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Msosa TC, Swai I, Aarnoutse R, Rinke de Wit TF, Ngowi K, Msefula C, Nliwasa M, Boer MSD. The Effect of Real-Time Medication Monitoring-Based Digital Adherence Tools on Adherence to Antiretroviral Therapy and Viral Suppression in People Living With HIV: A Systematic Literature Review and Meta-Analysis. J Acquir Immune Defic Syndr 2024; 96:411-420. [PMID: 38985562 PMCID: PMC11236270 DOI: 10.1097/qai.0000000000003449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 04/19/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND Universal antiretroviral therapy (ART) has led to improved treatment outcomes in persons living with HIV. Adherence to ART is required to achieve viral suppression. Real-time medication monitoring (RTMM)-based digital adherence tools (DATs) could be effective in improving ART adherence and viral suppression in persons living with HIV. OBJECTIVES The primary and secondary objectives of this review were to assess the effect of RTMM-based DATs on improving ART adherence and viral load suppression. METHODS We searched MEDLINE, Embase, and Global Health for publications published through October 11, 2022. Narrative synthesis and random effects meta-analyses were conducted to synthesize the results. RESULTS Of 638 papers identified, 8 were included. Six studies were randomized controlled trials (RCTs), and 2 were cohort studies. Two studies, an RCT in China (mean adherence: 96.2% vs 89.1%) and a crossover cohort study in Uganda (mean adherence: 84% vs 93%), demonstrated improved ART adherence. No studies demonstrated improved viral suppression. In the meta-analyses, we estimated that RTMM-based digital adherence tools had a statistically insignificant small positive effect on ART adherence and viral suppression with a standardized mean difference of 0.1922 [95% CI: -0.0268 to 0.4112, P-value: 0.0854] and viral suppression with an odds ratio of 1.3148 [95% CI: 0.9199 to 1.8791, P-value: 0.1331]. CONCLUSIONS Our meta-analyses found that RTMM-based DATs did not have a significant effect on ART adherence and viral suppression. However, due to few published studies available, heterogeneity of target populations, intervention designs, and adherence measurement instruments, more data are required to provide conclusive evidence.
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Affiliation(s)
- Takondwa Charles Msosa
- Department of Global Health, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Iraseni Swai
- Department of Global Health, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Rob Aarnoutse
- Radboud University Medical Center, Department of Pharmacy, Research Institute for Medical Innovation, Nijmegen, the Netherlands; and
| | - Tobias F. Rinke de Wit
- Department of Global Health, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Kennedy Ngowi
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
| | - Chisomo Msefula
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Marriott Nliwasa
- Helse Nord Tuberculosis Initiative, Kamuzu University of Health Sciences, Blantyre, Malawi
| | - Marion Sumari-de Boer
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Kilimanjaro Clinical Research Institute, Moshi, Tanzania
- Institute of Public Health, Kilimanjaro Christian Medical University College, Moshi, Tanzania
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Dale SK, Wright IA, Madhu A, Reid R, Shahid NN, Wright M, Sanders J, Phillips A, Rodriguez A, Safren SA. A Pilot Randomized Control Trial of the Striving Towards EmPowerment and Medication Adherence (STEP-AD) Intervention for Black Women Living with HIV. AIDS Behav 2024:10.1007/s10461-024-04408-w. [PMID: 39012452 DOI: 10.1007/s10461-024-04408-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2024] [Indexed: 07/17/2024]
Abstract
Black women living with HIV (BWLWH) face adversities associated with lower HIV medication adherence, viral non-suppression, and mental health symptoms (e.g., post-traumatic stress disorder) such as trauma/violence, racism, HIV-related discrimination/stigma, and gender-related stressors. We developed the first intervention based in cognitive behavioral therapy and culturally congruent coping for BWLWH to increase medication adherence and decrease PTSD symptoms by enhancing resilience, self-care, engagement in care, and coping for trauma, racism, HIV-related discrimination/stigma, and gender-related stressors. A pilot randomized control trial was conducted with BWLWH and histories of trauma who were at risk for their HIV viral load remaining or becoming detectable (i.e., below 80% medication adherence, detectable viral load in the past year, and/or missed HIV-related appointments). 119 BWLWH were assessed at baseline and 70 met inclusion criteria, completed one session of Life-Steps adherence counseling, and were randomized to either nine sessions of STEP-AD (Striving Towards EmPowerment and Medication Adherence) or ETAU (enhanced treatment as usual consisting of biweekly check-ins). Women completed a post intervention follow up assessment (3 months post baseline) and 3-month post intervention follow-up (6 months post baseline). Via STATA the difference-in-difference methodology with mixed models compared STEP-AD to ETAU on changes in outcomes over time. BWLWH in STEP-AD compared to E-TAU had significantly higher ART adherence (estimate = 9.36 p = 0.045) and lower likelihood of being clinically diagnosed with PTSD (OR = .07, estimate = - 2.66, p = 0.03) as well as borderline significance on higher CD4 count (estimate = 161.26, p = 0.05). Our findings suggest preliminary efficacy of STEP-AD in improving ART adherence, mental health, and immune function.
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Affiliation(s)
- Sannisha K Dale
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Miami, FL, 33146, USA.
| | - Ian A Wright
- Department of Economics, Miami Herbert Business School, University of Miami, Miami, FL, USA
| | - Aarti Madhu
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Miami, FL, 33146, USA
| | - Rachelle Reid
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Miami, FL, 33146, USA
| | - Naysha N Shahid
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Miami, FL, 33146, USA
| | - Mya Wright
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Miami, FL, 33146, USA
| | - Jasmyn Sanders
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Miami, FL, 33146, USA
| | - Arnetta Phillips
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Miami, FL, 33146, USA
| | - Allan Rodriguez
- Clinical Immunology, Infectious Diseases, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Steven A Safren
- Department of Psychology, University of Miami, 5665 Ponce de Leon Blvd, Miami, FL, 33146, USA
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Ogello VA, Rono BK, Ngure K, Sedah E, Thuo NB, Musinguzi N, Baeten JM, Bukusi EA, Mugo NR, Haberer JE. Acceptability and feasibility of long-term, real-time electronic adherence monitoring of HIV pre-exposure prophylaxis (PrEP) use among young women in Kenya: A mixed methods study. PLoS One 2024; 19:e0299168. [PMID: 38451884 PMCID: PMC10919630 DOI: 10.1371/journal.pone.0299168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 02/05/2024] [Indexed: 03/09/2024] Open
Abstract
Real-time electronic adherence monitoring involves "smart" pill boxes that record and monitor openings as a proxy for pill taking and may be useful in understanding and supporting PrEP use; however, acceptability and/or feasibility for PrEP users is uncertain. We sought to understand the experiences of using a real-time electronic adherence monitor for PrEP delivery among young women in Kisumu and Thika, Kenya. We used the Wisepill device to monitor PrEP use among 18-24-year-old women for two years. Half of the participants were randomized to also receive SMS adherence reminders (daily or as needed for missed doses). We assessed acceptability quantitatively and qualitatively according to the four constructs of Unified Theory of Acceptance and Use of Technology (UTAUT): performance expectancy, effort expectancy, social influence, and facilitating conditions. We assessed feasibility by monitor functionality during periods of PrEP use. We analyzed quantitative data descriptively and compared by site and over time; qualitative data were analyzed inductively and deductively. The median age was 21 years (IQR 19-22), median education was 12 years (IQR 10-13), 182 (53%) had disclosed PrEP use, and 55 (16%) reported recent intimate partner violence. Most participants reported high levels of usefulness and high interest in using the monitor with few problems or worries reported throughout follow-up. Feasibility was high overall with some differences by site (96% functional monitor days in Kisumu vs 88% in Thika). Few monitors were reported lost (N = 29; 8%) or dysfunctional (N = 11; 3%). In qualitative interviews, electronic monitoring was perceived as useful because it supported privacy, confidentiality, easy storage, and PrEP adherence. Effort was generally considered low. Participants expressed some concern for stigma from monitor and/or PrEP use. Facilitating conditions involved the monitor size, color, and battery life. Overall, real-time electronic adherence monitoring was a highly acceptable and feasible approach to understand PrEP adherence among young women in a sub-Saharan African setting.
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Affiliation(s)
- Vallery A. Ogello
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Kenneth Ngure
- Department of Community Health, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Eric Sedah
- Center for microbiology research, Kenya Medical Research Institute, Kisumu, Kenya
| | - Nicholas B. Thuo
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
| | | | - Jared M. Baeten
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
- Gilead Sciences, Foster City, California, United States of America
| | - Elizabeth A. Bukusi
- Center for microbiology research, Kenya Medical Research Institute, Kisumu, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Nelly R. Mugo
- Center of Clinical Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, United States of America
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
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Arch JJ, Crespi CM, Levin ME, Genung SR, Nealis M, Mitchell JL, Bright EE, Albright K, Magidson JF, Stanton AL. Randomized Controlled Pilot Trial of a Low-Touch Remotely-Delivered Values Intervention to Promote Adherence to Adjuvant Endocrine Therapy Among Breast Cancer Survivors. Ann Behav Med 2022; 56:856-871. [PMID: 35323853 PMCID: PMC9345183 DOI: 10.1093/abm/kaab118] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Oral anti-cancer treatments such as adjuvant endocrine therapies (AET) for breast cancer survivors are commonly used but adherence is a challenge. Few low-touch, scalable interventions exist to increase ET adherence. PURPOSE To evaluate the acceptability, feasibility, and initial efficacy of a low-touch, remotely-delivered values plus AET education intervention (REACH) to promote AET adherence. METHODS A mixed-methods trial randomized 88 breast cancer survivors 1:1 to REACH or Education alone. Wisepill real-time electronic adherence monitoring tracked monthly AET adherence during a 1-month baseline through 6-month follow-up (FU) (primary outcome). Patient-reported outcomes were evaluated through 3- and 6-month FU (secondary). Multiple indices of intervention feasibility and acceptability were evaluated. Qualitative exit interviews (n = 38) further assessed participants' perceptions of feasibility/acceptability and recommendations for intervention adaptation. RESULTS The trial showed strong feasibility and acceptability, with an eligible-to-enrolled rate of 85%, 100% completion of the main intervention sessions, and "good" intervention satisfaction ratings on average. For Wisepill-assessed AET adherence, REACH outperformed Education for Month 1 of FU (p = .027) and not thereafter. Participants in REACH maintained high adherence until Month 4 of FU, whereas in Education, adherence declined significantly in Month 1. Conditions did not differ in self-reported adherence, positive affective attitudes, future intentions, or necessity beliefs. REACH trended toward less negative AET attitudes than Education at 3-month FU (p = .057) reflecting improvement in REACH (p = .004) but not Education (p = .809). Exploratory moderator analyses showed that average to highly positive baseline AET affective attitudes and oncologist-patient communication each predicted higher adherence following REACH than Education; low levels did not. Participants identified recommendations to strengthen the interventions. CONCLUSIONS REACH, a low-touch values intervention, showed good feasibility and acceptability, and initial promise in improving objectively-assessed AET adherence among breast cancer survivors (relative to education alone). Future research should target improving REACH's tailoring and endurance.
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Affiliation(s)
- Joanna J Arch
- Department of Psychology and Neuroscience, University of Colorado Boulder, 345 UCB Muenzinger, Boulder, CO, 80309-0345, USA
- Division of Cancer Prevention and Control, University of Colorado Cancer Center, Aurora, CO, USA
| | - Catherine M Crespi
- Fielding School of Public Health, Department of Biostatistics, University of California Los Angeles, Los Angeles, CA, USA
| | - Michael E Levin
- Department of Psychology, Utah State University, Logan, UT, USA
| | - Sarah R Genung
- Department of Psychology and Neuroscience, University of Colorado Boulder, 345 UCB Muenzinger, Boulder, CO, 80309-0345, USA
| | - Madeline Nealis
- Department of Psychology and Neuroscience, University of Colorado Boulder, 345 UCB Muenzinger, Boulder, CO, 80309-0345, USA
| | | | - Emma E Bright
- Department of Psychology and Neuroscience, University of Colorado Boulder, 345 UCB Muenzinger, Boulder, CO, 80309-0345, USA
| | - Karen Albright
- Department of Medicine, Division of General Internal Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Annette L Stanton
- Department of Psychology, University of California Los Angeles, Los Angeles, CA, USA
- Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, Los Angeles, CA, USA
- Jonsson Comprehensive Cancer Center, University of California Los Angeles, Los Angeles, CA, USA
- Semel Institute for Neuroscience, Cousins Center for Psychoneuroimmunology, University of California Los Angeles, Los Angeles, CA, USA
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5
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Perceptions About Local ART Adherence Norms and Personal Adherence Behavior Among Adults Living with HIV in Rural Uganda. AIDS Behav 2022; 26:1892-1904. [PMID: 35034237 DOI: 10.1007/s10461-021-03540-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2021] [Indexed: 01/08/2023]
Abstract
Although misperceived norms often drive personal health behaviors, we do not know about this phenomenon in the context of antiretroviral therapy (ART) adherence. We conducted a cross-sectional study including all persons living with HIV (PLWH) on ART across eight villages in one parish in a rural region of southwestern Uganda. We used surveys to measure personal reports of ART adherence (not missing any doses of ART in the past 7 days was considered optimal adherence whereas missing doses was considered suboptimal adherence) and perceived norms about the local ART adherence norm (whether or not each individual thought 'most other PLWH on ART in this parish' missed any doses in the past 7 days). Multivariable Poisson regression models were used to estimate the association between perceived norms and personal adherence. Among 159 PLWH on ART (95% response rate), 142 (89%) reported no missed doses. However, 119 (75%) thought most individuals in this population of PLWH on ART were sub-optimally adherent. This misperception about the local ART adherence norm was prevalent in every subgroup of PLWH. Misperceiving the local ART adherence norm to be sub-optimal adherence was associated with a reduced likelihood of optimal adherence among married PLWH (adjusted relative risk [aRR] = 0.83; 95% confidence interval [CI] 0.71-0.97). The association was similar but imprecisely estimated for all PLWH (aRR = 0.91; 95% CI 0.82-1.01). Interventions to correct misperceived ART adherence norms as a stand-alone intervention or as a complement to other adherence promotion programs may influence ART adherence behavior and perhaps reduce HIV-related stigma.
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6
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Mason M, Cho Y, Rayo J, Gong Y, Harris M, Jiang Y. Technologies for Medication Adherence Monitoring and Technology Assessment Criteria: Narrative Review. JMIR Mhealth Uhealth 2022; 10:e35157. [PMID: 35266873 PMCID: PMC8949687 DOI: 10.2196/35157] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/23/2022] [Accepted: 01/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Accurate measurement and monitoring of patient medication adherence is a global challenge because of the absence of gold standard methods for adherence measurement. Recent attention has been directed toward the adoption of technologies for medication adherence monitoring, as they provide the opportunity for continuous tracking of individual medication adherence behavior. However, current medication adherence monitoring technologies vary according to their technical features and data capture methods, leading to differences in their respective advantages and limitations. Overall, appropriate criteria to guide the assessment of medication adherence monitoring technologies for optimal adoption and use are lacking. OBJECTIVE This study aims to provide a narrative review of current medication adherence monitoring technologies and propose a set of technology assessment criteria to support technology development and adoption. METHODS A literature search was conducted on PubMed, Scopus, CINAHL, and ProQuest Technology Collection (2010-present) using the combination of keywords medication adherence, measurement technology, and monitoring technology. The selection focused on studies related to medication adherence monitoring technology and its development and use. The technological features, data capture methods, and potential advantages and limitations of the identified technology applications were extracted. Methods for using data for adherence monitoring were also identified. Common recurring elements were synthesized as potential technology assessment criteria. RESULTS Of the 3865 articles retrieved, 98 (2.54%) were included in the final review, which reported a variety of technology applications for monitoring medication adherence, including electronic pill bottles or boxes, ingestible sensors, electronic medication management systems, blister pack technology, patient self-report technology, video-based technology, and motion sensor technology. Technical features varied by technology type, with common expectations for using these technologies to accurately monitor medication adherence and increase adoption in patients' daily lives owing to their unobtrusiveness and convenience of use. Most technologies were able to provide real-time monitoring of medication-taking behaviors but relied on proxy measures of medication adherence. Successful implementation of these technologies in clinical settings has rarely been reported. In all, 28 technology assessment criteria were identified and organized into the following five categories: development information, technology features, adherence to data collection and management, feasibility and implementation, and acceptability and usability. CONCLUSIONS This narrative review summarizes the technical features, data capture methods, and various advantages and limitations of medication adherence monitoring technology reported in the literature and the proposed criteria for assessing medication adherence monitoring technologies. This collection of assessment criteria can be a useful tool to guide the development and selection of relevant technologies, facilitating the optimal adoption and effective use of technology to improve medication adherence outcomes. Future studies are needed to further validate the medication adherence monitoring technology assessment criteria and construct an appropriate technology assessment framework.
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Affiliation(s)
- Madilyn Mason
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Youmin Cho
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Jessica Rayo
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Yang Gong
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Marcelline Harris
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
| | - Yun Jiang
- School of Nursing, University of Michigan, Ann Arbor, MI, United States
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Cuco RM, Loquiha O, Juga A, Couto A, Meggi B, Vubil A, Sevene E, Osman N, Temermam M, Degomme O, Sidat M, Bhatt N. Nevirapine hair and plasma concentrations and HIV-1 viral suppression among HIV infected ante-partum and post-partum women attended in a mother and child prevention program in Maputo city, Mozambique. PLoS One 2022; 17:e0261522. [PMID: 35143515 PMCID: PMC8830619 DOI: 10.1371/journal.pone.0261522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 12/05/2021] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Prevention of mother to child transmission of HIV (PMTCT) is frequently challenged by irregular access to more effective anti-retroviral therapy. Nevirapine single dose (sdNVP), sdNVP+AZT+3TC for MTCT prophylaxis and NVP+ AZT+3TC for treatment and PMTCT were withdrawn due to low genetic resistance barrier and low efficacy. However current PMTCT lines in Mozambique include DTG+3TC+TDF, TDF+3TC+EFV, DTG +ABC+3TC, and AZT + NVP syrup prophylaxis for exposed babies. We assessed NVP hair and plasma concentrations and association with HIV-1RNA suppression among HIV+ ante-partum and post-partum women under PMTCT in Maputo, Mozambique. METHODS From December 2013 to November 2014, prospectively were enrolled 200 HIV+ ante-partum women on 200mg nevirapine and zidovudine 300 plus lamivudine 150mg twice daily at least with 3 months treatment and seen again at 24 weeks post-partum. Self-reported pill-taking adherence, NVP concentrations in hair, plasma, hemoglobin, CD4 cell count, HIV-1 RNA load was evaluated. NVP concentration in hair and plasma was analyzed as categorical quartile variable based on better data fit. NVP concentration was set between ≤3.77 ng/ml in plasma and ≤17,20 ng/mg in hair in quartile one to ≥5.36 ng/ml in plasma and ≥53.21 ng/mg in hair in quartile four. Logistic regression models for repeated measures were calculated. Following the World Health Organization (WHO) guidelines we set viral suppression at HIV-1RNA < 1000 c/mL. Outcome was HIV-1 RNA<1000 copies/ml. Predictor was NVP concentration in hair categorized in quartiles. RESULTS In total 369 person-visits (median of 1.85) were recorded. Self-reported adherence was 98% (IQR 97-100%) at ante-partum. In 25% person visits, NVP concentrations were within therapeutic levels (3.77 ng/ml to 5.35 ng/ml) in plasma and (17.20 ng/mg to 53.20 ng/mg) in hair. In 50% person visits NVP concentrations were above 5.36 ng/ml in plasm and 53.21 ng/mg in hair. HIV-1 RNA suppression was found in 34.7% of women with two viral loads, one at enrollment and another in post-partum. Odds of HIV-1 RNA suppression in quartile 4, was about 6 times higher than in quartile 1 (p-value = 0.006) for NVP hair concentration and 7 times for NVP plasma concentration (p-value = 0.012). CONCLUSIONS The study results alert for potential low efficacy of current PMTCT drug regimens in use in Mozambique. Affordable means for individual monitoring adherence, ART plasma and hair levels, drug resistant and HIV-1 RNA levels monitoring are recommended for prompt identification of inadequate drug regimens exposure patterns and adjust accordingly.
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Affiliation(s)
- Rosa Marlene Cuco
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- National Directorate of Public Health, Ministry of Health, Maputo, Mozambique
- International Centre for Reproductive Health (ICRH), University of Gent, Gent, Belgium
| | - Osvaldo Loquiha
- Department of Mathematics and Informatics, Faculty of Sciences Eduardo Mondlane University, Maputo, Mozambique
| | - Adelino Juga
- Department of Mathematics and Informatics, Faculty of Sciences Eduardo Mondlane University, Maputo, Mozambique
| | - Aleny Couto
- National Directorate of Public Health, Ministry of Health, Maputo, Mozambique
| | - Bindiya Meggi
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - Adolfo Vubil
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
| | - Esperança Sevene
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Nafissa Osman
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
- Department of Gynecology and Obstetrics at Maputo Central Hospital, Maputo, Mozambique
| | - Marleen Temermam
- International Centre for Reproductive Health (ICRH), University of Gent, Gent, Belgium
- Department of Gynecology and Obstetrics, Aga Khan University Hospital, Nairobi, Kenya
| | - Olivier Degomme
- International Centre for Reproductive Health (ICRH), University of Gent, Gent, Belgium
| | - Mohsin Sidat
- Faculty of Medicine, Eduardo Mondlane University, Maputo, Mozambique
| | - Nilesh Bhatt
- Instituto Nacional de Saúde (INS), Marracuene, Mozambique
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Mutagonda RF, Mlyuka HJ, Maganda BA, Kamuhabwa AAR. Adherence, Effectiveness and Safety of Dolutegravir Based Antiretroviral Regimens among HIV Infected Children and Adolescents in Tanzania. J Int Assoc Provid AIDS Care 2022; 21:23259582221109613. [PMID: 35776522 PMCID: PMC9257168 DOI: 10.1177/23259582221109613] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 05/31/2022] [Accepted: 06/04/2022] [Indexed: 11/17/2022] Open
Abstract
Objectives:This study aimed at assessing adherence, effectiveness, and safety of DTG-based HAART regimens among HIV-infected children and adolescents in Tanzania. Methods: This was a single-center prospective cohort study, conducted at the pediatric HIV Clinic in Mbeya, Tanzania. A binary logistic regression model was used to determine predictors of undetectable viral load at week 24. The results were significant when P-value was <0.05. Results: A total of 200 patients were enrolled with the majority (85.5%) being treatment experienced. High adherence levels (71%) were observed using the pharmacy refill method. At week 24, the overall proportion of patients with undetectable viral load was 70.2%. The predictors of undetectable viral load were age, World Health Organization (WHO) clinical stage, baseline VL and adherence to pharmacy refill. Conclusion: The majority of patients attained undetectable viral load 6 months after using DTG based regimen. DTG-based regimens were generally safe with few ADEs reported.
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Affiliation(s)
- Ritah F. Mutagonda
- Department of Clinical Pharmacy and Pharmacology, School of
Pharmacy, Muhimbili University of Health and Allied
Sciences, Dar es salaam, Tanzania
| | - Hamu J. Mlyuka
- Department of Clinical Pharmacy and Pharmacology, School of
Pharmacy, Muhimbili University of Health and Allied
Sciences, Dar es salaam, Tanzania
| | - Betty A. Maganda
- Department of Pharmaceutics and Pharmacy practice, School of
Pharmacy, Muhimbili University of Health and Allied
Sciences, Dar es salaam, Tanzania
| | - Appolinary A. R. Kamuhabwa
- Department of Clinical Pharmacy and Pharmacology, School of
Pharmacy, Muhimbili University of Health and Allied
Sciences, Dar es salaam, Tanzania
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9
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Sabin LL, Simmons E, Halim N, Hamer DH, Gifford AL, West RL, Larson A, Bonawitz R, Aroda P, Banigbe B, Holderman AJ, Murray L, DeSilva MB, Gasuza J, Mukasa B, Messersmith LJ. Real-time Feedback to Improve HIV Treatment Adherence in Pregnant and Postpartum Women in Uganda: A Randomized Controlled Trial. AIDS Behav 2022; 26:3834-3847. [PMID: 35704124 PMCID: PMC9640413 DOI: 10.1007/s10461-022-03712-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2022] [Indexed: 01/26/2023]
Abstract
We assessed an intervention aimed at improving adherence to antiretroviral therapy (ART) among pregnant and postpartum women living with HIV (PPWLH). We randomized 133 pregnant women initiating ART in Uganda to receive text reminders generated by real time-enabled electronic monitors and data-informed counseling through 3 months postpartum (PPM3) or standard care. Intention-to-treat analyses found low adherence levels and no intervention impact. Proportions achieving ≥95% adherence in PPM3 were 16.4% vs. 9.1% (t = -1.14, p = 0.26) in intervention vs. comparison groups, respectively; 30.9% vs. 29.1% achieved ≥80% adherence. Additional analyses found significant adherence declines after delivery, and no effect on disease progression (CD4-cell count, viral load), though treatment interruptions were significantly fewer in intervention participants. Per-protocol analyses encompassing participants who used adherence monitors as designed experienced better outcomes, suggesting potential benefit for some PPWLH. The study was registered on ClinicalTrials.Gov (NCT02396394).
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Affiliation(s)
- Lora L. Sabin
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA
| | - Elizabeth Simmons
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA ,Carolina Population Center, University of North Carolina at Chapel Hill, 27516 Chapel Hill, NC USA
| | - Nafisa Halim
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA
| | - Davidson H. Hamer
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA ,Department of Medicine, Boston University School of Medicine, 02118 Boston, MA USA
| | - Allen L. Gifford
- Department of Medicine, Boston University School of Medicine, 02118 Boston, MA USA ,Department of Health Law, Policy, and Management, Boston University School of Public Health, 02118 Boston, MA USA ,Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System, 02130 Boston, MA United States
| | - Rebecca L. West
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA
| | - Anna Larson
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA
| | - Rachael Bonawitz
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA
| | | | - Bolanle Banigbe
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA
| | - Alayna J. Holderman
- Department of Human Genetics, University of Pittsburgh School of Public Health, 15261 Pittsburgh, PA USA
| | - Lisa Murray
- Department of Epidemiology & Biostatistics, Boston University School of Public Health, 02118 Boston, MA USA
| | - Mary B. DeSilva
- Center for Excellence in Public Health, University of New England, 04103 Portland, ME USA
| | | | | | - Lisa J. Messersmith
- Department of Global Health, Boston University School of Public Health, 801 Massachusetts Avenue, Crosstown Center, 3rd Floor, 02118 Boston, MA USA
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10
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Byonanebye DM, Mackline H, Sekaggya-Wiltshire C, Kiragga AN, Lamorde M, Oseku E, King R, Parkes-Ratanshi R. Impact of a mobile phone-based interactive voice response software on tuberculosis treatment outcomes in Uganda (CFL-TB): a protocol for a randomized controlled trial. Trials 2021; 22:391. [PMID: 34120649 PMCID: PMC8201814 DOI: 10.1186/s13063-021-05352-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 06/02/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Throughout the last decade, tuberculosis (TB) treatment success has not surpassed 90%, the global target. The impact of mobile health interventions (MHIs) on TB treatment outcomes is unknown, especially in low- and middle-income countries (LMICs). MHIs, including interactive voice response technology (IVRT), may enhance adherence and retention in the care of patients with tuberculosis and improve TB treatment outcomes. This study seeks to determine the impact of IVRT-based MHI on TB treatment success (treatment completion and cure rates) in patients with TB receiving care at five public health facilities in Uganda. METHODS We used a theory-based and human-centered design (HCD) to adapt an already piloted software to design "Call for life-TB" (CFL-TB), an MHI that utilizes IVRT to deliver adherence and appointment reminders and allows remote symptom reporting. This open-label, multicenter, randomized controlled trial (RCT), with nested qualitative and economic evaluation studies, will determine the impact of CFL-TB on TB treatment success in patients with drug-susceptible TB in Uganda. Participants (n = 274) at the five study sites will be randomized (1:1 ratio) to either control (standard of care) or intervention (adherence and appointment reminders, and health tips) arms. Multivariable regression models will be used to compare treatment success, adherence to treatment and clinic appointments, and treatment completion at 6 months post-enrolment. Additionally, we will determine the cost-effectiveness, acceptability, and perceptions of stakeholders. The study received national ethical approval and was conducted in accordance with the international ethical guidelines. DISCUSSION This randomized controlled trial aims to evaluate interactive voice response technology in the context of resource-limited settings with a high burden of TB and high illiteracy rates. The software to be evaluated was developed using HCD and the intervention was based on the IMB model. The software is tailored to the local context and is interoperable with the MHI ecosystem. The HCD approach ensures higher usability of the MHI by integrating human factors in the prototype development. This research will contribute towards the understanding of the implementation and impact of the MHI on TB treatment outcomes and the health system, especially in LMICs. TRIAL REGISTRATION ClinicalTrials.gov NCT04709159 . Registered on January 14, 2021.
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Affiliation(s)
- Dathan Mirembe Byonanebye
- Makerere University School of Public Health, P.O. Box 7072, Kampala, Uganda. .,Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda.
| | - Hope Mackline
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | | | - Agnes N Kiragga
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Mohammed Lamorde
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Elizabeth Oseku
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
| | - Rachel King
- Infectious Diseases Institute, Makerere University, P.O. Box 22418, Kampala, Uganda
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11
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Approaches to Objectively Measure Antiretroviral Medication Adherence and Drive Adherence Interventions. Curr HIV/AIDS Rep 2020; 17:301-314. [PMID: 32424549 PMCID: PMC7363551 DOI: 10.1007/s11904-020-00502-5] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Traditional methods to assess antiretroviral adherence, such as self-report, pill counts, and pharmacy refill data, may be inaccurate in determining actual pill-taking to both antiretroviral therapy (ART) or pre-exposure prophylaxis (PrEP). HIV viral loads serve as surrogates of adherence on ART, but loss of virologic control may occur well after decreases in adherence and viral loads are not relevant to PrEP. RECENT FINDINGS Pharmacologic measures of adherence, electronic adherence monitors, and ingestible electronic pills all serve as more objective metrics of adherence, surpassing self-report in predicting outcomes. Pharmacologic metrics can identify either recent adherence or cumulative adherence. Recent dosing measures include antiretroviral levels in plasma or urine, as well as emtricitabine-triphosphate in dried blood spots (DBS) for those on tenofovir-emtricitabine-based therapy. A urine tenofovir test has recently been developed into a point-of-care test for bedside adherence monitoring. Cumulative adherence metrics assess adherence over weeks to months and include measurement of tenofovir-diphosphate in peripheral blood mononuclear cells or DBS, as well as ART levels in hair. Electronic adherence monitors and ingestible electronic pills can track pill bottle openings or medication ingestion, respectively. New and objective approaches in adherence monitoring can be used to detect nonadherence prior to loss of prevention efficacy or virologic control with PrEP or ART, respectively.
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12
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Marhefka SL, Lockhart E, Turner D, Wang W, Dolcini MM, Baldwin JA, Roig-Romero RM, Lescano CM, Glueckauf RL. Social Determinants of Potential eHealth Engagement Among People Living with HIV Receiving Ryan White Case Management: Health Equity Implications from Project TECH. AIDS Behav 2020; 24:1463-1475. [PMID: 31828450 DOI: 10.1007/s10461-019-02723-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Evaluate the relationships between social characteristics of Floridian persons living with HIV (PLWH) and both use of digital technologies and willingness to use eHealth for HIV-related information. METHODS Ryan White case managers (N = 155) from 55 agencies in 47 Florida counties administered a survey to PLWH (N = 1268) from June 2016-April 2017. Multilevel logistic regression models were used to identify correlates of technology use and willingness. RESULTS Use of mobile phones with text messaging was high (89%). Older (vs. younger) adults and non-Hispanic blacks (vs. whites) were less likely to use most technologies. These groups, along with Hispanics (vs. whites) were less likely to express willingness to use technologies for HIV-related information in models adjusting for use. CONCLUSIONS Among PLWH in Florida, eHealth-related inequities exist. Willingness to engage in HIV-related eHealth is affected by social determinants, even when considering technology access. Although eHealth may reduce some healthcare inequities, it may exacerbate others.
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Affiliation(s)
- Stephanie L Marhefka
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612, USA.
| | - Elizabeth Lockhart
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612, USA
| | - DeAnne Turner
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612, USA
| | - Wei Wang
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612, USA
- Centre for Addiction and Mental Health (CAMH), Toronto, Canada
| | - M Margaret Dolcini
- Hallie E. Ford Center for Healthy Children and Families, College of Public Health and Human Sciences, Oregon State University, Corvallis, OR, USA
| | - Julie A Baldwin
- Department of Health Sciences, Northern Arizona University, Flagstaff, AZ, USA
| | - Regina Maria Roig-Romero
- College of Public Health, University of South Florida, 13201 Bruce B. Downs Blvd., MDC 56, Tampa, FL, 33612, USA
| | - Celia M Lescano
- Department of Mental Health Law & Policy, College of Behavioral & Community Sciences, University of South Florida, Tampa, FL, 33612, USA
| | - Robert L Glueckauf
- Department of Behavioral Sciences & Social Medicine, College of Medicine Florida State University, Florida State University, Tallahassee, FL, USA
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13
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Demena BA, Artavia-Mora L, Ouedraogo D, Thiombiano BA, Wagner N. A Systematic Review of Mobile Phone Interventions (SMS/IVR/Calls) to Improve Adherence and Retention to Antiretroviral Treatment in Low-and Middle-Income Countries. AIDS Patient Care STDS 2020; 34:59-71. [PMID: 32049555 DOI: 10.1089/apc.2019.0181] [Citation(s) in RCA: 54] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
The use of mobile health technologies (mHealth) to ameliorate HIV care has considerably risen in low- and middle-income countries (LMICs) since 2010. Yet, the discrepancies in the results of accompanying studies warrant an updated and systematic consolidation of all available evidence. We report a systematic review of studies testing whether text/image messages, interactive voice response reminders, or calls promote adherence and retention to antiretroviral therapy (ART) in LMICs. We systematically compiled studies published in English until June 2018 from PubMed/Medline, Web of Science, WHO database, ProQuest Dissertations and Theses, and manual search. We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2009 and used frequency analysis to assess reported findings. In total, we compiled 35 published articles: 27 completed studies and 8 protocols. Among the main 27 studies, 17 examine adherence, 5 retention, and 5 both measures. Results indicate that 56% report positive and statistically significantly impacts of mHealth on primary outcomes, the remaining 44% report insignificant results. While 41% of studies found a positive and significant effect for adherence, only 12% improved retention. The evidence shows ambiguous results (with high variability) about the effectiveness of mobile phone-assisted mHealth interventions to boost adherence and retention to ART. The literature also points to short follow-up periods, small samples, and limited geographical coverage. Hence, future research should focus on evaluating longer interventions with more patients spread across wider areas to address whether mHealth can be effectively used in LMICs.
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Affiliation(s)
- Binyam Afewerk Demena
- Institute of Social Studies, Erasmus University Rotterdam, The Hague, The Netherlands
| | - Luis Artavia-Mora
- Institute of Social Studies, Erasmus University Rotterdam, The Hague, The Netherlands
| | - Dénis Ouedraogo
- Institut du Développement Rural, Université Nazi Boni (Former Université Polytechnique de Bobo-Dioulasso), Bobo-Dioulasso, Burkina Faso
| | - Boundia Alexandre Thiombiano
- Institut du Développement Rural, Université Nazi Boni (Former Université Polytechnique de Bobo-Dioulasso), Bobo-Dioulasso, Burkina Faso
| | - Natascha Wagner
- Institute of Social Studies, Erasmus University Rotterdam, The Hague, The Netherlands
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14
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Hattingh M, Matthee M, Smuts H, Pappas I, Dwivedi YK, Mäntymäki M. A Multistakeholder-Centric Data Analytics Governance Framework for Medication Adherence and Improvement in Rural Settings. LECTURE NOTES IN COMPUTER SCIENCE 2020. [PMCID: PMC7134227 DOI: 10.1007/978-3-030-45002-1_35] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Good medication adherence is directly proportional to good health recovery and general improvement of a patient’s health condition. Although many good medication adherence monitoring methods/techniques exist, the level of medication adherence for some chronic diseases by patients in rural settings is still suboptimal. Hence, the need for healthcare organisations to devise viable governance frameworks that will facilitate effective medication adherence monitoring and improved adherence by patients. This paper presents the conceptual overview of a governance framework for medication adherence monitoring and improvement that enables the collaboration of multiple stakeholders and data analytics (MUCODAF) in support of the patient in the treatment journey. The framework allows relevant stakeholders such as Healthcare workers (HCW), family members, and close friends to collaborate in support of a patient through the engagement of critical human factors such as empathy, motivation, encouragement, flexibility, and negotiation. The use cases of the framework, its technical composition, and the implementation plan are discussed in this paper. A concrete example of the application of the governance framework for medication adherence monitoring and improvement for a Tuberculosis patient in the African Country of Lesotho is presented to highlight the plausibility of the framework.
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15
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Paladino AJ, Anderson JN, Krukowski RA, Waters T, Kocak M, Graff C, Blue R, Jones TN, Buzaglo J, Vidal G, Schwartzberg L, Graetz I. THRIVE study protocol: a randomized controlled trial evaluating a web-based app and tailored messages to improve adherence to adjuvant endocrine therapy among women with breast cancer. BMC Health Serv Res 2019; 19:977. [PMID: 31856812 PMCID: PMC6924011 DOI: 10.1186/s12913-019-4588-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Long-term use of adjuvant endocrine therapy (AET) among women with early-stage, hormone receptor-positive breast cancer significantly reduces the risk of hospitalizations, cancer recurrence, and mortality. AET is associated with adverse symptoms that often result in poor adherence. A web-enabled app offers a novel way to communicate and manage symptoms for women on AET. In a region with significant racial disparities in breast cancer outcomes, our study tests the impact of a web-enabled app that collects and transmits patient-reported symptoms to healthcare teams to facilitate timely and responsive symptom management on medication adherence. Methods In this randomized controlled trial, we randomize 300 patients initiating AET to one of three arms: 1) an “App” group (n = 100) that receives weekly reminders to use the THRIVE study app; 2) an “App+Feedback” group (n = 100) that receives weekly reminders and tailored feedback based on their use of the app; or 3) a “Usual Care” group (n = 100) that receives usual care only. Participants are stratified by race: 50% White and 50% Black. The duration of the intervention is six months following enrollment, and outcomes are assessed at 12-months. The primary outcome is adherence, which is captured using an electronic monitoring pillbox. Secondary outcomes include symptom burden, quality of life, self-efficacy for managing symptoms, and healthcare costs. We also evaluate the impact of the intervention on racial disparities in adherence. Data are derived from three sources: electronic health record data to capture treatment changes, healthcare utilization, and health outcomes; self-report survey data related to adherence, symptom burden, and quality of life; and an electronic medication monitoring device that captures adherence. Discussion A successful web-enabled intervention could be disseminated across systems, conditions, and populations. By evaluating the impact of this intervention on a comprehensive set of measures, including AET adherence, patient outcomes, and costs, our study will provide valuable and actionable results for providers, policy makers, and insurers who strive to achieve the “Triple Aim” – reduce costs while improving health outcomes and the patient care experience. Trial registration NCT03592771. Prospectively registered on July 19, 2018.
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Affiliation(s)
- Andrew J Paladino
- Department of Health Policy and Management, Emory University, Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA, USA.,The West Cancer Center & Research Institute, Memphis, TN, USA
| | - Janeane N Anderson
- College of Nursing, The University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN, USA
| | - Rebecca A Krukowski
- Department of Preventive Medicine, The University of Tennessee Health Science Center, College of Medicine, 66 N Pauline St, Memphis, TN, USA
| | - Teresa Waters
- Department of Health Management and Policy, The University of Kentucky, College of Public Health, Lexington, KY, USA
| | - Mehmet Kocak
- Department of Preventive Medicine, The University of Tennessee Health Science Center, College of Medicine, 66 N Pauline St, Memphis, TN, USA
| | - Carolyn Graff
- College of Nursing, The University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN, USA
| | - Ryan Blue
- College of Nursing, The University of Tennessee Health Science Center, 920 Madison Avenue, Memphis, TN, USA
| | - Tameka N Jones
- The West Cancer Center & Research Institute, Memphis, TN, USA
| | - Joanne Buzaglo
- Department of Patient Reported Outcomes, Vector Oncology, Memphis, TN, USA
| | - Gregory Vidal
- The West Cancer Center & Research Institute, Memphis, TN, USA
| | | | - Ilana Graetz
- Department of Health Policy and Management, Emory University, Rollins School of Public Health, 1518 Clifton Road, Atlanta, GA, USA. .,Department of Preventive Medicine, The University of Tennessee Health Science Center, College of Medicine, 66 N Pauline St, Memphis, TN, USA.
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16
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If You Build It, Will They Use It? Preferences for Antiretroviral Therapy (ART) Adherence Monitoring Among People Who Inject Drugs (PWID) in Kazakhstan. AIDS Behav 2019; 23:3294-3305. [PMID: 30741397 DOI: 10.1007/s10461-019-02421-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Adherence to antiretroviral therapy (ART) is an important predictor of long-term treatment success and is associated with optimal individual and public health outcomes. Novel technologies, such as electronic monitoring devices (EMDs) or pharmacokinetic testing, provide more objective measures of ART adherence than traditional measures of adherence (e.g., self-report) and may facilitate improved adherence through the provision of patient feedback. This study examines preferences for ART adherence monitoring among people who inject drugs (PWID) in Kazakhstan. In-depth interviews were conducted with 20 HIV-positive PWID, 18 of their intimate partners, and 7 AIDS Center healthcare providers in Almaty, Kazakhstan. Results indicated that patients varied in their preferences of which strategies would be most effective and acceptable to use in monitoring their adherence. Overall, patients were highly enthusiastic about the potential use of pharmacokinetic testing. Many participants supported the use of EMDs, though some were concerned about having their adherence tracked. Other participants thought reminders through text messaging or smart phone applications would be helpful, though several had concerns about confidentiality and others worried about technological difficulties operating a smart phone. Future studies should evaluate the feasibility and impact of providing quantitative drug levels as feedback for ART adherence using biomarkers of longer-term ART exposure, (i.e., hair sampling or dried blood spot testing).
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17
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Antiretroviral Therapy Adherence Interruptions Are Associated With Systemic Inflammation Among Ugandans Who Achieved Viral Suppression. J Acquir Immune Defic Syndr 2019; 82:386-391. [PMID: 31658181 PMCID: PMC6820698 DOI: 10.1097/qai.0000000000002148] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Residual systemic inflammation, which is associated with non-AIDS clinical outcomes, may persist despite viral suppression. We assessed the effect of antiretroviral therapy (ART) adherence interruptions on systemic inflammation among Ugandans living with HIV who were virally suppressed. SETTING We evaluated adults initiating first-line ART at a regional referral hospital clinic in Mbarara, Uganda. METHODS Plasma concentrations of interleukin-6 (IL-6), D-dimer, soluble sCD14, sCD163, the kynurenine/tryptophan (K/T) ratio, and CD8 T-cell activation (HLA-DR/CD38 coexpression) were measured at baseline and 6 months after ART initiation among participants who achieved viral suppression (<400 copies/mL) at 6 months. ART adherence was monitored electronically. Time spent in an adherence interruption was computed as the percentage of days when the running average adherence was ≤10%. We fit adjusted linear regressions to evaluate the effect of time spent in an interruption on the log-transformed plasma concentrations of the inflammation biomarkers. RESULTS Of 282 participants, 70% were women, and the median age was 34 years. At baseline, median CD4 and median log viral load were 135 cells per microliter and 5.1 copies per milliliter, respectively. In the adjusted analysis, a running average adherence of <10% was associated with higher sCD14 (+3%; P < 0.008), sCD163 (+5%; P = 0.002), D-dimer (+10%; P = 0.007), HLA-DR/CD8 (+3%; P < 0.025), IL-6 (+14%; P = 0.008), and K:T ratio (+5%; P = 0.002). These findings were largely robust to adjustment for average adherence, as well as higher thresholds of running average adherence, albeit with decreased statistical significance. CONCLUSIONS Increased time spent in adherence interruptions is associated with increased levels of inflammation, despite viral suppression above and beyond average adherence.
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18
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Holstad MM, Higgins M, Bauman M, Farber EW, Waldrop-Valverde D, Okwandu O, Ofotokun I. Picture Pill Count: An Innovative, Reliable, Valid and Feasible Method to Measure Adherence to ART. AIDS Behav 2019; 23:2210-2217. [PMID: 31041625 DOI: 10.1007/s10461-019-02513-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We report the reliability, validity, and feasibility of self-performed picture pill count (PPC) as an adherence measure that was used in a randomized trial with HIV positive people living in rural Georgia. The first 61 (of 149) participants conducted an additional PPC 1-2 days after baseline. Reliability, measured by a PPC scoring instrument, analyzed participants' ability to reproduce high quality pill count photographs free from artifact or blurring that could hamper accurate visualization of the pills and bottle labels. Except for label blur, baseline photographs (performed with coaching by study staff) and independently performed post-baseline photographs were rated as acceptable quality (> 93%). Label blur significantly worsened between the baseline and post-baseline scoring (93% vs 80%, p = 0.039), possibly indicating that participants required more education to ensure readability. Validity was determined by comparing the number of pills entered into the PC survey with the number of pills in the texted PPC; 77.5% of participants had perfectly matched pill counts (r = 0.690, p < 0.001). We found PCC to be a reliable and valid method of measuring adherence. The high rate of participant satisfaction underscores its feasibility. It provides an innovative alternative to other more invasive and labor intensive methods of measuring adherence using pill counts.
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Affiliation(s)
- Marcia M Holstad
- Nell Hodgson School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA.
| | - Melinda Higgins
- Nell Hodgson School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA
| | - Maya Bauman
- Nell Hodgson School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA
| | - Eugene W Farber
- School of Medicine, Department of Psychiatry and Behavioral Sciences, Emory University, Atlanta, GA, 30322, USA
| | - Drenna Waldrop-Valverde
- Nell Hodgson School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA
| | - Oluchi Okwandu
- Nell Hodgson School of Nursing, Emory University, 1520 Clifton Road, Atlanta, GA, 30322, USA
| | - Igho Ofotokun
- School of Medicine, Department of Medicine, Emory University, Atlanta, GA, 30322, USA
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19
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Bell KM, Haberer JE. Actionable Adherence Monitoring: Technological Methods to Monitor and Support Adherence to Antiretroviral Therapy. Curr HIV/AIDS Rep 2019; 15:388-396. [PMID: 30232578 DOI: 10.1007/s11904-018-0413-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
PURPOSE OF REVIEW Current digital technologies are being used for "actionable adherence monitoring"; that is, technologies that can be used to identify episodes of non-adherence to ART in a timely manner such that tailored interventions based on adherence data can be provided when and where they are needed most. RECENT FINDINGS Current digital communication technologies used to monitor ART adherence include electronic adherence monitors (EAMs), digital ingestion monitors, cellular phones, and electronic pharmacy refill tracking systems. Currently available real-time adherence monitoring approaches based on cellular technology allow for the delivery of interventions precisely when and where they are needed. Such technology can potentially enable significant efficiency of care delivery and impact on adherence and associated clinical outcomes. Standard digital advances, such as automated reminders in EAM and electronic pharmacy records, may also achieve improvements with relatively lower cost and easier implementation. Future research is needed to improve the functionality of these approaches, with attention paid to system-level issues through implementation science, as well as acceptability and ethical considerations at the individual level.
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Affiliation(s)
- Kate M Bell
- Center for Global Health, Massachusetts General Hospital, 125 Nashua St, Suite 722, Boston, MA, 02114, USA
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, 125 Nashua St, Suite 722, Boston, MA, 02114, USA.
- Harvard Medical School, Boston, MA, USA.
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20
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Castillo-Mancilla JR, Haberer JE. Adherence Measurements in HIV: New Advancements in Pharmacologic Methods and Real-Time Monitoring. Curr HIV/AIDS Rep 2019; 15:49-59. [PMID: 29380227 DOI: 10.1007/s11904-018-0377-0] [Citation(s) in RCA: 88] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
PURPOSE OF REVIEW In this review, we present new developments in antiretroviral adherence, focusing on pharmacological measures and real-time adherence monitoring. In addition, new strategies on how to incorporate these new measures into research and clinical care are proposed. RECENT FINDINGS Antiretroviral drug concentrations in hair and dried blood spots are two novel pharmacological measures of cumulative drug adherence and exposure that have been recently evaluated in HIV treatment and pre-exposure prophylaxis. Real-time adherence monitoring using electronic devices has also proven highly informative, feasible, and well accepted, offering the possibility for an immediate intervention when non-adherence is detected. Both approaches offer considerable advantages over traditional adherence measures in predicting efficacy. New methods to objectively monitor adherence in real-time and over long time periods have been developed. Further research is required to better understand how these measures can optimize adherence and, ultimately, improve clinical outcomes in HIV treatment and prevention.
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Affiliation(s)
- Jose R Castillo-Mancilla
- Division of Infectious Diseases, Department of Medicine, University of Colorado Anschutz Medical Campus, Medicine/Infectious Diseases, 12700 E 19th Ave., B168, Aurora, CO, 80045, USA.
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
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21
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Stringer KL, Azuero A, Ott C, Psaros C, Jagielski CH, Safren SA, Haberer JE, Kempf MC. Feasibility and Acceptability of Real-Time Antiretroviral Adherence Monitoring among Depressed Women Living with HIV in the Deep South of the US. AIDS Behav 2019; 23:1306-1314. [PMID: 30377982 DOI: 10.1007/s10461-018-2322-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
This study presents feasibility and acceptability data on the use of a real-time wireless electronic adherence monitor (EAM), among African American women living with HIV with co-occurring depression, residing in remote areas of the Southeastern United States. EAM and self-report ART adherence was monitored over an average of 14.8 weeks among 25 participants who were recruited at four HIV clinics in Alabama. Intra-class correlation showed a low degree of concordance between EAM and self-report (ICC = 0.33, 95% bootstrap CI 0.13, 0.59). 83% of data collected via EAM was transmitted in real-time. Due to technological failures, 11.4% were not transmitted in real-time, but were later recovered, and 5.7% were lost entirely. Acceptability was examined through surveys and qualitative interviews. Results suggest that EAM monitoring is acceptable and feasible in a rural US setting; however, technological difficulties, such as loss of connectivity may impede the device's usefulness for just-in-time adherence interventions.
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Affiliation(s)
| | - Andres Azuero
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Corilyn Ott
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Christina Psaros
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Steven A Safren
- Department of Psychology, University of Miami, Miami, FL, USA
| | - Jessica E Haberer
- Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Mirjam-Colette Kempf
- School of Nursing, University of Alabama at Birmingham, Birmingham, AL, USA.
- Departments of Health Behavior and Epidemiology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA.
- Division of Infectious Diseases, School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
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22
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Martelli G, Antonucci R, Mukurasi A, Zepherine H, Nöstlinger C. Adherence to antiretroviral treatment among children and adolescents in Tanzania: Comparison between pill count and viral load outcomes in a rural context of Mwanza region. PLoS One 2019; 14:e0214014. [PMID: 30897131 PMCID: PMC6428300 DOI: 10.1371/journal.pone.0214014] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 03/05/2019] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Adherence to antiretroviral treatment is a key challenge for paediatric HIV care. Among children and adolescents living with HIV, lower levels of adherence have been reported compared to adults. Individual, caregiver-, health services-related and sociocultural factors were shown to impact on these outcomes. Study objectives were to assess adherence in a paediatric population in rural Tanzania comparing two measurement methods, and to investigate the association between virologic suppression and demographic, clinical, drug- and family-related factors. METHODS This cross-sectional study was conducted among children and adolescents enrolled in Bukumbi HIV Care and Treatment Clinic (Misungwi district, Mwanza region) in the north of Tanzania, where the HIV prevalence is 7.2%. Adherence was measured through viral load and pill count. Kappa statistics assessed the level of agreement between the methods; bivariate and multivariable analyses identified factors independently associated with virologic suppression. RESULTS N = 72 participants (n = 49 children; n = 23 adolescents) with a median age of eight years were enrolled. 62.5% and 65.3% of the individuals presented an optimal adherence according to viral load and pill count respectively, but among 40% viral load results diverged from the pill count method. In multivariable analysis, living outside Misungwi district and having CD4 counts above 500/μl were significantly associated with optimal adherence. CONCLUSION Children and adolescents living with HIV in Mwanza show high rates of suboptimal adherence. The poor agreement between pill count and viral load results raises concerns about the interpretation of these measurements in clinical practice.
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Affiliation(s)
- Giulia Martelli
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- * E-mail:
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23
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Al-Hassany L, Kloosterboer SM, Dierckx B, Koch BCP. Assessing methods of measuring medication adherence in chronically ill children-a narrative review. Patient Prefer Adherence 2019; 13:1175-1189. [PMID: 31413546 PMCID: PMC6660631 DOI: 10.2147/ppa.s200058] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/13/2019] [Indexed: 12/24/2022] Open
Abstract
Nonadherence in children who use long-term medication is a serious problem and assessing adherence is an important step to provide solutions to this problem. Medication adherence can be measured by several methods, including (a) self-report questionnaires or structured interviews, (b) therapeutic drug monitoring (TDM), (c) electronic devices, and (d) pick-up/refill rates. The objective of this narrative review is to provide an overview of the literature about methods for the measurement of medication adherence in chronically ill children and adolescents. Therefore, we conducted a literature search by using multiple databases. Four methods of monitoring medication adherence are presented for the most described chronic diseases: asthma, HIV/AIDS, epilepsy, diabetes mellitus and ADHD. First, 10 commonly used self-report questionnaires and structured interviews are described, including the main characteristics, (dis)advantages and their validation studies. Second, the use of TDM in pediatric trials for medication adherence measurement is discussed. New sampling methods (e.g. dried blood spot) and sampling matrices (e.g. hair, saliva and urine) have shown their benefits for TDM in children. Third, electronic devices to measure medication adherence in children are presented, being developed for several drug administration routes. Fourth, the analyses, advantages and disadvantages of pharmacy data are discussed. The usage of this data requires specific calculations and interpretations to assess adherence. As presented in this review, every adherence method has specific (dis)advantages. When deciding which adherence method is applicable, validity and generalizability should be taken into account. Combining multiple methods seems to offer the best solution in the daily clinical practice.
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Affiliation(s)
- Linda Al-Hassany
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy, Rotterdam, The Netherlands
- Correspondence: Linda Al-HassanyDepartment of Hospital Pharmacy, University Medical Center Rotterdam, Postal Box 2040, Rotterdam3000 CA, The NetherlandsTel +3 110 703 3202Email
| | - Sanne M Kloosterboer
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy, Rotterdam, The Netherlands
| | - Bram Dierckx
- Erasmus MC, University Medical Center Rotterdam, Department Child and Adolescent Psychiatry, Rotterdam, The Netherlands
| | - Birgit CP Koch
- Erasmus MC, University Medical Center Rotterdam, Department of Hospital Pharmacy, Rotterdam, The Netherlands
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24
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Almeida-Brasil CC, Moodie EEM, Cardoso TS, Nascimento ED, Ceccato MDGB. Comparison of the predictive performance of adherence measures for virologic failure detection in people living with HIV: a systematic review and pairwise meta-analysis. AIDS Care 2018; 31:647-659. [PMID: 30516060 DOI: 10.1080/09540121.2018.1554241] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
A critical feature of an adherence assessment tool is its ability to predict virologic failure in people living with HIV (PLHIV). We, therefore, aimed to compare the predictive performance of commonly used adherence measures. We systematically searched MEDLINE, Embase and LILACS up to February 2018, to identify relevant observational studies comparing the effects of any two of the following adherence measurements on virologic outcomes: electronic monitoring, pill count, pharmacy refill, self-report and physician assessment. We analyzed data by pairwise meta-analyzes with a random-effects model. The proportion of virologic failures among non-adherent participants in each adherence measure was used to calculate the odds ratio (OR), with 95% Confidence Intervals (95%CI). Heterogeneity was assessed, with potential causes identified by sensitivity and subgroup analysis. We included 38 studies with individual patient data for 18,010 patients. All possible comparisons between pairs of the five adherence measures were considered and a total of nine comparison groups could be established. Meta-analysis suggested that self-report was a better predictor of virologic failure than pill count when the recall period was within one week (OR: 2.35, 95%CI: 1.07-5.18, p = 0.03). Physician assessment had higher odds of predicting virologic failure than did either self-report (OR: 2.63, 95%CI: 1.37-5.26, p < 0.01) or pharmacy refill (OR: 3.57, 95%CI: 1.69-7.14, p < 0.001). There was no difference in the predictive performance between any of the other measures that we were able to compare (p > 0.05). The combination of multiple measures did not increase the predictive value when compared to any of the measures alone. Low-cost and simple adherence measures such as self-report predict virologic failure better than or equally well as objective measures. Our results suggest that there is no need to use expensive or time-consuming adherence measures when the objective is to identify PLHIV at risk of treatment failure.
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Affiliation(s)
- Celline Cardoso Almeida-Brasil
- a Department of Social Pharmacy , Universidade Federal de Minas Gerais , Belo Horizonte , Brazil.,b Department of Epidemiology, Biostatistics and Occupational Health , McGill University , Montréal , Canada
| | - Erica E M Moodie
- b Department of Epidemiology, Biostatistics and Occupational Health , McGill University , Montréal , Canada
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25
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Campbell JI, Eyal N, Musiimenta A, Burns B, Natukunda S, Musinguzi N, Haberer JE. Ugandan Study Participants Experience Electronic Monitoring of Antiretroviral Therapy Adherence as Welcomed Pressure to Adhere. AIDS Behav 2018; 22:3363-3372. [PMID: 29926301 PMCID: PMC6309333 DOI: 10.1007/s10461-018-2200-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Many new technologies monitor patients' and study participants' medical adherence. Some have cautioned that these devices transgress personal autonomy and ethics. But do they? This qualitative study explored how Ugandan study participants perceive the effect of electronic monitoring of their adherence to antiretroviral therapy (ART) on their freedoms to be non-adherent and pursue other activities that monitoring may inadvertently expose. Between August 2014 and June 2015, we interviewed 60 Ugandans living with HIV and enrolled in the Uganda AIDS Rural Treatment Outcomes (UARTO) study, a longitudinal, observational study involving electronic adherence monitors (EAMs) to assess ART adherence. We also interviewed 6 UARTO research assistants. Both direct and indirect content analysis were used to interpret interview transcripts. We found that monitoring created a sense of pressure to adhere to ART, which some participants described as "forcing" them to adhere. However, even participants who felt that monitoring forced them to take medications perceived using the EAM as conducive to their fundamental goal of high ART adherence. Overall, even if monitoring may have limited participants' effective freedom to be non-adherent, participants welcomed any such effect. No participant rejected the EAM on the grounds that it would limit that effective freedom. Reports that monitoring altered behaviors unrelated to pill-taking were rare. Researchers should continue to be vigilant about the ways in which behavioral health monitoring affects autonomy, but should also recognize that even autonomy-limiting monitoring strategies may enable participants to achieve their own goals.
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Affiliation(s)
- Jeffrey I Campbell
- Department of Pediatrics, Boston Medical Center, and Boston Children's Hospital, One Boston Medical Center Pl, Dowling 3rd Floor, Boston, MA, 02118, USA.
| | - Nir Eyal
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
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26
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Mechanism of Change in Cognitive Behavioral Therapy for Body Image and Self-Care on ART Adherence Among Sexual Minority Men Living with HIV. AIDS Behav 2018; 22:2711-2717. [PMID: 29752620 DOI: 10.1007/s10461-018-2143-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
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.
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27
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Dworkin MS, Chakraborty A, Zychowski D, Donenberg G, Novak R, Garofalo R. Self-efficacy and ability to read as factors associated with antiretroviral therapy adherence in an HIV-infected population. Int J STD AIDS 2018; 29:1154-1164. [PMID: 29890903 DOI: 10.1177/0956462418776073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Determining the barriers and facilitators of antiretroviral adherence among former and current substance users may be useful in the creation of successful interventions that target this hard-to-reach population. We performed a cross-sectional study of HIV-infected patients (N = 123) prescribed antiretroviral therapy at four Chicago healthcare venues. Bivariate and multivariable analyses were performed to determine factors associated with non-adherence based on definitions of non-adherence (any missed doses) within the past 4-day, 14-day, and 1-month time periods. Factors consistently associated with non-adherence in bivariate and multivariate analyses, regardless of duration of non-adherence definition, were lower confidence in taking medication consistently and less self-reported ability to read. These data reveal the importance of self-efficacy and ability to read (rather than specific knowledge of CD4 and viral load definitions) in the design of interventions in a population of HIV-infected persons with significant substance use.
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Affiliation(s)
- Mark S Dworkin
- 1 Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Apurba Chakraborty
- 1 Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Diana Zychowski
- 1 Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Geri Donenberg
- 1 Division of Epidemiology and Biostatistics, University of Illinois at Chicago School of Public Health, Chicago, IL, USA
| | - Richard Novak
- 2 Section of Infectious Diseases, University of Illinois at Chicago College of Medicine, Chicago, IL USA
| | - Robert Garofalo
- 3 Department of Pediatrics, Northwestern University/Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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28
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Eysenbach G, Atukunda EC, Tumuhimbise W, Pisarski EE, Tam M, Wyatt MA, Ware NC, Haberer JE. Acceptability and Feasibility of Real-Time Antiretroviral Therapy Adherence Interventions in Rural Uganda: Mixed-Method Pilot Randomized Controlled Trial. JMIR Mhealth Uhealth 2018; 6:e122. [PMID: 29773527 PMCID: PMC5981052 DOI: 10.2196/mhealth.9031] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 01/11/2018] [Accepted: 03/19/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Wireless electronic adherence monitors can detect antiretroviral therapy (ART) adherence lapses and trigger interventions in real time, thus potentially avoiding unnecessary HIV viremia. Evidence about the acceptability and feasibility of these monitors and associated interventions, however, is limited. OBJECTIVE The aim of this study was to assess the acceptability and feasibility of real-time adherence monitoring linked to text messaging (short message service, SMS) reminders and notifications to support adherence among individuals living with HIV who are taking ART in rural southwestern Uganda. METHODS Individuals living with HIV who were initiating ART were enrolled in a pilot randomized controlled trial and followed up for 9 months. Participants received a real-time adherence monitor and were randomized to one of the following study arms: (1) scheduled SMS, (2) SMS triggered by missed or delayed doses, or (3) no SMS. SMS notifications were also sent to 45 patient-identified social supporters for sustained adherence lapses in the scheduled SMS and triggered SMS arms. Study participants and social supporters participated in qualitative semistructured in-depth interviews on acceptability and feasibility of this technology. An inductive, content analytic approach, framed by the unified theory of acceptance and use of technology model, was used to analyze qualitative data. Quantitative feasibility data, including device functionality and SMS tracking data, were recorded based upon device metrics collected electronically and summarized descriptively. RESULTS A total of 63 participants participated in the study. Participants reported that real-time monitoring intervention linked to SMS reminders and notifications are generally acceptable; the predominant feedback was perceived utility-the intervention was beneficial in motivating and reminding patients to take medication, as well as enabling provision of social support. The intervention was found to be technically feasible, as data were obtained from most participants as expected most of the time. Potential challenges included the impact of the technology on confidentiality, shared phone ownership, usability skills, and availability of electricity. CONCLUSIONS Real-time adherence monitoring integrated with SMS reminders and social support notifications is a generally acceptable (based primarily on perceived utility) and feasible intervention in a resource-limited country. Future efforts should focus on optimized device design, user training to overcome the challenges we encountered, cost effectiveness studies, as well as studying the monitoring aspect of the device without accompanying interventions. TRIAL REGISTRATION ClinicalTrials.gov NCT01957865; https://clinicaltrials.gov/ct2/show/NCT01957865 (Archived by WebCite at http://www.webcitation.org/6zFiDlXDa).
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Affiliation(s)
| | | | | | | | - Melanie Tam
- Wake Forest School of Medicine, Winston-Salem, NC, United States
| | - Monique A Wyatt
- Harvard Medical School, Boston, MA, United States.,Harvard Global, Cambridge, MA, United States
| | - Norma C Ware
- Harvard Medical School, Boston, MA, United States
| | - Jessica E Haberer
- Harvard Medical School and Massachusetts General Hospital, Boston, MA, United States
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29
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Bionghi N, Daftary A, Maharaj B, Msibi Z, Amico KR, Friedland G, Orrell C, Padayatchi N, O'Donnell MR. Pilot evaluation of a second-generation electronic pill box for adherence to Bedaquiline and antiretroviral therapy in drug-resistant TB/HIV co-infected patients in KwaZulu-Natal, South Africa. BMC Infect Dis 2018; 18:171. [PMID: 29642874 PMCID: PMC5896111 DOI: 10.1186/s12879-018-3080-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Accepted: 04/03/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The introduction of Bedaquiline, the first new antimycobacterial drug in over 40 years, has highlighted the critical importance of medication adherence in drug-resistant tuberculosis (DR-TB) treatment to prevent amplified drug-resistance and derive sustained benefit. Real-time electronic dose monitoring (EDM) accurately measures adherence and allows for titration of adherence support for anti-retroviral therapy (ART). The goal of this study was to evaluate the accuracy and acceptability of a next-generation electronic pillbox (Wisepill RT2000) for Bedaquiline-containing TB regimens. METHODS Eligible patients were DR-TB/HIV co-infected adults hospitalized for the initiation of Bedaquiline-containing treatment regimens in KwaZulu-Natal, South Africa. A one-way crossover design was used to evaluate levels of adherence and patient acceptance of EDM. Each patient was given a Wisepill device which was filled with ART, Levofloxacin or Bedaquiline over three consecutive weeks. Medication adherence was measured using Wisepill counts, patient-reported seven-day recall, and weekly pill count. An open-ended qualitative questionnaire at the end of the study evaluated participant acceptability of the Wisepill device. RESULTS We enrolled 21 DR-TB/HIV co-infected inpatients admitted for the initiation of Bedaquiline from August through September 2016. In aggregate patients were similarly adherent to Bedaquiline (100%) compared to Levofloxacin (100%) and ART (98.9%) by pill count. Wisepill was more sensitive (100%) compared to seven-day recall (0%) in detecting non-adherence events (p = 0.02). Patients reported positive experiences with Wisepill and expressed willingness to use the device during a full course of DR-TB treatment. There were no concerns about stigma, confidentiality, or remote monitoring. CONCLUSION In this pilot study patients were highly adherent to Bedaquiline by all adherence measures. However, there was lower adherence to ART by pill count and Wisepill suggesting a possible challenge for adherence with ART. The use of EDM identified significantly more missed doses than seven-day recall. Wisepill was highly acceptable to DR-TB/HIV patients in South Africa, and is a promising modality to support and monitor medication adherence in complex treatment regimens.
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Affiliation(s)
- N Bionghi
- Columbia University College of Physicians and Surgeons, NY, NY, USA.,CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - A Daftary
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa.,McGill International TB Centre, McGill University, Montreal, Canada
| | - B Maharaj
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - Z Msibi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - K R Amico
- University of Michigan School of Public Health, Ann Arbor, MI, USA
| | | | - C Orrell
- Desmond Tutu HIV Centre, University of Cape Town, Cape Town, South Africa
| | - N Padayatchi
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa
| | - M R O'Donnell
- CAPRISA MRC- HIV-TB Pathogenesis and Treatment Research Unit, Durban, South Africa. .,Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, NY, NY, USA. .,Department of Epidemiology, Mailman School of Public Health, Columbia University Medical Center, NY, NY, USA.
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30
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Mudhune V, Gvetadze R, Girde S, Ndivo R, Angira F, Zeh C, Thomas T, Lecher SL. 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. AIDS Behav 2018; 22:918-928. [PMID: 28197845 DOI: 10.1007/s10461-017-1724-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
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.
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Affiliation(s)
- Victor Mudhune
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Roman Gvetadze
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop G-45, Atlanta, GA, 30333, USA
| | | | - Richard Ndivo
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Frank Angira
- HIV Research Branch, Kenya Medical Research Institute, Kisumu, Kenya
| | - Clement Zeh
- Centers for Disease Control and Prevention, HIV Research Branch, Kisumu, Kenya
| | - Timothy Thomas
- Centers for Disease Control and Prevention, HIV Research Branch, Kisumu, Kenya
| | - Shirley Lee Lecher
- Division of HIV/AIDS Prevention, Centers for Disease Control and Prevention, 1600 Clifton Road, Mail Stop G-45, Atlanta, GA, 30333, USA.
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31
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Gras G. Use of telemedicine in the management of infectious diseases. Med Mal Infect 2018; 48:231-237. [PMID: 29452936 DOI: 10.1016/j.medmal.2018.01.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 01/08/2018] [Indexed: 11/30/2022]
Abstract
Communication technologies have invaded our daily lives. Several studies have assessed these technologies in the management of infectious diseases (mainly HIV). Weekly short text messages and real-time compliance monitoring assessed in HIV patients are both associated with higher compliance in low-income countries. Virtual consultations to monitor stable chronic HIV patients or tuberculosis treatment in high-income countries appear to be acceptable and efficient. Although assessed in small studies, virtual monitoring seems to reinforce the doctor-patient relationship and the relation between primary care settings and hospitals in various infectious diseases (endocarditis, urinary tract infection, skin and soft tissue infection, HIV, tuberculosis, hepatitis C). A better prevention of infectious diseases (mainly sexually transmitted infections) seems to be observed with telemedicine tools. As fees for teleconsultation or telemonitoring have yet to be defined, the development and evaluation (cost effectiveness) of these tools are difficult. The regulatory framework will need to be improved to encourage such developments, all the while ensuring the confidentiality of data. The development of new tools will require the collaboration of physicians, users, and healthcare systems.
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Affiliation(s)
- G Gras
- Maladies infectieuses, CHU Bretonneau, 2, boulevard Tonnelé, 37044 Tours cedex, France.
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32
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Technological methods to measure adherence to antiretroviral therapy and preexposure prophylaxis. Curr Opin HIV AIDS 2017; 12:467-474. [PMID: 28590335 DOI: 10.1097/coh.0000000000000393] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The WHO's Consolidated Guidelines (2016) call for research on improved methods to proactively monitor adherence and identify those individuals who have the greatest needs for adherence support. This review aims to elucidate the latest technologies available to measure adherence to HIV antiretroviral therapy and preexposure prophylaxis against HIV infection and present their utility in various settings and populations. RECENT FINDINGS Within the last few years, advances have been made in the features of existing technology to measure adherence (real-time electronic adherence measurements), additional approaches have been developed (digital medicine systems) and improved (short message service surveys), and point of care testing for pharmacokinetic measures are under development. SUMMARY Technology advances in adherence measurement are promising for improved accuracy and, in some cases, the ability to intervene with adherence challenges in real time. This progress will greatly further our understanding of adherence behavior, as well as the ability to effectively link interventions with individuals who need them, thus maximizing the clinical and public health benefits of both antiretroviral therapy and preexposure prophylaxis.
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Brief Report: Context Matters: PrEP Adherence is Associated With Sexual Behavior Among HIV Serodiscordant Couples in East Africa. J Acquir Immune Defic Syndr 2017; 76:488-492. [PMID: 28961676 DOI: 10.1097/qai.0000000000001548] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Short message service (SMS) surveys are a promising tool for understanding whether preexposure prophylaxis (PrEP) adherence aligns with risk for HIV acquisition-a concept known as prevention-effective adherence. METHODS The Partners Demonstration Project was an open-label study of integrated PrEP and antiretroviral therapy (ART) delivery among high-risk HIV serodiscordant couples in East Africa. HIV-uninfected partners were offered PrEP until their HIV-infected partner had taken ART for ≥6 months. At 2 study sites, HIV-uninfected partners were offered enrollment into the Partners Mobile Adherence to PrEP (PMAP) substudy based on ongoing PrEP use, personal cell phone ownership, and ability to use SMS. SMS surveys asked about PrEP adherence and sexual activity in the previous 24 hours; these surveys were sent daily for the 7 days before and 7 days after routine study visits in the Partners Demonstration Project. RESULTS The PMAP substudy enrolled 373 HIV-uninfected partners; 69% were men and mean age was 31 years. Participants completed 17,030 of 23,056 SMS surveys sent (74%) with a mean of 47 surveys per participant over 9.8 months of follow-up. While HIV-infected partner use of ART was <6 months, mean reported PrEP adherence was 92% on surveys concurrently reporting sex within the serodiscordant partnership, and 84% on surveys reporting no sex (P < 0.001). DISCUSSION SMS surveys provided daily assessment of concurrent PrEP adherence and sexual behavior. Higher PrEP adherence was temporally associated with increased risk for HIV acquisition.
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34
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Daftary A, Hirsch-Moverman Y, Kassie GM, Melaku Z, Gadisa T, Saito S, Howard AA. A Qualitative Evaluation of the Acceptability of an Interactive Voice Response System to Enhance Adherence to Isoniazid Preventive Therapy Among People Living with HIV in Ethiopia. AIDS Behav 2017; 21:3057-3067. [PMID: 27221743 PMCID: PMC5156579 DOI: 10.1007/s10461-016-1432-8] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Interactive voice response (IVR) is increasingly used to monitor and promote medication adherence. In 2014, we evaluated patient acceptability toward IVR as part of the ENRICH Study, aimed to enhance adherence to isoniazid preventive therapy for tuberculosis prevention among HIV-positive adults in Ethiopia. Qualitative interviews were completed with 30 participants exposed to 2867 IVR calls, of which 24 % were completely answered. Individualized IVR options, treatment education, and time and cost savings facilitated IVR utilization, whereas poor IVR instruction, network and power malfunctions, one-way communication with providers, and delayed clinic follow-up inhibited utilization. IVR acceptability was complicated by HIV confidentiality, mobile phone access and literacy, and patient-provider trust. Incomplete calls likely reminded patients to take medication but were less likely to capture adherence or side effect data. Simple, automated systems that deliver health messages and triage clinic visits appear to be acceptable in this resource-limited setting.
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Affiliation(s)
- Amrita Daftary
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, 13th Floor, New York, New York, 10032, USA.
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Nelson R. Mandela School of Medicine, University of KwaZulu Natal, Durban, South Africa.
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
| | - Yael Hirsch-Moverman
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, 13th Floor, New York, New York, 10032, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Getnet M Kassie
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Zenebe Melaku
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, 13th Floor, New York, New York, 10032, USA
| | - Tsigereda Gadisa
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, 13th Floor, New York, New York, 10032, USA
| | - Suzue Saito
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, 13th Floor, New York, New York, 10032, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
| | - Andrea A Howard
- ICAP, Mailman School of Public Health, Columbia University, 722 West 168th Street, 13th Floor, New York, New York, 10032, USA
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, USA
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Andriesen J, Bull S, Dietrich J, Haberer JE, Van Der Pol B, Voronin Y, Wall KM, Whalen C, Priddy F. Using Digital Technologies in Clinical HIV Research: Real-World Applications and Considerations for Future Work. J Med Internet Res 2017; 19:e274. [PMID: 28760729 PMCID: PMC5556256 DOI: 10.2196/jmir.7513] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 04/26/2017] [Accepted: 04/29/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Digital technologies, especially if used in novel ways, provide a number of potential advantages to clinical research in trials related to human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) and may greatly facilitate operations as well as data collection and analysis. These technologies may even allow answering questions that are not answerable with older technologies. However, they come with a variety of potential concerns for both the participants and the trial sponsors. The exact challenges and means for alleviation depend on the technology and on the population in which it is deployed, and the rapidly changing landscape of digital technologies presents a challenge for creating future-proof guidelines for technology application. OBJECTIVE The aim of this study was to identify and summarize some common themes that are frequently encountered by researchers in this context and highlight those that should be carefully considered before making a decision to include these technologies in their research. METHODS In April 2016, the Global HIV Vaccine Enterprise surveyed the field for research groups with recent experience in novel applications of digital technologies in HIV clinical research and convened these groups for a 1-day meeting. Real-world uses of various technologies were presented and discussed by 46 attendees, most of whom were researchers involved in the design and conduct of clinical trials of biomedical HIV prevention and treatment approaches. After the meeting, a small group of organizers reviewed the presentations and feedback obtained during the meeting and categorized various lessons-learned to identify common themes. A group of 9 experts developed a draft summary of the findings that was circulated via email to all 46 attendees for review. Taking into account the feedback received, the group finalized the considerations that are presented here. RESULTS Meeting presenters and attendees discussed the many successful applications of digital technologies to improve research outcomes, such as those for recruitment and enrollment, participant identification, informed consent, data collection, data quality, and protocol or treatment adherence. These discussions also revealed unintended consequence of technology usage, including risks to study participants and risks to study integrity. CONCLUSIONS Key lessons learned from these discussions included the need to thoroughly evaluate systems to be used, the idea that early success may not be sustained throughout the study, that some failures will occur, and considerations for study-provided devices. Additionally, taking these key lessons into account, the group generated recommendations on how to move forward with the use of technology in HIV vaccine and biomedical prevention trials.
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Affiliation(s)
| | - Sheana Bull
- Colorado School of Public Health, Denver, CO, United States
| | - Janan Dietrich
- Perinatal HIV Research Unit (PHRU), Faculty of Health Sciences, University of the Witwatersrand, Soweto, South Africa
| | - Jessica E Haberer
- Massachusetts General Hospital/Harvard Medical School, Boston, MA, United States
| | | | - Yegor Voronin
- Global HIV Vaccine Enterprise, New York, NY, United States
| | | | - Christopher Whalen
- Research Data & Communications Technologies Corp., Garrett Park, MD, United States
| | - Frances Priddy
- International AIDS Vaccine Initiative, New York, NY, United States
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Blashill AJ, Safren SA, Wilhelm S, Jampel J, Taylor SW, O'Cleirigh C, Mayer KH. Cognitive behavioral therapy for body image and self-care (CBT-BISC) in sexual minority men living with HIV: A randomized controlled trial. Health Psychol 2017; 36:937-946. [PMID: 28541068 DOI: 10.1037/hea0000505] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Body image disturbance is a distressing and interfering problem among many sexual minority men living with HIV, and is associated with elevated depressive symptoms and poor HIV self-care (e.g., antiretroviral therapy [ART] nonadherence). The current study tested the preliminary efficacy of a newly created intervention: cognitive-behavioral therapy for body image and self-care (CBT-BISC) for this population. METHOD The current study entailed a 2-arm randomized controlled trial (N = 44) comparing CBT-BISC to an enhanced treatment as usual (ETAU) condition. Analyses were conducted at 3 and 6 months after baseline. The primary outcome was body image disturbance (BDD-YBOCS), and secondary outcomes were ART adherence (electronically monitored via Wisepill), depressive symptoms (MADRS), and global functioning (GAF). RESULTS At 3 months, the CBT-BISC condition showed substantial improvement in BDD-YBOCS (b = -13.6, SE = 2.7, 95% CI [-19.0, -8.3], p < .001; dppc2 = 2.39); MADRS (b = -4.9, SE = 2.8, 95% CI [-10.6, .70], p = .086; dppc2 = .87); ART adherence (b = 8.8, SE = 3.3, 95% CI [2.0, 15.6], p = .01; dppc2 = .94); and GAF (b = 12.3, SE = 3.2, 95% CI [6.1, 18.6], p < .001; dppc2 = 2.91) compared with the ETAU condition. Results were generally maintained, or improved, at 6 months; although, adherence findings were mixed depending on the calculation method. CONCLUSIONS CBT-BISC shows preliminary efficacy in the integrated treatment of body image disturbance and HIV self-care behaviors among sexual minority men living with HIV. (PsycINFO Database Record
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Orrell C, Cohen K, Leisegang R, Bangsberg DR, Wood R, Maartens G. Comparison of six methods to estimate adherence in an ART-naïve cohort in a resource-poor setting: which best predicts virological and resistance outcomes? AIDS Res Ther 2017; 14:20. [PMID: 28376815 PMCID: PMC5379739 DOI: 10.1186/s12981-017-0138-y] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Accepted: 03/01/2017] [Indexed: 11/16/2022] Open
Abstract
Background Incomplete adherence to antiretroviral therapy (ART) results in virologic failure and resistance. It remains unclear which adherence measure best predicts these outcomes. We compared six patient-reported and objective adherence measures in one ART-naïve cohort in South Africa. Methods We recruited 230 participants from a community ART clinic and prospectively collected demographic data, CD4 count and HIV-RNA at weeks 0, 16 and 48. We quantified adherence using 3-day self-report (SR), clinic-based pill count (CPC), average adherence by pharmacy refill (PR-average), calculation of medication-free days (PR-gaps), efavirenz therapeutic drug monitoring (TDM) and an electronic adherence monitoring device (EAMD). Associations between adherence measures and virologic and genotypic outcomes were modelled using logistic regression, with the area under the curve (AUC) from the receiver operator characteristic (ROC) analyses derived to assess performance of adherence measures in predicting outcomes. Results At week 48 median (IQR) adherence was: SR 100% (100–100), CPC 100% (95–107), PR-average 103% (95–105), PR-gaps 100% (95–100) and EAMD 86% (59–94), and efavirenz concentrations were therapeutic (>1 mg/L) in 92%. EAMD, PR-average, PR-gaps and CPC best predicted virological outcome at week 48 with AUC ROC of 0.73 (95% CI 0.61–0.83), 0.73 (95% CI 0.61–0.85), 0.72 (95% CI 0.59–0.84) and 0.64 (95% CI 0.52–0.76) respectively. EAMD, PR-gaps and PR-average were highly predictive of detection of resistance mutations at week 48, with AUC ROC of 0.92 (95% CI 0.87–0.97), 0.86 (0.67–1.0) and 0.83 (95% CI 0.65–1.0) respectively. SR and TDM were poorly predictive of outcomes at week 48. Conclusion EAMD and both PR measures predicted resistance and virological failure similarly. Pharmacy refill data is a pragmatic adherence measure in resource-limited settings where electronic monitoring is unavailable. Trial registration The trial was retrospectively registered in the Pan African Clinical Trials Registry, number PACTR201311000641402, on the 13 Sep 2013 (www.pactr.org). The first participant was enrolled on the 12th July 2012. The last patient last visit (week 48) was 15 April 2014 Electronic supplementary material The online version of this article (doi:10.1186/s12981-017-0138-y) contains supplementary material, which is available to authorized users.
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Haberer JE, Sabin L, Amico KR, Orrell C, Galárraga O, Tsai AC, Vreeman RC, Wilson I, Sam‐Agudu NA, Blaschke TF, Vrijens B, Mellins CA, Remien RH, Weiser SD, Lowenthal E, Stirratt MJ, Sow PS, Thomas B, Ford N, Mills E, Lester R, Nachega JB, Bwana BM, Ssewamala F, Mbuagbaw L, Munderi P, Geng E, Bangsberg DR. Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations. J Int AIDS Soc 2017; 20:21371. [PMID: 28630651 PMCID: PMC5467606 DOI: 10.7448/ias.20.1.21371] [Citation(s) in RCA: 117] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Accepted: 02/24/2017] [Indexed: 01/01/2023] Open
Abstract
Introduction: Successful population-level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale-up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource-limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource-limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta-analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low- and middle-income countries. Interventions are categorized broadly as education and counselling; information and communication technology-enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource-limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi-media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.
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Affiliation(s)
- Jessica E. Haberer
- Massachusetts General Hospital Global Health, Boston, MA, USA
- Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Lora Sabin
- Department of Global Health, Center for Global Health and Department, Boston University School of Public Health, Boston, MA, USA
| | - K. Rivet Amico
- Department of Health Behavior and Health Education, University of Michigan School of Public Health, Ann Arbor, MI, USA
| | - Catherine Orrell
- Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine, and Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - Omar Galárraga
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Alexander C. Tsai
- Chester M. Pierce, MD Division of Global Psychiatry, Massachusetts General Hospital, Boston, MA, USA
| | - Rachel C. Vreeman
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Ira Wilson
- Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI, USA
| | - Nadia A. Sam‐Agudu
- Clinical Department, Institute of Human Virology Nigeria, Abuja, Nigeria
- Institute of Human Virology and Department of Pediatrics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Terrence F. Blaschke
- Department of Medicine and Clinical Pharmacology, Stanford University School of Medicine, Stanford, CA, USA
| | - Bernard Vrijens
- Department of Biostatistics, University of Liège, Liège, Wallonia, Belgium
- WestRock Healthcare, Sion, Switzerland
| | - Claude A. Mellins
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Robert H. Remien
- HIV Center for Clinical and Behavioral Studies, NYSPI and Department of Psychiatry, Columbia; University, New York, NY, USA
| | - Sheri D. Weiser
- Division of HIV, ID and Global Medicine, Department of Medicine, University of California, San Francisco, CA, USA
| | - Elizabeth Lowenthal
- Departments of Pediatrics and Epidemiology, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Michael J. Stirratt
- Division of AIDS Research, National Institute of Mental Health, Bethesda, MD, USA
| | - Papa Salif Sow
- Bill and Melinda Gates Foundation, Seattle, WA, USA
- Department of Infectious diseases, University of Dakar, Dakar, Sénégal
| | | | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Edward Mills
- Faculty of Health Sciences, University of Ottawa, Ottawa, Ontario, Canada
| | - Richard Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia
| | - Jean B. Nachega
- Department of Epidemiology, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Bosco Mwebesa Bwana
- Department of Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Fred Ssewamala
- Columbia University School of Social Work & School of International and Public Affairs, New York, NY, USA
| | - Lawrence Mbuagbaw
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Paula Munderi
- HIV Care Research Program, Medical Research Council, Uganda Virus Research Institute, Entebbe, Uganda
| | - Elvin Geng
- Division of HIV, Infectious Disease and Global Medicine, San Francisco General Hospital, Department of Medicine, University of California, San Francisco, CA, USA
| | - David R. Bangsberg
- Oregon Health & Sciences University‐Portland State University School of Public Health, Portland, OR, USA
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Phillips AN, Cambiano V, Nakagawa F, Bansi-Matharu L, Sow PS, Ehrenkranz P, Ford D, Mugurungi O, Apollo T, Murungu J, Bangsberg DR, Revill P. Cost Effectiveness of Potential ART Adherence Monitoring Interventions in Sub-Saharan Africa. PLoS One 2016; 11:e0167654. [PMID: 27977702 PMCID: PMC5157976 DOI: 10.1371/journal.pone.0167654] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Accepted: 11/17/2016] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Interventions based around objective measurement of adherence to antiretroviral drugs for HIV have potential to improve adherence and to enable differentiation of care such that clinical visits are reduced in those with high adherence. It would be useful to understand the approximate upper limit of cost that could be considered for such interventions of a given effectiveness in order to be cost effective. Such information can guide whether to implement an intervention in the light of a trial showing a certain effectiveness and cost. METHODS An individual-based model, calibrated to Zimbabwe, which incorporates effects of adherence and resistance to antiretroviral therapy, was used to model the potential impact of adherence monitoring-based interventions on viral suppression, death rates, disability adjusted life years and costs. Potential component effects of the intervention were: enhanced average adherence when on ART, reduced risk of ART discontinuation, and reduced risk of resistance acquisition. We considered a situation in which viral load monitoring is not available and one in which it is. In the former case, it was assumed that care would be differentiated based on the adherence level, with fewer clinic visits in those demonstrated to have high adherence. In the latter case, care was assumed to be primarily differentiated according to viral load level. The maximum intervention cost required to be cost effective was calculated based on a cost effectiveness threshold of $500 per DALY averted. FINDINGS In the absence of viral load monitoring, an adherence monitoring-based intervention which results in a durable 6% increase in the proportion of ART experienced people with viral load < 1000 cps/mL was cost effective if it cost up to $50 per person-year on ART, mainly driven by the cost savings of differentiation of care. In the presence of viral load monitoring availability, an intervention with a similar effect on viral load suppression was cost-effective when costing $23-$32 per year, depending on whether the adherence intervention is used to reduce the level of need for viral load measurement. CONCLUSION The cost thresholds identified suggest that there is clear scope for adherence monitoring-based interventions to provide net population health gain, with potential cost-effective use in situations where viral load monitoring is or is not available. Our results guide the implementation of future adherence monitoring interventions found in randomized trials to have health benefit.
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Affiliation(s)
- Andrew N Phillips
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | - Valentina Cambiano
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | - Fumiyo Nakagawa
- Research Department of Infection & Population Health, UCL, London, United Kingdom
| | | | - Papa Salif Sow
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Peter Ehrenkranz
- Bill & Melinda Gates Foundation, Seattle, Washington, United States of America
| | - Deborah Ford
- Institute for Clinical Trials and Methodology, UCL, London, United Kingdom
| | | | | | | | - David R. Bangsberg
- Oregon Health Sciences University-Portland State University School of Public Health, Portland, Oregon, United States of America
| | - Paul Revill
- Centre for Health Economics, University of York, York, United Kingdom
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van Vlerken LG, Lieveld FI, van Meer S, Koek GH, van Nieuwkerk KMJ, Friederich P, Arends JE, Siersema PD, Burger DM, van Erpecum KJ. Adherence to ribavirin in chronic hepatitis C patients on antiviral treatment: Results from a randomized controlled trial using real-time medication monitoring. Clin Res Hepatol Gastroenterol 2016; 40:622-630. [PMID: 26867863 DOI: 10.1016/j.clinre.2015.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 12/17/2015] [Accepted: 12/25/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND OBJECTIVE Adherence is essential in antiviral therapy for chronic hepatitis C. We investigated the effect of real-time medication monitoring on adherence to ribavirin. METHODS In this randomized controlled trial, patients in the intervention group received a medication dispenser that monitored ribavirin intake real-time during 24 weeks PEG-interferon/ribavirin±boceprevir or telaprevir. Patients in the control group received standard-of-care. Adherence was also measured by pill count. RESULTS Seventy-two patients were assigned to either intervention (n=35) or control groups (n=37). Median adherence by pill count was 96% (range: 43%-100%) with 30 (94%) of patients exhibiting≥80% adherence. Perfect adherence (i.e. 100%) was similar in intervention and control groups: 22 (85%) vs. 15 (75%) (P=0.47). Adherences by real-time medication monitoring and by pill count did not correlate (R=0.19, P=0.36). No predictors of poor adherence could be identified. Ribavirin trough levels after 8 weeks (median: 2.4 vs. 2.7mg/L, P=0.30) and 24 weeks (median: 3.0 vs. 3.0mg/L, P=0.69), and virological responses did not differ between intervention and control groups. CONCLUSIONS Adherence to ribavirin during PEG-interferon containing therapy in chronic hepatitis C is high. Real-time medication monitoring did not influence adherence to ribavirin, plasma ribavirin levels or virological responses.
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Affiliation(s)
- Lotte G van Vlerken
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Faydra I Lieveld
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; Department of Internal Medicine and Infectious Diseases, University Medical Center of Utrecht, Utrecht, The Netherlands
| | - Suzanne van Meer
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands
| | - Ger H Koek
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Karin M J van Nieuwkerk
- Department of Gastroenterology and Hepatology, Free University Medical Center, Amsterdam, The Netherlands
| | - Pieter Friederich
- Department of Gastroenterology and Hepatology, Catharina Hospital, Eindhoven, The Netherlands
| | - Joop E Arends
- Department of Internal Medicine and Infectious Diseases, University Medical Center of Utrecht, Utrecht, The Netherlands
| | - Peter D Siersema
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands; Department of Gastroenterology and Hepatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - David M Burger
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Karel J van Erpecum
- Department of Gastroenterology and Hepatology, University Medical Center of Utrecht, P.O. Box 85500, 3508 GA Utrecht, The Netherlands.
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Cerutti B, Broers B, Masetsibi M, Faturiyele O, Toti-Mokoteli L, Motlatsi M, Bader J, Klimkait T, Labhardt ND. Alcohol use and depression: link with adherence and viral suppression in adult patients on antiretroviral therapy in rural Lesotho, Southern Africa: a cross-sectional study. BMC Public Health 2016; 16:947. [PMID: 27608764 PMCID: PMC5015267 DOI: 10.1186/s12889-016-3209-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 06/24/2016] [Indexed: 11/30/2022] Open
Abstract
Background Depression and alcohol use disorder have been shown to be associated with poor adherence to antiretroviral therapy (ART). Studies examining their association with viral suppression in rural Africa are, however, scarce. Methods This study reports prevalence of depressive symptoms and alcohol use disorder, and their potential association with adherence and viral suppression in adult patients on ART in ten clinics in rural Lesotho, Southern Africa. Results Among 1,388 adult patients (69 % women), 80.7 % were alcohol abstinent, 6.3 % were hazardous drinkers (men: 10.7 %, women: 4.4 %, p < 0.001). The prevalence of depressive symptoms was 28.8 % (men 20.2 %, women 32.7 %, p < 0.001). Both alcohol consumption (adjusted odds-ratio: 2.09, 95 % CI: 1.58-2.77) and alcohol use disorder (2.73, 95 % CI: 1.68-4.42) were significantly associated with poor adherence. There was, however, no significant association with viral suppression. Conclusions Whereas the results of this study confirm previously reported association of alcohol use disorder with adherence to ART, there was no association with viral suppression. Trial registration April 28th 2014; NCT02126696.
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Affiliation(s)
- Bernard Cerutti
- Faculty of Medicine, University of Geneva, UDREM, 1 Rue Michel Servet, 1211, Geneva 4, Switzerland.
| | - Barbara Broers
- Dependencies Unit, Department of Community Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | | | | | - Mokete Motlatsi
- SolidarMed, Swiss Organization for Health in Africa, Maseru, Lesotho
| | - Joelle Bader
- Department of Biomedicine, University of Basel, Basel, Switzerland
| | - Thomas Klimkait
- Department of Biostatistics, Epidemiology and Public Health Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
| | - Niklaus D Labhardt
- Clinical Research Unit, Swiss Tropical and Public Health Institute, Basel, Switzerland
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Cell Phone-Based and Adherence Device Technologies for HIV Care and Treatment in Resource-Limited Settings: Recent Advances. Curr HIV/AIDS Rep 2016; 12:523-31. [PMID: 26439917 DOI: 10.1007/s11904-015-0282-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Numerous cell phone-based and adherence monitoring technologies have been developed to address barriers to effective HIV prevention, testing, and treatment. Because most people living with HIV and AIDS reside in resource-limited settings (RLS), it is important to understand the development and use of these technologies in RLS. Recent research on cell phone-based technologies has focused on HIV education, linkage to and retention in care, disease tracking, and antiretroviral therapy adherence reminders. Advances in adherence devices have focused on real-time adherence monitors, which have been used for both antiretroviral therapy and pre-exposure prophylaxis. Real-time monitoring has recently been combined with cell phone-based technologies to create real-time adherence interventions using short message service (SMS). New developments in adherence technologies are exploring ingestion monitoring and metabolite detection to confirm adherence. This article provides an overview of recent advances in these two families of technologies and includes research on their acceptability and cost-effectiveness when available. It additionally outlines key challenges and needed research as use of these technologies continues to expand and evolve.
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Ware NC, Pisarski EE, Tam M, Wyatt MA, Atukunda E, Musiimenta A, Bangsberg DR, Haberer JE. The Meanings in the messages: how SMS reminders and real-time adherence monitoring improve antiretroviral therapy adherence in rural Uganda. AIDS 2016; 30:1287-94. [PMID: 26807967 PMCID: PMC4853242 DOI: 10.1097/qad.0000000000001035] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 12/22/2015] [Accepted: 01/04/2016] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To understand how a pilot intervention combining SMS reminders with real-time adherence monitoring improved adherence to HIV antiretroviral therapy (ART) for adults initiating treatment in rural Uganda. DESIGN Qualitative study, conducted with a pilot randomized controlled trial. METHODS Sixty-two pilot intervention study participants took part in qualitative interviews on: preferences for content; frequency and timing of SMS adherence reminders; understandings and experiences of SMS reminders; and understandings and experiences of real-time adherence monitoring. Analysis of interview data was inductive and derived categories describing how participants experienced the intervention, and what it meant to them. RESULTS SMS reminders prompted taking individual doses of antiretroviral therapy, and helped to develop a 'habit' of adherence. Real-time adherence monitoring was experienced as 'being seen'; participants interpreted 'being seen' as an opportunity to demonstrate seriousness of commitment to treatment and 'taking responsibility' for adherence. Both SMS reminders and real-time monitoring were interpreted as signs of 'caring' by the healthcare system. Feeling 'cared about' offset depressed mood and invigorated adherence. CONCLUSION Although serving as reminders, SMS messages and real-time adherence monitoring also had larger emotional and moral meanings for participants that they felt improved their adherence. Understanding the larger 'meanings in the messages,' as well as their more literal content and function, will be central in delineating how SMS reminders and other adherence interventions using cellular technology work or do not work in varying contexts.
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Affiliation(s)
- Norma C. Ware
- Department of Global Health and Social Medicine, Harvard Medical School
- Division of Global Health Equity, Department of Medicine, Brigham & Women's Hospital, Boston, Massachusetts, USA
| | - Emily E. Pisarski
- Department of Global Health and Social Medicine, Harvard Medical School
| | - Melanie Tam
- Department of Global Health and Social Medicine, Harvard Medical School
| | - Monique A. Wyatt
- Department of Global Health and Social Medicine, Harvard Medical School
| | - Esther Atukunda
- Mbarara University of Science and Technology, Mbarara, Uganda
| | | | - David R. Bangsberg
- Center for Global Health, Massachusetts General Hospital
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jessica E. Haberer
- Center for Global Health, Massachusetts General Hospital
- Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
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de Sumari-de Boer IM, van den Boogaard J, Ngowi KM, Semvua HH, Kiwango KW, Aarnoutse RE, Nieuwkerk PT, Kibiki GS. Feasibility of Real Time Medication Monitoring Among HIV Infected and TB Patients in a Resource-Limited Setting. AIDS Behav 2016; 20:1097-107. [PMID: 26604004 DOI: 10.1007/s10461-015-1254-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
HIV infected and tuberculosis (TB) patients need high levels of treatment adherence to achieve optimal treatment outcomes. We conducted a pilot-study on real time medication monitoring (RTMM) in a resource-limited setting. We enrolled five HIV infected and five TB patients from Kilimanjaro, Tanzania. They took their medication using RTMM. When the device was not opened on time, patients received a reminder SMS. After 3 months, we interviewed patients. Six patients (60 %) reached adherence of >95 %. Nine-hundred-twenty-two of 1104 intakes (84 %) were on time. Five-hundred reminders (45 %) were sent, of which 202 (40 %) were incorrect, because of an unstable mobile network. Nine patients found the device helpful and nine mentioned it keeps medication safe. Six patients reported that the size was too big. Five patients mentioned they received incorrect reminders. The device is considered useful in Kilimanjaro. Optimization of the device should consider network connectivity and the size of the device.
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Affiliation(s)
- I Marion de Sumari-de Boer
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania.
| | - Jossy van den Boogaard
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
| | - Kennedy M Ngowi
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
| | - Hadija H Semvua
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
| | - Krisanta W Kiwango
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
| | - Rob E Aarnoutse
- Department of Pharmacy, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pythia T Nieuwkerk
- Department of Medical Psychology, Amsterdam Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Gibson S Kibiki
- Department of clinical trials, Kilimanjaro Clinical Research Institute, Dr. I Marion Sumari-de Boer, PO Box 2236, Moshi, Tanzania
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Comparison of subjective and objective adherence measures for preexposure prophylaxis against HIV infection among serodiscordant couples in East Africa. AIDS 2016; 30:1121-9. [PMID: 26785125 DOI: 10.1097/qad.0000000000001024] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Preexposure prophylaxis (PrEP) efficacy is highly dependent on adherence. Yet, it is unclear which adherence measures perform best for PrEP. METHODS We compared three types of self-reported adherence questions (rating of ability to adhere, frequency of doses taken, percentage of doses taken) and three forms of objective adherence measurement [unannounced pill counts (UPC), electronic monitoring, plasma tenofovir levels] using data from an ancillary adherence study within a clinical trial of PrEP among East African serodiscordant couples (Partners PrEP Study). Monthly measures were assessed for the first 6 months of follow-up. RESULTS One thousand, one hundred and forty-seven participants contributed 6048 person-months of data to this analysis. Median adherence was high: self-reported rating (90%), self-reported frequency (93%), and self-reported percentage (97%); UPC (99%); and electronic monitoring (97%). Prevalence of steady-state daily dosing (SSDD; ≥40 ng/ml) was 74% in a random subset of tenofovir samples obtained from 365 participants. Discrimination of SSDD versus less than SSDD levels was poor for self-reported rating [area under the receiver-operating curve (AROC) 0.54], self-reported frequency (AROC 0.52), self-reported percentage (AROC 0.56) and UPC (AROC 0.58), but moderate for electronic monitoring (AROC 0.70). Correlation was moderate among self-reported measures, adherence (0.61-0.66), but low for these self-reported measures compared with UPC (0.32-0.36) and with electronic monitoring (0.22-0.28). CONCLUSION Electronic monitoring was the only adherence measure with meaningful ability to discriminate between SSDD and less than SSDD plasma tenofovir levels. Correlation between subjective and objective measures was poor. Future research should explore novel approaches to adherence measurement as PrEP moves into demonstration projects and programmatic implementation.
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Campbell JI, Eyal N, Musiimenta A, Haberer JE. Ethical Questions in Medical Electronic Adherence Monitoring. J Gen Intern Med 2016; 31:338-42. [PMID: 26358284 PMCID: PMC4762813 DOI: 10.1007/s11606-015-3502-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 05/15/2015] [Accepted: 08/14/2015] [Indexed: 11/30/2022]
Abstract
Electronic adherence monitors (EAMs) record and report an array of health behaviors, ranging from taking daily medications to wearing medical devices. EAMs are utilized in research worldwide and are being investigated for clinical use. However, there is also growing popular concern about the extent to which electronic devices may be used to monitor individuals, including allegations in the media that EAMs represent a move towards "Big Brother" in medicine. Here, we highlight the unique benefits as well as the potential ethical challenges that electronic adherence monitoring generates. These challenges surround autonomy, privacy and confidentiality, trust, and ancillary care obligations. We describe key questions within each of these domains that warrant further investigation, and present potential solutions to many of the concerns raised.
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Affiliation(s)
| | - Nir Eyal
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA.
| | - Angella Musiimenta
- Department of Information Technology, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Jessica E Haberer
- Center for Global Health, Massachusetts General Hospital, Boston, MA, USA.,Department of Medicine, Harvard Medical School, Boston, MA, USA
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A Randomized Controlled Trial of Real-Time Electronic Adherence Monitoring With Text Message Dosing Reminders in People Starting First-Line Antiretroviral Therapy. J Acquir Immune Defic Syndr 2016. [PMID: 26218411 DOI: 10.1097/qai.0000000000000770] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND There are conflicting findings about whether mobile phone text message reminders impact on antiretroviral adherence. We hypothesized that text reminders sent when dosing was late would improve adherence and HIV viral suppression. METHODS Antiretroviral therapy (ART)-naive participants, from a South African outpatient ART clinic, were randomized to standard of care (SoC, 3 pretreatment education sessions), or intervention (SoC and automated text reminders if dosing >30 minutes late). Dosing time was recorded by real-time electronic adherence monitoring devices, given to participants at ART start. CD4 cell count and HIV RNA were determined at baseline, 16 and 48 weeks. Primary outcome was cumulative adherence execution by electronic adherence monitoring device. HIV-1 viral suppression (<40 copies/mL) at week 48 and count of treatment interruptions (TIs) >72 hours were secondary outcomes. Analysis was by intention to treat (missing = failure). Registration was with the Pan-African Clinical Trials Registry: PACTR201311000641402. RESULTS A total of 230 participants were randomly assigned to control (n = 115) or intervention (n = 115) arms. Median adherence was 82.1% (interquartile range, 56.6%-94.6%) in the intervention arm, compared with 80.4% (interquartile range, 52.8%-93.8%) for SoC [adjusted odds ratio for adherence 1.08; 95% confidence interval (CI): 0.77 to 1.52]. Suppressed HIV RNA (<40 copies/mL) occurred in 80 (69.6%) of control and 75 (65.2%) of intervention (adjusted odds ratio for virological failure in intervention arm 0.77; 95% CI: 0.42 to 1.40). In the intervention arm, the count of TIs of >72 hours was reduced (adjusted incident rate ratio, 0.84; 95% CI: 0.75 to 0.94). CONCLUSIONS Text message reminders linked to late doses detected by real-time adherence monitoring reduced the number of prolonged TIs, but did not significantly improve adherence or viral suppression.
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Nerini E, Bruno F, Citterio F, Schena FP. Nonadherence to immunosuppressive therapy in kidney transplant recipients: can technology help? J Nephrol 2016; 29:627-36. [DOI: 10.1007/s40620-016-0273-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Accepted: 02/03/2016] [Indexed: 10/22/2022]
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Magidson JF, Saal W, Nel A, Remmert JE, Kagee A. Relationship between depressive symptoms, alcohol use, and antiretroviral therapy adherence among HIV-infected, clinic-attending patients in South Africa. J Health Psychol 2016; 22:1426-1433. [PMID: 26884445 DOI: 10.1177/1359105316628743] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Despite the prevalence of depression and alcohol use among HIV-infected individuals, few studies have examined their association together in relation to nonadherence to antiretroviral therapy in sub-Saharan Africa. This study examined depressive symptoms, alcohol use, and other psychosocial factors (stigma, demographic characteristics) in relation to nonadherence to antiretroviral therapy among clinic-attending, HIV-infected individuals in South Africa ( n = 101). Nonadherence was assessed using event-level measurement (missed doses over the past weekend). Multivariable logistic regression analyses revealed that only alcohol use, over and above depressive symptoms and education level, was associated with antiretroviral therapy nonadherence(AOR = 1.15; 95%CI = 1.02-1.29; p < .05). Findings point to the independent association of alcohol use and nonadherence to antiretroviral therapy above and beyond depressive symptoms.
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Duration of Antiretroviral Therapy Adherence Interruption Is Associated With Risk of Virologic Rebound as Determined by Real-Time Adherence Monitoring in Rural Uganda. J Acquir Immune Defic Syndr 2016; 70:386-92. [PMID: 26110445 DOI: 10.1097/qai.0000000000000737] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antiretroviral therapy (ART) adherence interruptions have been associated with viral rebound; however, the true risk is unknown because HIV RNA has never been measured during ongoing interruptions. METHODS The Uganda AIDS Rural Treatment Outcomes Study is an observational longitudinal cohort of adults initiating ART. We monitored adherence with the device that wirelessly transmits records of device openings, and routinely assessed HIV RNA quarterly. When lapses of 48+ hours between device openings were detected, we made unannounced visits to participants to investigate the cause and assess HIV RNA. Generalized estimating equation logistic regressions were used to assess factors associated with viral rebound. RESULTS We followed 479 participants (median: 25 months per participant). Most were women (72%), median age was 36 years, median pre-ART CD4 count was 198 cells per microliter, median pre-ART HIV RNA level was 5.0 log10 copies per milliliter, and median duration of prior viral suppression was 13 months. A total of 587 adherence interruptions followed confirmed prior viral suppression, of which 13 (2%) had detectable viral rebound. Viral rebound was associated with duration of adherence interruption (odds ratio: 1.25 for each day beyond 48 hours; P = 0.007) and 30-day adherence before the interruption (odds ratio: 0.73; P = 0.02). DISCUSSION This article is the first demonstration of HIV RNA rebound during adherence interruptions objectively measured in real time. Odds of viral rebound increased by 25% with each day beyond 48 hours. Real-time adherence monitoring was feasible in a sub-Saharan African setting. Further research should assess the potential for real-time adherence interventions to sustain adherence to affordable first-line regimens.
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