'Simply forgot' is the most frequently stated reason for missed doses of HAART irrespective of degree of adherence

"We Take Care of Our Young, No Matter What," Experiences of Engagement in HIV Care Among Black Mothers Parenting Dependent Children in Southwestern Pennsylvania: A Retrospective Descriptive Qualitative Study

ABSTRACT

This retrospective descriptive study sought to explore the lived experiences of Black mothers with HIV navigating HIV medical care while parenting dependent children. Six themes were generated from the semi-structured interviews conducted with mothers ( N = 9) related to motherhood, interactions with health care systems and providers, coping, social support, HIV self-management, and HIV prevention. Findings suggested that supportive interpersonal relationships with HIV health care providers, HIV nondisclosure to family and friends, and social network support, inclusive of health care providers, were protective factors in achieving optimal treatment adherence and viral suppression. Findings may inform interventions for improving social support and reducing stigma in HIV care for Black mothers with HIV who are parenting dependent children.

Exploring patient medication adherence and data mining methods in clinical big data: A contemporary review

BACKGROUND

Increasingly, patient medication adherence data are being consolidated from claims databases and electronic health records (EHRs). Such databases offer an indirect avenue to gauge medication adherence in our data-rich healthcare milieu. The surge in data accessibility, coupled with the pressing need for its conversion to actionable insights, has spotlighted data mining, with machine learning (ML) emerging as a pivotal technique. Nonadherence poses heightened health risks and escalates medical costs. This paper elucidates the synergistic interaction between medical database mining for medication adherence and the role of ML in fostering knowledge discovery.

METHODS

We conducted a comprehensive review of EHR applications in the realm of medication adherence, leveraging ML techniques. We expounded on the evolution and structure of medical databases pertinent to medication adherence and harnessed both supervised and unsupervised ML paradigms to delve into adherence and its ramifications.

RESULTS

Our study underscores the applications of medical databases and ML, encompassing both supervised and unsupervised learning, for medication adherence in clinical big data. Databases like SEER and NHANES, often underutilized due to their intricacies, have gained prominence. Employing ML to excavate patient medication logs from these databases facilitates adherence analysis. Such findings are pivotal for clinical decision-making, risk stratification, and scholarly pursuits, aiming to elevate healthcare quality.

CONCLUSION

Advanced data mining in the era of big data has revolutionized medication adherence research, thereby enhancing patient care. Emphasizing bespoke interventions and research could herald transformative shifts in therapeutic modalities.

Oral antiviral treatments for COVID-19: opportunities and challenges

The use of antiviral COVID-19 medications can successfully inhibit SARS-CoV-2 replication and prevent disease progression to a more severe form. However, the timing of antiviral treatment plays a crucial role in this regard. Oral antiviral drugs provide an opportunity to manage SARS-CoV-2 infection without a need for hospital admission, easing the general burden that COVID-19 can have on the healthcare system. This review paper (i) presents the potential pharmaceutical antiviral targets, including various host-based targets and viral-based targets, (ii) characterizes the first-generation anti-SARS-CoV-2 oral drugs (nirmatrelvir/ritonavir and molnupiravir), (iii) summarizes the clinical progress of other oral antivirals for use in COVID-19, (iv) discusses ethical issues in such clinical trials and (v) presents challenges associated with the use of oral antivirals in clinical practice. Oral COVID-19 antivirals represent a part of the strategy to adapt to long-term co-existence with SARS-CoV-2 in a manner that prevents healthcare from being overwhelmed. It is pivotal to ensure equal and fair global access to the currently available oral antivirals and those authorized in the future.

Forgetting to take HIV antiretroviral therapy: a qualitative exploration of medication adherence in the third decade of the HIV epidemic in the United States

Optimal adherence to HIV antiretroviral therapy (ART) is challenging, and racial/ethnic disparities in adherence rates are substantial. The most common reason persons living with HIV (PLWH) give for missed ART doses is forgetting. We took a qualitative exploratory approach to describe, from the perspectives of African American/Black and Hispanic/Latino PLWH, what it means to forget to take ART and factors that influence forgetting. Participants (N = 18) were purposively sampled for maximum variability and engaged in semi-structured/in-depth interviews on HIV/ART management. The analysis took a directed content analysis approach. Participants were mostly male (56%) and African American/Black (79%), between 50 and 69 years old, and had lived with HIV for an average of 21 years. Findings were organised into six inter-related themes: (1) forgetting to take ART was a shorthand description of a complex phenomenon, but rarely a simple lapse of memory; (2) ‘forgetting’ was means of managing negative emotions associated with HIV; (3) life events triggered mental health distress/substance use which disrupted adherence; (4) historical traumatic events (including AZT monotherapy) and recent trauma/loss contributed to forgetting; (5) patient-provider interactions could support or impede adherence; and (6) intrinsic motivation was fundamental. Implications for HIV social service and health care settings are described.

What should patients do if they miss a dose of medication? A theoretical approach

Medication adherence is a major problem for patients with chronic diseases that require long term pharmacotherapy. Many unanswered questions surround adherence, including how adherence rates translate into treatment efficacy and how missed doses of medication should be handled. To address these questions, we formulate and analyze a mathematical model of the drug concentration in a patient with imperfect adherence. We find exact formulas for drug concentration statistics, including the mean, the coefficient of variation, and the deviation from perfect adherence. We determine how adherence rates translate into drug concentrations, and how this depends on the drug half-life, the dosing interval, and how missed doses are handled. While clinical recommendations require extensive validation and should depend on drug and patient specifics, as a general principle our theory suggests that nonadherence is best mitigated by taking double doses following missed doses if the drug has a long half-life. This conclusion contradicts some existing recommendations that cite long drug half-lives as the reason to avoid a double dose after a missed dose. Furthermore, we show that a patient who takes double doses after missed doses can have at most only slightly more drug in their body than a perfectly adherent patient if the drug half-life is long. We also investigate other ways of handling missed doses, including taking an extra fractional dose following a missed dose. We discuss our results in the context of hypothyroid patients taking levothyroxine.

Medication Adherence Reminder System for Virtual Home Assistants: Mixed Methods Evaluation Study

Background

Medication nonadherence is a global public health challenge that results in suboptimal health outcomes and increases health care costs. Forgetting to take medicines is one of the most common reasons for unintentional medication nonadherence. Research findings indicate that voice-activated virtual home assistants, such as Amazon Echo and Google Home devices, may be useful in promoting medication adherence.

Objective

This study aims to create a medication adherence app (skill), MedBuddy, for Amazon Echo devices and measure the use, usability, and usefulness of this medication-taking reminder skill.

Methods

A single-group, mixed methods, cohort feasibility study was conducted with women who took oral contraceptives (N=25). Participants were undergraduate students (age: mean 21.8 years, SD 6.2) at an urban university in the Southeast United States. Participants were given an Amazon Echo Dot with MedBuddy—a new medication reminder skill for Echo devices created by our team—attached to their study account, which they used for 60 days. Participants self-reported their baseline and poststudy medication adherence. MedBuddy use was objectively evaluated by tracking participants’ interactions with MedBuddy through Amazon Alexa. The usability and usefulness of MedBuddy were evaluated through a poststudy interview in which participants responded to both quantitative and qualitative questions.

Results

Participants’ interactions with MedBuddy, as tracked through Amazon Alexa, only occurred on half of the study days (mean 50.97, SD 29.5). At study end, participants reported missing their medication less in the past 1 and 6 months compared with baseline (χ²₁=0.9 and χ²₁=0.4, respectively; McNemar test: P<.001 for both). However, there was no significant difference in participants’ reported adherence to consistently taking medication within the same 2-hour time frame every day in the past 1 or 6 months at the end of the study compared with baseline (χ²₁=3.5 and χ²₁=0.4, respectively; McNemar test: P=.63 and P=.07, respectively). Overall feedback about usability was positive, and participants provided constructive feedback about the skill’s features that could be improved. Participants’ evaluation of MedBuddy’s usefulness was overwhelmingly positive—most (15/23, 65%) said that they would continue using MedBuddy as a medication reminder if provided with the opportunity and that they would recommend it to others. MedBuddy features that participants enjoyed were an external prompt separate from their phone, the ability to hear the reminder prompt from a separate room, multiple reminders, and verbal responses to prompts.

Conclusions

The findings of this feasibility study indicate that the MedBuddy medication reminder skill may be useful in promoting medication adherence. However, the skill could benefit from further usability enhancements.

Inhibitory control is associated with medication adherence in young HIV patients without comorbidities

OBJECTIVE

In the present study we evaluated the incremental contribution of executive cognition (EC) subprocesses to antiretroviral medication adherence.

METHOD

A comprehensive EC test battery assessing updating/working memory, mental flexibility, and inhibitory control, along with measures assessing non-executive cognitive functions were completed by 100 individuals with HIV. Medication adherence was determined via a visual analogue self-report scale and the Medication Adherence Questionnaire. Potential predictors, including demographic and clinical characteristics and neuropsychological performances on EC and other cognitive tasks were regressed to medication adherence. Predictive variables related to executive processes were added in the final block of the hierarchical regression model in order to assess their incremental predictive ability on medication adherence.

RESULTS

23% of the variance in the visual analogue scale was explained by treatment complexity, memory and EC performance. A measure of inhibitory control, in particular, predicted self-reported medication adherence above and beyond demographic, clinical and other cognitive factors.

CONCLUSIONS

The contribution of EC to self-reported medication adherence in young seropositive adults was limited, but inhibitory control was associated with proper medication management above and beyond demographic, clinical and other cognitive functions.

Accuracy of machine learning-based prediction of medication adherence in clinical research

Medication non-adherence represents a significant barrier to treatment efficacy. Remote, real-time measurement of medication dosing can facilitate dynamic prediction of risk for medication non-adherence, which in-turn allows for proactive clinical intervention to optimize health outcomes. We examine the accuracy of dynamic prediction of non-adherence using data from remote real-time measurements of medication dosing. Participants across a large set of clinical trials (n = 4,182) were observed via a smartphone application that video records patients taking their prescribed medication. The patients' primary diagnosis, demographics, and prior indication of observed adherence/non-adherence were utilized to predict (1) adherence rates ≥ 80% across the clinical trial, (2) adherence ≥ 80% for the subsequent week, and (3) adherence the subsequent day using machine learning-based classification models. Empirically observed adherence was demonstrated to be the strongest predictor of future adherence/non-adherence. Collectively, the classification models accurately predicted adherence across the trial (AUC = 0.83), the subsequent week (AUC = 0.87) and the subsequent day (AUC = 0.87). Real-time measurement of dosing can be utilized to dynamically predict medication adherence with high accuracy.

A Qualitative Exploration of "Mother First" Identity and Antiretroviral Adherence among African American Women Living with HIV in the Mid-South Region of the United States

The majority of African American women living with HIV are of child-bearing age and large numbers of these women express a desire to have children. Extant research suggests that motherhood provides HIV-positive women with a sense of hope and normalcy and, in some cases, is associated with positive HIV-related health behaviors. Guided by the tenets of the culture-centered approach (CCA), this qualitative study sought to understand the relationship between motherhood identity and ART adherence among a sample of 50 African American women living with HIV in the Mid-South region of the United States. Our theoretically-informed thematic analysis of in-depth interviews with all 50 women produced three primary themes: (1) experiencing HIV through the lens of motherhood, (2) the physical and social realities of the "mother first" orientation while living with HIV, and (3) the impact of the "mother first" orientation on ART adherence and self-care. These findings identify how participants' "mother first" identity orientation interacts with their sociocultural environment to enable and constrain their attempts at ART adherence. The findings also provide empirical evidence to support the CCA's theorizing regarding the ways in which the materiality of structures interact with symbolic cultural meanings to (re)produce health inequalities.

Factors Associated With Sex-Related Pre-exposure Prophylaxis Adherence Among Men Who Have Sex With Men in New York City in HPTN 067

BACKGROUND

HPTN 067 assessed the feasibility of daily and non-daily dosing of open-label emtricitabine/tenofovir disoproxil fumarate (FTC/TDF)-based pre-exposure prophylaxis (PrEP).

METHODS

Factors associated with sex-related PrEP adherence were assessed among men who have sex with men (MSM) randomized to one of 3 PrEP dosing arms in HPTN 067 in New York City. Sex-related PrEP adherence was defined per protocol as at least 1 PrEP tablet taken within 4 days pre-sex and at least 1 additional PrEP tablet taken within 24 hours post-sex, assessed via electronic drug monitoring and weekly interviews. Demographic data and behavioral measures were evaluated for association with sex-related PrEP adherence. Logistic regression for clustered data was used to estimate the unadjusted and adjusted odds ratios.

RESULTS

Of 176 randomized MSM participants, 59% were Black, 10% White, 25% Hispanic, and 6% other; median age was 31 years. In the multivariable analyses, higher sex-related PrEP adherence was significantly associated with daily dosing arm, older age, employment, and higher PrEP adherence behavioral skills. Lower sex-related PrEP adherence was significantly associated with identifying as Black or Hispanic (compared with White), opiate use, and reporting "I forgot" as an adherence barrier.

CONCLUSIONS

This analysis identified populations of MSM who might benefit from additional support to optimize PrEP adherence, including those who are younger, unemployed, or opiate users. MSM with lower PrEP behavioral skills may benefit from targeted interventions. Further study is needed to assess racial and ethnic disparities in PrEP adherence, which may reflect broader social and economic inequalities not captured in this study.

An update on the Barriers to Adherence and a Definition of Self-Report Non-adherence Given Advancements in Antiretroviral Therapy (ART)

Relying on the most frequently reported barriers to adherence and convenient definitions of non-adherence may lead to less valid results. We used a dominance analysis (a regression-based approach) to identify the most important barriers to adherence based on effect size using data collected through an online survey. The survey included the Adherence Barrier Questionnaire, self-reported non-adherence defined as a 4-day treatment interruption, and HIV clinical outcomes. The sample (N = 1217) was largely male, gay identified, and White. Nearly 1 in 3 participants reported "simply forgot" as a barrier; however, in a dominance analysis, it yielded a small effect size it its association with a 4-day treatment interruption. Further, dominance analyses stratified by race/ethnicity and age suggested that not all barriers impact all groups equally. The most frequently reported barriers to adherence were not the most important, and interventions should focus on barriers more strongly linked to clinical outcomes.

Efficacy and safety of a medication dose reminder feature in a digital health offering with the use of sensor-enabled medicines

OBJECTIVES

Over one-half of patients with chronic diseases, such as hypertension and type 2 diabetes (DM), do not take medicines as prescribed. This study assessed the efficacy and safety of "seeing" versus "not seeing" medication dose reminders regarding medication adherence and risk for overdose.

DESIGN

Post hoc analysis.

SETTING AND PARTICIPANTS

Outpatient setting. Adult subjects (18 years of age or older) with uncontrolled hypertension and DM.

MAIN OUTCOME MEASURES

Subjects enrolled in this institutional review board-approved study were assigned to either use digital health (DH) with the use of sensor-enabled medicines (coencapsulated medicines with an ingestible sensor) for 4 or 12 weeks or receive usual care based on a cluster-randomized design. All subjects were followed for 12 weeks. Subjects using DH were included in the post hoc study consisting of an efficacy analysis and a safety analysis. A main efficacy outcome of comparison of subjects taking medicine with or without "seeing" DH medication dose reminders was assessed. Safety analysis assessed risk of overdosing after DH medication dose reminders.

RESULTS

In 57 subjects included in the efficacy analysis, DH device reminder messages were associated with a 16 ± 16% increase (75 ± 18% when seeing vs. 59 ± 24% when not seeing mobile dose reminders) in medication taking if not taken before dose reminder. The mean overall adherence for all subjects was 86 ± 12%; the mean on-time adherence was 69.7 ± 19.7%. Subjects with lower adherence benefited more from seeing DH reminder messages. In the safety study (n = 74 subjects and 24,426 medication ingestions), no events of overdoses related to DH medication dose reminders occurred.

CONCLUSION

This study demonstrates benefits of DH medication dose reminders to improve medication adherence, especially in patients with lower adherence; DH medication dose reminders also appear to be safe.

Evaluating an enhanced adherence intervention among HIV positive adolescents failing atazanavir/ritonavir-based second line antiretroviral treatment at a public health clinic

Sustaining virological suppression among HIV-infected adolescents is challenging. We evaluated a home-based adherence intervention and characterized self-reported adherence, virological response and drug resistance among adolescents failing atazanavir/ritonavir (ATV/r)-based 2^nd line treatment.

Causes of HIV Drug Non-Adherence in Korea: Korea HIV/AIDS Cohort Study, 2006-2015

We aimed to determine the initial adherence of HIV cohort patients to ART (antiretroviral therapy), and reasons for non-adherence. Patients who received ART at the time of enrollment in the Korea HIV/AIDS Cohort were included in this study. Treatment adherence was determined at the baseline interview by self-reported questionnaire. Eight-hundred thirty two HIV-infected patients received ART. Of these, 253 (30.4%) patients skipped ART more than once a month. The most common reason of skipping medication was "simply forgot" (60.4%).

Medication Adherence in 13- to 24-Year-Old Youth Living With HIV

Despite advances in HIV medicine, adherence presents as a barrier to effective treatment for youth. We designed this study to assess medication knowledge, adherence, and factors affecting adherence in youth with HIV. Participants were 72 youth ages 13 to 24 years with perinatally or behaviorally acquired HIV. Demographic data were collected and a self-report adherence interview was administered. Interviews were audio-recorded to allow for qualitative data analysis. Self-reported adherence varied depending on the framing of questions, with participants reporting greater adherence when asked how many doses they had missed within the past 7 days compared to results from a 7-day recall interview. At least 74% of the sample said they sometimes forgot to take their medication. A taxonomic approach to the qualitative analysis revealed internal and external facilitators and barriers to adherence. Findings suggest a need for education and provider support to include strategies to improve adherence.

Patient engagement and patient support programs in allergy immunotherapy: a call to action for improving long-term adherence

Allergy immunotherapy (AIT) is acknowledged to produce beneficial mid- and long-term clinical and immunologic effects and increased quality of life in patients with allergic respiratory diseases (such as allergic rhinoconjunctivitis and allergic asthma). However, poor adherence to AIT (due to intentional and/or non-intentional factors) is still a barrier to achieving these benefits. There is an urgent need for patient support programs (PSPs) that encompass communication, educational and motivational components. In the field of AIT, a PSP should be capable of (1) improving adherence, (2) boosting patient engagement, (3) explaining how AIT differs from pharmacological allergy treatments; (4) increasing health literacy about chronic, progressive, immunoglobulin-E-mediated immune diseases, (5) helping the patient to understand and manage local or systemic adverse events, and (6) providing and/or predicting local data on aeroallergen levels. We reviewed the literature in this field and have identified a number of practical issues to be addressed when implementing a PSP for AIT: the measurement of adherence, the choice of technologies, reminders, communication channels and content, the use of "push" messaging and social networks, interactivity, and the involvement of caregivers and patient leaders. A key issue is "hi-tech" (i.e. approaches based mainly on information technology) vs. "hi-touch" (based mainly on interaction with humans, i.e. family members, patient mentors and healthcare professionals). We conclude that multistakeholder PSPs (combining patient-, provider and society-based actions) must now be developed and tested with a view to increasing adherence, efficacy and safety in the field of AIT.

Reasons for Missing Antiretroviral Therapy: Results from a Multi-Country Study in Tanzania, Uganda, and Zambia

OBJECTIVES

To identify the reasons patients miss taking their antiretroviral therapy (ART) and the proportion who miss their ART because of symptoms; and to explore the association between symptoms and incomplete adherence.

METHODS

Secondary analysis of data collected during a cross-sectional study that examined ART adherence among adults from 18 purposefully selected sites in Tanzania, Uganda, and Zambia. We interviewed 250 systematically selected patients per facility (≥ 18 years) on reasons for missing ART and symptoms they had experienced (using the HIV Symptom Index). We abstracted clinical data from the patients' medical, pharmacy, and laboratory records. Incomplete adherence was defined as having missed ART for at least 48 consecutive hours during the past 3 months.

RESULTS

Twenty-nine percent of participants reported at least one reason for having ever missed ART (1278/4425). The most frequent reason was simply forgetting (681/1278 or 53%), followed by ART-related hunger or not having enough food (30%), and symptoms (12%). The median number of symptoms reported by participants was 4 (IQR: 2-7). Every additional symptom increased the odds of incomplete adherence by 12% (OR: 1.1, 95% CI: 1.1-1.2). Female participants and participants initiated on a regimen containing stavudine were more likely to report greater numbers of symptoms.

CONCLUSIONS

Symptoms were a common reason for missing ART, together with simply forgetting and food insecurity. A combination of ART regimens with fewer side effects, use of mobile phone text message reminders, and integration of food supplementation and livelihood programmes into HIV programmes, have the potential to decrease missed ART and hence to improve adherence and the outcomes of ART programmes.

The Impact of Non-Antiretroviral Polypharmacy on the Continuity of Antiretroviral Therapy (ART) Among HIV Patients

Improved survival achieved by many patients with HIV/AIDS has complicated their medical care as increasing numbers of co-morbidities leads to polypharmacy, increased pill burdens, and greater risks of drug-drug interactions potentially compromising antiretroviral treatment (ART). We examined the impact of non-antiretroviral polypharmacy on ART for all adults followed at the Southern Alberta Clinic, Calgary, Canada. Polypharmacy was defined as ≥5 daily medications. We compared the impact of polypharmacy on continuous (i.e., remaining on same ART for ≥6 months) vs. non-continuous (i.e., discontinuing or switching ART) ART dosing frequency, number of ART pills, number of non-ART medications, and age. Of 1190 (89.5%) patients on ART, 95% were on three-drug regimens, 63.9% on QD ART, and 62% ≥3 ART pills daily; 32.2% were experiencing polypharmacy. Polypharmacy was associated with lower CD4, AIDS, >180 months living with HIV, higher numbers of ART pills, and older age (all p < 0.01); 32.1% stopped or switched ART. Polypharmacy increased the risk for non-continuous ART (36.8% vs. 30.0%; p < 0.01). Non-continuous ART increased with daily ART pill count but not increased age. Non-adherence and adverse effects accounted for the majority of non-continuous ART. We found a strong association between polypharmacy and non-continuous ART, potentially leading to effective ART being compromised. Collaborative approaches are needed to anticipate the negative impacts of polypharmacy.

Barriers to uptake of prevention of mother-to-child transmission of HIV services among mothers of vertically infected HIV-seropositive infants in Makurdi, Nigeria

BACKGROUND

Perinatal transmission of human immunodeficiency virus (HIV) continues in Nigeria because of the poor use of prevention of mother-to-child transmission of HIV (PMTCT) services. This study reports on the barriers preventing mothers of vertically infected HIV-seropositive infants to use the PMTCT services at the Federal Medical Centre, Makurdi, Nigeria.

METHODS

This is a descriptive study conducted between January and April, 2014. A quantitative survey was applied to detect barriers along the PMTCT services cascade among 52 mothers of vertically infected HIV-seropositive infants. This includes 22 women who attended antenatal care at the Federal Medical Centre (designated as Group A mothers) and 30 women who did not receive any form of PMTCT service (Group B mothers). The study was supplemented with a focused group discussion involving 12 discussants from the two groups.

RESULTS

In the quantitative assessment: among the Group A mothers, falling asleep was the most common reason (n=22, 100%) for missing therapeutic/prophylactic antiretroviral medicine; financial constraint (n=22, 100%) was the most common reason for antenatal care visit defaults; and a lot of the mothers (n=11, 50.0%) did not give nevirapine to their newborns because they delivered at home. Among Group B mothers, unawareness of HIV-seropositive status was the most common reason (n=28, 93.3%) given for not accessing PMTCT services. In the qualitative study: noninvolvement of male partners, stigma and discrimination experienced by HIV-seropositive mothers, financial constraints in couples, involvement of traditional birth attendants in antenatal care and delivery of HIV-infected women, unawareness of HIV-seropositive status by pregnant women, poor health system, and the lack of funding for PMTCT services at private and rural health facilities were the major barriers preventing the use of PMTCT services.

CONCLUSION

In order to reduce the missed opportunities for PMTCT interventions in Makurdi and by extension the Benue State it represents in Nigeria, strong political and financial commitments are needed to overcome the identified barriers.

Post-ART Symptoms Were Not the Problem: A Qualitative Study on Adherence to ART in HIV-Infected Patients in a Mozambican Rural Hospital

Objective

The objective of this qualitative study was to explore how clinical symptoms may affect adherence to antiretroviral therapy (ART) in HIV patients, and to explore factors, perceptions and attitudes related to adherence to therapy.

Design

A qualitative study was carried out in the context of the prospective cohort study “Evaluation of Immune Reconstitution Following Initiation of Highly Active Antiretroviral Treatment in Manhiça, Mozambique”. In-depth Interviews were conducted twice in a sub-sample of the study cohort (51 participants), at six-month intervals.

Results

Most participants (73%) knew that AIDS is a chronic disease and that ART does not cure it. Nine participants (18%) were non-adherent at some point and two (4%) abandoned ART. All participants but five reported having symptoms after starting ART, mainly attributed to pills needing time to act and body’s reaction to the treatment. In spite of the perceived severity of the symptoms, only two people reported they discontinued the treatment due to symptoms. Almost all participants reported feeling comfortable with the HIV clinic organization and procedures, but afraid of staff being hostile if they did not follow the rules or if the health worker visited their home. Family was one of the most important source of support according participants. Almost all participants with children said that a decisive factor to follow the treatment was the desire to be able to look after them.

Conclusions

Experiencing symptoms after starting treatment was not a barrier to adherence to ART. Factors related to adherence included control measures set up by the health facility (exhaustive follow up, support, information) and family and community support. Indirect ART-related expenses did jeopardise adherence.

Antiretroviral therapy adherence strategies used by patients of a large HIV clinic in Lesotho

A high degree of adherence to antiretroviral therapy (ART) in patients infected with human immunodeficiency virus (HIV) is necessary for long term treatment effects. This study explores the role of timing of ART intake, the information patients received from health workers, local adherence patterns, barriers to and facilitators of ART among 28 HIV-positive adults at the Senkatana HIV Clinic in Maseru, Lesotho. This qualitative, semi-structured interview study was carried out during February and March of 2011 and responses were analyzed inspired by the Grounded Theory method. Results were then compared and discussed between the authors and the main themes that emerged were categorized. The majority of the respondents reported having missed one or more doses of medicine in the past and it was a widespread belief among patients that they were required to skip the dose of ART if they were "late". The main barriers to adherence were interruptions of daily routines or leaving the house without sufficient medicine. The use of mobile phone alarms, phone clocks and support from family and friends were major facilitators of adherence. None of the patients reported to have been counseled on family support or the use of mobile phones as helpful methods in maintaining or improving adherence to ART. Being on-time with ART was emphasized during counseling by health workers. In conclusion, patients should be advised to take the dose as soon as they remember instead of skipping the dose completely when they are late. Mobile phones and family support could be subjects to focus on during future counseling particularly with the growing numbers of mobile phones in Africa and the current focus on telemedicine.

Adherence to highly active antiretroviral therapy in a tertiary care hospital in West Bengal, India

INTRODUCTION

The introduction of highly active antiretroviral therapy (HAART) for the treatment of human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) has led to the reduction of mortality and the improvement of the quality of life of people living with HIV/AIDS (PLWHA). The present study was conducted to determine the pattern of adherence to HAART among PLWHA, and to assess the factor(s) affecting nonadherence, if any.

METHODS

This study was a hospital-based analytical, cross-sectional epidemiological study conducted between July and October 2011. A total of 370 adult HIV-positive patients registered in the Antiretroviral Therapy Centre of Burdwan Medical College and Hospital, West Bengal, India, were included. Nonadherence was defined as missing at least a single dose of medicine within the last four days. Data was analysed using the Statistical Package for the Social Sciences version 19.0 (IBM Corp, Armonk, NY, USA).

RESULTS

A total of 87.6% of patients were found to be adherent to HAART. Principal causes of nonadherence were forgetting to take medicine (70.2%), being away from home (65.2%), and busyness with other things (64.7%). Multivariate logistic regression analysis revealed that nonadherence was significantly associated with a positive family history of HIV/AIDS (odds ratio [OR] 16; 95% confidence interval [CI] 2.2-114.3; p = 0.01), occurrence of side effects with HAART (OR 9.81; 95% CI 1.9-51.7; p = 0.01) and employment (OR 5.93; 95% CI 1.5-23.2; p = 0.01).

CONCLUSION

Although overall adherence was high, the factors that affect nonadherence can be addressed with proper counselling and motivation of patients and their family members. Adherence to HAART could delay the progression of this lethal disease and minimise the risk of developing drug resistance.

Appreciating Reasons for Nonadherence in Women

Women aged 15-24 years have an HIV infection rate twice that of men the same age. In this study we examined reasons why HIV-infected women taking antiretroviral therapy (ART) report missing HIV medications. Women (N = 206) on ART were 2.2 times more likely to endorse reasons pertaining to forgetfulness versus reasons pertaining to problems taking pills (OR = 2.2, 95% CI = 1.63, 2.94, p <.001). There was a difference between the adherent and nonadherent groups in types of reasons overall (p <.001, 95% CI = -3.82, -2.03). Using a patient-centered approach to understand type of nonadherence (intentional vs. unintentional) may support development of novel interventions.

Alcohol use, antiretroviral therapy adherence, and preferences regarding an alcohol-focused adherence intervention in patients with human immunodeficiency virus

BACKGROUND

The primary objectives of this study were to determine the association between alcohol and antiretroviral therapy (ART) adherence and the perceived appropriateness and acceptability of elements of an adherence counseling program with a focus on alcohol-related ART nonadherence among a sample of ART recipients in human immunodeficiency virus (HIV) clinics in Tshwane, South Africa.

METHODS

We conducted a cross-sectional study with purposive sampling. The sample comprised 304 male and female ART recipients at two President's Emergency Plan For AIDS Relief-supported HIV clinics. Using an interview schedule, we assessed patients' alcohol use (Alcohol Use Disorders Identification Test), other drug use, level of adherence to ART, and reasons for missing ART doses (AIDS Clinical Trials Group adherence instrument). Additionally, patients' views were solicited on: the likely effectiveness of potential facilitators; the preferred quantity, duration, format, and setting of the sessions; the usefulness of having family members/friends attend sessions along with the patient; and potential skill sets to be imparted.

RESULTS

About half of the male drinkers' and three quarters of the female drinkers' Alcohol Use Disorders Identification Test scores were suggestive of hazardous or harmful drinking. Average self-reported ART adherence was 89.7%. There was a significant association between level of alcohol use and degree of ART adherence. Overall, participants perceived two clinic-based sessions, each of one hour's duration, in a group format, and facilitated by a peer or adherence counselor, as most appropriate and acceptable. Participants also had a favorable attitude towards family and friends accompanying them to the sessions. They also favored an alcohol-focused adherence counseling program that employs motivational interviewing and cognitive behavioral therapy-type approaches.

CONCLUSION

The association between alcohol use and ART nonadherence points to a need for alcohol-focused ART adherence interventions. Patients' perceptions suggest their amenability to clinic-based brief motivational interviewing and cognitive behavioral therapy-type adherence interventions delivered by lay persons in group settings. Further research should investigate how best to implement such interventions in the existing health system.

What are validated self-report adherence scales really measuring?: a systematic review

AIMS

Medication non-adherence is a significant health problem. There are numerous methods for measuring adherence, but no single method performs well on all criteria. The purpose of this systematic review is to (i) identify self-report medication adherence scales that have been correlated with comparison measures of medication-taking behaviour, (ii) assess how these scales measure adherence and (iii) explore how these adherence scales have been validated.

METHODS

Cinahl and PubMed databases were used to search articles written in English on the development or validation of medication adherence scales dating to August 2012. The search terms used were medication adherence, medication non-adherence, medication compliance and names of each scale. Data such as barriers identified and validation comparison measures were extracted and compared.

RESULTS

Sixty articles were included in the review, which consisted of 43 adherence scales. Adherence scales include items that either elicit information regarding the patient's medication-taking behaviour and/or attempts to identify barriers to good medication-taking behaviour or beliefs associated with adherence. The validation strategies employed depended on whether the focus of the scale was to measure medication-taking behaviour or identify barriers or beliefs.

CONCLUSIONS

Supporting patients to be adherent requires information on their medication-taking behaviour, barriers to adherence and beliefs about medicines. Adherence scales have the potential to explore these aspects of adherence, but currently there has been a greater focus on measuring medication-taking behaviour. Selecting the 'right' adherence scale(s) requires consideration of what needs to be measured and how (and in whom) the scale has been validated.

Adherence and health care costs

Medication nonadherence is an important public health consideration, affecting health outcomes and overall health care costs. This review considers the most recent developments in adherence research with a focus on the impact of medication adherence on health care costs in the US health system. We describe the magnitude of the nonadherence problem and related costs, with an extensive discussion of the mechanisms underlying the impact of nonadherence on costs. Specifically, we summarize the impact of nonadherence on health care costs in several chronic diseases, such as diabetes and asthma. A brief analysis of existing research study designs, along with suggestions for future research focus, is provided. Finally, given the ongoing changes in the US health care system, we also address some of the most relevant and current trends in health care, including pharmacist-led medication therapy management and electronic (e)-prescribing.

Relationships among neurocognitive status, medication adherence measured by pharmacy refill records, and virologic suppression in HIV-infected persons

BACKGROUND

Optimal antiretroviral therapy (ART) effectiveness depends on medication adherence, which is a complex behavior with many contributing factors, including neurocognitive function. Pharmacy refill records offer a promising and practical tool to assess adherence.

METHODS

A substudy of the CHARTER (CNS HIV Anti-Retroviral Therapy Effects Research) study was conducted at the Johns Hopkins University (JHU) and the University of Washington. Pharmacy refill records were the primary method to measure ART adherence, indexed to a "sentinel" drug with the highest central nervous system penetration-effectiveness score. Standardized neuromedical, neuropsychological, psychiatric, and substance use assessments were performed at enrollment and at 6 months. Regression models were used to determine factors associated with adherence and relationships between adherence and changes in plasma and cerebrospinal fluid HIV RNA concentrations between visits.

RESULTS

Among 80 (33 at JHU and 47 at University of Washington) participants, the mean adherence score was 86.4%, with no difference between sites. In the final multivariable model, better neurocognitive function was associated with better adherence, especially among participants who were at JHU, male, and HIV infected for a longer period of time. Worse performance in working memory tests was associated with worse adherence. Better adherence predicted greater decreases in cerebrospinal fluid HIV RNA between visits.

CONCLUSIONS

Poorer global neurocognitive functioning and deficits in working memory were associated with lower adherence defined by a pharmacy refill record measure, suggesting that assessments of cognitive function, and working memory in particular, may identify patients at risk for poor ART adherence who would benefit from adherence support.

What are validated self-report adherence scales really measuring?: a systematic review

AIMS

Medication non-adherence is a significant health problem. There are numerous methods for measuring adherence, but no single method performs well on all criteria. The purpose of this systematic review is to (i) identify self-report medication adherence scales that have been correlated with comparison measures of medication-taking behaviour, (ii) assess how these scales measure adherence and (iii) explore how these adherence scales have been validated.

METHODS

Cinahl and PubMed databases were used to search articles written in English on the development or validation of medication adherence scales dating to August 2012. The search terms used were medication adherence, medication non-adherence, medication compliance and names of each scale. Data such as barriers identified and validation comparison measures were extracted and compared.

RESULTS

Sixty articles were included in the review, which consisted of 43 adherence scales. Adherence scales include items that either elicit information regarding the patient's medication-taking behaviour and/or attempts to identify barriers to good medication-taking behaviour or beliefs associated with adherence. The validation strategies employed depended on whether the focus of the scale was to measure medication-taking behaviour or identify barriers or beliefs.

CONCLUSIONS

Supporting patients to be adherent requires information on their medication-taking behaviour, barriers to adherence and beliefs about medicines. Adherence scales have the potential to explore these aspects of adherence, but currently there has been a greater focus on measuring medication-taking behaviour. Selecting the 'right' adherence scale(s) requires consideration of what needs to be measured and how (and in whom) the scale has been validated.

Number of daily pills, dosing schedule, self-reported adherence and health status in 2010: a large cross-sectional study of HIV-infected patients on antiretroviral therapy

OBJECTIVES

The aim of the study was to assess whether pill burden is associated with self-reported adherence to current combination antiretroviral regimens and health status in a large sample of unselected and chronically treated HIV-infected patients.

METHODS

An adherence and health status questionnaire was offered to all patients collecting their drugs between March and May 2010 at our clinic; both parameters were primarily evaluated using a visual analogue scale. Linear correlations were evaluated using Spearman's correlation coefficient. Wilcoxon's rank-sum test and the χ(2) test were used to compare quantitative and qualitative variables. The generalized linear model was used in multivariable analyses.

RESULTS

Among 2763 subjects on treatment during the study period, 2114 (78.8% male; mean age 46.9 ± 8.84 years) were tested for adherence; 1803 (85.3%) had viral loads < 50 HIV-1 RNA copies/mL. After adjusting for age, gender, HIV risk factor, current CD4 count, pill burden and dosing interval, adherence was higher in patients with undetectable HIV RNA (P < 0.0001) and directly associated with current CD4 count (P = 0.029). After adjusting for the same variables, health status was better in patients with undetectable viraemia (P = 0.004) and in men who have sex with men (MSM) and heterosexuals compared with injecting drug users and those with other risk factors (P < 0.0001 for MSM and P = 0.008 for heterosexuals); it was also directly associated with current CD4 count (P < 0.0001) and inversely associated with age (P < 0.0001) and pill burden (P = 0.019).

CONCLUSIONS

In this highly adherent population, the number of daily pills was related to self-reported health status but not to self-reported adherence, whereas the dosing interval did not influence self-reported adherence or health status.

HIV treatment adherence, drug resistance, virologic failure: evolving concepts

Poor adherence to combined antiretroviral therapy (cART) has been shown to be a major determinant of virologic failure, emergence of drug resistant virus, disease progression, hospitalizations, mortality, and health care costs. While high adherence levels can be achieved in both resource-rich and resource-limited settings following initiation of cART, long-term adherence remains a challenge regardless of available resources. Barriers to optimal adherence may originate from individual (biological, socio-cultural, behavioral), pharmacological, and societal factors. Although patients and providers should continuously strive for maximum adherence to cART, there is accumulating evidence that each class of antiretroviral therapy has specific adherence-drug resistance relationship characteristics allowing certain regimens more flexibility than others. There is not a universally accepted measure for cART adherence, since each method has distinct advantages and disadvantages including cost, complexity, accuracy, precision, intrusiveness and bias. Development of a real-time cART adherence monitoring tool will enable the development of novel, pre-emptive adherence-improving strategies. The application of these strategies may ultimately prove to be the most cost-effective method to reduce morbidity and mortality for the individual and decrease the likelihood of HIV transmission and emergence of resistance in the community.

Problems taking pills: understanding HIV medication adherence from a new perspective

HIV medication adherence remains a challenge for people taking antiretroviral therapy. In the last decade research in this area has proliferated, yet there is a need for novel research approaches that provide information on the development of successful medication adherence interventions. This study examined several key potential correlates of reasons for missed medication in a diverse sample of people living with HIV/AIDS (PLWHA) from nine cities in the US using an ordinal regression model. Examining the reasons for missed medication in relationship with regimen type, symptom experience, AIDS diagnosis, other health conditions, and social support offers a new approach. Problems taking pills (a factor of five reasons) was significantly associated (p=0.003) with use of a protease inhibitor (PI) regimen. A person taking a PI regimen has a 70% increase of having more problems taking pills versus a non-PI regimen. Symptom experience (odds ratio [OR]: 3.8; 95% confidence interval [CI]: 2.7, 5.2) and other health conditions (OR: 0.7; 95% CI: 0.45, 0.98) were found to be independently associated with problems taking pills. This new perspective may provide a framework for further conceptualizing new analyses that are related to enhancing adherence intervention research and development.

Factors associated with reduced compliance of children to dental preventive measures

The aim of this study was to record self-reported factors for non-compliance to 'dental home' preventive measures among pediatric patients, and to clarify whether number or frequency of recall appointments increases their long-term compliance to dental home. Children attending recall appointments in a pediatric dental clinic were interviewed regarding their compliance as well as factors for non-compliance with the previously recommended preventive measures. Files of 651 children were analyzed. A significant positive correlation was found between compliance with regular teeth brushing twice a day (p < 0.0001), using correct fluoride concentration toothpaste (p < 0.0001), drinking water between meals (p < 0.0001), using Elmex gel (p < 0.0001), flossing (p < 0.002) and number of recall appointments. The most common factor for non-compliance to 'dental home' was 'I forgot'. Not flossing was commonly justified by performance difficulty while non-compliance to Elmex gel or to mouth rinses was attributed mainly to 'bad taste'. Additional common reasons were 'it was finished', 'my parents did not purchase', 'I did not find it at home', 'I did not know I need to'. Frequency and number of recall appointments might improve compliance with dental preventive measures. Referring to the specific factors of personal non-compliance may increase compliance.

Knowledge of and attitudes towards depression and adherence to treatment: the Antidepressant Adherence Scale (AAS)

BACKGROUND

Non-adherence to treatment can result from forgetting, carelessness, stopping the drug when feeling worse, or stopping the drug when feeling better.

OBJECTIVE

To develop and psychometrically assess a brief instrument that can be easily used in clinical practice to measure adherence to antidepressants.

METHOD

We developed the Antidepressants Adherence Scale (AAS); a self report rating scale including four items to assess the degree to which forgetting, carelessness, and stopping due to feeling worse or feeling better interfere with adherence in the last 4 weeks. Our proposed four-item adherence instrument was developed based on previous research and theory.

PARTICIPANTS

Experts in mood disorders (n=12) participated in the formal validity assessment of the instrument, and the developed instrument was administered to patients who were prescribed antidepressants (n=63). All patients also completed a multiple choice question instrument to measure knowledge of depression, and a Likert self report questionnaire to assess attitudes towards depression and its treatment.

RESULTS

There was 90% agreement among experts that the items were highly relevant providing strong evidence for content validity. Also, there was empirical evidence for validity. There were significant correlations (p<0.05) between knowledge and attitude subscales and adherence items. The internal consistency reliability (Cronbach's alpha) was 0.66 for the instrument.

CONCLUSION AND SIGNIFICANCE

Knowledge of and attitudes to depression and its treatment may have significant impact on the adherence to antidepressants. The AAS can be used in clinical settings (2-3 min to administer) to evaluate patients' adherence to antidepressants.

Factors affecting first-month adherence to antiretroviral therapy among HIV-positive adults in South Africa

This study explores the influence of baseline factors on first-month adherence to highly active antiretroviral therapy (HAART) among adults. The study design involved a review of routinely collected patient information in the CAPRISA AIDS Treatment (CAT) programme, at a rural and an urban clinic in KwaZulu-Natal Province, South Africa. The records of 688 patients enrolled in the CAT programme between June 2004 and September 2006 were analysed. Adherence was calculated from pharmacy records (pill counts) and patients were considered adherent if they had taken at least 95% of their prescribed drugs. Logistic regression was used to analyse the data and account for confounding factors. During the first month of therapy, 79% of the patients were adherent to HAART. HAART adherence was negatively associated with a higher baseline CD4 count. Women had better adherence if they attended voluntarily testing and counselling or if they had taken an HIV test because they were unwell, while men had higher adherence if they were tested due to perceived risk of HIV infection. HAART adherence was positively associated with higher age among patients who possessed cell phones and among patients who provided a source of income in the urban setting, but not in the rural setting. Though long-term data from this cohort is required to fully evaluate the impact of non-adherence in the first month of treatment, this study identifies specific groups of patients at higher risk for whom adherence counselling should be targeted and tailored. For example, first-month HAART adherence can be improved by targeting patients initiated on treatment with a high CD4 count.

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

Background

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

Presentation of the hypothesis

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

Testing the hypothesis

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

Implications of the hypothesis

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

Factors facilitating and challenging access and adherence to antiretroviral therapy in a township in the Zambian Copperbelt: a qualitative study

Antiretroviral therapy is increasingly available in African communities. We set out to gain patient perceptions on factors that facilitate and challenge access and adherence to such therapy. We carried out two semi-structured interviews 12 months apart with 40 HIV-positive people drawn from three economically deprived townships in the Copperbelt, Zambia. We also conducted a focus group of 12 of these interviewees. Availability of medication in health facilities did not automatically ensure access to those in need. A prerequisite for commencing on treatment was a positive documented HIV test result, but too few HIV testing centres, fear of family and community rejection and male domination in sexual and social decision-making prevented a number from coming forward to be tested. Once within the system of care, further barriers, such as rumours of bad side-effects, inconsistent information, high costs of drugs (at the time of the first interviews), ongoing costs of additional medical tests, overcrowded systems and overworked staff, all hindered access to receiving treatment. When taken, therapy brought side-effects, the most common being increased appetite and hunger. Yet, despite these barriers and challenges many of those on treatment reported good adherence. Immediate factors, such as seeing ill people becoming well; being supported by a friend or family member; and having a watch or clock to keep to a regular regime, were important. The increase in the number of people who were expected to die but were now looking well also shifted community attitudes. HIV/AIDS is beginning to move from a hidden terminal disease to a chronic condition that is treatable.

The Role of Adherence to Antiretroviral Therapy in the Management of HIV Infection

Despite multiple studies demonstrating the relation between the success of highly active antiretroviral therapy (HAART) and adherence, inadequate adherence continues to be one of the most frequent reasons for poor treatment outcomes and/or lack of sustained treatment benefits. Interventions targeting patient-related social and psychologic barriers to adherence and issues related to mental health and substance abuse and access to health care may ameliorate their negative impact on adherence. Specific drug-related factors that influence adherence such as pill burden, dosing frequency, food requirements, and acute tolerability and safety concerns, however, are further issues that must be considered to optimize adherence. Fortunately, the availability of once-daily and coformulated agents with simple dosing requirements may help to improve adherence, and thereby make the difference between success and failure of HAART for some patients. A better understanding of adherence and its determinants and how to define specific goals in a given clinical setting are keys for clinicians to become more effective partners with patients in the achievement and maintenance of long-term virologic suppression and, more importantly, long-term health.