRTI/1PIr combinations were prescribed as first line regimen in patients with resistant HIV as well as in patients with susceptible strains (susceptible 45.3%; 173/382 vs. resistant 65.5%; 40/61). The majority of patients in both groups were treated successfully within the first year after ART-initiation (susceptible: 89.9%; 62/69; resistant: 7/9; 77.8%).

CONCLUSION

Overall prevalence of TDR remained stable at a high level but trends of resistance against drug classes differed over time. The significant decrease of NRTI-resistance in patients newly infected with HIV might be related to the introduction of novel antiretroviral drugs and a wider use of genotypic resistance analysis prior to treatment initiation.

Adherence to antiretroviral therapy among HIV-infected drug users: a meta-analysis

We conducted a meta-analysis of studies assessing adherence to highly active antiretroviral therapy (HAART) and a qualitative systematic review of factors associated with better HAART outcomes among HIV+ drug users (DU). Thirty-eight studies were considered, which analyzed 14,960 patients (11,394 HIV+ DU, 76.2%). Overall adherence (pooled percent of DU classified as adherent in each study) was 0.60 (95% CI: 0.52-0.68), similar to levels identified by studies conducted with HIV+ patients who are not drug users. Time frame used to measure adherence was an independent predictor of inter-study heterogeneity. The systematic review identified better HAART outcomes among former DU, those with less severe psychiatric conditions, those receiving opioid substitution therapy and/or psychosocial support. Patients initiating HAART with lower viral load and higher CD4 counts, and those without co-infections also had better treatment outcomes. Our findings suggest that HIV+ DU tend to be inappropriately assumed to be less adherent and unlikely to achieve desirable treatment outcomes, when compared to their non-DU cohort.

Strategies to promote adherence to antiretroviral therapy applied by Dutch HIV nurse consultants: a descriptive qualitative study

This study describes strategies used by Dutch HIV nurse consultants to promote adherence to antiretroviral therapy (ART) and the assumptions on which these strategies were based. The study used a descriptive qualitative design with individual and focus group interviews. Individual semi-structured interviews (n = 23) focusing on adherence-supporting procedures and case-based focus groups (3 groups with 5-7 participants each) focusing on adherence strategies were held with HIV nurse consultants (n = 19). The strategies described were mainly based on experience. Theoretical principles were rarely discussed and participants seldom referred to the literature. Adherence-promoting strategies were identified for two phases: (a) before beginning ART and (b) during follow-up care while on ART. Strategies that were not used in one specific phase were categorized under "all phases." Data yielded useful ideas for the care of HIV-infected patients, and findings can be applied to the development and use of adherence-promoting strategies.

A randomized, controlled, trial of short cycle intermittent compared to continuous antiretroviral therapy for the treatment of HIV infection in Uganda

BACKGROUND

Short cycle treatment interruption could reduce toxicity and drug costs and contribute to further expansion of antiretroviral therapy (ART) programs.

METHODS

A 72 week, non-inferiority trial enrolled one hundred forty six HIV positive persons receiving ART (CD4+ cell count > or =125 cells/mm(3) and HIV RNA plasma levels <50 copies/ml) in one of three arms: continuous, 7 days on/7 days off and 5 days on/2 days off treatment. Primary endpoint was ART treatment failure determined by plasma HIV RNA level, CD4+ cell count decrease, death attributed to study participation, or opportunistic infection.

RESULTS

Following enrollment of 32 participants, the 7 days on/7 days off arm was closed because of a failure rate of 31%. Six of 52 (11.5%) participants in the 5 days on/2 days off arm failed. Five had virologic failure and one participant had immunologic failure. Eleven of 51 (21.6%) participants in the continuous treatment arm failed. Nine had virologic failure with 1 death (lactic acidosis) and 1 clinical failure (extra-pulmonary TB). The upper 97.5% confidence boundary for the difference between the percent of non-failures in the 5 days on/2 days off arm (88.5% non-failure) compared to continuous treatment (78.4% non failure) was 4.8% which is well within the preset non-inferiority margin of 15%. No significant difference was found in time to failure in the 2 study arms (p = 0.39).

CONCLUSIONS

Short cycle 5 days on/2 days off intermittent ART was at least as effective as continuous therapy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT00339456.

Highly active antiretroviral therapy adherence and its determinants in selected hospitals from south and central Ethiopia

OBJECTIVE

To determine the adherence rate and its determinants among people living with HIV/AIDS on highly active antiretroviral therapy (HAART) in selected governmental hospitals from central and south Ethiopia.

METHODOLOGY

A cross-sectional study involving both qualitative and quantitative methods was conducted between August and October 2007 in Yirgalem, Hawassa, and Shashemene Hospitals. Quantitative data collection techniques include patient self-report and unannounced pill count and the qualitative methods employed were focus group discussions (FGDs), semi-structured interviews, and observations of health facilities.

RESULTS

Whereas females accounted for 56.4% (238), male participants were 43.6% (184) of the total participants. Adherence rate was 93.1% using 15-days self-report, but the rate came down to 88.1% when calculated using the unannounced pill count method (n = 90). Multivariate analysis revealed that being unmarried (OR = 0.119, CI = 0.016-0.901, p = 0.039), unemployment (OR = 0.011, CI = 0.000-0.288, p = 0.007); failure to disclose HIV status (OR = 0.433, CI = 0.198-0.949, p = 0.037); lack of support from family (OR = 0.393, CI = 0.163-0.947, p = 0.037); or others (OR = 0.332, CI = 0.144-0.845, p = 0.043); alcohol drinking (OR = 0.210, CI = 0.071-0.617, p = 0.003); treatment regimen, stavudine(40)-lamuvidine-nevirapine (OR = 0.174, CI = 0.033-0.923, p = 0.040), azathymidine-lamuvidine-nevirapine (OR = 0.172, CI = 0.034-0.867, p = 0.033) and dosing three times daily (OR = 0.073, CI = 0.018-0.290, p = 0.000) regimens were found to be associated with non-adherence. Moreover, time since diagnosis was associated with adherence, as those tested HIV-positive >or= 6 months prior to date of interview (OR = 4.064, CI = 1.23-19.316, p = 0.047) had better adherence rate.

CONCLUSION

The adherence rate obtained in this study was higher than the rates seen in developed countries despite the fact that many of the participants live in very poor conditions.

Impact of different patterns of nonadherence on the outcome of highly active antiretroviral therapy in patients with long-term follow-up

OBJECTIVES

The aim of the study was to evaluate the impact of different patterns of nonadherence on treatment outcomes in patients with long-term follow-up.

METHODS

This cohort study included patients who began highly active antiretroviral therapy during 1996-1999, with the last follow-up in 2007. Adherence was evaluated every 2 months by monitoring of pharmacy refills and by using self-reports. Patients were considered nonadherent at a specific visit when less than 90% of the prescribed drugs had been taken. Adherence was categorized as follows. (A) Continuous adherence: a patient had to be adherent in all of the evaluations throughout the period of follow-up. (B) Treatment interruption: drugs were not taken for more than 3 days, for any reason. Treatment failure was defined as viral load >500 HIV-1 RNA copies/mL or death. Cox proportional risk models were used to calculate adjusted relative hazards (ARHs) of treatment failure.

RESULTS

A total of 540 patients were included in the study, with a median follow-up of 8.3 years. Only 32.78% of patients achieved and maintained continuous adherence, and 42.78% of patients had treatment interruptions. Noncontinuous adherence [ARH 1.48; 95% confidence interval (CI) 1.02-2.14] and treatment interruptions (ARH 1.39; 95% CI 1.04-1.85) were associated with treatment failure for the overall cohort; however, for patients with more than 3 years of follow-up, only treatment interruptions were independently associated with treatment failure.

CONCLUSIONS

Only one-third of patients managed to achieve continuous adherence, and almost half of the patients had treatment interruptions, which have a particularly marked effect on treatment outcomes over the long term.

HIV care providers' implementation of routine alcohol reduction support for their patients

Screening and brief intervention (SBI) for alcohol reduction is an important health promoting strategy for patients with HIV, and HIV care providers are optimally situated to support their patients' reduction efforts. We report results from analyses that use data collected from providers (n = 115) in 7 hospital-based HIV care centers in the New York City metropolitan area in 2007 concerning their routine use of 11 alcohol SBI components with their patients. Providers routinely implemented 5 or more of these alcohol SBI components if they (1) had a specific caseload (and were therefore responsible for a smaller number of patients), (2) had greater exposure to information about alcohol's effect on HIV, (3) had been in their present positions for at least 1 year, and (4) had greater self efficacy to support patients' alcohol reduction efforts. Findings suggest the importance of educating all HIV care providers about both the negative impact of excessive alcohol use on patients with HIV and the importance and value of alcohol SBIs. Findings also suggest the value of promoting increased self efficacy for at least some providers in implementing alcohol SBI components, especially through targeted alcohol SBI training.

Cost effectiveness of facility-based care, home-based care and mobile clinics for provision of antiretroviral therapy in Uganda

Stakeholders in HIV/AIDS care currently use different programmes for provision of antiretroviral therapy (ART) in Uganda. It is not known which of these represents the best value for money. To compare the cost effectiveness of home-based care (HBC), facility-based care (FBC) and mobile clinic care (MCC) for provision of ART in Uganda. Incremental cost-effectiveness analysis was performed using decision and Markov modeling of adult AIDS patients in WHO Clinical Stage 3 and 4 from the perspective of the Ugandan healthcare system. The main outcome measures were cost (year 2008 values), life expectancy in life-years (LY) and the incremental cost-effectiveness ratio (ICER) measured as cost per QALY or LY gained over 10 years. Ten-year mean undiscounted life expectancy was lowest for FBC (3.6 LY), followed by MCC (4.3 LY) and highest for HBC (5.3 LY), while the mean discounted QALYs were also lowest for FBC (2.3), followed by MCC (2.9) and highest for HBC (3.7). The 10-year mean costs per patient were lowest for FBC ($US3212), followed by MCC ($US4782) and highest for HBC ($US7033). The ICER was lower for MCC versus FBC ($US2241 per LY and $US2615 per QALY) than for HBC versus MCC ($US2251 per LY and $US2814 per QALY). FBC remained cost effective in univariate and probabilistic sensitivity analyses. FBC appears to be the most cost-effective programme for provision of ART in Uganda. This analysis supports the implementation of FBC for scale-up and sustainability of ART in Uganda. HBC and MCC would be competitive only if there is increased access, increased adherence or reduced cost.