Adherence to antiretroviral therapy among women with HIV infection

Clinical and demographic predictors of antiretroviral efficacy in HIV-HBV co-infected patients

BACKGROUND

The clinical and demographic characteristics that predict antiretroviral efficacy among patients co-infected with HIV and hepatitis B virus (HBV) remain poorly defined. We evaluated HIV virological suppression and rebound in a cohort of HIV-HBV co-infected patients initiated on antiretroviral therapy.

METHODS

A retrospective cohort analysis was performed with Canadian Observation Cohort Collaboration data. Cox proportional hazards models were used to determine the factors associated with time to virological suppression and time to virological rebound.

RESULTS

HBV status was available for 2,419 participants. A total of 8% were HBV co-infected, of whom 95% achieved virological suppression. After virological suppression, 29% of HIV-HBV co-infected participants experienced HIV virological rebound. HBV co-infection itself did not predict virological suppression or rebound risk. The rate of virological suppression was lower among patients with a history of injection drug use or baseline CD4 cell counts of <199 cells per cubic millimetre. Low baseline HIV RNA and men-who-have-sex-with-men status were significantly associated with a higher rate of virological suppression. Injection drug use and non-White race predicted viral rebound.

CONCLUSIONS

HBV co-infected HIV patients achieve similar antiretroviral outcomes as those living with HIV mono-infection. Equitable treatment outcomes may be approached by targeting resources to key subpopulations living with HIV-HBV co-infection.

Cervical cancer screening adherence among HIV-positive female smokers from a comprehensive HIV clinic

HIV-positive women are at elevated risk for developing cervical cancer. While emerging research suggests that gynecologic health care is underutilized by HIV-positive women, factors associated with adherence to Pap testing, especially among HIV-positive female smokers are not well known. We utilized baseline data from a smoking cessation trial and electronic medical records to assess Pap smear screening prevalence and the associated characteristics among the HIV-positive female participants (n = 138). 46 % of the women had at least 1 Pap test in the year following study enrollment. Multiple logistic regression analysis indicated that younger age, African American race, hazardous drinking, increased number of cigarettes smoked per day, and smoking risk perception were associated with non-adherence to Pap smear screening. Cervical cancer screening was severely underutilized by women in this study. Findings underscore the importance of identifying predictors of non-adherence and addressing multiple risk factors and behavioral patterns among HIV-positive women who smoke.

Characterizing HIV medication adherence for virologic success among individuals living with HIV/AIDS: Experience with the CNS HIV Antiretroviral Therapy Effects Research (CHARTER) cohort

Antiretroviral therapy (ART) has changed HIV related illness from terminal to chronic by suppressing viral load which results in immunologic and clinical improvement. Success with ART is dependent on optimal adherence, commonly categorized as >95%. As medication type, class and frequency of use continue to evolve, we assessed adherence levels related to viral suppression. Using a cross-sectional analysis with secondary data (n = 381) from an ongoing multi-site study on impact of ART on the Central Nervous System (CNS), we compared self-reported adherence rates with biological outcomes of HIV-RNA copies/ml, and CD4 cell/mm3. Adherence to ART measures included taking all prescribed medication as directed on schedule and following dietary restrictions. While depression was a barrier to adherence, undetectable viral suppression was achieved at pill adherence percentages lower than 95%. Practice, research and policy implications are discussed in the context of patient-, provider-, and system-level factors influencing adherence to ART.

A systematic review comparing antiretroviral adherence descriptive and intervention studies conducted in the USA

We examined the extent to which studies aimed at testing interventions to improve antiretroviral adherence have targeted the facilitators of and barriers known to affect adherence. Of the 88 reports reviewed, 41 were reports of descriptive studies conducted with US HIV-positive women and 47 were reports of intervention studies conducted with US HIV-positive persons. We extracted from the descriptive studies all findings addressing any factor linked to antiretroviral adherence and from the intervention studies, information on the nature of the intervention, the adherence problem targeted, the persons targeted for the intervention, and the intervention outcomes desired. We discerned congruence between the prominence of substance abuse as a factor identified in the descriptive studies as a barrier to adherence and its prominence as the problem most addressed in those reports of intervention studies that specified the problems targeted for intervention. We also discerned congruence between the prominence of family and provider support as factors identified in the descriptive studies as facilitators of adherence and the presence of social support as an intervention component and outcome variable. Less discernible in the reports of intervention studies was specific attention to other factors prominent in the descriptive studies, which may be due to the complex nature of the problem, individualistic and rationalist slant of interventions, or simply the ways interventions were presented. Our review raises issues about niche standardization and intervention tailoring, targeting, and fidelity.

In or out? Methodological considerations for including and excluding findings from a meta-analysis of predictors of antiretroviral adherence in HIV-positive women

AIM

This paper is a discussion detailing the decisions concerning whether to include or exclude findings from a meta-analysis of report of quantitative studies of antiretroviral adherence in HIV-positive women.

BACKGROUND

Publication constraints and the absence of reflexivity as a criterion for validity in, and reporting of, quantitative research preclude detailing the many judgements made in the course of a meta-analysis. Yet, such an accounting would assist researchers better to address the unique challenges to meta-analysis presented by the bodies of research they have targeted for review, and to show the subjectivity, albeit disciplined, that characterizes the meta-analytic process.

DATA SOURCES

Data were 29 published and unpublished studies on antiretroviral adherence in HIV-positive women of any race/ethnicity, class, or nationality living in the United States of America. The studies were retrieved between June 2005 and January 2006 using 40 databases.

REVIEW METHODS

Findings were included if they met the statistical assumptions of meta-analysis, including: (1) normal distribution of observations; (2) homogeneity of variances; and (3) independence of observations.

RESULTS

Relevant studies and findings were excluded because of issues related to differences in study design, different operationalizations of dependent and independent variables, multiple cuts from common longitudinal data sets, and presentation of unadjusted and adjusted findings. These reasons led to the exclusion of 73% of unadjusted relationships and 87% of adjusted relationships from our data set, leaving few findings to synthesize.

CONCLUSION

Decisions made during research synthesis studies may result in more information losses than gains, thereby obliging researchers to find ways to preserve findings that are potentially valuable for practice.

Using qualitative metasummary to synthesize qualitative and quantitative descriptive findings

The new imperative in the health disciplines to be more methodologically inclusive has generated a growing interest in mixed research synthesis, or the integration of qualitative and quantitative research findings. Qualitative metasummary is a quantitatively oriented aggregation of qualitative findings originally developed to accommodate the distinctive features of qualitative surveys. Yet these findings are similar in form and mode of production to the descriptive findings researchers often present in addition to the results of bivariate and multivariable analyses. Qualitative metasummary, which includes the extraction, grouping, and formatting of findings, and the calculation of frequency and intensity effect sizes, can be used to produce mixed research syntheses and to conduct a posteriori analyses of the relationship between reports and findings.

Adherence to HAART: a systematic review of developed and developing nation patient-reported barriers and facilitators

BACKGROUND

Adherence to highly active antiretroviral therapy (HAART) medication is the greatest patient-enabled predictor of treatment success and mortality for those who have access to drugs. We systematically reviewed the literature to determine patient-reported barriers and facilitators to adhering to antiretroviral therapy.

METHODS AND FINDINGS

We examined both developed and developing nations. We searched the following databases: AMED (inception to June 2005), Campbell Collaboration (inception to June 2005), CinAhl (inception to June 2005), Cochrane Library (inception to June 2005), Embase (inception to June 2005), ERIC (inception to June 2005), MedLine (inception to June 2005), and NHS EED (inception to June 2005). We retrieved studies conducted in both developed and developing nation settings that examined barriers and facilitators addressing adherence. Both qualitative and quantitative studies were included. We independently, in duplicate, extracted data reported in qualitative studies addressing adherence. We then examined all quantitative studies addressing barriers and facilitators noted from the qualitative studies. In order to place the findings of the qualitative studies in a generalizable context, we meta-analyzed the surveys to determine a best estimate of the overall prevalence of issues. We included 37 qualitative studies and 47 studies using a quantitative methodology (surveys). Seventy-two studies (35 qualitative) were conducted in developed nations, while the remaining 12 (two qualitative) were conducted in developing nations. Important barriers reported in both economic settings included fear of disclosure, concomitant substance abuse, forgetfulness, suspicions of treatment, regimens that are too complicated, number of pills required, decreased quality of life, work and family responsibilities, falling asleep, and access to medication. Important facilitators reported by patients in developed nation settings included having a sense of self-worth, seeing positive effects of antiretrovirals, accepting their seropositivity, understanding the need for strict adherence, making use of reminder tools, and having a simple regimen. Among 37 separate meta-analyses examining the generalizability of these findings, we found large heterogeneity.

CONCLUSIONS

We found that important barriers to adherence are consistent across multiple settings and countries. Research is urgently needed to determine patient-important factors for adherence in developing world settings. Clinicians should use this information to engage in open discussion with patients to promote adherence and identify barriers and facilitators within their own populations.

Research results have expiration dates: ensuring timely systematic reviews

Time and timeliness are key issues in appraising and ensuring the clinical relevance of systematic reviews. Time considerations entering the systematic review process include the history of the clinical problem, disease, or treatment that is the target of the review, and the history of the research conducted to address it. These considerations guide: (i) formulation of the research problems and questions; (ii) setting of parameters for the search and retrieval of studies; (iii) determination of inclusion and exclusion criteria; (iv) appraisal of the clinical relevance of findings; (v) selection of the findings that will be synthesized; and (vi) interpretation of the results of that synthesis.

HIV infection in women utilizing a major hospital in Andhra Pradesh, India, 1993-2004

BACKGROUND

Despite the high prevalence rates of HIV infection in women, epidemiological studies conducted exclusively on HIV-reactive women are very sparse, particularly from the state of Andhra Pradesh, India, where the overall prevalence rate among antenatal women is 2.1%.

STUDY POPULATION

Medical records of 2643 HIV-reactive women, identified during a 12-year period, were reviewed for epidemiological and clinical information about HIV in women.

RESULTS

The overall prevalence of HIV-reactive women was 1.6% and trends were in parallel with those observed by the HIV sentinel surveillance study from our state. Overall 24.5% of HIV-infected cases were women, ranging from 6.3% in 1993 to 28.9% in 2004. HIV infection was increasingly found in women over 30 years of age. Heterosexual contact (87.3%) was the most common route of HIV transmission. The majority (75.2%) of the women were asymptomatic. Women, compared to men, suffered more from respiratory and bacterial infections, often pneumonia, and from gender-specific manifestations like vaginal candidal infections. Following the introduction of antiretroviral (ARV) therapy in our hospital in 1999, only 8.5% of HIV-reactive women have received ARV treatment.

CONCLUSION

There is a need for gender- and age-specific HIV surveillance among women, especially from areas of high prevalence. Our study shows that there are good reasons to be concerned about the effects of HIV in women. We stress the importance of increasing the focus of attention on the impact of this pandemic on women as we enter the 25th year since its emergence.

Self-care of women growing older with HIV and/or AIDS

The purpose of this report is to describe the ways older women living with HIV perceive of and practice self-care. Data are taken from a culturally diverse subsample of 9 women age 50 years or older who participated in a larger longitudinal qualitative study of women who were HIV infected. During a period of 2 years, 10 semistructured narrative interviews were conducted with each of the 9 participants to gain an in-depth understanding of their experiences with symptom management, adherence to medical regimens, reduction of HIV risk, access to health care and social services, and personal efforts to maintain their health. Transcribed data were managed using Nvivo software and analyzed using multistaged narrative analysis. Findings suggest that mature women living with HIV integrate actions to maintain bodily comfort and improve physical well-being with actions that champion and conserve the existential self. Excerpts from their interviews illustrate this dialectical understanding of self-care.

Medication adherence and persistence: a comprehensive review

Estimates of adherence to long-term medication regimens range from 17% to 80%, and nonadherence (or nonpersistence) can lead to increased morbidity, mortality, and healthcare costs. Multifaceted interventions that target specific barriers to adherence are most effective, because they address the problems and reinforce positive behaviors. Providers must assess their patients' understanding of the illness and its treatment, communicate the benefits of the treatment, assess their patients' readiness to carry out the treatment plan, and discuss any barriers or obstacles to adherence that patients may have. A positive, supporting, and trusting relationship between patient and provider improves adherence. Individual patient factors also affect adherence. For example, conditions that impair cognition have a negative impact on adherence. Other factors--such as the lack of a support network, limited English proficiency, inability to obtain and pay for medications, or severe adverse effects or the fear of such effects--are all barriers to adherence. There are multiple reasons for nonadherence or nonpersistence; the solution needs to be tailored to the individual patient's needs. To have an impact on adherence, healthcare providers must understand the barriers to adherence and the methods or tools needed to overcome them. This report describes the barriers to medication adherence and persistence and interventions that have been used to address them; it also identifies interventions and compliance aids that practitioners and organizations can implement.

Successful adherence after multiple HIV treatment failures

BACKGROUND

Non-adherence to human immunodeficiency virus (HIV) medications often results in irreparable drug resistance and poor outcomes. Hence, care providers generally think that treatment of HIV disease should be delayed until a person is 'ready' to adhere. However, little research has focused on understanding the process that results in readiness for successful adherence.

AIM

The aim of this phenomenological study was to describe and understand the experience and decision-making processes of people who became adherent to their HIV medication regimens after previously failing treatment because of non-adherence.

METHOD

A Husserlian phenomenological approach was taken, and in-depth interviews were analysed using Giorgi's method of phenomenological description and analysis.

FINDINGS

Thirteen HIV-positive men and women who had previously failed two or more treatment regimens because of non-adherence were purposefully selected from two infectious diseases clinics in the Midwest region of the United States. They had achieved and sustained adherence to their HIV medications for 1 year or longer without formal intervention. All participants experienced a 'trigger' event preceding the process that led to the ability to incorporate lifestyle and health behaviour changes necessary for successful adherence. Factors associated with the process leading to adherence were: changing attitudes towards HIV medication, finding the right health care provider, creating the right support system, getting control of life and having goals.

CONCLUSIONS

This study demonstrated that HIV-positive individuals who had been non-adherent and had been viewed as 'difficult to treat' nonetheless successfully adhered to treatment once they became 'ready'. Findings from this study implicate that readiness may be a necessary component for successful adherence, particularly in HIV-positive individuals who have previously failed treatment. Understanding the relationship between the phenomenon of readiness and subsequent HIV treatment adherence has implications for clinical decision-making and for development of interventions that enhance adherence and prevent HIV drug resistance.

Assessment of Readiness for Adherence by HIV-Positive Males Who Had Previously Failed Treatment

The purpose of this prospective pilot study was to examine the relationship between the level of readiness for health behavior change and adherence by HIV-positive males (n = 19) who had previously failed treatment due to nonadherence. Participants completed the Index of Readiness (IR), an instrument measuring readiness to initiate health behavior change, prior to beginning new antiretroviral medications. After 6 months, participants were divided into two mutually exclusive groups: those who reached and sustained viral suppression and those who did not. Participants who experienced and sustained viral suppression had statistically significantly higher scores on the Identification of Barriers/Creating Strategies subscale of the IR compared to participants who did not reach viral suppression. Results from this preliminary study indicate that readiness may be a key component in successful adherence and that the IR may be a useful tool in assessing readiness for adherence to antiretroviral medications.

Attitudes toward HIV protease inhibitors and medication adherence in an inner city HIV population

The objective of this pilot study was to examine attitudes toward protease inhibitors (PIs) among HIV-infected individuals and to assess the relationship between PI attitudes and adherence to PIs. Respondents were recruited from four AIDS service organizations in New York City; the total sample consisted of 97 HIV-infected individuals who were taking a PI. The sample consisted largely of African Americans and Latinos from inner city areas, and most had a low level of education. Adherence was suboptimal, with more than 50% of respondents failing to take their PI medications exactly as prescribed within the previous month. Individuals who had recently used illegal drugs within the past 6 months were more likely to be nonadherent to PIs. Those who were not adherent to PI medications reported greater concern about the side effects of PIs and were more likely to believe that it was acceptable to skip doses of PIs.

An HIV Self-Care Symptom Management Intervention for African American Mothers

BACKGROUND

Human immunodeficiency virus (HIV) infection has become a serious health problem for low-income African American women in their childbearing years. Interventions that help them cope with feelings about having HIV and increase their understanding of HIV as a chronic disease in which self-care practices, regular health visits, and medications can improve the quality of life can lead to better health outcomes.

OBJECTIVE

This study aimed to determine the efficacy of an HIV self-care symptom management intervention for emotional distress and perceptions of health among low-income African American mothers with HIV.

METHOD

Women caregivers of young children were randomly assigned to self-care symptom management intervention or usual care. The intervention, based on a conceptual model related to HIV in African American women, involved six home visits by registered nurses. A baseline pretest and two posttests were conducted with the mothers in both groups. Emotional distress was assessed as depressive symptoms, affective state, stigma, and worry about HIV. Health, self-reported by the mothers, included the number of infections and aspects of health-related quality of life (i.e., perception of health, physical function, energy, health distress, and role function).

RESULTS

Regarding emotional distress, the mothers in the experimental group reported fewer feelings of stigma than the mothers in the control group. Outcome assessments of health indicated that the mothers in the experimental group reported higher physical function scores than the control mothers. Within group analysis over time showed a reduction in negative affective state (depression/dejection and tension/anxiety) and stigma as well as infections in the intervention group mothers, whereas a decline in physical and role function was found in the control group.

CONCLUSIONS

The HIV symptom management intervention has potential as a case management or clinical intervention model for use by public health nurses visiting the home or by advanced practice nurses who see HIV-infected women in primary care or specialty clinics.

Factors that influence adherence to HIV medications: perceptions of women and health care providers

The purpose of this pilot study was to explore factors that influence adherence to antiretroviral therapy (ART) in women with human immunodeficiency virus (HIV) disease. Antiretroviral medications that reduce viral count and prolong the time between a diagnosis of HIV disease and acquired immunodeficiency syndrome (AIDS) are expensive, numerous, and have multiple side effects. Common reasons for not adhering to the medication regimen include ART side effects and a dosage schedule that disrupts daily activities. Failure to take or errors in taking ART can result in an exacerbation of symptoms and disease progression or the development of drug-resistant strains of HIV. Women and providers in separate focus groups identified factors that facilitated and hindered adherence to ART. Knowledge of factors that influence adherence to ART will facilitate the development of interventions. Patient-provider relationships and side effects of weight gain are discussed as factors that influence adherence to ART.