A measurement model of medication adherence to highly active antiretroviral therapy and its relation to viral load in HIV-positive adults

Discrepancies between self-reported medication in adherence and indirect measurement adherence among patients undergoing antiretroviral therapy: a systematic review

BACKGROUND

Given the critical importance of medication adherence in HIV/AIDS treatment, this study aims to compare medication adherence measured by self-report (SR) and indirect measurement among antiretroviral therapy (ART) patients, exploring the differences of adherence results measured by different tools.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library to identify all relevant literature published up to November 22, 2023, without language restrictions, reporting adherence to ART measured by both SR and indirect measurement methods, while also analyzing individual and group adherence separately. Discrepancies between SR and indirect measurement results were assessed using the Mann-Whitney U test or Wilcoxon signed-rank test, with correlations evaluated using the Pearson correlation coefficient. Following one-to-one comparisons, meta-epidemiological one-step analysis was conducted, and network meta-analysis techniques were applied to compare results obtained through specific adherence assessment tools reported in the identified articles.

RESULTS

The analysis encompassed 65 original studies involving 13,667 HIV/AIDS patients, leading to 112 one-to-one comparisons between SR and indirect measurement tools. Statistically significant differences were observed between SR and indirect measurement tools regarding both individual and group adherence (P < 0.05), with Pearson correlation coefficients of 0.843 for individual adherence and 0.684 for group adherence. During meta-epidemiological one-step analysis, SR-measured adherence was determined to be 3.94% (95% CI: -4.48-13.44%) higher for individual adherence and 16.14% (95% CI: 0.81-18.84%) higher for group adherence compared to indirectly measured results. Subgroup analysis indicated that factors such as the year of reporting and geographic region appeared to influence the discrepancies between SR and indirect measurements. Furthermore, network meta-analysis revealed that for both individual and group adherence, the results obtained from most SR and indirect measurement tools were higher than those from electronic monitoring devices, with some demonstrating statistical significance (P < 0.05).

CONCLUSIONS

The findings underscored the complexity of accurately measuring medication adherence among ART patients. Significant variability was observed across studies, with self-report methods showing a significant tendency towards overestimation. Year of reporting, geographic region, and adherence measurement tools appeared to influence the differences between SR and indirect measurements. Future research should focus on developing and validating integrated adherence measurements that can combine SR data with indirect measures to achieve a more comprehensive understanding of adherence behaviors.

A Scoping Review of Methods Used to Assess Medication Adherence in Patients with Chronic Conditions

BACKGROUND

Medication nonadherence of patients with chronic conditions is a complex phenomenon contributing to increased economic burden and decreased quality of life. Intervention development relies on accurately assessing adherence but no "gold standard" method currently exists.

PURPOSE

The present scoping review aimed to: (a) review and describe current methods of assessing medication adherence (MA) in patients with chronic conditions with the highest nonadherence rates (asthma, cancer, diabetes, epilepsy, HIV/AIDS, hypertension), (b) outline and compare the evidence on the quality indicators between assessment methods (e.g., sensitivity), and (c) provide evidence-based recommendations.

METHODS

PubMed, PsycINFO and Scopus databases were screened, resulting in 62,592 studies of which 71 met criteria and were included.

RESULTS

Twenty-seven self-report and 10 nonself-report measures were identified. The Medication Adherence Report Scale (MARS-5) was found to be the most accurate self-report, whereas electronic monitoring devices such as Medication Event Monitoring System (MEMS) corresponded to the most accurate nonself-report. Higher MA rates were reported when assessed using self-reports compared to nonself-reports, except from pill counts.

CONCLUSIONS

Professionals are advised to use a combination of self-report (like MARS-5) and nonself-report measures (like MEMS) as these were found to be the most accurate and reliable measures. This is the first review examining self and nonself-report methods for MA, across chronic conditions with the highest nonadherence rates and provides evidence-based recommendations. It highlights that MA assessment methods are understudied in certain conditions, like epilepsy. Before selecting a MA measure, professionals are advised to inspect its quality indicators. Feasibility of measures should be explored in future studies as there is presently a lack of evidence.

Methods for Measuring Multiple Medication Adherence: A Systematic Review-Report of the ISPOR Medication Adherence and Persistence Special Interest Group

BACKGROUND

A broad literature base exists for measuring medication adherence to monotherapeutic regimens, but publications are less extensive for measuring adherence to multiple medications.

OBJECTIVES

To identify and characterize the multiple medication adherence (MMA) methods used in the literature.

METHODS

A literature search was conducted using PubMed, PsycINFO, the International Pharmaceutical Abstracts, the Cumulative Index to Nursing and Allied Health Literature and the Cochrane Library databases on methods used to measure MMA published between January 1973 and May 2015. A two-step screening process was used; all abstracts were screened by pairs of researchers independently, followed by a full-text review identifying the method for calculating MMA. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed to conduct this systematic review. For studies that met the eligibility criteria, general study and adherence-specific characteristics and the number and type of MMA measurement methods were summarized.

RESULTS

The 147 studies that were included originated from 32 countries, in 13 disease states. Of these studies, 26 used proportion of days covered, 23 used medication possession ratio, and 72 used self-reported questionnaires (e.g., the Morisky Scale) to assess MMA. About 50% of the studies included more than one method for measuring MMA, and different variations of medication possession ratio and proportion of days covered were used for measuring MMA.

CONCLUSIONS

There appears to be no standardized method to measure MMA. With an increasing prevalence of polypharmacy, more efforts should be directed toward constructing robust measures suitable to evaluate adherence to complex regimens. Future research to understand the validity and reliability of MMA measures and their effects on objective clinical outcomes is also needed.

Mechanism of Change in Cognitive Behavioral Therapy for Body Image and Self-Care on ART Adherence Among Sexual Minority Men Living with HIV

Body image disturbance is a common problem reported among sexual minority men living with HIV, and is associated with poor antiretroviral therapy (ART) adherence. Recently, a novel integrated intervention (cognitive behavioral therapy for body image and self-care; CBT-BISC) was developed and pilot tested to simultaneously improve body image and ART adherence in this population. Although CBT-BISC has demonstrated preliminary efficacy in improving ART adherence, the mechanisms of change are unknown. Utilizing data from a two-armed randomized controlled trial (N = 44 sexual minority men living with HIV), comparing CBT-BISC to an enhanced treatment as usual (ETAU) condition, sequential process mediation via latent difference scores was assessed, with changes in body image disturbance entered as the mechanism between treatment condition and changes in ART adherence. Participants assigned to CBT-BISC reported statistically significant reductions in body image disturbance post-intervention, which subsequently predicted changes in ART adherence from post-intervention to long term follow-up (b = 20.01, SE = 9.11, t = 2.19, p = 0.028). One pathway in which CBT-BISC positively impacts ART adherence is through reductions in body image disturbance. Body image disturbance represents one, of likely several, mechanism that prospectively predicts ART adherence among sexual minority men living with HIV.

Correlation of Adherence by Pill Count, Self-report, MEMS and Plasma Drug Levels to Treatment Response Among Women Receiving ARV Therapy for PMTCT in Kenya

Success of antiretroviral therapy depends on adherence to effective treatment. We evaluated four adherence methods and their correlation with immunological and virologic response among women receiving PMTCT. Univariable and multivariable analyses were used to assess how adherence by pill count (n = 463), self-report (n = 463), MEMS (n = 129) and plasma drug level (n = 89) was associated with viral load suppression within a 6 months period. Longitudinal analysis was performed to determine the correlation of CD4 cell count with each measure of adherence. For all measures of adherence, sustained viral suppression was less likely for participants in the lowest category of adherence. Although CD4 cell count increased substantially over time, there was no significant association with adherence by the methods. Multiple strategies can be used successfully to monitor treatment adherence. Persons with ≥95% adherence by any method used in this study were more likely to have a favorable treatment outcome.

Tratamento antirretroviral: adesão e a influência da depressão em usuários com HIV/Aids atendidos na atenção primária

RESUMO A adesão ao tratamento é um dos maiores desafios ao tratamento de HIV (Vírus da Imunodeficiência Humana), e a depressão, um fator de impacto. Objetivou-se identificar se a depressão interfere na adesão. Para tanto, utilizou-se um método de multiabordagem de adesão, entrevista aberta e o Inventário de Depressão de Beck para rastreamento de depressão. A relação entre depressão e não adesão não se verificou, apesar de a prevalência de depressão ser de 22,24%. Os pacientes admitiram medo do estigma e dificuldade em seguir o tratamento antirretroviral em decorrência dos efeitos adversos do medicamento. Detectou-se a importância da rede social de proteção e evidenciou-se a necessidade da construção de uma rede de cuidados.

A Multilevel Conceptual Framework to Understand the Role of Food Insecurity on Antiretroviral Therapy Adherence in Low-Resource Settings: From Theory to Practice

The objective of this study was to describe a multilevel conceptual framework to understand the role of food insecurity on antiretroviral therapy adherence. The authors illustrated an example of how they used the multilevel framework to develop an intervention for poor people living with HIV in a rural and low-resource community. The framework incorporates intrapersonal, interpersonal, and structural-level theories of understanding and changing health behaviors. The framework recognizes the role of personal, social, and environmental factors on cognition and behavior, with particular attention to ways in which treatment adherence is enabled or prevented by structural conditions, such as food insecurity.

Implementation and assessment of a prevention with positives intervention among people living with HIV at five hospitals in Thailand

BACKGROUND

We implemented a hospital-based prevention with positives (PwP) intervention among people living with HIV (PLHIV) that included HIV transmission risk screening, short HIV prevention messages, family planning, HIV disclosure counseling, and partner HIV testing at five hospitals in Thailand. We assessed changes in sexual risk behaviors among PLHIV who received the PwP services at the hospitals.

METHODS

From January 2008-March 2009, we systematically selected a subset of PLHIV receiving care at the five hospitals to offer participation in the PwP intervention. We collected demographic, risk behavior, and laboratory data using a standardized questionnaire. We analyzed data from PLHIV who completed at least four visits, using generalized estimating equations to identify baseline participant characteristics that were associated with adopting sexual practices less likely to be associated with HIV transmission during follow-up.

RESULTS

A total of 830 PLHIV were interviewed and 756 (91.1%) completed four visits. The median age of these 756 participants was 37 years, 400 (52.9%) were women, and 475 (62.8%) had a steady partner. At baseline, 353 (74.3%) of the steady partners had been tested for HIV and 132 (37.4%) had tested negative. Among the 756 PLHIV, 427 (56.5%) reported having sex in the 3 months before enrollment and 413 (54.6%) in the 3 months before the fourth visit. The proportion reporting having vaginal or anal sex without a condom decreased from 20.8% at baseline to 5.1% at the fourth visit (p<0.001). Factors associated (p<0.05) with abstinence or 100% condom use at follow-up visits included: completing ≥ two visits, being diagnosed with HIV for longer than 3 months, and receiving HIV prevention messages from a doctor (versus a nurse or counselor).

CONCLUSION

Safe sex behaviors increased among PLHIV receiving PwP services, suggesting that expansion of hospital-based PwP services may reduce the number of new HIV infections in Thailand.

Treatment adherence and illness self-management: introduction to the special issue

The current issue is devoted broadly to research on treatment adherence and chronic illness self-management behavior. As the prevalence of chronic illness increases, the pervasive problem of treatment nonadherence is increasingly viewed as having a major impact on treatment outcomes, public health and healthcare costs, making this issue particularly timely. Sixteen articles spanning an array of topics are presented; articles include empirical studies, statistical simulations, systematic reviews, and theoretical commentaries. Studies conducted with diverse patient populations (e.g., chronic headache, diabetes, end-stage renal disease, HIV, hypertension, severe obesity), samples (e.g., adolescents, ethnic/racial minorities, low-income adults, parents, spousal dyads), and designs (e.g., cross-sectional, longitudinal assessment, randomized controlled trial), are represented. This issue highlights psychosocial factors associated with nonadherence, promising interventions to promote adherence, and state-of-the art methods for the study of illness self-management. We hope these articles engender even more high quality, methodologically rigorous research in this important subfield of behavioral medicine.

Development and Validation of the HIV Medication Readiness Scale

Excellent medication adherence (> 95%) is required for optimal HIV treatment success. This study aimed to develop and validate a brief scale to assess psychological readiness for successfully starting and adhering to HIV medications. HIV-positive men and women (N = 142) from an HIV outpatient clinic completed the proposed HIV Medication Readiness Scale (HMRS) prior to starting HIV medications. The 10-item HMRS demonstrated high internal consistency (alpha = .90), test-retest reliability (r = .83), and sensitivity to change following a standardized 4-session psychoeducational intervention designed to increase readiness for successful adherence. Predictive validity was supported by higher readiness scores on the day starting HIV medications, predicting higher treatment adherence at 1-month follow-up. The HMRS is a brief, easy-to-use, clinically relevant tool that can assist in identifying people living with HIV at high risk of nonadherence, who might benefit from tailored readiness counseling prior to initiating HIV medications.

A scoping review of studies comparing the medication event monitoring system (MEMS) with alternative methods for measuring medication adherence

Different methods are available for measuring medication adherence. In this paper, we conducted a scoping review to identify and summarize evidence of all studies comparing the Medication Event Monitoring System (MEMS) with alternative methods for measuring medication adherence. A literature search was performed using the open database www.iAdherence.org that includes all original studies reporting findings from the MEMS. Papers comparing methods for measuring adherence to solid oral formulations were included. Data was extracted using a standardized extraction table. A total of 117 articles fulfilled the inclusion criteria, including 251 comparisons. Most frequent comparisons were against self-report (n = 119) and pill count (n = 59). Similar outcome measures were used in 210 comparisons (84%), among which 78 used dichotomous variables (adherent or not) and 132 used continuous measures (adherence expressed as percentage). Furthermore, 32% of all comparisons did not estimate adherence over the same coverage period and 44% of all comparisons did not use a statistical method or used a suboptimal one. Only eighty-seven (35%) comparisons had similar coverage periods, similar outcome measures and optimal statistical methods. Compared to MEMS, median adherence was grossly overestimated by 17% using self-report, by 8% using pill count and by 6% using rating. In conclusion, among all comparisons of MEMS versus alternative methods for measuring adherence, only a few used adequate comparisons in terms of outcome measures, coverage periods and statistical method. Researchers should therefore use stronger methodological frameworks when comparing measurement methods and be aware that non-electronic measures could lead to overestimation of medication adherence.

Baseline Substance Use Interferes with Maintenance of HIV Medication Adherence Skills

Cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV improves both adherence and depression outcomes relative to enhanced treatment as usual (ETAU). However, in persons with injection drug use (PWIDU) histories, adherence gains seen during treatment have not been maintained postintervention. Therefore, we examined whether heroin or cocaine use at study entry moderated acquisition or maintenance of adherence gains after CBT-AD. HIV-positive adults in treatment for opioid dependence (n = 89) were randomly assigned to CBT-AD or ETAU and completed 3-, 6-, and 12-month assessments. Participants were majority male (61%), white (48%), and heterosexual (79%). Hierarchical linear modeling was used to evaluate whether heroin or cocaine use at baseline interacted with intervention assignment to predict change in adherence during active treatment and follow-up. CBT-AD-related improvement in adherence during the active intervention period did not vary by baseline substance use. However, cocaine use (but not heroin use) at baseline interacted with intervention assignment to predict a significant decline in follow-up adherence (cocaine use × group condition coefficient = -0.77, t = -2.44, p = 0.02) such that by 12 months, adherence among CBT participants was significantly lower among those who used cocaine (45.0%) compared to those who did not (72.3%; t = 2.50, p = 0.018). HIV-positive PWIDU who use heroin or cocaine at baseline can benefit from the CBT-AD intervention to improve adherence to antiretroviral therapy; therefore, providers should not withhold an active psychosocial treatment for HIV-positive PWIDU who are using. Cocaine use at baseline may limit the degree to which gains are maintained postintervention, and therefore, booster sessions may be needed.

Alexithymia, Assertiveness and Psychosocial Functioning in HIV: Implications for Medication Adherence and Disease Severity

Psychosocial function and adherence to antiretroviral regimen are key factors in human immunodeficiency virus (HIV) disease management. Alexithymia (AL) is a trait deficit in the ability to identify and describe feelings, emotions and bodily sensations. A structural equation model was used to test whether high levels of AL indirectly relate to greater non-adherent behavior and HIV disease severity via psychosocial dysfunction. Blood draws for HIV-1 viral load and CD4 T-lymphocyte, along with psychosocial surveys were collected from 439 HIV positive adults aged 18-73 years. The structural model supports significant paths from: (1) AL to non-active patient involvement, psychological distress, and lower social support, (2) psychological distress and non-active involvement to non-adherent behavior, and (3) non-adherence to greater HIV disease severity (CFI = .97, RMSEA = .04, SRMR = .05). A second model confirmed the intermediary effect of greater patient assertiveness on the path from AL to social support and non-active patient involvement (CFI = .94, RMSEA = .04, SRMR = .05). Altogether, AL is indirectly linked with HIV disease management through it's association with poor psychosocial function, however greater patient assertiveness buffers the negative impact of AL on relationship quality with healthcare providers and members of one's social support network.

Medication Adherence Measures: An Overview

WHO reported that adherence among patients with chronic diseases averages only 50% in developed countries. This is recognized as a significant public health issue, since medication nonadherence leads to poor health outcomes and increased healthcare costs. Improving medication adherence is, therefore, crucial and revealed on many studies, suggesting interventions can improve medication adherence. One significant aspect of the strategies to improve medication adherence is to understand its magnitude. However, there is a lack of general guidance for researchers and healthcare professionals to choose the appropriate tools that can explore the extent of medication adherence and the reasons behind this problem in order to orchestrate subsequent interventions. This paper reviews both subjective and objective medication adherence measures, including direct measures, those involving secondary database analysis, electronic medication packaging (EMP) devices, pill count, and clinician assessments and self-report. Subjective measures generally provide explanations for patient's nonadherence whereas objective measures contribute to a more precise record of patient's medication-taking behavior. While choosing a suitable approach, researchers and healthcare professionals should balance the reliability and practicality, especially cost effectiveness, for their purpose. Meanwhile, because a perfect measure does not exist, a multimeasure approach seems to be the best solution currently.

The ABCs of Trait Anger, Psychological Distress, and Disease Severity in HIV

BACKGROUND

Trait anger consists of affective, behavioral, and cognitive (ABC) dimensions and may increase vulnerability for interpersonal conflict, diminished social support, and greater psychological distress. The concurrent influence of anger and psychosocial dysfunction on Human Immunodeficiency Virus (HIV) disease severity is unknown.

PURPOSE

The purpose of this study was to examine plausible psychosocial avenues (e.g., coping, social support, psychological distress), whereby trait anger may indirectly influence HIV disease status.

METHODS

Three hundred seventy-seven HIV seropositive adults, aged 18-55 years (58% AIDS-defined), completed a battery of psychosocial surveys and provided a fasting blood sample for HIV-1 viral load and T lymphocyte count assay.

RESULTS

A second-order factor model confirmed higher levels of the multidimensional anger trait, which was directly associated with elevated psychological distress and avoidant coping (p<.001) and indirectly associated with greater HIV disease severity (p<.01) (comparative fit index (CFI)=0.90, root-mean-square error of approximation (RMSEA)=0.06, standardized root-mean-square residual (SRMR)=0.06).

CONCLUSION

The model supports a role for the ABC components of anger, which may negatively influence immune function through various psychosocial mechanisms; however, longitudinal study is needed to elucidate these effects.

Psychosocial Syndemics are Additively Associated with Worse ART Adherence in HIV-Infected Individuals

Adherence to antiretroviral therapy (ART) among HIV-infected individuals is necessary to both individual and public health, and psychosocial problems have independently been associated with poor adherence. To date, studies have not systematically examined the effect of multiple, co-occurring psychosocial problems (i.e., "syndemics") on ART adherence. Participants included 333 HIV-infected individuals who completed a comprehensive baseline evaluation, as part of a clinical trial to evaluate an intervention to treat depression and optimize medication adherence. Participants completed self-report questionnaires, and trained clinicians completed semi-structured diagnostic interviews. ART non-adherence was objectively measured via an electronic pill cap (i.e., MEMS). As individuals reported a greater number of syndemic indicators, their odds of non-adherence increased. Co-occurring psychosocial problems have an additive effect on the risk for poor ART adherence. Future behavioral medicine interventions are needed that address these problems comprehensively, and/or the core mechanisms that they share.

The unique challenges facing HIV-positive patients who smoke cigarettes: HIV viremia, ART adherence, engagement in HIV care, and concurrent substance use

Evidence suggests that smoking may have negative associations with HIV health outcomes. The smoking rate in our sample of people living with HIV (N = 333) was triple that of the general population (57 v. 19 %). Regression analyses revealed that (smokers v. non-smokers) reported lower medication adherence (unstandardized beta = 9.01) and were more likely to have a detectable viral load (OR = 2.85, 95 % CI [1.53-5.30]). Smokers attended fewer routine medical visits (β = -0.16) and were more likely to report recent hospitalization (OR = 1.89, 95 % CI [0.99, 3.57]). Smokers ranked "health" as less important to their quality of life (β = -0.13) and were more likely to report problematic alcohol (OR = 2.40, 95 % CI [1.35, 4.30]), cocaine (OR = 2.87, 95 % CI [1.48-5.58]), heroin (OR = 4.75, 95 % CI [1.01, 22.30]), or marijuana use (OR = 3.08, 95 % CI [1.76-5.38]). Findings underscore the need for integrated behavioral smoking cessation interventions and routine tobacco screenings in HIV primary care.

Adherence among rural HIV-infected patients in the deep south: a comparison between single-tablet and multi-tablet once-daily regimens

BACKGROUND

Once-daily (QD), combination antiretroviral therapy (ART) can impact the willingness and ability of patients to take medications as directed. The impact of antiretroviral (ARV) drug adherence influenced by single-tablet (STR) versus multi-tablet regimens (MTR) among patients enrolled in the AIDS Drug Assistance Program (ADAP) in a rural environment has not yet been assessed.

MATERIAL AND METHODS

A retrospective chart review evaluated adherence and outcomes in adult HIV-infected patients enrolled in the ADAP at 2 ambulatory clinics in the Southeast, taking either a QD STR (efavirenz [EFV]/emtricitabine/tenofovir [TDF]) or a QD protease inhibitor (PI)-based, MTR (atazanavir [ATV], ritonavir [RTV], and emtricitabine/TDF) by evaluating pharmacy refill records, patient self-reported adherence, and virologic response.

RESULTS

A total of 389 patient records were analyzed (STR, n = 165 versus MTR, n = 224). There were more males, a higher percentage of treatment-naive patients, and more patients with a baseline CD4 count of >200 cells/mm(3) in the MTR group. Based on refill records, more patients on MTR were >90% adherent (61.6% versus 51.5%, P = .047). In a multivariable analysis, being treatment experienced was a negative predictor (odds ratio [OR] = 0.48, 0.29-0.78) for adherence. Regimen choice was not associated with adherence. More patients taking MTR were virologically suppressed at the end of the observation period. Regardless of the regimen, being >90% adherent was a significant predictor of virologic suppression (OR = 3.51, 1.98-6.23).

CONCLUSION

Treatment-experienced patients enrolled in ADAP are less likely to be adherent. A QD PI-based MTR may result in comparable adherence to an STR in a rural HIV-infected population.

The influence of psychological variables on health-related quality of life among HIV-positive individuals with a history of intravenous drug use

OBJECTIVE

Intravenous drug use (IDU) remains a prominent pathway of HIV transmission in the United States, though little is known about modifiable factors influencing quality of life among IDUs. The goal of this study was to evaluate the influence of psychological variables (e.g., depression and anxiety) on health-related quality of life among HIV-positive individuals with a history of IDU who were enrolled in outpatient treatment for opioid dependence.

METHOD

108 HIV-positive individuals with a history of IDU and participating in current outpatient treatment for opiate dependence who were screened for participation in a depression and adherence study reported sociodemographic data, depressive and anxiety symptoms, and health-related quality of life (HRQoL; Multidimensional Health Assessment using the ACTG-SF 21).

RESULTS

Multiple regression models controlling for disease stage and background characteristics identified significant negative relationships between General Health Perception and Functioning without Pain for anxiety and depression, and between Role Functioning and Physical Functioning for anxiety. CD4 cell count was significantly related to Physical Functioning only.

CONCLUSIONS

Results indicate that distress (both depression and anxiety) contribute significantly to variation in HRQoL over and above the effects of disease variables. Effective depression and anxiety treatment may result in improved overall functioning.

A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with uncontrolled type 2 diabetes

OBJECTIVE

To test cognitive behavioral therapy for adherence and depression (CBT-AD) in type 2 diabetes. We hypothesized that CBT-AD would improve adherence; depression; and, secondarily, hemoglobin A1c (A1C).

RESEARCH DESIGN AND METHODS

Eighty-seven adults with unipolar depression and uncontrolled type 2 diabetes received enhanced treatment as usual (ETAU), including medication adherence, self-monitoring of blood glucose (SMBG), and lifestyle counseling; a provider letter documented psychiatric diagnoses. Those randomized to the intervention arm also received 9-11 sessions of CBT-AD.

RESULTS

Immediately after acute treatment (4 months), adjusting for baseline, CBT-AD had 20.7 percentage points greater oral medication adherence on electronic pill cap (95% CI -31.14 to -10.22, P = 0.000); 30.2 percentage points greater SMBG adherence through glucometer downloads (95% CI -42.95 to -17.37, P = 0.000); 6.44 points lower depression scores on the Montgomery-Asberg Depression Rating Scale (95% CI 2.33-10.56, P = 0.002); 0.74 points lower on the Clinical Global Impression (95% CI 0.16-1.32, P = 0.01); and 0.72 units lower A1C (95% CI 0.29-1.15, P = 0.001) relative to ETAU. Analyses of 4-, 8-, and 12-month follow-up time points indicated that CBT-AD maintained 24.3 percentage points higher medication adherence (95% CI -38.2 to -10.3, P = 0.001); 16.9 percentage points greater SMBG adherence (95% CI -33.3 to -0.5, P = 0.043); and 0.63 units lower A1C (95% CI 0.06-1.2, P = 0.03) after acute treatment ended. For depression, there was some evidence of continued improvement posttreatment, but no between-group differences.

CONCLUSIONS

CBT-AD is an effective intervention for adherence, depression, and glycemic control, with enduring and clinically meaningful benefits for diabetes self-management and glycemic control in adults with type 2 diabetes and depression.

Non-adherence to topical treatments for actinic keratosis

BACKGROUND

There is limited information on the patterns of use, adherence rates, and factors that impact adherence with topical treatments for actinic keratosis (AK).

OBJECTIVES

To establish patterns of use and adherence with topical treatments for AK and to identify treatment-related factors that impact on adherence.

METHODS

A community-based, cross-sectional study was performed using a standardized questionnaire completed online or via telephone interview. Patients were stratified according to the presence of AK lesions on the scalp and/or other extremities; and presence of scarring resulting from treatment.

RESULTS

This study included 305 patients with AK who were currently using a patient-applied topical therapy for AK or had used one within the previous 12 months. In total, 88% (n = 268/305) of patients were either non-adherent, non-persistent or both non-adherent and non-persistent to topical therapy. Duration of treatment was associated with increasing rates of non-adherence (adjusted odds ratio [OR]; for treatment durations greater than 4 weeks, 2.2, P < 0.01): 52% of patients were non-adherent with 3-4 week treatment duration; 69% of patients with 4-8 week treatment duration; and 71% of patients with 6-12 week treatment duration. There were similar increases in non-persistence with increasing treatment duration (adjusted OR; for treatment durations greater than 4 weeks, 2.1, P < 0.05).

CONCLUSION

This study found high rates of non-adherence and non-persistence in patients with AK. Duration of treatment was a significant factor contributing to non-adherence and non-persistence to topical treatments. Patient-applied topical therapies that require less frequent application and have shorter treatment duration may be associated with improved adherence rates.

A proposal for quality standards for measuring medication adherence in research

A decade after widespread recognition that adherence to medication regimens is key to antiretroviral effectiveness, considerable controversy remains regarding a "gold standard" for adherence measurement. Each adherence measurement approach has strengths and weaknesses and each rests on specific assumptions. The range of assumptions regarding adherence measurement and the diversity with which each approach is implemented strongly suggest that the evaluation of a particular measure outside of the context in which it was used (e.g. the study's operational protocol) may result in undeserved confidence or lack of confidence in study results. The purpose of this paper is to propose a set of best practices across commonly used measurement methods. Recommendations regarding what information should be included in published reports regarding how adherence was measured are provided to promote improvement in the quality of measurement of medication adherence in research.

Substance use predictors of poor medication adherence: the role of substance use coping among HIV-infected patients in opioid dependence treatment

Many HIV-infected injection drug users (IDUs) continue to use illicit substances despite being in substance use treatment. Substance use is associated with non-adherence to HIV medications; however underlying mechanisms regarding this relation are understudied. The current investigation examined the role of substance use coping in terms of the relation between substance use and HIV medication adherence. Participants were 121 HIV-infected IDUs (41 % female, M age = 47, SD = 7.1) in opioid dependence treatment. Participants completed self-report questionnaires, were administered clinical interviews and oral toxicology screens, and used a medication-event-monitoring-system cap to assess 2 week HIV medication adherence. The use of cocaine and multiple substances were significantly related to decreased medication adherence. Substance use coping mediated these associations. Findings highlight the importance of assessing, monitoring, and targeting ongoing substance use, and ways to increase positive coping for HIV-infected IDUs in substance use treatment to aid in HIV medication adherence.

Feasibility and reliability of interactive voice response assessment of HIV medication adherence: research and clinical implications

BACKGROUND

There are well-documented negative consequences of nonadherence to HIV medications. Telephone-based interactive voice response (IVR) technologies may hold promise for assessing nonadherence in both research and clinical contexts; however, little psychometric research has been conducted on this topic.

OBJECTIVE

In the present pilot study, we test the feasibility and reliability of a simplified patient-initiated, daily IVR system with a convenience sample of HIV patients attending a university-affiliated infectious disease clinic.

METHODS

Participants were asked to call in to an IVR system to report adherence daily during 2 weeks of a larger prospective study. Response rates and patterns were analyzed for feasibility and compared to retrospective, self-report timeline follow-back (TLFB) adherence reporting.

RESULTS

The IVR protocol showed moderate feasibility, with participants reporting adherence behavior on 63.4% of days. However, agreement with TLFB data was low, particularly for days in which participants reported incomplete adherence.

CONCLUSIONS

The IVR protocol tested in the current trial shows some promise. Completion rates were higher than in previous trials. Future research is needed to further enhance the feasibility of IVR for HIV medication adherence and to compare responses to more objective measures on HIV adherence.

Depression longitudinally mediates the association of appearance concerns to ART non-adherence in HIV-infected individuals with a history of injection drug use

Appearance concerns are common among HIV-infected individuals, and previous cross-sectional and longitudinal data indicate that these concerns are associated with antiretroviral therapy (ART) non-adherence. However, to date, no known prospective data have explored the mechanism behind this relationship. Thus, the aim of the current study was to test depression severity as a prospective mediator of the relationship between appearance concerns and ART non-adherence in HIV-infected individuals with a history of injection drug use (IDU). Participants were 89 HIV-infected individuals with a history of IDU who participated in a prospective, randomized controlled trial of cognitive behavioral therapy for depression and medication adherence. Clinician-administered measures of depression severity and appearance concerns, along with electronic monitoring of ART non-adherence were included. Data were analyzed using longitudinal linear mixed-level modeling, and mediation was tested via the Monte Carlo Method of Assessing Mediation. Appearance concerns were predictive of depression severity, γ = .31, SE = .076, 95 % CI [.16, .46], t = 4.1, p = .0001, and depression severity was predictive of ART non-adherence, γ = 3.3, SE = 1.3, 95 % CI [.8, 5.8], t = 2.6, p = .01. The effect of appearance concerns on ART non-adherence, however, was significantly mediated by depression severity, γ = 1.02, 95 % CI [.21, 2.1]. Appearance concerns are associated with depression severity, which in turn is associated with ART non-adherence. Integrative interventions addressing appearance concerns, depression and ART adherence are needed, as this is one potential pathway towards worse health outcomes in HIV-infected individuals.

Suitability of an electronic reminder device for measuring drug adherence in elderly patients with complex medication

We evaluated an electronic reminder device for detecting non-adherence in elderly patients with complex medication regimens. Randomly selected, home-living elderly patients were studied. The patients were aged over 65 years and were taking more than four drugs. Patients received an electronic reminder device which contained a GSM communications module. They were visited three times over a one-year period by a nurse who counted their medicine supply. We compared the adherence measured by the electronic device with the actual adherence measured by the pill count. Almost half of the 315 patients dropped out of the study for various reasons, so the calculations were performed on 168 patients. The adherence measured by the electronic reminder system was 79% and was 92% measured by pill count (P<0.0001). The limits of agreement estimated by a Bland-Altman analysis were -57 to +30. We also compared electronically measured adherence at morning/evening intake times with pill count adherence in the morning/evening only. For the pill count, there was almost no difference between morning and evening adherence rates (93%). For electronic measurement, adherence rates were lower in the evening (75%) than in the morning (81%). Electronic reminders were less reliable than the pill count in measuring adherence. However, the electronic system may be a useful supplement to other, more time consuming methods for measuring adherence.

[Analysis of adherence and efficiency when replacing an antiretroviral therapy with efavirenz-emtricitabine-tenofovir in a single daily dose]

OBJECTIVE

To analyse whether the change of antiretroviral therapy to efavirenz/emtricitabine/tenofovir in a single daily dose (EETu) increases adherence and maintains effectiveness, and establish the cost increase caused by the change.

METHODS

An observational, retrospective, and intra-subject study, performed in the outpatient dispensing unit. The study period was 1 year (6 months before and 6 months after the change). Computer dispensing records and days of hospitalisation during the study period were reviewed, and the difference in treatment adherence calculated. To determine the effectiveness of treatment, viral load and CD4 lymphocytes data before and after the change were reviewed. The cost before and after treatment for each patient was determined, and therefore the annual cost increase and the incremental cost per patient.

RESULTS

The study included 127 patients. The difference in adherence was 0.6%. The percentage of poor adherence was 35.4% and 40.9% before and after the treatment change, respectively. The levels of CD4 lymphocytes and viral load did not change significantly with treatment. The economic analysis revealed an annual increase of 25,374.60 and €199.80 per patient.

CONCLUSIONS

The use of EETu did not improve the control of HIV infection in terms of effectiveness and adherence, and resulted in increased economic costs. Therefore, its choice as antiretroviral treatment will have to be based on criteria other than those described above.

Cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected injection drug users: a randomized controlled trial

OBJECTIVE

Depression and substance use, the most common comorbidities with HIV, are both associated with poor treatment adherence. Injection drug users comprise a substantial portion of individuals with HIV in the United States and globally. The present study tested cognitive behavioral therapy for adherence and depression (CBT-AD) in patients with HIV and depression in active substance abuse treatment for injection drug use.

METHOD

This is a 2-arm, randomized controlled trial (N = 89) comparing CBT-AD with enhanced treatment as usual (ETAU). Analyses were conducted for two time-frames: (a) baseline to post-treatment and (b) post-treatment to follow-up at 3 and 6 months after intervention discontinuation.

RESULTS

At post-treatment, the CBT-AD condition showed significantly greater improvement than ETAU in MEMS (electronic pill cap) based adherence, γslope = 0.8873, t(86) = 2.38, p = .02; dGMA-raw = 0.64, and depression, assessed by blinded assessor: Mongomery-Asberg Depression Rating Scale, F(1, 79) = 6.52, p < .01, d = 0.55; clinical global impression, F(1, 79) = 14.77, p < .001, d = 0.85. After treatment discontinuation, depression gains were maintained, but adherence gains were not. Viral load did not differ across condition; however, the CBT-AD condition had significant improvements in CD4 cell counts over time compared with ETAU, γslope = 2.09, t(76) = 2.20, p = .03, dGMA-raw = 0.60.

CONCLUSIONS

In patients managing multiple challenges including HIV, depression, substance dependence, and adherence, CBT-AD is a useful way to integrate treatment of depression with an adherence intervention. Continued adherence counseling is likely needed, however, to maintain or augment adherence gains in this population.

Revisiting measurement models in psychosomatic medicine research: a latent variable approach

In this article, we describe how a latent variable modeling approach to the specification of measurement error unifies and benefits traditional methods of examining reliability in psychology and medicine. The models presented include classical reliability and generalizability theory to account for measurement error, latent class analysis to assess sensitivity and specificity, and item response theory to improve questionnaire development. We also illustrate how working with latent variables, in addition to addressing measurement error, may help deal with some instances of missing data. Throughout the article, analyses and results from examples and published articles are presented to illustrate the advantage of working with latent variables.

Methodological issues in the assessment of diabetes treatment adherence

Improving treatment adherence in patients with diabetes remains an important objective of behavioral science research. However, progress is often limited by the heterogeneity in methods used to measure treatment adherence and difficulties in generalizing across methodologies. Various measurement methods are often used with little attention paid to questions regarding validity. Doubts about validity of adherence measurement often lead investigators to measure distal clinical outcomes instead, such as glycemic control, resulting in a loss of information. This article provides an overview of the literature on diabetes medication adherence, with a focus on measurement issues. We also consider work conducted in other chronic illnesses, particularly HIV/AIDS, that may have value in guiding future directions of diabetes medication adherence research. We highlight the need for focused investigation on how characteristics of self-report methodologies affect the validity of patient responses and conclude with practical recommendations based on the current state of the science.

Practical and analytic issues in the electronic assessment of adherence

Although medication adherence can be measured many ways, researchers often view electronic dose monitoring devices like the Medication Event Monitoring Systems (MEMS) as more valid than patient self-reports. MEMS are popular but have potential problems. Based on the literature and MEMS data analyses, the authors suggest the following approaches: (a) a 1- to 2-month run-in should be used to reduce MEMS reactivity, (b) MEMS should be used with other measures of adherence, (c) adherence should be measured continuously, or a cutoff should be defined based on pharmacological properties of the medication and the consequences of nonadherence, (d) MEMS data usually should be aggregated weekly or monthly and evaluated using multilevel modeling, (e) MEMS-based screening for nonadherence may miss some patients in need of intervention, and (f) researchers should use strategies like training patients to use MEMS and purchasing extra MEMS caps to improve the completeness and accuracy of MEMS data.

Suitability of measures of self-reported medication adherence for routine clinical use: a systematic review

BACKGROUND

There is a recognised need to build primary care medication adherence services which are tailored to patients' needs. Continuous quality improvement of such services requires a regular working method of measuring adherence in order to monitor effectiveness. Self report has been considered the method of choice for clinical use; it is cheap, relatively unobtrusive and able to distinguish between intentional and unintentional non-adherence, which have different underlying causes and therefore require different interventions. A self report adherence measure used in routine clinical practice would ideally be brief, acceptable to patients, valid, reliable, have the ability to distinguish between different types of non-adherence and be able to be completed by or in conjunction with carers where necessary.

METHODS

We systematically reviewed the literature in order to identify self report adherence measures currently available which are suitable for primary care and evaluate the extent to which they met the criteria described above. We searched the databases Medline, Embase, International Pharmaceutical Abstracts, Pharmline, CINAHL, PsycINFO and HaPI to identify studies reporting the development, validation or reliability of generic adherence measures. One reviewer screened all abstracts and assessed all relevant full text articles obtained and a second reviewer screened/assessed 10% to check reliability.

RESULTS

Fifty eight measures were identified. While validation data were presented in support of the vast majority of self reported measures (54/58), data for a relatively small number of measures was presented for reliability (16/58) and time to complete (3/58). Few were designed to have the ability to be completed by or in conjunction with carers and few were able to distinguish between different types of non-adherence, which limited their ability be used effectively in the continuous improvement of targeted adherence enhancing interventions. The data available suggested that patients find it easier to estimate general adherence than to report a specific number of doses missed. Visual analogue scales can be easier for patients than other types of scale but are not suitable for telephone administration.

CONCLUSIONS

There is a need for a measure which can be used in the routine continual quality monitoring of adherence services.

Childhood sexual abuse and health risk behaviors in patients with HIV and a history of injection drug use

Childhood sexual abuse (CSA) is related to poorer health outcomes, associated with increased risk for HIV acquisition, and prevalent among HIV risk groups. Links between CSA and health behavior are an important health concern. We examined the relationship between CSA and transmission risk behavior and medication adherence in 119 HIV-infected individuals with an injection drug use history. 47% reported CSA, with no gender difference. Individuals who experienced CSA were more likely to report sexual HIV transmission risk behavior in the past 6 months, more sexual partners, use of heroin in the past 30 days, and worse adherence to HIV medication than those who did not. These findings confirm that rates of CSA are high in this population, and suggest that a history of CSA may place people managing both HIV and opioid dependence at increased risk for HIV transmission, poor adherence to medication, and vulnerability to substance use relapse.

Factors associated with non-adherence to antiretroviral therapy in the SUN study

BACKGROUND

Adherence of 95% or greater to highly active combination antiretroviral therapy is generally considered necessary to achieve optimal virologic suppression in HIV-infected patients. Understanding factors associated with poor adherence is essential to improve patient compliance, maximize virologic suppression, and reduce morbidity and mortality.

METHODS

We evaluated baseline data from 528 patients taking antiretrovirals, enrolled from March 2004 to June 2006, in a multicenter, longitudinal, prospective cohort study (the SUN study). Using multiple logistic regression, we examined independent risk factors for non-adherence, defined as reporting having missed one or more antiretroviral doses in the past three days on the baseline questionnaire.

RESULTS

Of 528 participants (22% female, 28% black, median age 41 years, and median CD4 cell count 486 cells/mm(3)), 85 (16%) were non-adherent. In the final parsimonious multivariate model, factors independently associated with non-adherence included black race (adjusted odds ratio (aOR): 2.08, 95% confidence interval (CI): 1.20-3.60 vs. white race), being unemployed and looking for work (aOR: 2.03, 95% CI: 1.14-3.61 vs. all other employment categories), having been diagnosed with HIV ≥5 years ago (aOR: 1.95, 95% CI: 1.18-3.24 vs. being HIV-diagnosed <5 years ago), drinking three or more drinks per day (aOR: 1.73, 95% CI: 1.02-2.91 vs. drinking <3 drinks per day), and having not engaged in any aerobic exercise in the last 30 days (aOR: 2.13, 95% CI: 1.25-3.57).

CONCLUSION

Although the above factors may not be causally related to non-adherence, they might serve as proxies for identifying HIV-infected patients at greatest risk for non-adherence who may benefit from additional adherence support.

Predictors and patterns of participant adherence to a cortisol collection protocol

BACKGROUND

Cortisol, a stress-related hormone, has been measured in many psychoimmunological studies via collection of saliva; however, patterns of participant adherence to protocol procedures are rarely described in the literature.

OBJECTIVES

In this paper we examine adherence to a cortisol morning rise collection protocol and explore its associations with demographic predictors and fatigue.

METHOD

Participants included 262 breast cancer survivors enrolled in a National Institute of Nursing Research funded longitudinal intervention study (5R01NR010190, M. Mishel, P.I.). Self-reported times of salivary cortisol collection were recorded for each of 12 saliva samples. Adherence was assessed with respect to various demographic factors and fatigue. Participants were categorized as having high, moderate, or low adherence to the saliva collection protocol.

RESULTS

Overall, 117 (45%) participants had high adherence to the protocol, 117 (45%) participants had moderate adherence, and 28 (∼11%) participants had low adherence. Tests for proportionality for the polytomous logistic regression indicated that demographic predictors in our model had a similar association with each level of participant adherence. Women who did not adhere to the saliva collection were more likely to be African American (OR .50, CI .29-.88) and to report a high impact of fatigue on their behaviors (OR .88, CI .79-.98). Though other predictors in the model were not statistically significant (working full-time and living with at least one child under 18 years of age), the overall model was significant (χ(2)(4)=17.35, p<.01).

DISCUSSION

To our knowledge, this is the first study to examine profiles of participant adherence to a cortisol sampling protocol over multiple timepoints. By conceptualizing adherence as a polytomous outcome, future studies may give us insights into adherence trends in other populations with the aim of promoting adherence and designing more informed saliva collection protocols.

Validating five questions of antiretroviral nonadherence in a public-sector treatment program in rural South Africa

Simple questions are the most commonly used measures of antiretroviral treatment (ART) adherence in sub-Saharan Africa (SSA), but rarely validated. We administered five adherence questions in a public-sector primary care clinic in rural South Africa: 7-day recall of missed doses, 7-day recall of late doses, a six-level Likert item, a 30-day visual analogue scale of the proportion of doses missed, and recall of the time when an ART dose was last missed. We estimated question sensitivity and specificity in detecting immunologic (or virologic) failure assessed within 45 days of the adherence question date. Of 165 individuals, 7% had immunologic failure; 137 individuals had viral loads with 9% failure detected. The Likert item performed best for immunologic failure with sensitivity/specificity of 100%/5% (when defining nonadherence as self-reported adherence less than "excellent"), 42%/55% (less than "very good"), and 25%/95% (less than "good"). The remaining questions had sensitivities ≤17%, even when the least strict cutoffs defined nonadherence. When we stratified the analysis by gender, age, or education, question performance was not substantially better in any of the subsamples in comparison to the total sample. Five commonly used adherence questions performed poorly in identifying patients with treatment failure in a public-sector ART program in SSA. Valid adherence measurement instruments are urgently required to identify patients needing treatment support and those most at risk of treatment failure. Available estimates of ART adherence in SSA are mostly based on studies using adherence questions. It is thus unlikely that our understanding of ART adherence in the region is correct.

Cognitive Behavioral Therapy for Adherence and Depression (CBT-AD) in Type 2 Diabetes

Depression is one of the most common psychological problems among individuals diabetes, and it is associated with worse treatment adherence and clinical outcomes. As part of a program of treatment research aimed at integrating interventions for depression and treatment nonadherence, five depressed patients with suboptimally controlled type 2 diabetes were treated with 10-12 sessions of individual cognitive behavioral therapy for adherence and depression (CBT-AD) in a case-series design. The intervention was delivered in a hospital setting by a collaborative team consisting of a psychologist, a nurse educator, and a dietitian. Post-treatment, all participants demonstrated a decrease in depression severity and demonstrated improvements in diabetes self-care. Four of the five demonstrated improved glycemic control. These preliminary results provide evidence for the acceptability, feasibility, and potential utility of CBT-AD for patients with type 2 diabetes and depression.

Substance use and HIV disease progression in the HAART era: implications for the primary prevention of HIV

Prior to the era of highly active anti-retroviral therapy (HAART), cohort studies provided equivocal evidence to support the hypothesis that substance use predicts more rapid HIV disease progression. The present review examined the effects of substance use on HIV disease progression in cohort studies with follow-up that continued into the HAART era. Of the 20 studies included in this review, 16 observed that substance use predicted at least one indicator of HIV disease progression. Ten of the 11 studies that followed participants exclusively in the HAART era observed an effect of substance use on HIV disease progression. Findings across studies indicate that stimulant use promotes more rapid HIV disease progression and the effects of substance use on HIV disease progression can persist after controlling for self-reported HAART non-adherence. Future investigations that examine the bio-behavioral pathways whereby substance use promotes HIV disease progression should include: measures of HIV genotypic and phenotypic resistance, multi-method assessment of adherence, and assessment of co-morbid infections that are more prevalent among substance users. Although further mechanistic research is needed, findings from existing cohort studies have clear clinical implications. Implementing screening, brief intervention and referral to substance abuse treatment in HIV medical care could optimize health outcomes and decrease HIV transmission rates by boosting the effectiveness of "Test and Treat" approaches to HIV prevention.

Monitoramento e avaliação da adesão ao tratamento antirretroviral para HIV/aids: desafios e possibilidades

Devido aos avanços nas pesquisas e possibilidades de tratamento, a aids tornou-se uma doença crônica, com aumento relevante da qualidade de vida de pessoas acometidas, o que traz novos desafios para sua compreensão e enfrentamento. Nessa perspectiva, a adesão ao tratamento antirretroviral tem sido priorizada nas políticas públicas de países como o Brasil. O objetivo do artigo é discutir as possibilidades e desafios no processo de monitoramento e avaliação da adesão ao tratamento antirretroviral, bem como as vantagens e desvantagens das técnicas disponíveis para sua aferição, com destaque para o trabalho com pessoas de baixa escolaridade e em países com recursos limitados. Conclui-se que é necessário considerar aspectos logísticos, conceituais e empíricos na escolha de métodos para monitorar a adesão, tendo por base os contextos socioculturais e econômicos, principalmente em países com recursos limitados. Conclui-se também que identificar formas mais adequadas e efetivas de medir a adesão ainda se constitui em desafios para pesquisadores e profissionais de saúde que atuam em HIV/aids.

Concordance of adherence measurement using self-reported adherence questionnaires and medication monitoring devices

The primary objective of this review was to identify and examine the literature on the association between medication adherence self-reported questionnaires (SRQs) and medication monitoring devices. The primary literature search was performed for 1980-2009 using PubMed, PubMed In Process and Non-Indexed, Ovid MEDLINE, Ovid MEDLINE In-Process, PsycINFO (EBSCO), CINAHL (EBSCO), Ovid HealthStar, EMBASE (Elsevier) and Cochrane Databases and using the following search terms: 'patient compliance', 'medication adherence', 'treatment compliance', 'drug monitoring', 'drug therapy', 'electronic', 'digital', 'computer', 'monitor', 'monitoring', 'drug', 'drugs', 'pharmaceutical preparations', 'compliance' and 'medications'. We identified studies that included SRQs and electronic monitoring devices to measure adherence and focused on the SRQs that were found to be moderately to highly correlated with the monitoring devices. Of the 1679 citations found via the primary search, 41 full-text articles were reviewed for correlation between monitoring devices and SRQs. A majority (68%) of articles reported high (27%), moderate (29%) or significant (12%) correlation between monitoring devices (37 using Medication Event Monitoring System [MEMS®] and four using other devices) and SRQs (11 identified and numerous other unnamed SRQs). The most commonly used SRQs were the Adult/Pediatric AIDS Clinical Trial Group (AACTG/PACTG; 24.4%, 10/41) followed by the 4-item Morisky (9.8%, 4/41), Brief Medication Questionnaire (9.8%, 4/41) and visual analogue scale (VAS; 7.3%, 3/41). Although study designs differed across the articles, SRQs appeared to report a higher rate of medication adherence (+14.9%) than monitoring devices. In conclusion, several medication adherence SRQs were validated using electronic monitoring devices. A majority of them showed high or moderate correlation with medication adherence measured using monitoring devices, and could be considered for measuring patient-reported adherence prospectively.

A comparison of adherence assessment methods utilized in the United States: perspectives of researchers, HIV-infected children, and their caregivers

This study sought to elucidate methodological issues in adherence research by comparing multiple methods of assessing adherence to antiretroviral medication. From 2003 to 2004, 24 youths with vertically infected HIV disease (mean age = 14.0 years; range, 8-18) and their caregivers participated in a 6-month study. These children were all on highly active antiretroviral therapy (HAART) and were relatively healthy (mean CD4 absolute count = 711.8 +/- 604.5). Adherence was assessed with the Medication Event Monitoring System (MEMS), pill counts, and interviews. Patients and caregivers completed the Perceptions of Adherence Study Participation (PASP) questionnaire. MEMS provided the most detailed adherence information, and good reliability was indicated by significant correlations with medical markers. Pill counts provided similar adherence rates, while patients and caregivers reported nearly perfect adherence in interviews. Problems were experienced with each method: MEMS were expensive, had cap malfunctions, and lack a consistent guiding principle for data interpretation. With pill counts, families forgot to bring all medication bottles to clinic, and interviews were compromised by social desirability and difficulty reaching families by telephone. Most patients and caregivers believed study participation improved the child's adherence, although PASP ratings were unrelated to adherence at the study endpoint. While MEMS may be most reliable, pill counts offer comparable data and are less costly, while interviews seemed least accurate in this study. Most participants reported positive perceptions of their research experience. A consensus among researchers is needed for defining and measuring adherence, and specific recommendations are offered for achieving this goal.

[The role of oncology nurses in treatment outcomes. What can we do for the patients' compliance treated with intravenous zoledronic acid?]

Patients with cancer and bone metastasis usually need to be treated with bisphosphonates to reduce or delay skeletal complications (pathologic fracture, hypercalcemia, surgery or radiotherapy). The nurses can provide important education to patients, support and encourage use of bisphosphonates throughout therapy. Literatures, training, congress reports provide useful information about bisphosphonate therapy, side effects, adverse events etc. However, patients need more information to support them during courses. To optimize the care, nurses can monitor pain scores, changes in mobility, adverse events, creating clearance levels. A useful tool for recording these parameters is a patients-diary. The nurse should fill out the diary at each patients visit and compare it to the baseline information before treatment. At the same time they can get some information from the patient's performance (adequate hydration, dental hygiene). Nurses play an important role in the care of patients during bisphosphonate therapy and in supporting patients to continue treatment to preserve their functional independence.

An alternative methodology for the prediction of adherence to anti HIV treatment

Background

Successful treatment of HIV-positive patients is fundamental to controlling the progression to AIDS. Causes of treatment failure are either related to drug resistance and/or insufficient drug levels in the blood. Severe side effects, coupled with the intense nature of many regimens, can lead to treatment fatigue and consequently to periodic or permanent non-adherence. Although non-adherence is a recognised problem in HIV treatment, it is still poorly detected in both clinical practice and research and often based on unreliable information such as self-reports, or in a research setting, Medication Events Monitoring System caps or prescription refill rates. To meet the need for having objective information on adherence, we propose a method using viral load and HIV genome sequence data to identify non-adherence amongst patients.

Presentation of the hypothesis

With non-adherence operationally defined as a sharp increase in viral load in the absence of mutation, it is hypothesised that periods of non-adherence can be identified retrospectively based on the observed relationship between changes in viral load and mutation.

Testing the hypothesis

Spikes in the viral load (VL) can be identified from time periods over which VL rises above the undetectable level to a point at which the VL decreases by a threshold amount. The presence of mutations can be established by comparing each sequence to a reference sequence and by comparing sequences in pairs taken sequentially in time, in order to identify changes within the sequences at or around 'treatment change events'. Observed spikes in VL measurements without mutation in the corresponding sequence data then serve as a proxy indicator of non-adherence.

Implications of the hypothesis

It is envisaged that the validation of the hypothesised approach will serve as a first step on the road to clinical practice. The information inferred from clinical data on adherence would be a crucially important feature of treatment prediction tools provided for practitioners to aid daily practice. In addition, distinct characteristics of biological markers routinely used to assess the state of the disease may be identified in the adherent and non-adherent groups. This latter approach would directly help clinicians to differentiate between non-responding and non-adherent patients.

A randomized controlled trial of cognitive behavioral therapy for adherence and depression (CBT-AD) in HIV-infected individuals

OBJECTIVE

To evaluate cognitive-behavioral therapy to enhance medication adherence and reduce depression (CBT-AD) in individuals with HIV.

DESIGN

A two arm, randomized, controlled, cross-over trial comparing CBT-AD to enhanced treatment as usual only (ETAU). ETAU, which both groups received, included a single-session intervention for adherence and a letter to the patient's provider documenting her or his continued depression. The intervention group also received 10 to 12 sessions of CBT-AD.

MAIN OUTCOME MEASURES

Adherence to antiretroviral therapy as assessed by Medication Event Monitoring Systems (MEMs) and depression as assessed by blinded structured evaluation.

RESULTS

At the acute outcome assessment (3-months), those who received CBT-AD evidenced significantly greater improvements in medication adherence and depression relative to the comparison group. Those who were originally assigned to the comparison group who chose to cross over to CBT-AD showed similar improvements in both depression and adherence outcomes. Treatment gains for those in the intervention group were generally maintained at 6- and 12-month follow-up assessments. By the end of the follow-up period, those originally assigned CBT-AD demonstrated improvements in plasma HIV RNA concentrations, though these differences did not emerge before the cross-over, and hence there were not between-groups differences.

CONCLUSIONS

CBT-AD is a potentially efficacious approach for individuals with HIV struggling with depression and adherence. Replication and extension in larger efficacy trials are needed.

Diagnostic value of different adherence measures using electronic monitoring and virologic failure as reference standards

Nonadherence to antiretroviral therapy is a substantial problem in HIV and jeopardizes the success of treatment. Accurate measurement of nonadherence is therefore imperative for good clinical management but no gold standard has been agreed on yet. In a single-center prospective study nonadherence was assessed by electronic monitoring: percentage of doses missed and drug holidays and by three self reports: (1) a visual analogue scale (VAS): percentage of overall doses taken; (2) the Swiss HIV Cohort Study Adherence Questionnaire (SHCS-AQ): percentage of overall doses missed and drug holidays and (3) the European HIV Treatment Questionnaire (EHTQ): percentage of doses missed and drug holidays for each antiretroviral drug separately. Virologic failure prospectively assessed during 1 year, and electronic monitoring were used as reference standards. Using virologic failure as reference standard, the best results were for (1) the SHCS-AQ after electronic monitoring (sensitivity, 87.5%; specificity, 78.6%); (2) electronic monitoring (sensitivity, 75%; specificity, 85.6%), and (3) the VAS combined with the SHCS-AQ before electronic monitoring (sensitivity, 87.5%; specificity, 58.6%). The sensitivity of the complex EHTQ was less than 50%. Asking simple questions about doses taken or missed is more sensitive than complex questioning about each drug separately. Combining the VAS with the SHCS-AQ seems a feasible nonadherence measure for daily clinical practice. Self-reports perform better after electronic monitoring: their diagnostic value could be lower when given independently.

Psychological distress, killer lymphocytes and disease severity in HIV/AIDS

Immunocellular mechanisms that account for the association between psychosocial risk factors and increased susceptibility to faster progression of HIV/AIDS are largely unknown. This study used structural equation modeling to test the hypothesis that enumerative and functional alterations in killer lymphocytes mediate the relationship between higher levels of psychological distress (defined by perceived stress, anxiety and depressive symptoms) and greater HIV disease severity (defined by HIV-1 viral load and T-helper (CD4(+)) cell count), independent of standard demographic and various HIV-related covariates. Participants were 200 HIV-1 seropositive adults on combination antiretroviral therapy (ages 20-55 years; 67% men; 62% black; 84% AIDS). The data fit a psychoimmune model in which the significant relationship between higher distress levels and greater disease severity was mediated by diminished natural killer (NK) cell count and cytotoxic function, as well as increased cytotoxic (CD8(+)) T-cell activation. Overall the findings indicated that the psychoimmune model accounted for 67% of the variation in HIV disease severity. In contrast, the data did not support a reverse directionality mediation model, where greater HIV disease severity predicted greater distress as a function of killer lymphocyte status. In sum, the psychoimmune associations of the final model are physiologically consistent and suggest that distress-related alterations in killer lymphocyte immunity may play a role in the biobehavioral mechanisms linked with HIV-1 pathogenesis.