Antiretroviral therapy adherence support: recommendations and future directions

Patient Education and Decision Support for Long-Acting Injectable HIV Antiretroviral Therapy: Protocol for Tool Development and Pilot Testing with Ryan White HIV/AIDS Program Medical Case Management Programs in New York

BACKGROUND

Long-acting injectable (LAI) HIV antiretroviral therapy (ART) presents a major opportunity to facilitate and sustain HIV viral suppression, thus improving health and survival among people living with HIV and reducing the risk of onward transmission. However, realizing the public health potential of LAI ART requires reaching patients who face barriers to daily oral ART adherence and thus can clinically benefit from alternative treatment modalities. Ryan White HIV/AIDS Program Part A medical case management (MCM) programs provide an array of services to address barriers to HIV care and treatment among economically and socially marginalized people living with HIV. These programs have demonstrated effectiveness in improving engagement along the continuum of care, but findings of limited program impact on durable viral suppression highlight the need to further innovate and hone strategies to support long-term ART adherence.

OBJECTIVE

This study aims to adapt and expand Ryan White MCM service strategies to integrate LAI ART regimen options, with the larger goal of improving health outcomes in the populations that could most benefit from alternatives to daily oral ART regimens.

METHODS

In 3 phases of work involving patient and provider participants, this study uses role-specific focus groups to elicit perceptions of LAI versus daily oral ART; discrete choice experiment (DCE) surveys to quantify preferences for different ART delivery options and related supports; and a nonrandomized trial to assess the implementation and utility of newly developed tools at 6 partnering Ryan White HIV/AIDS Program Part A MCM programs based in urban, suburban, and semirural areas of New York. Findings from the focus groups and DCEs, as well as feedback from advisory board meetings, informed the design and selection of the tools: a patient-facing, 2-page fact sheet, including frequently asked questions and a side-by-side comparison of LAI with daily oral ART; a patient-facing informational video available on YouTube (Google Inc); and a patient-provider decision aid. Implementation outcomes, measured through provider interviews, surveys, and service reporting, will guide further specification of strategies to integrate LAI ART options into MCM program workflows.

RESULTS

The study was funded in late April 2021 and received approval from the institutional review board in May 2021 under protocol 20-096. Focus groups were conducted in late 2021 (n=21), DCEs ran from June 2022 to January 2023 (n=378), and tools for piloting were developed by May 2023. The trial (May 2023 through January 2024) has enrolled >200 patients.

CONCLUSIONS

This study is designed to provide evidence regarding the acceptability, feasibility, appropriateness, and utility of a package of patient-oriented tools for comparing and deciding between LAI ART and daily oral ART options. Study strengths include formative work to guide tool development, a mixed methods approach, and the testing of tools in real-world safety-net service settings.

TRIAL REGISTRATION

Clinicaltrials.gov NCT05833542; https://clinicaltrials.gov/study/NCT05833542.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/56892.

It's all about connection: Determinants of social support and the influence on HIV treatment interruptions among people living with HIV in British Columbia, Canada

BACKGROUND

Social support has previously been found to be associated with improved health outcomes of individuals managing chronic illnesses, including amongst people living with HIV (PLWH). For women and people who use injection drugs who continue to experience treatment disparities in comparison to other PLWH, social support may have potential in facilitating better treatment engagement and retention. In this analysis, we examined determinants of social support as measured by the Medical Outcomes Study - Social Support Survey (MOS-SSS) scale, and quantified the relationship between MOS-SSS and HIV treatment interruptions (TIs) among PLWH in British Columbia, Canada.

METHODS

Between January 2016 and September 2018, we used purposive sampling to enroll PLWH, 19 years of age or older living in British Columbia into the STOP HIV/AIDS Program Evaluation study. Participants completed a baseline survey at enrolment which included the MOS-SSS scale, where higher MOS-SSS scores indicated greater social support. Multivariable linear regression modeled the association between key explanatory variables and MOS-SSS scores, whereas multivariable logistic regression modeled the association between MOS-SSS scores and experiencing TIs while controlling for confounders.

RESULTS

Among 644 PLWH, we found that having a history of injection drug use more than 12 months ago but not within the last 12 months, self-identifying as Indigenous, and sexual activity in the last 12 months were positively associated with MOS-SSS, while being single, divorced, or dating (vs. married), experiences of lifetime violence, and diagnosis of a mental health disorder were inversely associated. In a separate multivariable model adjusted for gender, ethnicity, recent homelessness, sexual activity in the last 12 months, and recent injection drug use, we found that higher MOS-SSS scores, indicating more social support, were associated with a lower likelihood of HIV treatment interruptions (adjusted odds ratio: 0.90 per 10-unit increase, 95% confidence interval: 0.83, 0.99).

CONCLUSIONS

Social support may be an important protective factor in ensuring HIV treatment continuity among PLWH. Future research should examine effective means to build social support among communities that have potential to promote increased treatment engagement.

Study protocol for data to suppression (D2S): a cluster-randomised, stepped-wedge effectiveness trial of a reporting and capacity-building intervention to improve HIV viral suppression in housing and behavioural health programmes in New York City

INTRODUCTION

With progress in the 'diagnose', 'link' and 'retain' stages of the HIV care continuum, viral suppression (VS) gains increasingly hinge on antiretroviral adherence among people with HIV (PWH) retained in care. The Centers for Disease Control and Prevention estimate that unsuppressed viral load among PWH in care accounts for 20% of onward transmission. HIV intervention strategies include 'data to care' (D2C)-using surveillance to identify out-of-care PWH for follow-up. However, most D2C efforts target care linkage, not antiretroviral adherence, and limit client-level data sharing to medical (versus support-service) providers. Drawing on lessons learnt in D2C and successful local pilots, we designed a 'data-to-suppression' intervention that offers HIV support-service programmes surveillance-based reports listing their virally unsuppressed clients and capacity-building assistance for quality-improvement activities. We aimed to scale and test the intervention in agencies delivering Ryan White HIV/AIDS Programme-funded behavioural health and housing services.

METHODS AND ANALYSIS

To estimate intervention effects, this study applies a cross-sectional, stepped-wedge design to the intervention's rollout to 27 agencies randomised within matched pairs to early or delayed implementation. Data from three 12-month periods (pre-implementation, partial implementation and full implementation) will be examined to assess intervention effects on timely VS (within 6 months of a report listing the client as needing follow-up for VS). Based on projected enrolment (n=1619) and a pre-implementation outcome probability of 0.40-0.45, the detectable effect size with 80% power is an OR of 2.12 (relative risk: 1.41-1.46).

ETHICS AND DISSEMINATION

This study was approved by the New York City Department of Health and Mental Hygiene's institutional review board (protocol: 21-036) with a waiver of informed consent. Findings will be disseminated via publications, conferences and meetings including provider-agency representatives.

TRIAL REGISTRATION NUMBER

NCT05140421.

Adapting and Implementing an Evidence-Based Reentry Intervention for Incarcerated Transgender Women: Lessons Learned

Incarceration is a significant public health issue that disproportionately impacts transgender (trans) women, particularly those of color. The cycle of incarceration interacts with high levels of substance use, mental illness, and HIV to produce a high disease burden among trans women, but, to date, there are no published studies of trans-specific reentry support interventions. Informed by the Model of Gender Affirmation, we systematically adapted and pilot tested the evidence-based Project START intervention to create Girlfriends Connect (GC), a reentry support intervention for trans women incarcerated in a county jail. Qualitative interviews with trans women (10 prerelease and 6 postrelease) and community social service providers and jail staff (n = 7) who serve justice-involved transgender women, as well as input from a community advisory board, informed our adaptation. We then conducted a pilot randomized controlled trial (n = 14) and a service implementation project (n = 16) of GC to examine its feasibility and acceptability. Lessons learned include the importance of peer facilitators, facilitated referral to gender-affirming community resources, and obtaining programmatic buy-in from jail staff and administration. Results indicate that GC is feasible and acceptable, and holds promise in improving the health of transgender women reentering the community after a period of incarceration.

Adherence to HIV Antiretroviral Therapy Among Pregnant and Breastfeeding Women, Non-Pregnant Women, and Men in Burkina Faso: Nationwide Analysis 2019-2020

BACKGROUND

Since the scale-up of antiretroviral therapy (ART) services in Burkina-Faso, achieving an AIDS-free generation depends on optimal ART adherence. However, no data exists on the population group differences on the level of ART adherence in Burkina-Faso. This study analyzes ART adherence among pregnant-and breastfeeding-women, non-pregnant women, and men in Burkina-Faso.

METHODS

From December 2019 to March 2020, a cross-sectional study among adult HIV-infected patients in Burkina-Faso, belonging either to the active file or the Prevention of Mother-To-Child Transmission programs was conducted. An analysis was performed and adherence was measured based on the number of times, patients did not meet the number of doses prescribed and did not take the ART treatment in the month prior to the survey. Logistic-regression models were used to identify factors associated with poor ART adherence and the adjusted odds ratios (aORs) with their 95% confidence intervals (95% CI) were reported.

RESULTS

The prevalence of good adherence was higher in the group of pregnant-and breastfeeding-women (86.6%, n = 112) compared to the other groups (73.1%, n=1017 in non-pregnant women and 72.0%, n = 318 in men). No association was found between ART adherence and the socio-demographic, clinical, and therapeutic characteristics of pregnant-and breastfeeding-women and men groups. However, non-pregnant women with a high level of education (aOR = 1.70; 95% CI: 1.16-2.49), having ever belonged to a support group (aOR= 1.47; 95% CI: 1.07-2.04), not having income-generating occupations (aOR= 1.53; 95% CI: 1.11-2.12), and in advanced clinical stage (aOR= 1.42; 95% CI: 1.06-1.91) were more susceptible to have poor adherence compared to their pairs.

CONCLUSION

Findings showed a large difference in ART adherence among pregnant-and breastfeeding-women, non-pregnant women and men and highlight the need for differentiated healthcare delivery according to population while specifically considering addressing the interest in early initiation of treatment and the benefit of support groups meeting.

A Preliminary Test of an mHealth Facilitated Health Coaching Intervention to Improve Medication Adherence among Persons Living with HIV

This study examined feasibility, acceptability, and preliminary efficacy of an mHealth facilitated health coaching antiretroviral therapy (ART) adherence intervention. Persons living with HIV (n = 53) were randomized to an in-person adherence session and 12 months of app access and health coaching via the app (Fitbit Plus) versus single adherence session (SOC). At baseline and 1, 3, 6, and 12 months, we measured ART adherence, substance use, and depressive symptoms. We also conducted individual qualitative interviews. The intervention was found to be largely feasible and highly acceptable, with the health coach spending an average of 2.4 min per month with a participant and 76.5% of Fitbit Plus participants using the app regularly at 12 months. While most comparisons were not significant, the pattern of results was consistent with better adherence in the Fitbit Plus compared to SOC condition. Substance use was significantly associated with poorer ART adherence while depressive symptoms were not.ClinicalTrials.gov Identifier: NCT02676128; Registered: 2/8/2016.

START (Supporting Treatment Adherence Readiness through Training) Improves Both HIV Antiretroviral Adherence and Viral Reduction, and is Cost Effective: Results of a Multi-site Randomized Controlled Trial

The START (Supporting Treatment Adherence Readiness through Training) intervention was examined for its effects on ART adherence and virologic suppression relative to usual care. A sample of 176 clients about to start or restart ART were randomized (83 to START, 93 to usual care) at HIV clinics in the Los Angeles area. Primary outcomes included electronically monitored dose-taking adherence and HIV viral load; primary end points were months 6 and 24, with group differences examined using nonresponse-weighted means or proportions, effect sizes, and significance testing. Item nonresponse was addressed using multiple imputation. 166 (94.3%) participants started ART, of whom 124 (74.7%) were still in care at month 6, and 90 (54.2%) at month 24. In comparison to the usual care control group, the START group had higher dose-taking adherence at month 6 (86.2% vs. 71.6%, d = 0.56, p = 0.01), which was sustained through month 24 (86.0% vs. 61.1%, d =1.01, p < 0.0001). While rates of undetectable viral load did not differ between groups at month 6 or 24, the mean reduction in viral load (log₁₀ copies/mm³) at month 24 was significantly greater in the intervention arm (3.0 vs. 2.7; d = 0.40, p = 0.047). An estimated cost of $132 per person was needed to obtain a 10% increase in dose-taking adherence over 24 months from the intervention. These findings suggest that START is cost effective in producing a medium to large effect on dose-taking adherence that is durable over 24 months, and a modest long-term effect on viral reduction.Trial registration Clinicaltrials.gov NCT02329782 (registered December 22, 2014).

Interventions to Improve Adherence to Antiretroviral Therapy (ART) in Sub-Saharan Africa: An Updated Systematic Review

Optimal adherence to antiretroviral therapy (ART) remains the bedrock of effective therapy and management of human immunodeficiency virus (HIV). This systematic review examines the effect of interventions in improving ART adherence in sub-Saharan Africa (SSA), which bears the largest global burden of HIV infection. In accordance with PRISMA guidelines, and based on our inclusion and exclusion criteria, PUBMED, MEDLINE, and Google Scholar databases were searched for published studies on ART adherence interventions from 2010 to 2019. Thirty-one eligible studies published between 2010 to 2019 were identified, the categories of interventions were structural, behavioral, biological, cognitive, and combination. Study characteristics varied across design, intervention type, intervention setting, country, and outcome measurements. Many of the studies were behavioral interventions conducted in hospitals with more studies being randomized controlled trial (RCT) interventions. Despite the study variations, twenty-four studies recorded improvements. Notwithstanding, more quality studies such as RCTs should be conducted, especially among key affected populations (KAPs) to control transmission of resistant strains of the virus. Reliable objective measures of adherence should replace the conventional subjective self-report. Furthermore, long-term interventions with longer duration should be considered when evaluating the effectiveness of interventions.

Examining Correlates of Pre-ART and Early ART Adherence to Identify Key Factors Influencing Adherence Readiness

Although current standard of care for HIV typically involves immediate initiation of antiretroviral therapy (ART), most patients can benefit from first assessing adherence readiness and addressing any barriers to optimal adherence. A sample of 176 HIV patients planning to start ART enrolled in a controlled trial of an adherence intervention that was based on the Information Motivation and Behavioral skills (IMB) model of health behavior. We examined correlates of multiple adherence readiness measures, as well as electronically measured early ART adherence, to identify variables most important for readiness to adhere well at the start of treatment. Education level, recency of HIV diagnosis and knowledge and commitment to adherence were found to be associated with both ART readiness and early ART adherence. These findings suggest that resources to support adherence readiness should target more experienced HIV patients, and strive to bolster knowledge and attitudes that reinforce commitment to adherence.

A Mobile Health App to Improve HIV Medication Adherence: Protocol for a Pilot Randomized Controlled Trial

BACKGROUND

Adherence to antiretroviral therapy (ART) is essential for allowing persons living with HIV to live longer, healthier lives. However, a large portion of this population has suboptimal adherence and are not virally suppressed. Conventional interventions aimed at improving ART adherence lack portability and scalability, and improvements in adherence are not often sustained. Mobile health (mHealth) ART interventions offer a low-cost and accessible method of improving adherence, but many have limited functionality and do not offer comprehensive support. The combination of an mHealth intervention with a face-to-face adherence intervention and interactive health coaching feature may offer sufficient support in a manner that is sensitive to resource limitations that are often found in HIV treatment settings. This paper details the protocol of a study designed to evaluate the potential of an enhanced mHealth intervention for improving ART adherence.

OBJECTIVE

The primary objective of this study is to assess the feasibility and acceptability of the Fitbit Plus app enhanced with a face-to-face LifeSteps session (Fitbit Plus condition) for improving ART adherence. In addition, we will determine the preliminary efficacy of the intervention by calculating treatment effect sizes.

METHODS

This study will be conducted in 2 phases. The intervention will be developed and piloted with a small group of participants during phase 1. Pilot participants will provide feedback that will be used to refine the intervention for phase 2. In phase 2, a preliminary randomized controlled trial (RCT) comparing Fitbit Plus with a condition that approximates the standard of care (SOC) will be conducted with 60 persons living with HIV. Interviews will be conducted with RCT participants at baseline, and follow-up interviews will be conducted at 1, 3, 6, and 12 months. ART adherence is the primary outcome and will be monitored throughout the study via electronic pill boxes. Effect sizes will be generated using a fractional logit model estimated by generalized estimating equations.

RESULTS

Phase 1 of this trial is complete; data collection for phase 2 is ongoing. Follow-ups with enrolled participants will conclude in January 2020.

CONCLUSIONS

This study will contribute to the literature on ART adherence and may produce an efficacious intervention. Owing to a small sample size, there may be insufficient power to detect statistically significant differences between Fitbit Plus and SOC. However, if Fitbit Plus is found to be acceptable and feasible and yields promising effect size estimates, this pilot study could serve as the foundation for a larger, fully powered trial of Fitbit Plus.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02676128; https://clinicaltrials.gov/ct2/show/NCT02676128.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/15356.

Patient Perceptions of Text Messaging to Improve Antiretroviral Therapy Adherence: A Qualitative Study of Patients in a Ryan White Clinic

Evidence on the use of short message service (SMS) to improve medication adherence in people living with HIV (PLHIV) is mounting, yet qualitative research on patient perceptions regarding SMS content and utility for HIV/AIDS remains nascent. To explore the experience of receiving medication reminders via SMS among PLHIV, 45 uninsured and underinsured PLHIV nested within the intervention arm of a larger study received daily, 1-way SMS adherence reminders. Qualitative data were collected by face-to-face, structured interview and were analyzed using conventional content analysis methods. Three main themes emerged from the data: (1) reminders helping with adherence, (2) concerns about delivery modes, and (3) the need for confidentiality. Study findings offer enhanced focus on an emerging strategy in patient-centered HIV care: Equipped with greater context on the experiences of PLHIV using SMS adherence reminders, health-care providers can offer more targeted support and thereby maximize the benefits of this popular and powerful technology.

Investigating client satisfaction with antiretroviral treatment services in South-South Nigeria

Client satisfaction is a key method of evaluating the quality of healthcare services. This research investigated client satisfaction with anti-retroviral treatment services in selected outpatient facilities in Rivers State. This study was a qualitative study carried out in four antiretroviral treatment (ART) facilities in Rivers State, Nigeria. Researchers conducted nine Key Informant Interviews (KIIs), 25 In-depth interviews (IDIs) and eight Focus Group Discussion (FGDs) among 73 Persons Living with HIVs (PLHIVS) consisting of 31 males and 42 females, using a topic guide. Interviews were recorded, transcribed and analysed using thematic content analysis. Majority of study participants interviewed reported being very satisfied with confidentiality, health worker attitude, interpersonal communication, counselling, and availability of drugs. The major sources of dissatisfaction included overcrowding, long waiting time and inadequate/expensive laboratory services. Suggestions proffered for improving the quality of care at the centres included increasing staff strength at the treatment centres, improving the quality and cost of laboratory services, and infrastructure upgrade. This study demonstrates the role health workers and facility processes play in satisfaction with services at HIV treatment centres. Health workers, programme officers, and managers in HIV prevention, care and treatment need to pay attention to these issues if they would be successful in improving the quality of care for PLHIVs.

Systematic procedures to promote U.S. HIV medication adherence via Photovoice

Medication adherence is essential to promote the health of people living with HIV (PL-HIV) and prevent HIV transmission in the U.S. Novel medication health promotion interventions are needed that address patient-centeredness, understandability, and communication with providers. The aims of this article are to define the systematic stages we used to develop an effective health promotion intervention via the products (e.g. images and stories) of Photovoice. We designed an intervention to improve HIV adherence knowledge, attitudes, and communication with providers through Photovoice. 16 PL-HIV used Photovoice strategies to describe their experiences with medication via images and captions and create an intervention (10 adherence promotion posters) that integrated photo-stories of their adherence motivators, journeys from sickness to health, and how they manage and counter HIV stigma. We outline the systematic process we used to adapt Photovoice to create the effective intervention for replication. The process included six stages: (i) identify scope of the project; (ii) create collaborative project team; (iii) design project materials; (iv) review and revise materials with team members; (v) disseminate materials; and (vi) evaluate materials. Photovoice is used traditionally as a social action research method. In this project, it was adapted to create patient-driven images and stories for health promotion posters. Poster viewers experienced improved self-efficacy for HIV medication adherence. Describing the adaptation of the Photovoice process in a deliberate and transparent way can support fidelity to the essence of the participant-driven method, while also allowing researchers and practitioners to replicate Photovoice as a successful health promotion intervention.

Adherence Connection for Counseling, Education, and Support: Research Protocol for a Proof-of-Concept Study

Background

The highest rates of new HIV infections are observed in African Americans and Hispanics/Latinos (ethnic minority) adolescents and young adults (youth). HIV-infected ethnic minority youth are less likely to initiate and maintain adherence to antiretroviral treatment (ART) and medical care, as compared with their adult counterparts.

Objective

The objective of this research protocol was to describe our proposed methods for testing a peer-led mobile health cognitive behavioral intervention, delivered via remote videoconferencing and smartphones with HIV-infected ethnic minority youth, Adherence Connection for Counseling, Education, and Support (ACCESS). Our secondary aim was to obtain initial estimates of the biobehavioral impact of ACCESS on HIV virologic outcomes and self-reported ART adherence, beliefs and knowledge about ART treatment, adherence self-efficacy, and health care utilization (retention in care).

Methods

An exploratory, sequential mixed-methods study design will be used with conceptual determinants of adherence behavior informed by the information-motivation-behavioral skills model. HIV-infected ethnic minority youth aged 16 to 29 years with a detectable HIV serum viral load of more than 200 copies/ml (N=25) will be recruited. Qualitative pretesting will be conducted, including semistructured, in-depth, individual interviews with a convenience sample meeting the study inclusion criteria. Preliminary analysis of qualitative data will be used to inform and tailor the ACCESS intervention. Testing and implementation will include a one-group pre-posttest pilot, delivered by a trained successful peer health coach who lives with HIV and is well-engaged in HIV care and taking ART. A total of 5 peer-led remote videoconferencing sessions will be delivered using study-funded smartphones and targeting adherence information (HIV knowledge), motivation (beliefs and perceptions), and behavioral skills (self-efficacy). Participant satisfaction will be assessed with poststudy focus groups and quantitative survey methodology. Bivariate analyses will be computed to compare pre- and postintervention changes in HIV biomarkers, self-reported ART adherence, beliefs and knowledge about ART, adherence self-efficacy, and retention in care.

Results

As of December 2018, we are in the data analysis phase of this pilot and anticipate completion with dissemination of final study findings by spring/summer 2019. The major outcomes will include intervention feasibility, acceptability, and preliminary evidence of impact on serum HIV RNA quantitative viral load (primary adherence outcome variable). Self-reported ART adherence and retention in care will be assessed as secondary outcomes. Findings from the qualitative pretesting will contribute to an improved understanding of adherence behavior.

Conclusions

Should the ACCESS intervention prove feasible and acceptable, this research protocol will contribute to a shift in existent HIV research paradigms by offering a blueprint for technology-enabled peer-led interventions and models.

International Registered Report Identifier (IRRID)

DERR1-10.2196/12543

Perspectives of US women participating in a candidate PrEP study: adherence, acceptability and future use intentions

INTRODUCTION

Limited data exist on acceptability of candidate pre-exposure prophylaxis (PrEP) regimens among US women. We evaluated PrEP experiences, attitudes and future use intentions among sexually active women who completed the US-based HIV Prevention Trials Network 069/AIDS Clinical Trials Group 5305 study.

METHODS

Women participated in the study between March 2013 and November 2015. We analysed computer-assisted self-interview (CASI) surveys among 130 women and conducted in-depth interviews among a subset of 26 women from three sites. Interviews were conducted in mid/late-2015.

RESULTS

Most women (57%) reported very good/excellent PrEP adherence on CASI, although 21% acknowledged over-reporting adherence at least some of the time. Commitment to preventing HIV infection, a sense of ownership of the study, and keeping pills stored in a visible location facilitated adherence. Adherence barriers included "simply forgetting" and being away from home. Most women interviewed did not intend to use PrEP in the future because of lack of perceived need due to their own (as opposed to their partners') low-risk behaviour and concerns about affordability - but not because of side effects or other characteristics of the regimens.

DISCUSSION

Improving HIV prevention options for US women will require access to affordable PrEP as well as expanding women's understanding of relationship- and community-level factors that increase their risk of acquiring HIV.

Beliefs in Antiretroviral Treatment and Self-Efficacy in HIV Management are Associated with Distinctive HIV Treatment Trajectories

An online survey was conducted among people living with HIV (PLHIV) in Australia to discern key factors associated with distinctive ART use patterns. The sample (N = 358), was further divided into three groups: those on ART continuously since initiation (n = 208, 58.1%); those on ART intermittently (n = 117, 32.7%); and those not on ART at the time of survey (n = 33, 9.2%). ART non-users were the most likely to hold serious concerns about ART that outweighed perceived necessities (benefits) from ART (AOR = 0.13; 95% CI 0.06-0.29; p < 0.001). They were also the least self-efficacious in HIV disease management (AOR = 0.29; 95% CI 0.09-0.87; p = 0.028). Intermittent ART users were more likely to receive their HIV diagnosis prior to 2003 (AOR = 0.38; 95% CI 0.28-0.53; p < 0.001) and perceive lower HIV management self-efficacy (AOR = 0.50, 95% CI 0.28-0.87; p = 0.015) than continuous users. ART-related beliefs and perceived self-efficacy in HIV self-management play an important role in achieving universal treatment uptake and sustained high levels of adherence.

Challenges and opportunities for gender-affirming healthcare for transgender women in prison

Purpose The purpose of this paper is to briefly address three interrelated areas of concerns - victimization, housing placement and healthcare provision - related to the health and welfare of transgender women in jails, prisons and other types of detention facilities. Design/methodology/approach Drawing on a growing body of research on health risks for transgender women who are detained in facilities in California and elsewhere, the authors provide recommendations for policy and practice that constitutes gender-affirming healthcare for transgender women behind bars. Findings Policymakers, correctional leaders, and prison-based clinicians have a number of opportunities to address the welfare of transgender women in jails, prisons and other types of detention facilities. Originality/value This policy brief offers concrete steps government officials can take to better meet their professional and constitutional obligations, provide higher quality care for transgender women involved in the criminal justice system, and effectuate positive changes in transgender women's health and welfare both inside and outside of carceral environments.

"Poems in the Entrance Area": Using Photo-Stories to Promote HIV Medication Adherence

Adherence to antiretroviral medication among people living with HIV (PL-HIV) is critical to individual and public health. By some estimates only a quarter of PL-HIV are sufficiently adherent, underscoring a continued need for adherence-promoting strategies. In this analysis we explore the effect of adherence education posters developed via Photovoice. A group of PL-HIV generated images and captions to describe their adherence experiences and used their photo-stories to design 10 posters. We assessed viewers' ( N = 111) adherence knowledge, self-efficacy, and communication changes quantitatively and qualitatively before and 3 months after poster placement in the clinic. We analyzed quantitative data with an independent groups t test or a Mann-Whitney test, and qualitative interviews via theme analysis. Quantitative findings indicated no significant differences. Qualitative interviewees said that posters enhanced knowledge with nonthreatening, relatable information; self-efficacy by motivating patients to take medicine and disclose HIV to others; and communication by facilitating adherence conversations and creating a visually supportive clinic. Divergent quantitative and qualitative findings can be partially explained by inquiry methods. The posters may be more effective as part of discussions about their content, like those facilitated by qualitative interviews. Additional research regarding the application of Photovoice to health promotion is warranted.

Come as You Are: Improving Care Engagement and Viral Load Suppression Among HIV Care Coordination Clients with Lower Mental Health Functioning, Unstable Housing, and Hard Drug Use

Lower mental health functioning, unstable housing, and drug use can complicate HIV clinical management. Merging programmatic and surveillance data, we examined characteristics and outcomes for HIV Care Coordination clients enrolled between December 2009 and March 2013. For clients diagnosed over 12 months before enrollment, we calculated post- versus pre-enrollment relative risks for short-term (12-month) care engagement and viral suppression. Both outcomes significantly improved in all subgroups, including those with lower mental health functioning, unstable housing, or hard drug use. Analyses further stratified within barrier-affected groups showed a tendency toward greater improvement when that barrier was reduced during the follow-up year.

The influence of depressive symptoms and substance use on adherence to antiretroviral therapy. A cross-sectional prevalence study

CONTEXT AND OBJECTIVE

Adherence to antiretroviral treatment (ART) is not a stable condition, but is dynamic, like mental conditions. The aim of this study was to examine whether non-adherence to ART is related to demographic and immunological variables, substance use and presence of depressive symptoms.

DESIGN AND SETTING

This was a cross-sectional prevalence study carried out at a public AIDS treatment center in the city of São Paulo, Brazil, between July 2006 and January 2007.

METHODS

438 patients on regular ART schedules with recent laboratory tests answered a demographic questionnaire, questions about substance use, the Hamilton Depression Rating Scale (HDRS) and the Simplified Medication Adherence Questionnaire (SMAQ).

RESULTS

The prevalence of non-adherence over the past three months (a pattern of treatment interruption) was 46.3%, and 27.2% also reported this in the past week (a pattern of missed doses). ART interruption was significantly related to older age, lower CD4+ cell count and homosexual/bisexual transmission. The pattern of missed doses was significantly related to younger age, higher HDRS scores and higher viral load of RNA HIV.

CONCLUSION

ART interruption may reflect recall errors and changes to the Brazilian demographic characteristics of HIV infection. The missed doses may reflect lifestyle characteristics of younger individuals. Attendance for HIV-positive individuals, particularly younger patients, should involve interventions and counseling in relation to the presence of depressive symptoms.

What we know and what we do not know about factors associated with and interventions to promote antiretroviral adherence

Antiretroviral therapy (ART) adherence remains critical for achieving successful outcomes. Factors affecting ART adherence can occur at the individual level or be related to the treatment regimen, daily schedule, and/or interpersonal relationships. While treatment-related barriers have diminished with recent simplified ART regimens, guidelines still recommend considering regimen simplicity. ART readiness should be assessed prior to starting ART, with follow-up adherence assessments once ART is initiated, and at all subsequent clinical visits. Adherence interventions work best when multifaceted, targeted for at-risk and nonadherent participants, and tailored to individuals' needs. Successful interventions have included education and counseling, provision of social support, directly observed therapy, and financial incentives. Pillboxes and two-way short-text messaging service (SMS) reminders have been shown to be effective and are widely recommended tools for promoting ART adherence. Further research is needed to determine the optimal combination of adherence interventions, as well as generalizability, implementation, and cost-effectiveness.

Adherence to antiretroviral therapy among HIV-infected adults in the United States

National estimates of antiretroviral therapy (ART) adherence and adherence support services utilization are needed to inform efforts to improve the health of HIV-infected persons in the United States. In a nationally representative sample of HIV-infected adults receiving medical care, 86% self-reported taking all ART doses in the past 72 hours. Overall, 20% reported using adherence support services and 2% reported an unmet need for services. If all nonadherent persons not receiving adherence support and all persons with a self-perceived unmet need for adherence support accessed services, resources to support ∼42,673 additional persons would be needed. Factors associated with lower adherence included younger age, female gender, depression, stimulant use, binge alcohol use, greater than once-daily dosing, longer time since HIV diagnosis, and patient beliefs. Predictors of adherence are multifactorial so multiple targeted strategies to improve adherence are warranted. Providing adherence support services to all those in need may require additional resources.

Development of an electronic medical record based alert for risk of HIV treatment failure in a low-resource setting

Background

The adoption of electronic medical record systems in resource-limited settings can help clinicians monitor patients' adherence to HIV antiretroviral therapy (ART) and identify patients at risk of future ART failure, allowing resources to be targeted to those most at risk.

Methods

Among adult patients enrolled on ART from 2005–2013 at two large, public-sector hospitals in Haiti, ART failure was assessed after 6–12 months on treatment, based on the World Health Organization's immunologic and clinical criteria. We identified models for predicting ART failure based on ART adherence measures and other patient characteristics. We assessed performance of candidate models using area under the receiver operating curve, and validated results using a randomly-split data sample. The selected prediction model was used to generate a risk score, and its ability to differentiate ART failure risk over a 42-month follow-up period was tested using stratified Kaplan Meier survival curves.

Results

Among 923 patients with CD4 results available during the period 6–12 months after ART initiation, 196 (21.2%) met ART failure criteria. The pharmacy-based proportion of days covered (PDC) measure performed best among five possible ART adherence measures at predicting ART failure. Average PDC during the first 6 months on ART was 79.0% among cases of ART failure and 88.6% among cases of non-failure (p<0.01). When additional information including sex, baseline CD4, and duration of enrollment in HIV care prior to ART initiation were added to PDC, the risk score differentiated between those who did and did not meet failure criteria over 42 months following ART initiation.

Conclusions

Pharmacy data are most useful for new ART adherence alerts within iSanté. Such alerts offer potential to help clinicians identify patients at high risk of ART failure so that they can be targeted with adherence support interventions, before ART failure occurs.

Younger age, recent HIV diagnosis, no welfare support and no annual sexually transmissible infection screening are associated with nonuse of antiretroviral therapy among HIV-positive gay men in Australia

OBJECTIVES

With the increasing momentum to maximize the benefits of antiretroviral therapy (ART), better understanding of opportunities and challenges in increasing ART coverage and promoting early ART initiation is urgently needed. Key sociodemographic, clinical and behavioural factors associated with Australian HIV-positive gay men's current nonuse of ART were systematically examined.

METHODS

Data were based on 1911 responses from HIV-positive men who had participated in the Australian Gay Community Periodic Surveys (GCPS) between 2010 and 2012. Stratified univariate analysis and multivariate logistic regression were used.

RESULTS

A majority of the participants were recruited from gay community venues and events and self-identified as gay or homosexual. On average, they were 44 years old and had been living with HIV for at least 10 years. Close to 80% (n=1555) were taking ART, with >90% further reporting an undetectable viral load at the time of the survey. From 2010 to 2012, there had been a moderate increase in ART uptake [adjusted odds ratio (AOR) 1.40; 95% confidence interval (CI) 1.20-1.65]. In addition, younger age (AOR 1.66; 95% CI 1.45-1.92), recent HIV diagnosis (AOR 1.78; 95% CI 1.59-1.98), not receiving any social welfare payments (AOR 2.20; 95% CI 1.05-2.54) and no annual screening for sexually transmissible infections (AOR 1.55; 95% CI 1.03-2.34) were independently associated with ART nonuse.

CONCLUSIONS

Current ART coverage among HIV-positive gay men in Australia is reasonably high. To further increase ART coverage and promote early ART initiation in this population, better clinical care and sustained structural support are needed for HIV management throughout their life course.

Text message intervention designs to promote adherence to antiretroviral therapy (ART): a meta-analysis of randomized controlled trials

Background

The efficacy of antiretroviral therapy depends on patient adherence to a daily medication regimen, yet many patients fail to adhere at high enough rates to maintain health and reduce the risk of transmitting HIV. Given the explosive global growth of cellular-mobile phone use, text-messaging interventions to promote adherence are especially appropriate. This meta-analysis synthesized available text messaging interventions to promote antiretroviral therapy adherence in people living with HIV.

Methods

We performed Boolean searches of electronic databases, hand searches of recent year conference abstracts and reverse searches. Included studies (1) targeted antiretroviral therapy adherence in a sample of people living with HIV, (2) used a randomized-controlled trial design to examine a text messaging intervention, and (3) reported at least one adherence measurement or clinical outcome.

Results

Eight studies, including 9 interventions, met inclusion criteria. Text-messaging interventions yielded significantly higher adherence than control conditions (OR = 1.39; 95% CI = 1.18, 1.64). Sensitivity analyses of intervention characteristics suggested that studies had larger effects when interventions (1) were sent less frequently than daily, (2) supported bidirectional communication, (3) included personalized message content, and (4) were matched to participants’ antiretroviral therapy dosing schedule. Interventions were also associated with improved viral load and/or CD4+ count (k = 3; OR = 1.56; 95% CI = 1.11, 2.20).

Conclusions

Text-messaging can support antiretroviral therapy adherence. Researchers should consider the adoption of less frequent messaging interventions with content and timing that is individually tailored and designed to evoke a reply from the recipient. Future research is needed in order to determine how best to optimize efficacy.

The key role of adherence for the effectiveness of antiretroviral-based prevention: state of the science and implications for the Asia-Pacific region

Remarkable advances have been made in the last few years in biomedical strategies to prevent onward transmission of HIV (treatment as prevention (TasP)) and prevent infection among at-risk populations through pre-exposure prophylaxis (PrEP). Numerous issues remain heavily debated, primarily concerning the feasibility of leveraging resources for both widespread access to antiretroviral therapy (ART) for those living with HIV and access to effective prevention antiretrovirals (ARVs) among those at risk for infection. Even with consistent and wide-spread access to ARVs, the behavioural pathway from ARV access to successful rapid and durable suppression or reaching levels of PrEP adherence that confer high rates of protection is increasingly well recognised. For either 'biobehavioural' strategy to have maximal individual and community benefit, individuals accessing them must actually use them. In this review, the unique and overlapping factors influencing adherence to ART and PrEP are identified, with an emphasis on the behavioural, social and structural facilitators and barriers to TasP and PrEP success. The implications of the current research base and evidence generated specifically within the Asia-Pacific region are discussed.