Randomized Factorial Trial of Phone-Delivered Support Counseling and Daily Text Message Reminders for HIV Treatment Adherence

Developing and testing a web-based platform for antiretroviral therapy (ART) adherence support among adolescents and young adults (AYA) living with HIV

Objective

Describe the development and testing of a web-based platform for antiretroviral treatment (ART) adherence support among HIV+ adolescents and young adults (AYA) in a randomized controlled trial (RCT).

Methods

A seven-member multi-disciplinary team operationalized the flat, password protected, web-based platform. Manualized protocols guided the objectives and content for each of the eight web-based sessions. Team members evaluated usability and content validity. Client satisfaction and perceived ease of use was evaluated with the first ten HIV+ AYA participants.

Results

The web-based platform was developed, evaluated, refined, implemented and pilot tested between September 2020 to April 2022. Usability was rated as high; the evaluation of content validity showed an excellent fit between session content and objectives. HIV+ AYA participants (mean age = 24.2 years) were satisfied with the quality, type, and amount of support/education received, and found the platform easy to use, operate, and navigate. Average time spent per session was 6.5 min.

Conclusion

Findings support the usability, validity, acceptability, and feasibility of this web-based platform for ART adherence support among HIV+ AYA.

Innovation

Our research and findings are responsive to research gaps and the need for transparency in the methodological development and testing of web-based control arms for ART adherence support among HIV+ AYA.

Effects of telehealth-assisted interventions among people living with HIV/AIDS: A systematic review and meta-analysis of randomized controlled studies

INTRODUCTION

Taking antiretroviral therapy (ART) is a daily necessity for people living with HIV but these individuals experience multiple barriers and challenges to medication adherence. Interventions to support medication adherence have yielded effects in the expected direction, but the extent to which telehealth or virtually delivered interventions to promote adherence are effective among people living with HIV/AIDS remains unknown. We aimed to address this knowledge gap and inform future research and practice that promotes the well-being of people living with HIV/AIDs through telehealth interventions addressing medication use.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) was conducted using the following databases: Academic Search Complete, Cochrane library, Cumulative Index to Nursing and Allied Health Literature (CINAHL), EMBASE, MEDLINE, PubMed, OVID (UpToDate), and the Web of Science. Relevant full-text articles published through September 2021 were retrieved. The revised Cochrane risk of bias tool for randomized trials was used to assess the methodological quality of the included studies. A meta-analysis was performed using a random-effects model to calculate the pooled effects of telehealth-assisted interventions for people living with HIV/AIDS. Stata 16.0 was used for statistical analysis.

RESULTS

A total of 12 studies (N = 3557 participants) that used telehealth-assisted interventions for people living with HIV/AIDS were included. Telehealth interventions were found to increase the adherence to treatment (standardized mean difference [SMD]: 0.21; 95% confidence interval (CI): 0.03 to 0.40), to reduce depressive symptoms (SMD: -2,74; 95% CI: -3.39 to -2.09), and to improve perceived quality of life (SMD: 0.74; 95% CI: 0.37 to 1.10).

DISCUSSION

The meta-effects of telehealth-assisted interventions include significantly enhanced adherence to treatment, improved quality of life, and reduced depressive symptoms among people living with HIV/AIDS. These findings suggesting that delivering health management interventions remotely through telehealth-assisted modalities was both feasible and effective in yielding health benefits for people living with HIV/AIDS. Integrating telehealth-assisted interventions as a modality in HIV/AIDS care might support continuity of care and sustained well-being. Future research should evaluate telehealth intervention outcomes and examine mediating, moderating, or other tailorable variables affecting intervention effectiveness.

The three-item patient-reported instrument for retrospective adherence in resource constrained settings: reliability, validity and potential utility

INTRODUCTION

Patient-report instruments remain the most feasible and sustainable approaches for monitoring medication adherence in clinical settings. However, questions of their reliability and validity persist. Studies suggest that the 3-item instrument for retrospective adherence (IRA) developed by Wilson et al. offers a viable option for clinically monitoring medication adherence. Here we report the reliability and validity of the IRA among patients recruited from community-based HIV clinics and antiretroviral therapy (ART) dispensaries in a resource constrained township in Cape Town, South Africa.

METHODS

Women (n = 794) and men (n = 228) receiving ART completed the IRA at three time points: (a) in a face-to-face administration at enrollment (b) in1-week phone interview and (c) 1-month phone interview. Participants also provided contemporaneous blood samples for HIV viral load testing as a clinical outcome and unannounced phone-based pill counts as an objective assessment of ART adherence.

RESULTS

The IRA was internally consistent and showed evidence of time stability. The IRA also demonstrated validity with respect to pill count adherence, correlates of adherence, and HIV viral load. Response operating curve analysis yielded an area under the curve of 0.646, using 75% adherence as the cut-off, with 0.637 sensitivity and 0.567 specificity.

CONCLUSIONS

The IRA demonstrated reliability, construct validity and criterion validity in a resource constrained setting, supporting use of the IRA in research and clinical care.

Effect of Phone-Based Enhanced Adherence Counseling (EAC) Among Virally Unsuppressed Key Population (KP)

BACKGROUND

 Despite the reduced human immunodeficiency virus (HIV) disease burden in Nigeria and globally, the key populations (KPs) can be disproportionately burdened with HIV infection and lower treatment coverage and outcome. A viral load (VL) test is needed to monitor the treatment outcome of KP with VL suppression of < 1000 copies/mL, demonstrating a positive treatment outcome. For unsuppressed VL, enhanced adherence counseling (EAC) may improve viral suppression in people living with HIV/KPs living with HIV (PLHIV/KPLHIV). Conventionally, EAC sessions are done for 3 months through physical visits. Due to the challenges of monthly visits (including transportation, socioeconomic status, and high mobility among KPs), other EAC delivery models need to be explored. We aimed to assess the effect of phone EAC sessions among virally unsuppressed KPs compared to physical EAC.

METHOD

 Using a prospective intervention study design with a sample size of 484, unsuppressed KPLHIV in Delta State Nigeria were selectively stratified (non-randomized) using a simple stratification (ability vs. inability to physically attend EAC sessions in-person) into an intervention group and a control group, receiving phone-based EAC sessions and physical EAC sessions respectively. Repeated VL tests were done 3 months after the intervention, and viral suppression was pegged at the WHO recommendation of <1000 copies/mL. The SPSS version 24.0 (SPSS Inc., Chicago, USA) was used for data analysis of variables within and between study groups. Significance was interpreted at p < 0.05.

RESULT

 Participants were 87.4% males {out of which 75.0% (363/484) identified as men who have sex with men (MSM)} with a mean age of 26 ± 2 years. The intervention group had a slightly higher EAC completion rate at 99.6% than the control group (97.9%). Both groups showed significant differences in viral suppression from 0% to a mean suppression of 88.7% with p < 0.01. The intervention group achieved better suppression (90.5%) than the control group (86.7%).

CONCLUSION

 EAC effectively achieves viral suppression by up to 90% among KPLHIV. Phone-based EAC has also proven effective and, in our findings, slightly more effective than the conventional physical EAC and is recommended among KPLHIV with the known challenge of transportation or poor mobility.

Does telehealth affect the adherence to ART among patients with HIV? A systematic review and meta-analysis

BACKGROUND

Several studies have shown different effects of telehealth interventions on adherence to Antiretroviral therapy (ART) among people living with HIV. This study conducted a meta-analysis of Randomized Controlled Trials (RCTs) to estimate the pooled effect of telehealth interventions on the treatment adherence of HIV patients.

METHODS

The researchers conducted literature searches in Scopus, PubMed, Web of Science, Google Scholar, and Cochrane Central Register of Controlled Trials databases. In addition, open grey was systematically searched until January 2022 for RCTs around the effects of telehealth on adherence to treatment ART among patients with HIV. Each study's methodological quality was assessed using the Cochrane Collaboration tool. Pooled Standard Mean Differences (SMD) and Risk Ratio (RR) with 95% CI were calculated using the random effects model.

RESULTS

In total, 12 eligible articles were considered in the present systematic review. A random-effects meta-analysis using 5 RCTs yielded the pooled RR estimate of 1.18 (95% CI: 1.03 to 1.35, p < 0.05); I2 = 0, suggesting the adherence to treatment among patients with HIV who received telehealth intervention was significantly 18% upper than control groups. Moreover, the random effects analysis of SMD showed a positive effect for telehealth with SMR = 0.36 (95% CI: 0.22 to 0.49, p < 0.05); I2 = 91.9%, indicating that telehealth intervention increased ART adherence to the treatment group compared to the control group.

CONCLUSION

Telehealth intervention as a new modality of health care service delivery could be a valuable strategy to improve ART adherence among patients with HIV. It can strengthen the capacity of HIV care services. On a large scale, telehealth can be utilized as a supplementary component for ART delivery and retention toward successful adherence to the therapy.

The role of resilience in daily experiences of posttraumatic growth, affect, and HIV/AIDS stigma among people living with HIV

This study investigated the intraindividual variability in daily posttraumatic growth (PTG) versus posttraumatic depreciation (PTD), positive and negative affect (PA and NA), and HIV/AIDS stigma among people living with HIV (PLWH). In particular, we examined whether this variability derives from participants' resilience operationalized on a trait level. The participants included 67 PLWH, who completed a baseline questionnaire on resilience, measured with the Brief Resilience Scale. Following this, they completed the shortened versions of the following inventories over five consecutive days: the Posttraumatic Growth and Posttraumatic Depreciation Inventory V Expanded version Inventory, the Positive and Negative Affect Schedule - Expanded Form, and the Berger HIV Stigma Scale. Hierarchical linear modeling (HLM) was utilized to analyze the study results. We observed significant intraindividual variability in PTG, PTD, PA, NA, and perceived HIV/AIDS stigma. Resilience was related to PTG, PTD, PA, and NA but not to stigma. Moreover, higher resilience was associated with higher, stabler PA and lower, stabler NA. Our results highlight the need of further studies on the daily functioning of PLWH. Specifically, while health status is important, it does not appear to be the predominant source of everyday distress for PLWH. Consequently, psychological counselling for PLWH should concentrate more on the life of the person as a whole and not only on coping with HIV infection.

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

Background

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

Methods

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

Results

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

Conclusions

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

Supplementary Information

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

Psychosocial Interventions to Promote Undetectable HIV Viral Loads: A Systematic Review of Randomized Clinical Trials

Suppressing HIV viral loads to undetectable levels is essential for ending the HIV/AIDS epidemic. We evaluated randomized controlled trials aimed to increase antiretroviral medication adherence and promote undetectable viral loads among people living with HIV through November 22, 2019. We extracted data from 51 eligible interventions and analyzed the results using random effects models to compare intervention effects between groups within each intervention and across interventions. We also evaluated the relation between publication date and treatment effects. Only five interventions increased undetectable viral loads significantly. As a whole, the analyzed interventions were superior to Standard of Care in promoting undetectable viral loads. Interventions published more recently were not more effective in promoting undetectable viral loads. No treatment category consistently produced significant increases in undetectable viral loads. To end the HIV/AIDS epidemic, we should use interventions that can suppress HIV viral loads to undetectable levels.

Patients' and Providers' Views on Optimal Evidence-Based and Scalable Interventions for Individuals at High Risk of HIV Treatment Failure: Sequential Explorations Among Key Stakeholders in Cape Town, South Africa

To support translation of evidence-based interventions into practice for HIV patients at high risk of treatment failure, we conducted qualitative research in Cape Town, South Africa. After local health officials vetted interventions as potentially scalable, we held 41 in-depth interviews with patients with elevated viral load or a 3-month treatment gap at community clinics, followed by focus group discussions (FGDs) with 20 providers (physicians/nurses, counselors, and community health care workers). Interviews queried treatment barriers, solutions, and specific intervention options, including motivational text messages, data-informed counseling, individual counseling, peer support groups, check-in texts, and treatment buddies. Based on patients' preferences, motivational texts and treatment buddies were removed from consideration in subsequent FGDs. Patients most preferred peer support groups and check-in texts while individual counseling garnered the broadest support among providers. Check-in texts, peer support groups, and data-informed counseling were also endorsed by provider sub-groups. These strategies warrant attention for scale-up in South Africa and other resource-constrained settings.

Characteristics of psychosocial interventions to improve ART adherence in people living with HIV: A systematic review

The HIV/AIDS pandemic continues to be a significant global public health crisis. The main HIV/AIDS treatment is the antiretroviral therapy (ART), which is highly effective but depends on the patient's adherence to be successful. However, the adherence to antiretroviral therapy remains unsatisfactory across different populations, which raises considerable difficulties at both individual and collective levels. Suboptimal adherence to ART can be overcome through multidisciplinary management that includes evidence-based psychosocial interventions. Existing reviews on these interventions have focused mainly on studies with experimental designs, overlooking valuable interventions whose evidence comes from different study designs. Here, we aimed to carry out a comprehensive review of the current research on psychosocial interventions for ART adherence and their characteristics including studies with different designs. We conducted a systematic review following PRISMA guidelines. We searched five databases (Pubmed, EBSCO, LILACS, WoS and SCIELO) for articles reporting a psychosocial intervention to improve treatment adherence for people living with HIV (adults). The quality of each study was analyzed with standardized tools, and data were summarized using a narrative synthesis method. Twenty-three articles were identified for inclusion, and they demonstrated good to fair quality. Individual counseling was the most frequent intervention, followed by SMS reminders, education, and group support. Most interventions combined different strategies and self-efficacy was the most common underlying theoretical framework. This review provides insight into the main characteristics of current psychosocial interventions designed to improve ART treatment adherence. PROSPERO number: CRD42021252449.

Randomized Community Trial Comparing Telephone versus Clinic-Based Behavioral Health Counseling for People Living with HIV in a Rural Setting

PURPOSE

To test the efficacy of a theory-based behavioral intervention delivered via telephone versus clinic-based counseling to improve HIV outcomes and reduce alcohol consumption for people at-risk for treatment failure in a rural setting.

METHODS

Patients receiving HIV care (N = 240) were randomized using a computer-generated scheme to one of three conditions: (a) telephone behavioral health counseling, (b) clinic-based behavioral health counseling, or (c) attention control nutrition education. Behavioral counseling was delivered by either a community nurse or a paraprofessional patient navigator, with differences examined. Participants were followed for 12 months to assess medication adherence using unannounced pill counts and alcohol use measured by electronic daily text message assessments, and 18 months for HIV viral load and retention in care extracted from medical records.

FINDINGS

There was evidence for telephone and office-based counseling demonstrating greater medication adherence than the control condition but only in the short term. Clinic-based behavioral counseling significantly reduced alcohol use to a greater degree than telephone counseling and the control condition. There were no other differences between conditions. There were also no discernable differences between counseling delivered by the community nurse and the patient navigator.

CONCLUSIONS

Telephone and clinic-based counseling demonstrated improved medication adherence in the short term, while clinic-based counseling demonstrated reductions in alcohol use. The modest outcomes suggest that intensive intervention strategies are needed for patients that clinicians identify as at-risk for treatment discontinuation and treatment failure.

Text Messaging Improves HIV Care Continuum Outcomes Among Young Adult Trans Women Living with HIV: Text Me, Girl!

Young adult trans women living with HIV in the US exhibit suboptimal advancement through the HIV Care Continuum relative to national averages. From December 2016 through May 2018, 134 young adult trans women living with HIV enrolled in Text Me, Girl!, a theory-based, trans-specific text-messaging intervention designed to improve HIV Care Continuum outcomes. Participants (N = 130) averaged 29.5 years, were predominantly Latinx (43%) or African American/Black (40%). Clustered logistic and ordinal logistic multivariable models (n = 105; 366 observations) indicate that through 18-month follow-up, increased exposure to the text-messaging intervention was associated with significant (p < 0.05) increased retention to HIV care (adjusted odds ratio [aOR] 1.33) and biomarker-confirmed viral suppression (aOR 1.51); retention in the intervention was associated with significantly increased likelihood of ART uptake (aOR 2.95) and "excellent" ART adherence (aOR 10.44). Text Me, Girl! offers promising evidence that a unidirectional, automated text-messaging intervention can improve HIV care outcomes among young adult trans women living with HIV.

Comparative effects of telephone versus in-office behavioral counseling to improve HIV treatment outcomes among people living with HIV in a rural setting

With the expansion of telehealth services, there is a need for evidence-based treatment adherence interventions that can be delivered remotely to people living with HIV. Evidence-based behavioral health counseling can be delivered via telephone, as well as in-office services. However, there is limited research on counseling delivery formats and their differential outcomes. The purpose of this study was to conduct a head-to-head comparison of behavioral self-regulation counseling delivered by telephone versus behavioral self-regulation counseling delivered by in-office sessions to improve HIV treatment outcomes. Patients (N = 251) deemed at risk for discontinuing care and treatment failure living in a rural area of the southeastern USA were referred by their care provider. The trial implemented a Wennberg Randomized Preferential Design to rigorously test: (a) patient preference and (b) comparative effects on patient retention in care and treatment adherence. There was a clear patient preference for telephone-delivered counseling (69%) over in-office-delivered counseling (31%) and participants who received telephone counseling completed a greater number of sessions. There were few differences between the two intervention delivery formats on clinical appointment attendance, antiretroviral adherence, and HIV viral load. Overall improvements in health outcomes were not observed across delivery formats. Telephone-delivered counseling did show somewhat greater benefit for improving depression symptoms, whereas in-office services demonstrated greater benefits for reducing alcohol use. These results encourage offering most patients the choice of telephone and in-office behavioral health counseling and suggest that more intensive interventions may be needed to improve clinical outcomes for people living with HIV who may be at risk for discontinuing care or experiencing HIV treatment failure.

A Surveillance Data-Based Model System for Assessing the Effects of HIV Intervention and Prevention Strategies

OBJECTIVE

Build a dynamic model system to assess the effects of HIV intervention and prevention strategies on future annual numbers of new HIV infections, newly diagnosed cases of HIV infection, and deaths among persons infected with HIV.

DESIGN AND SETTING

Model parameters are defined to quantify the putative effects of HIV prevention strategies that would increase HIV testing, thereby diagnosing infection earlier; increase linkage to care and viral suppression, thereby reducing infectiousness; and increase the use of preexposure prophylaxis, thereby protecting persons at risk of infection. Surveillance data are used to determine the initial values of the model system's variables and parameters, and the impact on the future course of various outcome measures of achieving either specified target values or specified rates of change for the model parameters is examined.

PARTICIPANTS

A hypothetical population of persons with HIV infection and persons at risk of acquiring HIV infection.

MAIN OUTCOME MEASURES

HIV incidence, HIV prevalence, proportion of persons infected with HIV whose infection is diagnosed, and proportion of persons with diagnosed HIV infection who are virally suppressed.

RESULTS

A model system based on the basic year-to-year algebraic relationships among the model variables and relying almost exclusively on HIV surveillance data was developed to project the course of HIV disease over a specified time period. Based on the most recent HIV surveillance data in the United States-which show a relatively high proportion of infections having been diagnosed but a relatively low proportion of diagnosed persons being virally suppressed-increasing the proportion of diagnosed persons who are virally suppressed and increasing preexposure prophylaxis use appear to be the most effective ways of reducing new HIV infections and accomplishing national HIV prevention and care goals.

CONCLUSIONS

Both having current and accurate information regarding the epidemiologic dynamics of HIV infection and knowing the potential impact of prevention strategies are critical in order for limited HIV prevention resources to be optimally allocated.

Telephone-delivered behavioral health interventions for people living with HIV: patients' perspectives from a qualitative study

People living with HIV (PLWH) often experience mental health concerns as well as difficulties with medication adherence; they also report barriers to receipt of health services. Telephone-delivered interventions can overcome some of these barriers. To obtain patients' perspectives on telephone-delivered behavioral health services, we conducted a qualitative study with patients who participated in one of two telephone-delivered interventions (mindfulness training, health coaching) in a research trial. Patients (N = 42; M age = 46 years, 50% female, 26% Black) participated in semi-structured qualitative interviews after completing the study. They identified several advantages (e.g., being able to schedule sessions more flexibly compared to in-person appointments, ease of developing rapport with interventionists) as well as occasional challenges of phone delivery (e.g., network connectivity). Overall, PLWH view telephone-delivery as a convenient and flexible method to engage in behavioral health interventions.

Antiretroviral Therapy (ART)-related Knowledge Seeking among People Living with HIV (PLHIV) in China: Role of Information & Communication Technology (ICT)

This paper investigated the use of information communication technology (ICT) to seek antiretroviral therapy (ART)-related knowledge among people living with HIV (PLHIV) taking antiretroviral treatment in Guangxi, China. A total 1902 participants who undertook ART and had used ICT were recruited from 12 sites with the highest cumulative HIV incidence. A questionnaire survey was used to collect data on the participants’ sociodemographic characteristics, clinical outcomes, infections in the family and comorbidity, access to healthcare resources, ICT using behavior in HIV management, and ART-related knowledge. The results showed that 15% of the participants had searched HIV-related information online, fewer participants had contacted healthcare providers via computer (1.6%) or text messaging (11.9%), and only 7.7% of the participants had contacted other PLHIV using ICT. Education had a positive impact on the knowledge level of all three categories of ART-related knowledge. Participants with better medication and mechanisms knowledge were more likely to search HIV-related information online and less likely to contact healthcare providers using text messages. Findings of this study suggested that ICT was used as an effective approach to acquire some type of ART-related knowledge. ICT was underutilized in health communication among the PLHIV in this study due to low education level and insufficient eHealth literacy. Future intervention programs should address the customization of the communication tools and focus on improving the education level and eHealth literacy of the PLHIV to better promote ICT as an efficient platform for ART-related knowledge seeking.

Barriers and Facilitators to Engaging African American Men Who Have Sex With Men in the HIV Care Continuum: A Theory-Based Qualitative Study

African American men who have sex with men (MSM) have high rates of HIV, but interventions are needed to address their low rates of engagement in the HIV care continuum. To identify modifiable factors potentially affecting such engagement, we conducted qualitative interviews guided by the Theory of Planned Behavior with 27 African American MSM who had participated in an HIV risk-reduction intervention trial. Qualitative analyses resulted in four overarching themes: stigma, concerns with health care providers (HCPs), social support, and logistical issues. Facilitators of care continuum engagement included reassurance about health, feeling and looking better, receiving treatment, avoiding infecting others, good relations with HCP, and social support. Barriers included HIV stigma, concerns about confidentiality, negative perceptions of HCP, convenience and availability of testing/treatment facilities, cost, and lack of social support. Efforts to improve African American MSM HIV care continuum engagement should focus on individual and health care system changes.

Evidences on the effectiveness of text messages in the adherence to antiretroviral therapy in adults

ABSTRACT Objective: To analyze the evidence available in the literature on the effectiveness of text messages in the adherence to antiretroviral therapy in adults. Method: Integrative review. The search for primary studies was carried out in MEDLINE/PubMed, Web of Science, CINAHL, LILACS, and SCOPUS and the sample consisted of 18 studies, in April 2019, with no time delimitation. Results: The synthesis of the evidences indicated that, of the 18 analyzed articles, 11 showed an increase in the adherence rates to antiretroviral therapy and an increase in CD4, after using text messages. Conclusion: Text messages are an important tool for health education and the synthesis of knowledge can help nurses to obtain increasingly substantive adherence rates in relation to antiretroviral therapy.

Factors influencing adherence to antiretroviral treatment among adults accessing care from private health facilities in Malawi

BACKGROUND

Private health facilities are increasingly being recognized as the neglected partner in the provision of HIV services. The non-adherence rate in the study sites ranged from 19 to 22%. This study explored the factors associated with non-adherence from antiretroviral therapy (ART) among adult patients accessing ART services at two privately owned urban health facilities in Malawi.

METHODS

We conducted a descriptive qualitative approach employing in-depth interviews among adults who either defaulted or were retained in HIV care in two privately owned facilities in Malawi from March to July 2017. We purposively selected participants and interviewed a total of 6 ART providers and 24 ART clients. Data were analyzed manually using a thematic approach.

RESULTS

Overall, participants identified four facilitators for retention in care and four broad categories of barriers namely individual, psychological, drug related and human resource related factors. The factors that facilitated retention in care included follow up visits after missing a visit, adequate information education and counseling, and supportive relationships.

CONCLUSION

The main reason for defaulting from antiretrovirals (ARVs) was fear of disclosing an HIV status to avert potential stigma and discrimination. In implementing ART clinics due consideration and strategies need to be adopted to ensure that privacy and confidentiality is preserved. Although adoption of all the key Malawi Implementing strategies like expert clients and a guardian may optimize retention in care, there is need for prior analysis of how those may lead to unintended disclosure which inadvertently affects adherence. Furthermore, private facilities should orient their clients to the public facilities within the catchment area so that clients have an option for alternative access to HIV care in the event of financial constraints.

Design, validation and testing of short text messages for an HIV mobile-health intervention to improve antiretroviral treatment adherence in Mexico

Mobile Health (mHealth) interventions have become effective strategies to increase adherence to antiretroviral treatment (ART) in people living with HIV (PLWH). mHealth interventions use phone calls, e-mails, smartphone apps or short text messages (SMS) as reminders of medical appointments or ART adherence. SMS are a highly accepted mHealth strategy. Systematized processes to validate SMS tailored to end-user preferences are required to increase the effectiveness of mHealth interventions. We describe a structured approach to develop a set of SMS tailored to Mexican HIV+ individuals, focused on improving ART adherence and healthcare appointments. The process included three sequential phases: SMS design by HIV-healthcare professionals, validation by expert referees, and testing by PLWH. A set of 108 SMS in four categories (motivational self-healthcare messages, ART-collection, medical and laboratory-appointment reminders) was designed. Expert referees assessed 94.5% of messages as adequate, 65.7% as useful. Seventy-one SMS were further tested by PLWH, who considered 100% of SMS to be understandable and 57.7% useful. SMS had adequate intra-judge agreement scores for clarity and acceptability (ICC-2 = .08-.49). Qualitative feedback from expert referees and PLWH was incorporated into SMS. A final set of 41 highest-rated SMS was obtained. Careful validation of SMS could increase the effectiveness of mHealth interventions.

Housing First: Unsuppressed Viral Load Among Women Living with HIV in San Francisco

While poverty is an established barrier to achieving success at each step of the HIV care continuum, less is known about specific aspects of poverty and how they overlap with behavior in exceptionally low-income individuals who live in well-resourced areas. We considered unsuppressed viral load over 3 years among women living with HIV in San Francisco who used homeless shelters, low-income hotels and free meal programs. One-hundred twenty study participants were followed; 60% had > 1 unsuppressed viral load and 19% were unsuppressed at every visit. Across six-month intervals, the odds of unsuppressed viral load were 11% higher for every 10 nights spent sleeping on the street [Adjusted Odds Ratio (AOR) 1.11, 95% CI 1.02-1.20]; 16% higher for every 10 nights spent sleeping in a shelter (AOR/10 nights 1.16, 95% CI 1.06-1.27); 4% higher for every 10 nights spent sleeping in a single-room occupancy hotel (AOR/10 nights 1.04, 95% CI 1.02-1.07); and over threefold higher among women who experienced any recent incarceration (AOR 3.56, 95% CI 1.84-6.86). Violence and recent use of outpatient health care did not significantly predict viral suppression in adjusted analysis. While strategies to promote retention in care are important for vulnerable persons living with HIV, they are insufficient to ensure sustained viral suppression in low-income women experiencing homelessness and incarceration. Results presented here in combination with prior research linking incarceration to homelessness among women indicate that tailored interventions, which not only consider but prioritize affordable housing, are critical to achieving sustained viral suppression in low-income women living with HIV.

When is Enough, Enough? How the Absence of Dose-Determination Trials Impedes Implementation of HIV Behavioral Interventions

Carefully controlled clinical trials have determined that theory-based behavioral interventions delivered by adherence nurses, professional and paraprofessional counselors, and case managers improve ART adherence and viral suppression. However, there are no studies that empirically inform how much intervention is needed for which patient populations and at what cost. This Editorial raises the issue of how a lack of intervention dosing limits interpretation of trial results and impedes implementation, therefore calling for behavioral intervention dose-finding studies.

Cell Phone Counseling Improves Retention of Mothers With HIV Infection in Care and Infant HIV Testing in Kisumu, Kenya: A Randomized Controlled Study

BACKGROUND

We evaluated the effectiveness of a cell phone counseling intervention to promote retention in care and HIV testing of infants among women with HIV accessing prevention of mother-to-child services in Kisumu, Kenya.

METHODS

Between May 2013 and September 2015, we recruited 404 pregnant women with HIV who were between 14 and 36 weeks of gestation and randomly assigned them to the intervention (n=207) or control arm (n=197). Retention was assessed at delivery and at 6 and 14 weeks postpartum. We also measured uptake of infant HIV testing. The intervention comprised a fixed protocol of counselor-delivered phone calls to provide one-to-one need-based support. The number of calls made varied depending on when participants presented for antenatal care services; the maximum number was 42. The control group received routine care. We evaluated retention at 3 time points using the complementary log-log regression model taking into account factors associated with retention and loss to follow-up time. We calculated the incidence rate for HIV transmission among infants and used binary logistic regression to identify predictors of HIV infection among infants.

RESULTS

Participants attended on average 63% of the required number of counseling calls during the study period. Retention was higher in the intervention arm than the control arm at delivery (95.2% vs. 77.7%, respectively); 6 weeks postpartum (93.9% vs. 72.9%, respectively); and 14 weeks postpartum (83.3% vs. 66.5%, respectively) (P<.001). The counseling intervention (hazard ratio [HR]=0.29; 95% confidence interval [CI]=0.12, 0.69) and positive health perceptions (HR=0.99; 95% CI=0.98, 1.00) were associated with lower hazards of being lost to follow-up. HIV testing of infants was higher in the intervention than control arm (93% vs. 68%, respectively; P<.001). In total, 9 of 308 (2.9%) infants tested positive for HIV infection (incidence rate=0.39 infections/100 infant-weeks). Medication Possession Ratio (MPR) >90%, used to assess adherence to ART, was associated with lower odds of a positive HIV test among infants (adjusted odds ratio=0.20; 95% CI=0.04, 0.99). Attendance at antenatal and postnatal care visits was higher among participants in the intervention arm than the control arm.

CONCLUSIONS

The one-on-one tailored counseling delivered via cell phone was effective in retaining mothers with HIV infection in care and promoting uptake of infant HIV testing and antenatal and postnatal care services. Phone counseling offers a practical approach to reach and retain pregnant women with HIV infection and postpartum mothers in care, but greater emphasis on collection of medications and adherence is required.

Use of an mHealth Intervention to Improve Engagement in HIV Community-Based Care Among Persons Recently Released from a Correctional Facility in Washington, DC: A Pilot Study

We examined the preliminary effectiveness of a computerized counseling session plus post-incarceration text messaging intervention (CARE + Corrections) to support ART adherence and linkage/engagement in community care among recently incarcerated persons with HIV in Washington, D.C. Recently incarcerated persons with HIV ≥ 18 years old were recruited from the D.C. jail or community outreach and randomized to CARE + Corrections or control arm. Participants completed assessments at baseline, 3-months and 6-months. Multivariable random effects modeling identified predictors of suppressed viral load (≤ 200 copies/mL) and engagement in HIV care at 6 months. Participants (N = 110) were aged 42 (IQR 30-49); 58% male, 24% female, 18% transgender, 85% Black, and lifetime incarceration was a median of 7 years (IQR 2-15). More controls had a regular healthcare provider at baseline. Although not statistically significant, intervention participants had increased odds of viral suppression versus controls at 6 months (AOR 2.04; 95% CI 0.62, 6.70). Those reporting high ART adherence at baseline had higher odds of viral suppression at follow-up (AOR 10.77; 95% CI 1.83, 63.31). HIV care engagement was similar between the two groups, although both groups reported increased engagement at 6 months versus baseline. We observed a positive but non-significant association of viral suppression in the CARE + Corrections group, and care engagement increased in both groups after 6 months. Further attention to increasing viral suppression among CJ-involved persons with HIV upon community reentry is warranted.

Long-Term Effects of Psychological Interventions to Improve Adherence to Antiretroviral Treatment in HIV-Infected Persons: A Systematic Review and Meta-Analysis

We examined the efficacy of psychological adherence-enhancing interventions (AEIs) compared with usual care in HIV-infected adults under antiretroviral treatment (ART) by focusing on adherence and clinical HIV markers as outcomes in the short term and long term. We searched relevant databases for controlled studies that compared psychological AEIs with usual care. We included 31 comparisons from 27 individual studies in our meta-analyses. Psychological AEIs were significantly superior to usual care in improving adherence [standardized mean difference (SMD) 0.30, 95% CI 0.20-0.40] and reducing HIV viral load (SMD 0.15, 0.07-0.23) at the end of treatment. At the last follow-up, we found no difference between psychological AEIs and usual care, neither on adherence (SMD 0.07, -0.11-0.24) nor on clinical markers (SMD 0.06, -0.03-0.15). After excluding outliers from the analyses, between-study heterogeneity was small, and we did not identify any relevant moderators of intervention effects. In summary, psychological AEIs may significantly improve ART adherence and HIV viral load compared with usual care in the short term, but fail to be superior in achieving long-lasting improvements on ART adherence and clinical HIV markers as compared with usual care. Owing to limited quality and the majority of studies being conducted in the United States or Europe, our results have to be interpreted with caution, and are most relevant to the United States and Europe. The consistently reported difficulties to achieve sustained ART adherence improvements in previous and the present meta-analyses highlight the need to focus on maintaining ART adherence improvements in future research.

Feasibility of a Texting Intervention to Improve Medication Adherence Among Older HIV+ African Americans: A Mixed-Method Pilot Study

Antiretroviral therapy (ART) is the primary treatment for HIV, and adherence to it is crucial to addressing health disparities. Approximately half of individuals in the United States living with HIV are African Americans, and those over 45 years of age are more likely to die early from HIV/AIDS than their White counterparts. This mixed-method pilot study evaluated the feasibility of a text-based mobile phone intervention designed to improve ART adherence among older African Americans with HIV. Feasibility was assessed via implementation, participant adherence, acceptability, and satisfaction, as well as short-term impact on medication adherence, adherence-related self-efficacy, and positive affect. The intervention utilized pill reminder, motivational, and health educational texts. Participants (N = 21) ranged in age from 50 to 68 years. Outcomes were evaluated via quantitative results from self-report measures and qualitative data from four focus groups. Attrition to the study was 100%. After 8 weeks, participants reported statistically significant improvements in medication adherence, but not in self-efficacy or affect scores. Qualitative findings highlight the psychologically supportive potential of the intervention, challenges to adherence, as well as suggestions for improvement. The study demonstrates that a text messaging intervention may be feasible for older African Americans with HIV, and helpful in supporting ART adherence.

Stigma management intervention to improve antiretroviral therapy adherence: Phase-I test of concept trial, Cape Town South Africa

Combination antiretroviral therapy (cART) has transformed HIV infection from a universally fatal disease to a medically manageable chronic illness. We conducted a Phase-I test of concept intervention trial to examine feasibility and potential efficacy of behavioural self-regulation counselling designed to improve care retention and cART adherence. The intervention was culturally adapted from client-centered evidence-based interventions that are grounded in behavioural self-regulation theory and available in the US. The intervention adaptation included enhancements to directly address HIV stigma and alcohol-related sources of nonadherence. Fifty patients receiving cART in Cape Town, South Africa were randomised to receive either: (a) five weekly cellphone-delivered sessions of stigma and alcohol-enhanced behavioural self-regulation counselling or (b) a contact matched control condition. Participants were baseline assessed and followed for two weeks post-intervention, with 94% of participants retained throughout the study. Participants receiving the intervention significantly improved cART adherence from baseline-to-follow up and improvement was significantly greater than the control condition. Behaviours related to stigma and alcohol use that impede cART adherence were significantly reduced, and there was uptake of adherence improvement strategies. The current study supports the potential efficacy of relatively brief behavioural self-regulation counselling delivered by cellphone in a context of differentiated care in South Africa.

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

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

A perspective on nonadherence to drug therapy: psychological barriers and strategies to overcome nonadherence

Medication adherence represents an inefficiency and ongoing challenge within medical care. The problem has been long-recognized - indeed, the research literature contains thousands of articles on the topic. Nonetheless, because of the complex nature of the problem, it still cannot be considered to be solved. Reasons for nonadherence are myriad but psychological barriers to adherence are most difficult to mitigate and, thus, are the focus of this paper. The present narrative review sketches a summary of theoretical models commonly utilized to understand and help address medication nonadherence; uses a patient-centered care approach to contextualize the problem of nonadherence to drug therapies; and then outlines a set of best-practice recommendations based on the extant data and framed from the perspective of the Information-Motivation-Strategy model.

A Systematic Review on Promoting Adherence to Antiretroviral Therapy in HIV-infected Patients Using Mobile Phone Technology

OBJECTIVE

Adherence to antiretroviral therapy (ART) is paramount to successful long-term suppression of human immunodeficiency virus (HIV). For poorly adherent patients with HIV, barriers to remaining adherent may be overcome by the implementation of targeted interventions delivered via mobile devices. This systematic review is focused specifically on mobile phone technologies to deliver adherence interventions in HIV/acquired immunodeficiency syndrome (AIDS) populations.

METHODS

This review (PROSPERO #CRD42017065131) systematically extracted data from published literature from five databases on mobile phone interventions to improve adherence to ART for HIV. The reported studies had been conducted between 2007 and 2017. Risk of bias was assessed using the Cochrane method ranking each criterion as low, high, or unclear risk of bias.

RESULTS

Of the 835 articles returned, we identified 26 randomized controlled trials (RCTs), retrospective and prospective cohort trials, or mixed method studies with a comparison group that fit criteria for inclusion. No standard measure of adherence was consistent throughout the examined studies, and assessments by self-report, pill counting, and medication event monitoring system (MEMS) were utilized. The studies reported mixed results, with 17 reporting significant improvements to adherence, 3 reporting improvements without supplying p-values, and 6 reporting no significant change or a reduction in adherence.

CONCLUSION

The mixed nature of the results exemplifies the need for more comprehensive approaches and larger scale trials to confirm results observed in limited cohort sizes. To better retain satisfactory adherence within the HIV population, and especially in low-resource settings, we recommend that future interventions incorporate multiple strategies: mobile-based reminders, social support structures, and personalized content.

A Rapid Review of eHealth Interventions Addressing the Continuum of HIV Care (2007-2017)

National HIV prevention goals call for interventions that address Continuum of HIV Care (CoC) for persons living with HIV. Electronic health (eHealth) can leverage technology to rapidly develop and disseminate such interventions. We conducted a qualitative review to synthesize (a) technology types, (b) CoC outcomes, (c) theoretical frameworks, and (d) behavior change mechanisms. This rapid review of eHealth, HIV-related articles (2007-2017) focused on technology-based interventions that reported CoC-related outcomes. Forty-five studies met inclusion criteria. Mobile texting was the most commonly reported technology (44.4%, k = 20). About 75% (k = 34) of studies showed proven or preliminary efficacy for improving CoC-related outcomes. Most studies (60%, k = 27) focused on medication adherence; 20% (k = 9) measured virologic suppression. Many eHealth interventions with preliminary or proven efficacy relied on mobile technology and integrated knowledge/cognition as behavior change mechanisms. This review identified gaps in development and application of eHealth interventions regarding CoC.

Mobile Health Intervention to Increase Oral Cancer Therapy Adherence in Patients With Chronic Myeloid Leukemia (The REMIND System): Clinical Feasibility and Acceptability Assessment

Background

Optimal dosing of oral tyrosine kinase inhibitor therapy is critical to treatment success and survival of patients with chronic myeloid leukemia (CML). Drug intolerance secondary to toxicities and nonadherence are significant factors in treatment failure.

Objective

The objective of this study was to develop and pilot-test the clinical feasibility and acceptability of a mobile health system (REMIND) to increase oral drug adherence and patient symptom self-management among people with CML (chronic phase).

Methods

A multifaceted intervention was iteratively developed using the intervention development framework by Schofield and Chambers, consisting of defining the patient problem and iteratively refining the intervention. The clinical feasibility and acceptability were examined via patient and intervention nurse interviews, which were audiotaped, transcribed, and deductively content analyzed.

Results

The intervention comprised 2 synergistically operating elements: (1) daily medication reminders and routine assessment of side effects with evidence-based self-care advice delivered in real time and (2) question prompt list (QPL) questions and routinely collected individual patient adherence and side effect profile data used to shape nurses’ consultations, which employed motivational interviewing to support adoption of self-management behaviors. A total of 4 consultations and daily alerts and advice were delivered over 10 weeks. In total, 58% (10/17) of patients and 2 nurses participated in the pilot study. Patients reported several benefits of the intervention: help in establishing medication routines, resolution of symptom uncertainty, increased awareness of self-care, and informed decision making. Nurses also endorsed the intervention: it assisted in establishing pill-taking routines and patients developing effective solutions to adherence challenges.

Conclusions

The REMIND system with nurse support was usable and acceptable to both patients and nurses. It has the potential to improve adherence and side-effect management and should be further evaluated.

Lessons Learned From the Implementation of Seek, Test, Treat, Retain Interventions Using Mobile Phones and Text Messaging to Improve Engagement in HIV Care for Vulnerable Populations in the United States

In the United States, little is known about interventions that rely on mobile phones and/or text messaging to improve engagement in HIV care for vulnerable populations. Domestic studies using these technologies as part of the National Institute on Drug Abuse "Seek, Test, Treat, Retain" research initiative were queried regarding intervention components, implementation issues, participant characteristics, and descriptive statistics of mobile phone service delivery. Across five studies with 1,135 predominantly male, minority participants, implementation challenges occurred in three categories: (1) service interruptions; (2) billing/overage issues, and; (3) the participant user experience. Response rules for automated text messages frequently frustrated participants. The inability to reload minutes/texting capacity remotely was a significant barrier to intervention delivery. No study encountered confidentiality breaches. Service interruption was common, even if studies provided mobile phones and plans. Future studies should attend to the type of mobile phone and service, the participant user experience, and human subjects concerns.

Recent mobile health interventions to support medication adherence among HIV-positive MSM

PURPOSE OF REVIEW

We describe recent mobile health (mHealth) interventions supporting antiretroviral therapy (ART) medication adherence among HIV-positive MSM.

RECENT FINDINGS

Keyword searches (1 January 2016-13 May 2017) identified 721 citations. Seven publications reporting on six studies met inclusion criteria. Five studies focused on MSM. Interventions primarily employed text messaging (n = 4), whereas two focused on smartphone apps and one on social media. Three studies measured intervention impact on adherence and found increased ART use intentions (n = 1), self-reported adherence (n = 1), and viral suppression (n = 1, no control group). Other mHealth interventions for HIV-positive MSM focused on status disclosure and reducing sexual risk.

SUMMARY

mHealth interventions to support ART adherence among MSM show acceptability, feasibility, and preliminary efficacy. No recent mHealth interventions for MSM measured impact on viral suppression compared with a control condition despite earlier (pre-2015) evidence for efficacy. Studies are underway that include multiple features designed to improve adherence within complex smartphone or internet-based platforms. Areas for future growth include overcoming measurement and engagement challenges, developing tools for coordinating patient and provider adherence data, testing combination interventions, and adapting efficacious interventions for new languages and geographic settings.

Acceptability and efficacy of interactive short message service intervention in improving HIV medication adherence in Chinese antiretroviral treatment-naïve individuals

AIM

The aim of this study was to examine the acceptability and efficacy of interactive short message service (SMS) in improving medication adherence in antiretroviral treatment (ART)-naïve individuals living with HIV/AIDS in Hengyang, Hunan, China.

BACKGROUND

SMS via mobile phone has emerged as a potential tool for improving ART adherence. However, most studies used SMS only as a medication reminder, with few studies exploring the effect of comprehensive, interactive SMS.

PATIENTS AND METHODS

In a randomized controlled trial, 100 HIV-positive patients on ART for <3 months were randomized into control or intervention arm. Participants in the control group received routine standard instruction for ART medication in the HIV clinics, while the intervention group received 6 months of an SMS intervention in addition to the standard care. A total of 124 text messages within 6 modules were edited, preinstalled, and sent to participants according to personalized schedules. Knowledge (of HIV and HIV medications), self-reported antiretroviral adherence (Visual Analog Scale [VAS] and Community Programs for Clinical Research on AIDS [CPCRA] Antiretroviral Medication Self-Report), and CD4 count were assessed at baseline and immediate post-intervention. Intervention participants were interviewed after completion of the study about their satisfaction with and acceptability of the SMS intervention.

RESULTS

Baseline assessments were comparable between arms. Repeated-measures analysis showed that both HIV-related and ART medication knowledge of the intervention group showed better improvement over time than those of the control group after the intervention (P<0.0001). For the adherence measures, compared with the control group, participants in the intervention group had significantly higher VAS mean score (Z=2.735, P=0.006) and lower suboptimal adherence rate (Z=2.208, P=0.027) at the end of the study. The intervention had no effect on CD4 cell count. Almost all (96%) intervention participants reported satisfaction or high satisfaction with the SMS intervention, with 74% desiring to continue to receive the SMS intervention. The preferred frequency of messages was 1-2 messages per week.

CONCLUSION

An interactive SMS intervention with comprehensive content shows promising efficacy in promoting medication adherence in ART-naïve individuals. Future work might further refine its ability to optimally tailor the intervention for individual preferences.

Meta-analysis on the effect of text message reminders for HIV-related compliance

For the treatment of HIV, compliance in regard to appointment attendance and medication usage is critical. Various methods have been attempted to increased HIV care compliance, and a method that has inspired many published studies is text message reminders. We conducted a meta-analysis of the literature from inception through May 2016 using the following databases: Pubmed, Embase, CINAHL, Web of Science, and Cochrane. Examples of terms used in the search included exploded versions of "HIV, "AIDS", "cell phone", "SMS", "text message", "reminder". After abstract and manuscript review, articles were discussed with co-author and included based on consensus. We excluded qualitative analyses, observational studies without an intervention, and studies without a control or pre-intervention group. We used random-effects models to calculate odds ratios (OR) and standardized mean differences (SMDs) for the text message intervention. Thirty-four unique studies were found and included in the meta-analysis. For the seven articles relating to non-attendance, text message reminders significantly reduced the rates of non-attendance (OR, 0.66; 95% CI, 0.48-0.92; P = .01; I² = 52%). For the 20 articles on drug adherence, text message reminders significantly increased adherence (SMD, 0.87; 95% CI, 0.06-1.68; P = .04; I² = 99%). For the 11 articles with physiologic measures (CD4 count or viral load), text message reminders led to significant improvement (SMD, 1.53; 95% CI, 0.52-2.55; P = .003; I² = 99%). This meta-analysis reveals that text message reminders are a promising intervention that can be used to increase HIV care compliance when logistically feasible. Further study should focus on which populations benefit the most from this intervention, and successful implementers could create an established technological infrastructure for other clinics to adopt when seeking to boost compliance.