Computer-assisted self-interviewing (CASI) to improve provider assessment of adherence in routine clinical practice

Factors associated with declining to report the number of sexual partners using computer-assisted self-interviewing: a cross-sectional study among individuals attending a sexual health centre in Melbourne, Australia

Background The number of sexual partners is one of the most important risk factors for sexually transmissible infections (STIs), including HIV. The aim of the present study was to examine the association between declining to report the number of partners using computer-assisted self-interviewing (CASI) and HIV or STI positivity at a public sexual health centre in Melbourne, Australia, in 2016.

METHODS

Individuals were categorised into three risk populations: women, men who have sex with women only (MSW) and men who have sex with men (MSM). Logistic regression analysis was used to examine the association between declining to report the number of sexual partners in the past 12 months and HIV or STI positivity for women and MSW, with generalised estimating equations (GEE) used for estimation in MSM to address repeated-measures within individuals.

RESULTS

In all, 18085 individuals (5579 women, 6013 MSW, 6493 MSM) were included in the final analysis. There was no association between chlamydia positivity and declining to respond among women and MSW. MSM who declined to respond were more likely to be chlamydia positive (adjusted odds ratio1.21; 95% confidence interval (CI) 1.01-1.43). Known HIV-positive MSM and MSM newly diagnosed with HIV had 3.31-fold (95% CI 2.48-4.42) and 2.82-fold (95% CI 1.84-4.32) greater odds respectively of declining to respond compared with HIV-negative MSM. Gonorrhoea and syphilis positivity in MSM were not associated with declining to respond.

CONCLUSIONS

There was no association between declining to report the number of partners and chlamydia positivity among women and MSW. However, MSM who declined to report the number of partners were slightly more likely to have chlamydia and substantially more likely to be HIV positive.

Development and validation of the WebAd-Q Questionnaire to monitor adherence to HIV therapy

OBJECTIVE To present the development and validation of the WebAd-Q Questionnaire, a self-report instrument to monitor adherence to antiretroviral therapy in HIV/AIDS centers in Brazil. METHODS The WebAd-Q is an electronic questionnaire that has three questions about the use of antiretrovirals in the last week. It was constructed from interviews and focus groups with 38 patients. Its validity was tested in a study with a sample of 90 adult patients on antiretroviral therapy for at least three months. We used electronic monitoring bottles, pill counting, and self-report interview to compare adherence. The WebAd-Q was answered on the sixtieth day, twice, with at least one hour of interval. The viral load of the patients was obtained from the service records. We have analyzed the agreement between the answers to the WebAd-Q, the associations, and the correlations with viral load and performance compared to other measures of adherence. RESULTS Among the invited patients, 74 (82.2%) answered the WebAd-Q. No difficulties were reported to answer the questionnaire. The average answer time was 5 min 47 sec. The set of three questions of the WebAd-Q obtained agreement of 89.8%, with Kappa of 0.77 (95%CI 0.61-0.94). The non-adherence answers of the WebAd-Q were associated with detectable viral load. We obtained moderate viral load correlations with the non-adherence scale according to the WebAd-Q. For the three questions of the WebAd-Q, patients with non-adherence answers were also reported as less adherent according to the other measures of adherence. CONCLUSIONS The WebAd-Q answered all the issues considered relevant in the validation of questionnaires, was well understood by patients, was associated with viral load, and obtained good agreement and good performance compared to the other measures. The feasibility analysis of its implementation still depends on a national study on its applicability.

Gender-specific differences in high-risk sexual behaviors among methamphetamine users in Myanmar-China border city, Muse, Myanmar: who is at risk?

Background

Methamphetamine (MA) use is a significant public health concern due to its negative effects on health. However, to date, no epidemiological research has examined high-risk sexual behaviors (inconsistent condom use, having multiple sexual partners and having a history of sexually transmitted infections) among MA users. This topic is particularly important in Myanmar, which is recognized as one of the key MA production countries in the Southeast Asia region. Therefore, this study examined factors associated with high-risk sexual behaviors among MA users in Muse city, Myanmar.

Methods

A community-based cross-sectional study was conducted from January to March 2013 in Muse city, Northern Shan State, Myanmar. In total, 1183 MA users (772 male; 411 female) were recruited using respondent-driven sampling and a computer assisted self-interviewing method. Generalized estimating equation models were used to examine factors associated with high-risk sexual behaviors.

Results

A large proportion of MA users engaged in high-risk sexual behaviors (inconsistent condom use: males, 90.7%, females, 85.2%; multiple sexual partners: males, 94.2%, females, 47.2%; and history of STIs: males, 55.7%, females, 56.0%). Among males, being a multiple stimulants drug user (adjusted odds ratio [AOR] =1.77; 95% confidence interval [CI] =1.30–2.41) and being a client of sex workers (AOR = 1.41; 95% CI = 1.08–1.83) were risk factors for engaging in high-risk sexual behaviors. Among females, being a migrant worker (AOR = 2.70; 95% CI = 1.86–3.93) and being employed (AOR = 1.57; 95% CI = 1.13–2.18) were risk factors for engaging in high-risk sexual behaviors as well.

Conclusions

High-risk sexual behaviors were particularly pronounced among both male and female MA users. MA prevention programs that reflect gender considerations should be developed to pay more attention to vulnerable populations such as migrants, clients of sex workers, and less educated female MA users.

Gender difference in early initiation of methamphetamine use among current methamphetamine users in Muse, Northern Shan State, Myanmar

Background

Globally, methamphetamine (MA) use is a significant public health concern due to unprecedented health effects of its use. However, gender similarities and differences in early age of MA initiation and its risk factors among current MA users have been understudied in a developing country setting.

Methods

A community-based, cross-sectional study was conducted using a computer assisted self-interviewing program from January to March 2013 in Muse, Northern Shan State, Myanmar. A total of 1362 (775 male and 587 female) self-reported current MA users aged between 18 and 35 years were recruited using respondent-driven sampling. Two gender-stratified multiple logistic regression models (models I and II) were done for analysis.

Results

For similarities, 73.0% of males and 60.5% of females initiated MA before their 18th birthday. The early age of MA initiation was positively associated with the reasons and places of the first time MA use among both genders. For differences, males [hazard ratio 1.35; 95% confidence interval, 1.18–1.54] had a significantly higher risk than females to initiate MA at earlier age. Among male users, participants who had bisexual/homosexual preferences were more likely to initiate MA use earlier. In contrast, female users who exchanged sex for money and/or drugs were more likely to initiate MA in earlier age.

Conclusions

More than 60.0% of male and female participants initiated MA use early; however, males initiated use earlier than females. Although similarities were found among both genders, differences found in key risk factors for early age MA initiation suggest that gender-specific, MA prevention programs are urgently needed in Myanmar.

Predictors of willingness to use a smartphone for research in underserved persons living with HIV

OBJECTIVES

The burden of HIV/AIDS is borne disproportionally by a growing number of racial and ethnic minorities and socioeconomically disadvantaged individuals. Developing mHealth interventions for the everyday self-management needs of persons living with HIV (PLWH) can be challenging given the current constraints of the U.S. healthcare system, especially for those from underserved communities. In order to develop effective, evidence-based mHealth self-management interventions, we need a better understanding of the factors associated with mHealth research. The purpose of this study was to assess factors associated with PLWH's for participation in research using smartphones.

METHODS

We conducted a prospective cohort study (parent study) to examine the relationships among HIV self-management, age, gender and mental wellness. Relevant to this study, we analyzed the relationship between self-reported use of smartphones, willingness to use a smartphone for research, and other predictor variables including: HIV stigma, social isolation, social integration functions, and depression. We selected these variables because previous work indicated they may influence smartphone or mHealth use and because they also tend to be elevated in PLWH.

RESULTS

We found increased age, HIV stigma and social isolation were negatively associated with smartphone use, which supports the use of smartphones for conducting research with PLWH but also suggests that age, stigma, social integration functions and social isolation need to be considered in research involving PLWH.

CONCLUSIONS

Findings here support smartphone use in research involving PLWH. However, future mHealth interventions targeting PLWH should take into account the inverse relationship between smartphone use and age, HIV stigma, and social isolation, and other predictor variables.

Innovations in health and demographic surveillance systems to establish the causal impacts of HIV policies

PURPOSE OF REVIEW

Health and demographic surveillance systems (HDSS), in conjunction with HIV treatment cohorts, have made important contributions to our understanding of the impact of HIV treatment and treatment-related interventions in sub-Saharan Africa. The purpose of this review is to describe and discuss innovations in data collection and data linkage that will create new opportunities to establish the impacts of HIV treatment, as well as policies affecting the treatment cascade, on population health and economic and social outcomes.

RECENT FINDINGS

Novel approaches to routine collection of biomarkers, behavioural data, spatial data, social network information, migration events and mobile phone records can significantly strengthen the potential of HDSS to generate exposure and outcome data for causal analysis of HIV treatment impact and policies affecting the HIV treatment cascade. Additionally, by linking HDSS data to health service administration, education and welfare service records, researchers can substantially broaden opportunities to establish how HIV treatment affects health and economic outcomes when delivered through public sector health systems and at scale.

SUMMARY

As the HIV treatment scaleup in sub-Saharan Africa enters its second decade, it is becoming increasingly important to understand the long-term causal impacts of large-scale HIV treatment and related policies on broader population health outcomes, such as noncommunicable diseases, as well as on economic and social outcomes, such as family welfare and children's educational attainment. By collecting novel data and linking existing data to public sector records, HDSS can create near-unique opportunities to contribute to this research agenda.

Computerized counseling reduces HIV-1 viral load and sexual transmission risk: findings from a randomized controlled trial

OBJECTIVE

Evaluate a computerized intervention supporting antiretroviral therapy (ART) adherence and HIV transmission prevention.

DESIGN

Longitudinal randomized controlled trial.

SETTINGS

An academic HIV clinic and a community-based organization in Seattle.

SUBJECTS

In a total of 240 HIV-positive adults on ART, 209 completed 9-month follow-up (87% retention).

INTERVENTION

Randomization to computerized counseling or assessment only, 4 sessions over 9 months.

MAIN OUTCOME MEASURES

HIV-1 viral suppression, and self-reported ART adherence and transmission risks, compared using generalized estimating equations.

RESULTS

Overall, intervention participants had reduced viral load: mean 0.17 log10 decline, versus 0.13 increase in controls, P = 0.053, and significant difference in ART adherence baseline to 9 months (P = 0.046). Their sexual transmission risk behaviors decreased (odds ratio = 0.55, P = 0.020), a reduction not seen among controls (odds ratio = 1.1, P = 0.664), and a significant difference in change (P = 0.040). Intervention effect was driven by those most in need; among those with detectable virus at baseline (>30 copies/mL, n = 89), intervention effect was mean 0.60 log10 viral load decline versus 0.15 increase in controls, P = 0.034. ART adherence at the final follow-up was 13 points higher among intervention participants versus controls, P = 0.038.

CONCLUSIONS

Computerized counseling is promising for integrated ART adherence and safer sex, especially for individuals with problems in these areas. This is the first intervention to report improved ART adherence, viral suppression, and reduced secondary sexual transmission risk behavior.

A web-based intervention trial for depressive symptoms and subjective well-being in patients with chronic HIV infection

The current study examined the efficacy of a web-based intervention (WBI; Avanti) on symptoms of depression and well-being for patients diagnosed with HIV. A two-armed randomized trial recruited patients on antiretroviral therapy (ART) at an outpatient clinic. Thirty-six patients were allocated to Avanti and 31 patients to a control group. Primary outcomes were symptoms of depression and subjective well-being (SWB), and secondary outcomes included life satisfaction and affect balance. Paired tests showed that only patients following Avanti had significant improvements in SWB by 3 months as well as affect balance. No significant differences between groups were detected in any of the outcome parameters at baseline after 3 months, as expected from group size and variability in the parameters. However, time since HIV diagnosis and ART initiation moderated the effects of Avanti. In conclusion, our data show that patients with HIV infection may benefit from a WBI in adjunct to medical treatment.

Assessment of HIV-related risky behaviour: a comparative study of face-to-face interviews and polling booth surveys in the general population of Cotonou, Benin

OBJECTIVES

During the 2008 HIV prevalence survey carried out in the general population of Cotonou, Benin, face-to-face interviews (FTFI) were used to assess risky behaviours for HIV and other sexually transmitted infections (STI). We compared sexual behaviours reported in FTFI with those reported in polling booth surveys (PBS) carried out in parallel in an independent random sample of the same population.

METHODS

In PBS, respondents grouped by gender and marital status answered simple questions by putting tokens with question numbers in a green box (affirmative answers) or a red box (negative answers). Both boxes were placed inside a private booth. For each group and question, data were gathered together by type of answer. The structured and gender-specific FTFI guided by trained interviewers included all questions asked during PBS. Pearson χ2 or Fisher's exact test was used to compare FTFI and PBS according to affirmative answers.

RESULTS

Overall, respondents reported more stigmatised behaviours in PBS than in FTFI: the proportions of married women and men who reported ever having had commercial sex were 17.4% and 41.6% in PBS versus 1.8% and 19.6% in FTFI, respectively. The corresponding proportions among unmarried women and men were 16.1% and 25.5% in PBS versus 3.9% and 13.0% in FTFI, respectively. The proportion of married women who reported having had extramarital sex since marriage was 23.6% in PBS versus 4.6% in FTFI.

CONCLUSIONS

PBS are suitable to monitor reliable HIV/STI risk behaviours. Their use should be expanded in behavioural surveillance.

Development and field testing of an HIV medication touch screen computer patient adherence tool with telephone-based, targeted adherence counseling

BACKGROUND

HIV medication nonadherence is a major problem, yet many providers lack the time and training to carefully ask patients about their adherence.

OBJECTIVE

To design and pilot a technology-assisted intervention, for use in clinical settings, to identify nonadherent patients.

METHODS

The intervention uses audio computer-assisted self-interview (ACASI) to improve the assessment of adherence and medication-related problems. Patients completed a touch screen computer ACASI which generated graphic clinician and patient reports for discussion during the clinical encounter.

RESULTS

72 patients and 11 providers participated in this study. The patients easily completed the ACASI. Adherence was 63% (3-day) and 47% (30-day). Using the ACASI, 22% of patients identified themselves as nonadherent, when their providers perceived them as adherent.

CONCLUSIONS

This ACASI-based intervention is easy to use and helps identify nonadherence. The pilot test engendered enhancements including the addition of phone-based adherence counseling. A larger trial is underway to evaluate whether the intervention leads to improved HIV-related outcomes.

Adherence in people living with HIV/AIDS, mental illness, and chemical dependency: a review of the literature

Adherence to antiretroviral medications is central to reducing morbidity and mortality among people living with HIV/AIDS. Relatively few studies published to date address HIV adherence among special populations. The purpose of this article is to review the existing literature on HIV antiretroviral adherence, with an emphasis on studies among the triply diagnosed population of people living with HIV/AIDS, mental illness, and chemical dependency. In order to reflect the most current information available, data from conference proceedings, federally funded studies in progress, and the academic literature are presented for consideration.

A simple single-item rating scale to measure medication adherence: further evidence for convergent validity

BACKGROUND

Self-report measures of medication adherence are inexpensive and minimally intrusive. However, the validity of self-reported adherence is compromised by recall errors for missed doses and socially desirable responding.

METHOD

Examined the convergent validity of 2 self-report adherence measures administered by computerized interview: (a) recall of missed doses and (b) a single-item visual analogue rating scale (VAS). Adherence was also monitored using unannounced phone-based pill counts that served as an objective benchmark.

RESULTS

The VAS obtained adherence estimates that paralleled unannounced pill counts (UPCs). In contrast, self-reported recall (SR-recall) of missed medications consistently overestimated adherence. Correlations with participant characteristics also suggested that the computer-administered VAS was less influenced by response biases than SR-recall of missed medication doses.

CONCLUSIONS

A single-item VAS offers an inexpensive and valid method of assessing medication adherence that may be useful in clinical as well as research settings.

Characteristics associated with retention among African American and Latino adolescent HIV-positive men: results from the outreach, care, and prevention to engage HIV-seropositive young MSM of color special project of national significance initiative

BACKGROUND

Surveillance points to an urgent public health need for HIV prevention, access, and retention among young men of color who have sex with men (YMSM). The purpose of this multisite study was to evaluate the association between organizational- and individual-level characteristics and retention in HIV care among HIV-positive YMSM of color.

METHODS

Data were collected quarterly via face-to-face interviews and chart abstraction between June 2006 and September 2008. Participants were aged 16-24 years, enrolled at 1 of 8 participating youth-specific demonstration sites, and engaged or reengaged in HIV care within the last 30 days. Generalized estimating equations were used to examine factors associated with missing research and care visits. Stata v.9.0se was used for analysis.

RESULTS

Of 224 participants, the majority were African American (72.7%), 19-22 years old (66.5%), had graduated high school or equivalent (71.8%), identified as gay or homosexual (80.8%), and disclosed having had sex with a man before HIV diagnosis (98.2%). Over the first 2(1/4) years of the study, only 11.4% of visits were missed without explanation or patient contact. Characteristics associated with retention included being <21 years old, a history of depression, receipt of program services, and feeling respected at clinic; those associated with poorer retention included having a CD4 count <200 at baseline and being Latino.

CONCLUSIONS

Special Projects of National Significance programs were able to achieve a high level of retention over time, and individual and program characteristics were associated with retention. Latino YMSM, those not receiving services, and those not perceiving respect at the clinic were at increased risk of falling out of care. Retention is essential to providing HIV+ adolescents with treatment, including reducing antiretroviral resistance development. Innovative programs that address the needs of the YMSM of color population may result in improved retention.

Feasibility of using audio computer-assisted self-interview (ACASI) screening in routine HIV care

We evaluated the feasibility of implementing audio computer-assisted self-interviews (ACASI) as part of routine clinical care at two community hospital-based HIV clinics in New York City. Between June 2003 and August 2006, 215 patients completed 1001 ACASI sessions in English or Spanish prior to their scheduled clinical appointments. Topics covered included antiretroviral therapy adherence, depression symptoms, alcohol and drug use, and condom use. Patients and providers received feedback reports immediately after each session. Feasibility was evaluated by quantitative analysis of ACASI responses, medical chart reviews, a brief patient questionnaire administered at the conclusion of each computer session, patient focus groups, and semi-structured provider interviews. ACASI interviews frequently identified inadequate medication adherence and depression symptoms: at baseline, 31% of patients reported < or =95% adherence over the past three days and 52% had symptoms of depression (CES-D score > or =16). Substance abuse problems were identified less frequently. Patients were comfortable with the ACASI and appreciated it as an additional communication route with their providers; however, expectations about the level of communication achieved were sometimes higher than actual practice. Providers felt the summary feedback information was useful when received in a timely fashion and when they were familiar with the clinical indicators reported. Repeated ACASI sessions did not have a favorable impact on adherence, depression, or substance use outcomes. No improvements in HIV RNA suppression were observed in comparison to patients who did not participate in the study. We conclude that it is feasible to integrate an ACASI screening tool into routine HIV clinical care to identify patients with inadequate medication adherence and depression symptoms. Repeated screening was not associated with improved clinical outcomes. ACASI screening should be considered in HIV clinical care settings to assist providers in identifying patients with the greatest need for targeted psychosocial services including adherence support and depression care.

Review article: adherence to medication for chronic hepatitis C - building on the model of human immunodeficiency virus antiretroviral adherence research

BACKGROUND

Treatment of hepatitis C virus (HCV) infection with pegylated interferon/ribavirin achieves sustained virological response in up to 56% of HCV mono-infected patients and 40% of HCV/human immunodeficiency virus (HIV)-co-infected patients. The relationship of patient adherence to outcome warrants study.

AIM

To review comprehensively research on patient-missed doses to HCV treatment and discuss applicable research from adherence to HIV antiretroviral therapy.

METHODS

Publications were identified by PubMed searches using the keywords: adherence, compliance, hepatitis C virus, interferon and ribavirin.

RESULTS

The term 'non-adherence' differs in how it is used in the HCV from the HIV literature. In HCV, 'non-adherence' refers primarily to dose reductions by the clinician and early treatment discontinuation. In contrast, in HIV, 'non-adherence' refers primarily to patient-missed doses. Few data have been published on the rates of missed dose adherence to pegylated interferon/ribavirin and its relationship to virological response.

CONCLUSIONS

As HCV treatment becomes more complex with new classes of agents, adherence will be increasingly important to treatment success as resistance mutations may develop with suboptimal dosing of HCV enzyme inhibitors. HIV adherence research can be applied to that on HCV to establish accurate methods to assess adherence, investigate determinants of non-adherence and develop strategies to optimize adherence.

Sexually active HIV-positive patients frequently report never using condoms in audio computer-assisted self-interviews conducted at routine clinical visits

HIV prevention has become a new priority for HIV clinicians, as their patients live longer and more sexually active lives. Prevention interventions can be effective in clinical settings, but first patients must be screened and inconsistent condom use must be disclosed. Audio computer-assisted self-interviews (ACASI) are an effective way to elicit this sensitive information. We assessed condom use by ACASI among 198 English- or Spanish-speaking HIV patients at 2 community hospital-based HIV clinics in Queens and the Bronx, New York. Among 120 patients reporting sex with a regular partner in the past 4 weeks, 41 (34%) reported not using a condom every time and 22 (18%) reported never using a condom. Among 81 reporting sex with a casual partner in the past 4 weeks, 21 (26%) reported not using a condom every time and 12 (15%) reported never using a condom. Overall, 24 of 129 sexually active patients (19%) reported never using a condom. In a multivariable model controlling for age, race/ethnicity, gender, and HIV exposure category, depression symptoms (Center for Epidemiological Studies Depression Scale [CES-D] score >/= 16; p = 0.03) and self-reported antiretroviral medication non-adherence (</=95% doses in past 3 days; p = 0.03) were significantly associated with never using a condom with a regular or casual partner. ACASI interviews may be an effective way of identifying patients in clinical settings who require prevention counseling as well as other psychosocial services.

A visual medication schedule to improve anticoagulation control: a randomized, controlled trial

BACKGROUND

Misunderstanding between clinicians and patients may lead to medication-related errors and poor clinical outcomes, particularly in anticoagulant care.

METHODS

One hundred forty-seven chronic warfarin users were randomized to receive a visual medication schedule at each visit, along with brief counseling, versus standard care, and followed for 90 days. At baseline, patient and clinician reports of the prescribed warfarin regimen were recorded to identify patients as "discordant" versus "concordant" to determine whether the effect of the intervention varied with clinician-patient discordance.

RESULTS

At baseline, clinician-patient warfarin regimen discordance was common in intervention and control groups (38% versus 42%). Intervention subjects achieved anticoagulation control more rapidly than control subjects (median 28 versus 42 days; hazard ratio [HR], 1.43; confidence interval [CI], 1.00, 2.06). The benefit of the intervention was significant among subjects with baseline regimen discordance (median, 28 versus 49 days; HR, 1.92; CI, 1.08, 3.39) but not among subjects with baseline concordance (median 28 versus 35 days; HR, 1.14; CI, 0.71,1.83).

DISCUSSION

Among patients in poor anticoagulant control whose understanding of their warfarin regimen is discordant with their providers', a visual medication schedule, combined with brief counseling, reduced time to anticoagulation control. The study suggests a simple strategy to enhance medication safety and efficacy for at-risk patients.

Behavioral aspects of HIV care: adherence, depression, substance use, and HIV-transmission behaviors

A variety of psychosocial stressors are involved in living with HIV, maintaining a regimen of highly active antiretroviral therapy, and negotiating necessary self-care behaviors. Because health care providers are in regular contact with HIV-infected individuals in care, these contacts allow for the opportunity to assess and intervene on important variables related to quality of life and HIV outcomes. This article reviews information about four important behavioral aspects of HIV care: treatment adherence, depression, high-risk sex, and substance abuse. Efforts by health care providers to address these factors may result in better treatment outcomes, enhanced quality of life among HIV patients, and decreased HIV transmission.

The elusive gold standard. Future perspectives for HIV adherence assessment and intervention

There is no "gold standard" for the assessment of adherence to HIV/AIDS medications. Similarly, there is no single optimal tool that enhances adherence to HIV/AIDS treatment regimens. This article presents a model that provides a heuristic for selecting adherence assessment approaches and intervention strategies based on the purpose for which each is to be used. First, a broad distinction is made between research and clinical settings. Second, with each of these settings, the selection of assessments and interventions is based on the extent to which the focus is on HIV/AIDS in general or on adherence in particular. Examples applying the model are provided. Finally, new dimensions are discussed for expanding the model, with particular attention to applying the model to the resource-limited settings that are so important in efforts to reduce the morbidity and mortality associated with the global threat of HIV/AIDS.

Assessing antiretroviral adherence via electronic drug monitoring and self-report: an examination of key methodological issues

We explored methodological issues related to antiretroviral adherence assessment, using 6 months of data collected in a completed intervention trial involving 136 low-income HIV-positive outpatients in the Bronx, NY. Findings suggest that operationalizing adherence as a continuous (versus dichotomous) variable and averaging adherence estimates over multiple assessment points (versus using only one) explains greater variance in HIV-1 RNA viral load (VL). Self-reported estimates provided during a phone interview accounted for similar variance in VL as EDM estimates (R (2) = .17 phone versus .18 EDM). Self-reported adherence was not associated with a standard social desirability measure, and no difference in the accuracy of self-report adherence was observed for assessment periods of 1-3 days. Self-reported poor adherence was more closely associated with EDM adherence estimates than self-reported moderate and high adherence. On average across assessment points, fewer than 4% of participants who reported taking a dose of an incorrect amount of medication.

Language, literacy, and communication regarding medication in an anticoagulation clinic: a comparison of verbal vs. visual assessment

Despite the importance of clinician-patient communication, little is known about rates and predictors of medication miscommunication. Measuring rates of miscommunication, as well as differences between verbal and visual modes of assessment, can inform efforts to more effectively communicate about medications. We studied 220 diverse patients in an anticoagulation clinic to assess concordance between patient and clinician reports of warfarin regimens. Bilingual research assistants asked patients to (1) verbalize their prescribed weekly warfarin regimen and (2) identify this regimen from a digitized color menu of warfarin pills. We obtained clinician reports of patient regimens from chart review. Patients were categorized as having regimen concordance if there were no patient-clinician discrepancies in total weekly dosage. We then examined whether verbal and visual concordance rates varied with patient's language and health literacy. Fifty percent of patients achieved verbal concordance and 66% achieved visual concordance with clinicians regarding the weekly warfarin regimen (P < .001). Being a Cantonese speaker and having inadequate health literacy were associated with a lower odds of verbal concordance compared with English speakers and subjects with adequate health literacy (AOR 0.44, 0.21-0.93, AOR 0.50, 0.26-0.99, respectively). Neither language nor health literacy was associated with visual discordance. Shifting from verbal to visual modes was associated with greater patient-provider concordance across all patient subgroups, but especially for those with communication barriers.Clinician-patient discordance regarding patients' warfarin regimen was common but occurred less frequently when patients used a visual aid. Visual aids may improve the accuracy of medication assessment, especially for patients with communication barriers.

The importance of establishing regimen concordance in preventing medication errors in anticoagulant care

Miscommunication between patients and providers can have serious consequences, especially where medications are concerned. We examined whether regimen discordance between patient and provider, a possible result of miscommunication, contributes to unsafe medication management. We studied 220 patients taking warfarin in an anticoagulation clinic to characterize two medication assessment methods. We measured (1) adherence by asking patients to report any missed doses and (2) concordance between patients' and providers' reports of warfarin regimens. We categorized patients as having regimen adherence if they missed no doses, and concordance if there was patient-provider agreement in weekly dosage. We characterized anticoagulant outcomes as unsafe if international normalized ratio (INR) values were <2.0 (at risk for thrombosis) or >4.0 (at risk for hemorrhage), and explored relationships among adherence, concordance, and anticoagulant outcomes. One hundred fifty-five patients (71%) reported no missed doses during the prior 30 days. Poor adherence was associated with underanticoagulation (AOR 2.33, 1.56-3.45), but not overanticoagulation (AOR 1.36, 0.69-2.66). One hundred ten patients (50%) reported regimens discordant with clinicians' report. There was no relationship between patients' reports of adherence and concordance. Among adherent patients, discordance was associated with underanticoagulation (AOR 1.67, 1.00-2.78) and overanticoagulation (AOR 3.44, 1.32-9.09). Discordance regarding warfarin regimens is common and places patients at risk for adverse events. To promote safe and effective care, clinicians should separately determine adherence and regimen concordance during routine medication assessments. Systems need to be developed to ensure concordance in medication regimens.

Patient support and education for promoting adherence to highly active antiretroviral therapy for HIV/AIDS

BACKGROUND

Adherence to prescribed regimens is required to derive maximal benefit from many highly active antiretroviral therapy (HAART) regimens in people living with HIV/AIDS.

OBJECTIVES

To conduct a systematic review of the research literature on the effectiveness of patient support and education to improve adherence to HAART.

SEARCH STRATEGY

A systematic search of electronic databases was performed from January 1996 to May 2005.

SELECTION CRITERIA

Randomized controlled trials examining the effectiveness of patient support and education to improve adherence to HAART were considered for inclusion. Only those studies that measured adherence at a minimum of six weeks were included.

DATA COLLECTION AND ANALYSIS

Study selection, quality assessments and data abstraction were performed independently by two reviewers.

MAIN RESULTS

Nineteen studies involving a total of 2,159 participants met criteria for inclusion. It was not possible to conduct a meta-analysis due to study heterogeneity with respect to populations, interventions, comparison groups, outcomes, and length of follow-up. Sample sizes ranged from 22 to 367. The populations studied ranged from general HIV-positive populations to studies focusing exclusively on children, women, Latinos, or adults with a history of alcohol dependence, to studies focusing almost exclusively on men. Study interventions included cognitive behavioral therapy, motivational interviewing, medication management strategies, and interventions indirectly targeting adherence, such as programs directed to reduce risky sexual behaviours. Ten studies demonstrated a beneficial effect of the intervention on adherence. We found that interventions targeting practical medication management skills, those administered to individuals vs groups, and those interventions delivered over 12 weeks or more were associated with improved adherence outcomes. We also found that interventions targeting marginalized populations such as women, Latinos, or patients with a past history of alcoholism were not successful at improving adherence. We were unable to determine whether effective adherence interventions were associated with improved virological or immunological outcomes. Most studies had several methodological shortcomings leaving them vulnerable to potential biases.

AUTHORS' CONCLUSIONS

We found evidence to support the effectiveness of patient support and education interventions intended to improve adherence to antiretroviral therapy. Interventions targeting practical medication management skills, those interventions administered to individuals vs groups, and those interventions delivered over 12 weeks or more were associated with improved adherence outcomes. There is a need for standardization and increased methodological rigour in the conduct of adherence trials.

Measuring adherence to highly active antiretroviral therapy: implications for research and practice

Highly active antiretroviral therapy (HAART) has radically changed the course of HIV disease, producing substantial reductions in both HIV-related morbidity and mortality. However, the complexity of the typical daily HAART regimen is substantial, and high levels of adherence are essential for complete and long-term viral suppression and the avoidance of drug resistance. The complexity of HAART has made the assessment of medication adherence of paramount importance. Even though various methods are in use, each measures only a subset of adherence behaviors, and each measure has limited predictive validity. Given the individual and public health concerns associated with adherence to HAART, there is a need for the continued development and validation of measures of medication adherence.

Audio computer assisted self interview and face to face interview modes in assessing response bias among STD clinic patients

BACKGROUND

Audio computer assisted self interview (ACASI) may minimise social desirability bias in the ascertainment of sensitive behaviours. The aim of this study was to describe the difference in reporting risk behaviour in ACASI compared to a face to face interview (FFI) among public sexually transmitted diseases (STD) clinic attendees.

STUDY DESIGN

Randomly selected patients attending a public STD clinic in Baltimore, Maryland, sequentially took an ACASI formatted risk behaviour assessment followed by an FFI conducted by a single clinician, with both interview modalities surveying sexual and drug use behaviours. Binary responses were compared using the sign test, and categorical responses were compared using the Wilcoxon signed rank test to account for repeated measures.

RESULTS

671 (52% men, mean age 30 years, 95% African American) of 795 clinic attendees screened consented to participate. Subjects affirmed sensitive sexual behaviours such as same sex contact (p = 0.012), receptive rectal sexual exposure (p < 0.001), orogenital contact (p < 0.001), and a greater number of sex partners in the past month (p < 0.001) more frequently with ACASI than with an FFI. However, there were no differences in participant responses to questions on use of illicit drugs or needle sharing.

CONCLUSIONS

Among STD clinic patients, reporting of sensitive sexual risk behaviours to clinicians was much more susceptible to social desirability bias than was reporting of illegal drug use behaviours. In STD clinics where screening of sexual risk is an essential component of STD prevention, the use of ACASI may be a more reliable assessment method than traditional FFI.

A programmable prompting device improves adherence to highly active antiretroviral therapy in HIV-infected subjects with memory impairment

Background. Patients cite "forgetting" as a reason for nonadherence to highly active antiretroviral therapy (HAART). We measured the effect of a memory-prompting device on adherence to HAART in memory-intact and memory-impaired human immunodeficiency virus (HIV)-infected subjects.Methods. The study was a prospective, randomized, controlled trial involving 64 HIV-infected adults. The intervention was the Disease Management Assistance System (DMAS) device, combined with monthly adherence counseling. Control subjects received only adherence counseling. The DMAS was programmed with HAART regimen data to provide verbal reminders at dosing times. Adherence was measured for 24 weeks using electronic drug exposure monitor (eDEM) caps.Results. A total of 58 subjects completed the 24-week study period; 28 were HAART naive (12 DMAS users and 16 control subjects). Mean adherence scores did not differ significantly between DMAS users (80%) and control subjects (65%). Post hoc analysis of 31 memory-impaired subjects (14 DMAS users and 17 control subjects) revealed significantly higher adherence rates among DMAS users (77%), compared with control subjects (57%) (P=.001). However, analysis of memory-intact subjects showed that adherence was not significantly improved for DMAS users (83%), compared with control subjects (77%) (P=.25). At week twelve, 38% of the DMAS users and 14% of the control subjects had an undetectable plasma HIV RNA load (P=.014), and at week 24, the plasma HIV RNA load was undetectable for 34% of the DMAS users and 38% of the control subjects (P=.49). CD4(+) cell counts did not differ between the study arms. Virological and immunological responses were not related to DMAS use in memory-impaired subjects.Conclusion. The DMAS prompting device improved adherence for memory-impaired subjects but not for memory-intact subjects.

Adherence to antiretroviral therapy: An update of current concepts

The remarkable effectiveness of combination antiretroviral therapy (CART) in the treatment of HIV infection has placed a high premium on long-term adherence to therapy. Adherence levels to CART among HIV-infected individuals are similar to adherence levels with chronic medical conditions, such as diabetes and hypertension. However, unlike chronic medical conditions, medication adherence that is insufficient to maintain suppression of HIV replication will lead to drug resistance. Combination antiretroviral therapy regimen complexity and side-effect burden are clearly linked to adherence and are likely to be the factors most amenable to intervention. Adherence interventions that are multifaceted, flexible, and protracted are the most likely to be successful. Owing to the great benefits of CART even the small to modest gains in adherence that are achievable with adherence programs may prove to be cost effective.

The Correlation between Plasma Concentrations of Protease Inhibitors, Medication Adherence and Virological Outcome in HIV-Infected Patients

Background

Although adherence clearly influences response to antiretroviral therapy (ART), accurate assessment of adherence is problematic. The objective of this analysis was to assess the independent predictive value of protease inhibitor (PI) concentrations as a supplement to self-report as markers of medication adherence.

Methods

This retrospective analysis was conducted from a prospective clinical trial designed to compare the outcomes of frequent versus infrequent HIV RNA measurement used to manage antiretroviral therapy. For 131 patients, self-reported medication adherence, HIV RNA levels, CD4 counts and PI concentrations (unannounced, random samples) were measured at baseline (when patients changed to a new regimen) and every 2 months thereafter. The change in HIV RNA from baseline to month 6 (area-based measure) was used to evaluate overall response. The proportion of measured PI concentrations below the detection limit was used as an alternative marker of adherence. An undetectable concentration would be expected after missing a single dose.

Results

The mean baseline CD4 count was 125 cells/mm3 and the mean HIV RNA level was 4.7 log10 copies/ml. The mean change in log10 HIV RNA was -0.73 copies/ml. The mean percentage of self-reported adherence was 91% (range: 15–100%) and the mean proportion of undetectable PI concentrations was 27% (range: 0–100%, mean 2.5 samples/patient). The correlation between the two measures was -0.23 ( P=0.009). In a multivariate model, percentage of visits with undetectable PI concentrations ( P=0.02), percentage of medication adherence ( P=0.02), baseline HIV RNA level ( P=0.005), prior PI use ( P=0.0004), prior lamivudine (3TC) use ( P=0.0009) and randomization to the frequent HIV RNA measurement group ( P<0.0001) were all related to change in HIV RNA. After accounting for adherence, patients who always had detectable PI concentrations had an average of 0.4 log10 additional HIV RNA reduction compared with those who had no detectable concentrations.

Conclusions

Repeated, random PI concentration values are independently predictive of virological response and may add to self-report of adherence in understanding the response to ART.