A Longitudinal Analysis of Daily Pill Burden and Likelihood of Optimal Adherence to Antiretroviral Therapy Among People Living With HIV Who Use Drugs

Adherence to Anti-Retroviral Therapy (ART) and Its Determinants Among People Living with HIV/AIDS at Bonga, Kaffa, South-West Ethiopia

Background

The scaling-up of antiretroviral therapy (ART) is the greatest accomplishment to reduce the burden of acquired immunodeficiency syndromes (AIDS) to date. However, it requires optimal adherence to be effective. Thus, this study was designed to assess the level of adherence of people living with HIV (PLWH) to ART and its determinants in one of the hardest-hit areas with HIV in Ethiopia.

Methods

A health facility-based cross-sectional study design was conducted among adult PLWH, age >18 years, and receiving ART in southwest Ethiopia. Data was collected by face-to-face interviews following the Self-Rating Scale Item for drug adherence and from participants' medical cards. The effects of variables related to socio-demographic and socio-economic factors, disease and medication, health facilities, and patients' behavior on ART adherence were analyzed using a binary logistic regression model. The data was analyzed using R software.

Results

Self-reported good adherence to ART recorded in this study was 73.1% (n =301/412). The risk of poor adherence was significantly higher among those who were divorced, merchants, used ART for longer durationsand were found in stage IV WHO pathogenesis. Contrarily, those who had a positive perception of the effectiveness of ART had significantly better adherence to ART. Longer duration on ART and frequency of pills taken, ≥3 pills per day, were significantly associated with a low CD4+ cell count (<500 cells/mm3). For each unit increase in medication frequency per day, the likelihood of having a high viral load of >1000 copies/mL was 5.35 times higher.

Conclusion

The ART adherence documented in this study was graded as moderately low. Some variables, such as clinical, medical, and behavioral, were found to affect the adherence of people living with HIV to ART. Hence, care providers should be aware of such variables in the process of treatment, follow-up, and monitoring of people living with HIV in the study area.

The CARES Program: Improving Viral Suppression and Retention in Care Through a Comprehensive Team-Based Approach to Care for People with HIV and Complex Psychosocial Needs

Retention in HIV care and viral suppression rates remain suboptimal, especially among people with HIV (PWH) facing complex barriers to care such as mental health conditions, substance use disorders, and housing insecurity. The Center for Adherence, Retention, and Engagement Support (CARES) program utilizes an interdisciplinary team that delivers integrated services in a drop-in setting to provide individualized care to PWH with complex psychosocial needs. We describe the CARES program and evaluate its effectiveness in retaining patients in care to achieve virological suppression. We characterized 119 referrals of PWH experiencing homelessness, mental health conditions, and substance use disorders to CARES between 2011 and 2017, and collected data for a 24-month observation period through 2019. Outcomes of patients who participated in CARES were compared with those who were referred but did not participate. The primary outcome was viral suppression (<200 copies/mL) at least once during 2-year follow-up. Retention in care (≥2 completed medical visits ≥90 days apart in each year post-referral) was a secondary outcome. Of 119 PWH referred to CARES, 59 participated with ≥2 visits. Those who participated in CARES were more likely to achieve viral suppression [adjusted odds ratio (aOR) 3.50, 95% confidence interval (CI) 1.19-10.32] and to be retained in care (aOR 3.73, 95% CI 1.52-9.14) compared with those who were referred but did not participate. This analysis found that the CARES program improved retention in care and viral suppression among PWH with complex psychosocial needs and suggests that it may represent a useful model for future programming.

Adherence and Health Problems in Thai Travellers Living with HIV

It is important to focus on adherence to antiretroviral therapy (ART) and health problems of travellers living with HIV (TLWHIV) during travel. This study was conducted to investigate factors related to adherence and health problems among TLWHIV. This multicentre, cross-sectional observational study was conducted among TLWHIV in university hospitals from August 2019 to July 2020. Factors associated with adherence to ART were evaluated using a logistic regression model. Health problems and risk exposure were also examined among participants during travel. Of 321 TLWHIV, 20 (6.23%) showed moderate-to-poor adherence, among whom 3 (15%) had viral rebound after travelling. Travellers frequently missed ART during the first 3 days of their trip. International destination was associated with moderate-to-poor adherence. In total, 237 (73.8%) travellers reported health problems during travel, among whom 36 required medical attention. Sexual or sharp exposure was found in <5% of travellers during travel. Approximately 95% of Thai TLWHIV had good ART adherence. International destination was the major factor determining adherence. TLWHIV should be encouraged to seek pretravel consultation. Healthcare providers should discuss health risk prevention and teach about ART dosing during travel to enhance adherence and minimise toxicity.

Adherence to Antiretroviral Therapy by Medication Possession Ratio and Virological Suppression among Adolescents and Young Adults Living with HIV in Dar es Salaam, Tanzania

Background: Adherence to antiretroviral therapy (ART) is a strong determinant of virological suppression. We aimed to determine the magnitude of adherence as measured by medication possession ratio (MPR) and virological suppression with its predictors among adolescents and young adults (AYA) living with HIV on ART in Tanzania. Methods: This retrospective cohort study was conducted using archived data from HIV care and treatment centers in Dar es Salaam, Tanzania between 2015 and 2019. The logistic regression model assessed predictors for adherence and virological suppression. Results: Data of 5750 AYA living with HIV were analysed. The majority were females: 4748 (82.6%). About 63% had good adherence with MPR ≥ 85% at one year post ART initiation. Independent predictors of ART adherence were male sex (aOR = 1.3, 95% CI 1.1−1.5), CD4 > 500 cells/mm3 (aOR = 0.7, 95% CI: 0.6−0.9), WHO stage III (aOR = 1.6, 95% CI 1.3−1.9), enrollment in 2019 (aOR = 1.5, 95% CI 1.2−1.9), and virological suppression (aOR = 2.0, 95% CI 1.6−2.9). Using an Efavirenz- and a Nevirapine-based combination was associated with reduced odds of ART adherence (aOR = 0.3, 95% CI 0.1−0.8) and (aOR = 0.2, 95% CI 0.1−0.6), respectively. Predictors of virological suppression were MPR ≥ 85% (aOR = 2.0, 95% CI 1.6−2.4); CD4 > 500 cells/mm3 (aOR = 2.4, 95% CI 1.7−3.4), and once-daily dosing (aOR = 2.0, 95% CI 1.3−2.5). Conclusion: Adherence to ART among AYA living with HIV is suboptimal. Sex, year of enrollment, ART drug combination used, and immunological status at ART initiation are important predictors of adherence to ART and virological suppression.

Recreational Drug Use in People Living with HIV in Spain: Factors Associated with Drug Use and the Impact on Clinical Outcomes

We analysed the impact of recreational drug use (RDU) on different outcomes in people living with HIV (PLHIV). A multicentre retrospective cohort study was performed with two cohorts of PLHIV included: people using recreational drugs (PURD) vs. people not using recreational drugs (PNURD). Overall, 275 PLHIV were included. RDU was associated with men having sex with men (OR 4.14, 95% CI [1.14, 5.19]), previous sexually transmitted infections (OR 4.00, 95% CI [1.97, 8.13]), and current smoking (OR 2.74, 95% CI [1.44, 5.19]). While the CD₄/CD₈ ratio increased amongst PNURD during the follow-up year, it decreased amongst PURD (p = 0.050). PURD presented lower scores of self-reported and multi-interval antiretroviral adherence (p = 0.017, and p = 0.006, respectively), emotional well-being (p < 0.0001), and regular follow-up (p = 0.059), but paid more visits to the emergency unit (p = 0.046). RDU worsens clinical, immunological, and mental health outcomes amongst PLHIV.

Behavioral and Physical Activity Interventions for HAND

Approximately 30-50% of persons living with HIV manifest some degree of neurocognitive impairment. Even mild-to-moderate forms of HIV-associated neurocognitive disorders (HAND) can result in difficulties with everyday functioning, such as suboptimal medication adherence and impaired driving. Despite the pervasive presence and consequences of HAND, there is a significant unmet need to develop effective behavioral strategies to reduce the incidence and consequences of HAND. Although there is an absence of evidence-based behavioral interventions specific to HAND, the literature reviewed in this chapter suggest the following modifiable lifestyle factors as intervention targets: physical activity, diet, sleep, and antiretroviral medication adherence. Adoption and maintenance of these healthy lifestyle factors may reduce inflammation and oxidative stress, which, in turn, may reduce the incidence and/or severity of HAND.

Starting or Switching to an Integrase Inhibitor-Based Regimen Affects PTSD Symptoms in Women with HIV

As the use of Integrase inhibitor (INSTI)-class antiretroviral medications becomes more common to maintain long-term viral suppression, early reports suggest the potential for CNS side-effects when starting or switching to an INSTI-based regimen. In a population already at higher risk for developing mood and anxiety disorders, these drugs may have significant effects on PTSD scale symptom scores, particularly in women with HIV (WWH). A total of 551 participants were included after completing ≥ 1 WIHS study visits before and after starting/switching to an INSTI-based ART regimen. Of these, 14% were ART naïve, the remainder switched from primarily a protease inhibitor (PI) or non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. Using multivariable linear mixed effects models, we compared PTSD Civilian Checklist subscale scores before and after a "start/switch" to dolutegravir (DTG), raltegravir (RAL), or elvitegravir (EVG). Start/switch to EVG improved re-experiencing subscale symptoms (P's < 0.05). Switching to EVG improved symptoms of avoidance (P = 0.01). Starting RAL improved arousal subscale symptoms (P = 0.03); however, switching to RAL worsened re-experiencing subscale symptoms (P < 0.005). Starting DTG worsened avoidance subscale symptoms (P = 0.03), whereas switching to DTG did not change subscale or overall PTSD symptoms (P's > 0.08). In WWH, an EVG-based ART regimen is associated with improved PTSD symptoms, in both treatment naïve patients and those switching from other ART. While a RAL-based regimen was associated with better PTSD symptoms than in treatment naïve patients, switching onto a RAL-based regimen was associated with worse PTSD symptoms. DTG-based regimens either did not affect, or worsened symptoms, in both naïve and switch patients. Further studies are needed to determine mechanisms underlying differential effects of EVG, RAL and DTG on stress symptoms in WWH.

Promoting Undetectable Equals Untransmittable in Sub-Saharan Africa: Implication for Clinical Practice and ART Adherence

In the last decade, reliable scientific evidence has emerged to support the concept that undetectable viral loads prevent human immunodeficiency virus (HIV). Undetectable equals untransmissible (U = U) is a simple message that everyone can understand. The success of this concept depends on strict adherence to antiretroviral therapy (ART) and the attainment of suppressed viral loads (VLs). To achieve U = U in sub-Saharan Africa (SSA), poor adherence to ART, persistent low-level viremia, and the emergence of drug-resistant mutants are challenges that cannot be overlooked. Short of a cure for HIV, U = U can substantially reduce the burden and change the landscape of HIV epidemiology on the continent. From a public health perspective, the U = U concept will reduce stigmatization in persons living with HIV (PLWHIV) in SSA and strengthen public opinion to accept that HIV infection is not a death sentence. This will also promote ART adherence because PLWHIV will aim to achieve U = U within the shortest possible time. This article highlights challenges and barriers to achieving U = U and suggests how to promote the concept to make it beneficial and applicable in SSA. This concept, if expertly packaged by policy-makers, clinicians, health service providers, and HIV control programs, will help to stem the tide of the epidemic in SSA.

"Worn out": Coping strategies for managing antiretroviral treatment fatigue among urban people of color living with HIV who were recently disengaged from outpatient HIV care

Antiretroviral-related treatment fatigue is inconsistently defined in the literature on barriers to ART adherence. Research suggests that treatment fatigue is a salient challenge for people struggling with antiretroviral therapy adherence, but little is known about how people living with HIV attempt to manage this fatigue. Twenty-seven semi-structured interviews were conducted with low-income people of color living with HIV in NYC that were currently, or recently, disengaged from HIV care. The findings from this exploratory study suggest that treatment fatigue was common and that participants devised personal strategies to overcome it. These strategies included using reminder programs, requesting weekly rather than monthly pill quantities, and taking "pill holidays". The varied nature- and varying levels of effectiveness- of these strategies highlight the need for specific programming to provide tailored support. Future research should examine treatment fatigue as a specific subtype of adherence challenge, and aim to define pill fatigue clearly.

Treatment Patterns and Predictors of Adherence in HIV Patients Receiving Single- or Multiple-Tablet Darunavir, Cobicistat, Emtricitabine, and Tenofovir Alafenamide

PURPOSE

Darunavir, cobicistat, emtricitabine, and tenofovir alafenamide can be used as a single-tablet regimen (STR, DRV/c/FTC/TAF) or multiple-tablet regimen (MTR, DRV/c+FTC/TAF) to treat patients with human immunodeficiency virus (HIV). This study described treatment patterns and predictors of adherence among patients with HIV initiated on DRV/c/FTC/TAF or DRV/c+FTC/TAF.

PATIENTS AND METHODS

A retrospective longitudinal study was conducted using linked claims and electronic medical records from Decision Resources Group's Real World Data Repository (7/17/2017-6/1/2019). Treatment-naïve and treatment-experienced virologically suppressed adults with HIV-1 prescribed DRV/c/FTC/TAF or DRV/c+FTC/TAF (index date) were included. Six-month persistence (no treatment gaps >60 and >90 days) and adherence (proportion of days covered [PDC]) to the index regimen were evaluated among patients with ≥6 months of observation post-index. Predictors of low adherence (PDC<80%) were evaluated using a logistic regression model.

RESULTS

Among 2633 eligible patients (49.5 years old, 29% female, 37% African American/Black), 12% were treatment-naïve pre-index and 88% switched from a previous antiretroviral therapy; 84% initiated DRV/c/FTC/TAF and 16% initiated DRV/c+FTC/TAF. Among 822 DRV/c/FTC/TAF patients with ≥6 months of observation post-index, 80% and 86% had no >60- and >90-day gaps in DRV/c/FTC/TAF coverage, respectively, while among 204 DRV/c+FTC/TAF patients with ≥6 months of observation post-index, 69% and 75% had no >60- and >90-day gaps in DRV/c+FTC/TAF coverage, respectively. Mean (median) PDC for the index regimen was 81% (93%) for patients treated with DRV/c/FTC/TAF and 73% (83%) for patients treated with DRV/c+FTC/TAF. Predictors of low adherence included younger age (odds ratio [OR]=2.36, p=0.017), higher Quan-Charlson comorbidity index (OR=1.32, p=0.012), use of MTR regimen at index (OR=1.69, p=0.022), and prior low adherence (OR=2.56, p<0.001).

CONCLUSION

Among patients initiating a DRV/c-based regimen, those initiating STR had higher 6-month adherence/persistence than those initiating MTR, highlighting the potential benefits of the STR formulation, particularly among younger patients with multiple comorbidities and prior low adherence.

Predictors of Antiretroviral Adherence Self-efficacy Among People Living With HIV/AIDS in a Canadian Setting

BACKGROUND

Suboptimal adherence to antiretroviral therapy (ART) among people living with HIV/AIDS (PLWHA) who use illicit drugs remains an ongoing health concern. Although health outcomes associated with adherence self-efficacy have been well-documented, there is dearth research exploring the predictors of this construct. This study sought to identify possible determinants of adherence self-efficacy among a cohort of PLWHA who use illicit drugs.

METHODS

From December 2004 to May 2014, we collected data from the AIDS Care Cohort to evaluate Exposure to Survival Services, a prospective cohort of adult PLWHA who use illicit drugs in Vancouver, Canada. We used multivariate generalized estimating equation analyses to identify longitudinal factors independently associated with higher adherence self-efficacy.

RESULTS

Among 742 participants, 493 (66.4%) identified as male and 406 (54.7%) reported white ancestry. In multivariate generalized estimating equation analysis, older age at ART initiation (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI]: 1.00 to 1.03) and recent year of baseline interview (AOR = 1.08, 95% CI: 1.05 to 1.11) were independently associated with higher adherence self-efficacy, whereas homelessness (AOR = 0.78, 95% CI: 0.65 to 0.94), ≥daily crack smoking (AOR = 0.81, 95% CI: 0.68 to 0.96), experienced violence (AOR = 0.82, 95% CI: 0.69 to 0.98), and childhood abuse (AOR = 0.75, 95% CI: 0.60 to 0.92) were negatively associated.

CONCLUSIONS

These findings highlight the potential role that personal and contextual factors can play in predicting levels of ART adherence self-efficacy. Future research should seek to identify and validate strategies to optimize adherence self-efficacy.