Adherence to antiretroviral therapy: merging the clinical and social course of AIDS

Racial disparity in ART adherence is closed in states with high social trust: Results from the Medical Monitoring Project (MMP), 2015

Racial/ethnic disparities persist in antiretroviral therapy (ART) adherence and viral suppression. We examined associations between state-level social trust and individual-level ART adherence and viral suppression and assessed whether these relationships varied by race/ethnicity. The Medical Monitoring Project (MMP) annually reports nationally representative estimates of the behavioral and clinical characteristics of HIV-positive adults in primary care. A total of 3298 adults diagnosed with HIV between 2015 and 2016 from 16 US states were included. We used weighted logistic regression to model the association between state-level social trust, race/ethnicity (Non-Hispanic Black, White, and Hispanic/Latino), and cross-product interactions with ART adherence (a binary measure derived from three self-reported questions), and viral suppression (a binary measure corresponding to plasma HIV RNA < 200 copies/ml). Social trust was the percentage of people in each state who agreed that most people in their neighborhood could be trusted. A high level of social trust was associated with a higher likelihood of ART adherence (PR [prevalence ratio] = 1.17; 95% confidence interval [CI]: 1.05-1.30). In covariate-adjusted analyses, the association between state-level social trust and individual-level ART adherence significantly varied by race/ethnicity (Wald χ2  F = 9.8 [df = 4], p = 0.044). Social trust was positively associated with ART, but the effect was smaller for Blacks than for Whites (PR = 0.66; 95% CI: 0.57-0.82) in states with the lowest social trust. Black-White differences were closed and no longer significant above mean social trust (PP [predicted probability] = 0.50 vs. 0.53, at two standard deviations). Racial/ethnic disparities in ART adherence were closed among individuals living in states with high social trust. Understanding the mechanisms that promote social trust among neighbors may have downstream impacts on reducing disparities in ART adherence among people with HIV (PWH).

Barriers and Enablers for Adherence to Antiretroviral Therapy Among People Living With HIV/AIDS in the Era of COVID-19: A Qualitative Study From Pakistan

Background: With the increased availability of safe antiretroviral therapy (ART) in recent years, achieving optimal adherence and patient retention is becoming the biggest challenge for people living with HIV (PLWH). Care retention is influenced by several socioeconomic, socio-cultural, and government policies during the COVID-19 pandemic. Therefore, we aim to explore barriers and facilitators to adherence to ART among PLWH in Pakistan in general and COVID-19 pandemic related in particular.

Methods: Semi-structured interviews were conducted among 25 PLWH from December 2020 to April 2021 in the local language (Urdu) at the ART centre of Pakistan Institute of Medical Sciences, Islamabad, Pakistan. Interviews were audio-recorded in the local Urdu language, and bilingual expert (English, Urdu) transcribed verbatim, coded for themes and sub-themes, and analyzed using a phenomenological approach for thematic content analysis.

Results: Stigma and discrimination, fear of HIV disclosure, economic constraints, forgetfulness, religion (Ramadan, spiritual healing), adverse drug reactions, lack of social support, alternative therapies, and COVID-19-related lock-down and fear of lesser COVID-19 care due to HIV associated stigma were identified as barriers affecting the retention in HIV care. At the same time, positive social support, family responsibilities, use of reminders, the beneficial impact of ART, and initiation of telephone consultations, courier delivery, and long-term delivery of antiretrovirals during COVID-19 were identified as facilitators of HIV retention.

Conclusion: Improving adherence and retention is even more challenging due to COVID-19; therefore, it requires the integration of enhanced access to treatment with improved employment and social support. HIV care providers must understand these reported factors comprehensively and treat patients accordingly to ensure the continuum of HIV care. A coordinated approach including different stakeholders is required to facilitate patient retention in HIV care and consequently improve the clinical outcomes of PLWH.

Success at Scale: Outcomes of Community-Based Neurodevelopment Intervention (CASITA) for Children Ages 6-20 months With Risk of Delay in Lima, Peru

This study is a randomized controlled trial of a 12-week community-based group parenting intervention ("CASITA") in Lima, Peru. CASITA improved neurodevelopment in a pilot study of 60 Peruvian children and subsequently scaled to 3,000 households throughout the district. The objective of this study was to assess intervention effectiveness when implemented at scale. A total of 347 children ages 6-20 months (52.7% male, 100% identified as "mestizo") at risk for developmental difficulties were randomized to immediate or delayed CASITA. At 3 months after enrollment, the immediate arm showed significantly higher overall development, based on the Extended Ages and Stages Questionnaire and Home Observation for Measurement of the Environment scores (Cohen's ds = .36 and .31, respectively). Programs demonstrably effective at scale could help address children's development risks worldwide.

Multisite Study of Women Living With HIV's Perceived Barriers to, and Interest in, Long-Acting Injectable Antiretroviral Therapy

BACKGROUND

Adherence to antiretroviral therapy (ART) is imperative for viral suppression and reducing HIV transmission, but many people living with HIV report difficultly sustaining long-term adherence. Long-acting injectable (LAI) ART has the potential to transform HIV treatment and prevention. However, little LAI ART-related behavioral research has occurred among women, particularly outside of clinical trials.

SETTING

Six Women's Interagency HIV Study sites: New York, Chicago, Washington DC, Atlanta, Chapel Hill, and San Francisco.

METHODS

We conducted 59 in-depth interviews with women living with HIV across 6 Women's Interagency HIV Study sites (10 per site; 9 at Washington DC). We interviewed women who were not included in LAI ART clinical trials but who receive care at university settings that will administer LAI ART once it is approved. Interviews were recorded, transcribed, and analyzed using thematic content analysis.

RESULTS

Most women enthusiastically endorsed monthly LAI ART and would prefer it over pills. The following 3 reasons emerged for this preference: (1) convenience and confidentiality, (2) avoiding daily reminders about living with HIV, and (3) believing that shots are more effective than pills. Challenges remain, however, specifically around (1) medical mistrust, (2) concerns about safety and effectiveness, (3) pill burden for HIV and other conditions, and (4) barriers to additional medical visits.

CONCLUSIONS

Most women preferred LAI ART over daily pills given its benefits, including convenience, privacy, and perceived effectiveness. Future research should incorporate more women into LAI ART trials to better understand and align development with user concerns and preferences to enhance uptake.

The Impact of Formal and Informal Institutions on ART Drug Adherence

A successful antiretroviral therapy (ART) drug adherence is achieved when patients follow their prescribed regimen. This is determined by patient’s motivation that is influenced by resources associated with the patient, society, and relevant institutions. The aim of this study is to assess the impact of formal and informal actors on patients’ ART drug adherence. A qualitative study approach was conducted through face-to-face in-depth interviews of HIV-infected patients and key informants. The analysis was guided by a salutogenic model focusing on generalized resistance resources and a sense of coherence. The finding shows that 76% of the study participants achieved the recommended 95% adherence level. Several resources attributed to individuals, society, and public institutions influencing patients’ day-to-day life and their drug adherence were identified. Patients who are able to use the available resources easily develop sense of coherence and follow their prescribed drug regimen. Therefore, encouraging HIV-infected patients through formal and informal actors can enhance ART drug adherence.

Spinning plates: livelihood mobility, household responsibility and anti-retroviral treatment in an urban Zambian community during the HPTN 071 (PopART) study

INTRODUCTION

Qualitative data are lacking on the impact of mobility among people living with HIV (PLHIV) and their decision-making around anti-retroviral treatment (ART). We describe challenges of juggling household responsibility, livelihood mobility and HIV management for six PLHIV in urban Zambia.

METHODS

Six PLHIV (three men and three women, aged 21 to 44) were recruited from different geographic zones in one urban community drawn from a qualitative cohort in a social science component of a cluster-randomized trial (HPTN071 PopART). Participants were on ART (n = 2), not on ART (n = 2) and had started and stopped ART (n = 2). At least two in-depth interviews and participant observations, and three drop-in household visits with each were carried out between February and August 2017. Themed and comparative analysis was conducted.

RESULTS

The six participants relied on the informal economy to meet basic household needs. Routine livelihood mobility, either within the community and to a nearby town centre, or further afield for longer periods of time, was essential to get by. Although aware of ART benefits, only one of the six participants managed to successfully access and sustain treatment. The other five struggled to find time to access ART alongside other priorities, routine mobility and when daily routines were more chaotic. Difficulty in accessing ART was exacerbated by local health facility factors (congestion, a culture of reprimanding PLHIV who miss appointments, sporadic rationed drug supply), stigma and more limited social capital.

CONCLUSIONS

Using a time-space framework illustrated how household responsibility, livelihood mobility and HIV management every day were like spinning plates, each liable to topple and demanding constant attention. If universal lifelong ART is to be delivered, the current service model needs to adjust the limited time that some PLHIV have to access ART because of household responsibilities and the need to earn a living moving around, often away from home. Practical strategies that could facilitate ART access in the context of livelihood mobility include challenging the practice of reprimand, improving drug supply, having ART services more widely distributed, mapped and available at night and weekends, and an effective centralized client health information system.

Prevalence of nonadherence and its associated factors affecting on HIV adults follow-up at antiretroviral therapy clinic in Batu Hospital, Eastern Ethiopia

BACKGROUND

HIV/acquired immunodeficiency syndrome is a major public health problem and a development predicament that affects all sectors, drastically affecting the health, economic, and reducing social life expectancy, deepening poverty, and contributing to and exacerbating food shortages. Strict adherence to antiretroviral therapy (ART) regimen is essential to obtain the desired benefit and to avoid the emergence of drug resistance and clinical failure; therefore, this study is aimed to assess the antiretroviral (ARV) adherence among the HIV patients and suggesting them by possible ways for improving the adherence.

METHODS

A cross-sectional study was conducted in Batu Hospital, Batu town. The sample size was found to be 160, and systemic random sampling was used to collect data by providing a pretested structured questionnaire. The qualitative data were analyzed to identify the significance of the relationship between the dependent and independent variables.

RESULTS

A total of 160 patients was agreed to involve in our survey, 85.6% of patients were adherent by self-report. The main reason of nonadherence cited by the patients were; being away from home for some social reasons (33.4%), being too busy with other things (25.0%), simply forgot to take their ART (25.0%), developed toxicity or side effects (8.3%), having problems for fear of stigma and disclosure (8.3%), and (7.5%) of participants also shortage of ARV medications at hand because of some public holidays or weekends that coincide with date of appointments.

CONCLUSION AND RECOMMENDATIONS

The self-report adherence rate was higher than that seen in developing countries. Programs and clinical efforts to improve medication taking in the study setups should strive to provide the regular follow-up for patients, increase patients' awareness of the side effects of ARVs and possible remedies, integrate medications better into patients' daily routines, improve patients' confidence, trust, and satisfaction with their caregivers, and teach patients to use memory aids.

Operationalizing mHealth to improve patient care: a qualitative implementation science evaluation of the WelTel texting intervention in Canada and Kenya

BACKGROUND

Mobile health (mHealth) applications have proliferated across the globe with much enthusiasm, although few have reached scale and shown public health impact. In this study, we explored how different contextual factors influenced the implementation, effectiveness and potential for scale-up of WelTel, an easy-to-use and evidence-based mHealth intervention. WelTel uses two-way SMS communication to improve patient adherence to medication and engagement in care, and has been developed and tested in Canada and Kenya.

METHODS

We used a comparative qualitative case study design, which drew on 32 key informant interviews, conducted in 2016, with stakeholders involved in six WelTel projects. Our research was guided by the Consolidated Framework for Implementation Research (CFIR), a meta-theoretical framework, and our analysis relied on a modified approach to grounded theory, which allowed us to compare findings across these projects.

RESULTS

We found that WelTel had positive influences on the "culture of care" at local clinics and hospitals in Canada and Kenya, many of which stretched beyond the immediate patient-client relationship to influence wider organizational systems. However, these were mediated by clinician norms and practices, the availability of local champion staff, the receptivity and capacity of local management, and the particular characteristics of the technology platform, including the ability for adaptation and co-design. We also found that scale-up was influenced by different forms of data and evidence, which played important roles in legitimization and partnership building. Even with robust research evidence, scale-up was viewed as a precarious and uncertain process, embedded within the wider politics and financing of Canadian and Kenyan health systems. Challenges included juggling different interests, determining appropriate financing pathways, maintaining network growth, and "packaging" the intervention for impact and relevance.

CONCLUSIONS

Our comparative case study, of a unique transnational mobile health research network, revealed that moving from mHealth pilots to scale is a difficult, context-specific process that couples social and technological innovation. Fostering new organizational partnerships and ways of learning are paramount, as mHealth platforms straddle the world of research, industry and public health. Partnerships need to avoid the perils of the technological fix, and engage the structural barriers that mediate people's health and access to services.

From HIV diagnosis to initiation of treatment: Social transformation among people starting antiretroviral therapy in Peru

Social support is a key, yet elusive resource for HIV patients living in poverty in Lima, Peru. Despite a greater need for health services and encouragement from others, economic restraints, stigma, and trouble negotiating a fractured health system act as hurdles to accessing support. In this study, 33 people with HIV and 15 of their treatment supporters were interviewed upon initiation of antiretroviral therapy in order to understand changes in social support during this critical time, and how these changes affected their well-being. Everyone's social network underwent dramatic transformation, while some were rejected upon disclosure by people they knew, many successfully trimmed their social circles to a few trusted parties. Treatment supporters were most frequently the first to whom they disclosed their HIV status, and most backed the person with HIV, although sometimes out of obligation. HIV peers became a vital new source of strength. Ultimately, people with HIV who successfully reorganized their social network drew personal strength and self-worth from new and old relationships in their lives.

A qualitative study of patient motivation to adhere to combination antiretroviral therapy in South Africa

Taken as prescribed, that is, with high adherence, combination antiretroviral therapy (ART) has changed HIV infection and disease from being a sure predictor of death to a manageable chronic illness. Adherence, however, is difficult to achieve and maintain. The CAPRISA 058 study was conducted between 2007 and 2009 to test the efficacy of individualized motivational counselling to enhance ART adherence in South Africa. As part of the overall trial, a qualitative sub-study was conducted, including 30 individual interviews and four focus group discussions with patients in the first 9 months of ART initiation. Data were inductively analyzed, using thematic analysis, to identify themes central to ART adherence in this context. Four themes emerged that characterize the participants' experiences and high motivation to adhere to ART. Participants in this study were highly motivated to adhere, as they acknowledged that ART was 'life-giving', in the face of a large amount of morbidity and mortality. They were further supported by techniques of routine remembering, and highlighted the importance of good social support and access to supportive healthcare workers, to their continued success in negotiating their treatment. Participants in the current study told us that their adherence motivation is enhanced by free accessible care, approachable and supportive healthcare workers, broad social acceptance of ART, and past first-hand experiences with AIDS-related co-morbidity and mortality. Programs that include specific attention to these aspects of care will likely be successful in the long term.

Adherence to antiretroviral medications among persons who inject drugs in transitional, low and middle income countries: an international systematic review

Adherence to antiretroviral (ART) medication is vital to reducing morbidity and mortality among HIV positive persons. People who inject drugs (PWID) are at high risk for HIV infection in transitional/low/middle income countries (TLMIC). We conducted a systematic review of studies reporting adherence to ART among persons with active injection drug use and/or histories of injection drug use in TLMIC. Meta-regression was performed to examine relationships between location, adherence measurements, and follow-up period. Fifteen studies were included from seven countries. Adherence levels ranged from 33 to 97 %; mean weighted adherence was 72 %. ART adherence was associated with different methods of measuring adherence and studies conducted in Eastern Europe and East Asia. The great heterogeneity observed precludes generalization to TLMIC as a whole. Given the critical importance of ART adherence more research is needed on ART adherence among PWID in TLMIC, including the use of standardized methods for reporting adherence to ART.

Role of medication therapy management in preexposure prophylaxis therapy for HIV prevention

Patient medication adherence is a long-standing problem and is one that raises serious issues for patient health, public health, and health care quality. Medication nonadherence costs the US economy an estimated US$290 billion in avoidable medical spending every year. One of the most costly health conditions is HIV disease, which continues to be a serious health issue for parts of the world. About 34 million people are living with HIV around the world. With the emerging preventative treatment against HIV, known as preexposure prophylaxis (PrEP), come concerns surrounding the potential impact of nonadherence to this newly approved medication therapy. Nonadherence to antiretroviral treatments are commonly the root cause for patients not reaching their treatment goals, putting them at risk of progression and worsening of their disease and complications, such as increased risk of opportunistic infections. Therefore, it is essential to improve antiretroviral medication adherence. By identifying members who are nonadherent to their prescribed antiretroviral medications and working collaboratively with patients, physicians, and pharmacists, Medication Therapy Management (MTM) can potentially increase medication adherence by helping patients identify, resolve, and prevent issues that may affect their decision not to take a medication as intended.

Transition to adulthood and antiretroviral adherence among HIV-positive young Black men who have sex with men

OBJECTIVES

We conducted a qualitative study of HIV-positive young Black men who have sex with men (YBMSM) to explore their experiences of living with HIV and adhering to antiretroviral medications (ARVs) within the developmental context of their transition to adulthood.

METHODS

We conducted life history interviews with 20 HIV-positive YBMSM in Atlanta, Georgia, engaged in outpatient HIV care. We addressed these questions: (1) How do YBMSM living with HIV experience the transition to adulthood? and (2) What are the important sociocontextual influences on ARV adherence for YBMSM?

RESULTS

Successful transition to adulthood and optimal ARV adherence were inextricably linked. HIV's detrimental impact on development was moderated by the degree of physical illness at diagnosis. Many participants described resilient trajectories while coping with HIV. Adherence problems occurred primarily among participants who were not meeting their developmental goals.

CONCLUSIONS

Our findings support the need for early diagnosis and linkage to care, as well as the need to develop holistic, resilience-based interventions focusing on transition to adulthood. These findings have implications for individual clinical outcomes as well as ARV-based prevention efforts among YBMSM.

Bounded agency in humanitarian settings: a qualitative study of adherence to antiretroviral therapy among refugees situated in Kenya and Malaysia

HIV-positive refugees confront a variety of challenges in accessing and adhering to antiretroviral therapy (ART) and attaining durable viral suppression; however, there is little understanding of what these challenges are, how they are navigated, or how they may differ across humanitarian settings. We sought to document and examine accounts of the threats, barriers and facilitators experienced in relation to HIV treatment and care and to conduct comparisons across settings. We conducted semi-structured interviews among a purposive sample of 14 refugees attending a public, urban HIV clinic in Kuala Lumpur, Malaysia (July-September 2010), and 12 refugees attending a camp-based HIV clinic in Kakuma, Kenya (February-March 2011). We used framework methods and between-case comparison to analyze and interpret the data, identifying social and environmental factors that influenced adherence. The multiple issues that threatened adherence to antiretroviral therapy or precipitated actual adherence lapses clustered into three themes: "migration", "insecurity", and "resilience". The migration theme included issues related to crossing borders and integrating into treatment systems upon arrival in a host country. Challenges related to crossing borders were reported in both settings, but threats pertaining to integration into, and navigation of, a new health system were exclusive to the Malaysian setting. The insecurity theme included food insecurity, which was most commonly reported in the Kenyan setting; health systems insecurity, reported in both settings; and emotional insecurity, which was most common in the Kenyan setting. Resilient processes were reported in both settings. We drew on the concept of "bounded agency" to argue that, despite evidence of personal and community resilience, these processes were sometimes insufficient for overcoming social and environmental barriers to adherence. In general, interventions might aim to bolster individuals' range of action with targeted support that bolsters resilient processes. Specific interventions are needed to address locally-based food and health system insecurities.

Depression and patterns of self-reported adherence to antiretroviral therapy in Rwanda

We determined the prevalence of depression in HIV-infected adults on antiretroviral therapy in rural Rwanda and measured the association of depression with non-adherence. In all, 292 patients on antiretroviral therapy for ≥6 months were included. Adherence was self-reported by four-day recall, two- and seven-day treatment interruptions, and the CASE Index, which is a composite score accounting for difficulty taking medications on time, the average number of days per week a dose is missed, and the most recent missed dose. A total of 84% and 87% of participants reported good adherence by the four-day recall and CASE Index, respectively; 13% of participants reported two-day treatment interruptions; and 11% were depressed. Depression was significantly associated with two-day treatment interruptions but not with other measures of non-adherence. Self-reported adherence to antiretroviral therapy in rural Rwanda is high. Adherence assessments that do not consider treatment interruptions may miss important patterns of non-adherence, which may be especially prevalent among depressed individuals. Mental health interventions incorporated into routine HIV care may lead to improvements in mental health and adherence.

Adherence to antiretroviral therapy in Jinja, Uganda: a six-year follow-up study

Introduction

We report on the adherence experience of a group of people living with HIV on ART over six years in Uganda.

Methods

Between 2005 and 2009, we followed up 41 participants who were also part of a clinical trial comparing home and facility based delivery of ART in Jinja, eastern Uganda. We conducted qualitative in-depth interviews at enrolment, 3, 6, 18 and 30 months to capture experiences with adherence over time. In 2011 we returned to these participants to find out how they were fairing with long term adherence. We managed to retrace 24 participants and interviewed them about their experience. We thematically analysed the data and compared findings over time.

Results

Initially there were few barriers to adherence and many followed the adherence guidance closely. By year six, relaxation of these rules was noticeable although self-reported adherence continued to be high. Alcohol consumption was more common than before. Some relatives of the participants who had died claimed that some deaths were a result of alcohol. While participants reported that ART had allowed them to reclaim independence and return to work the changes in work and social routines created new challenges for adherence. Side effects like lipodystrophy were not only causing some stigma but for some tested their faith in the drugs. Many participants reported resumption of sexual lives but apart from those who selected same status partners, disclosure to new partners was minimal.

Conclusion

Good adherence practice to ART wanes over the long-term, and people who may have disclosed at initiation find it difficult to do so to new partners once they are healthy. Further adherence interventions and support with disclosure over the course of therapy may need to be considered. (Words: 283)

Evidence base for children affected by HIV and AIDS in low prevalence and concentrated epidemic countries: applicability to programming guidance from high prevalence countries

As global commitment grows to protect and support children affected by HIV and AIDS, questions remain about how best to meet the needs of these children in low prevalence settings and whether information from high prevalence countries can appropriately guide programming in these settings. A 2007 search for the evidence in low prevalence settings on situational challenges of HIV and AIDS-affected children and interventions to address these challenges identified 413 documents. They were reviewed and judged for quality of documentation and scientific rigor. Information was compiled across eight types of challenges (health and health care, nutrition and food security, education, protection, placement, psychosocial development, socioeconomic status, and stigma/ discrimination); and also assessed was strength of evidence for situational and intervention findings. Results were compared to three programming principles drawn from research in high prevalence countries: family-centered preventive efforts, treatment, and care; family-focused support to ensure capacity to care for and protect these children; and sustaining economic livelihood of HIV and AIDS-affected households. Findings show that children affected by HIV and AIDS in low prevalence settings face increased vulnerabilities similar to those in high prevalence settings. These findings support seeking and testing programmatic directions for interventions identified in high prevalence settings. However, low prevalence settings/countries are extremely diverse, and the strength of the evidence base among them was mixed (strong, moderate, and weak in study design and documentation), geographically limited, and had insufficient evidence on interventions to draw conclusions about how best to reduce additional vulnerabilities of affected children. Information on family, economic, sociocultural, and political factors within local contexts will be vital in the development of appropriate strategies to mitigate vulnerabilities.

Implementing evidence-based alcohol interventions in a resource-limited setting: novel delivery strategies in Tomsk, Russia

Effective implementation of evidence-based interventions in "real-world" settings can be challenging. Interventions based on externally valid trial findings can be even more difficult to apply in resource-limited settings, given marked differences-in provider experience, patient population, and health systems-between those settings and the typical clinical trial environment. Under the auspices of the Integrated Management of Physician-Delivered Alcohol Care for Tuberculosis Patients (IMPACT) study, a randomized, controlled effectiveness trial, and as an integrated component of tuberculosis treatment in Tomsk, Russia, we adapted two proven alcohol interventions to the delivery of care to 200 patients with alcohol use disorders. Tuberculosis providers performed screening for alcohol use disorders and also delivered naltrexone (with medical management) or a brief counseling intervention either independently or in combination as a seamless part of routine care. We report the innovations and challenges to intervention design, training, and delivery of both pharmacologic and behavioral alcohol interventions within programmatic tuberculosis treatment services. We also discuss the implications of these lessons learned within the context of meeting the challenge of providing evidence-based care in resource-limited settings.

"You must take the medications for you and for me": family caregivers promoting HIV medication adherence in China

China is experiencing a rapid increase in the incidence of HIV infections, which it is addressing proactively with broad implementation of antiretroviral therapy (ART). Within a cultural context extolling familial responsibility, family caregiving may be an important component to promote medication adherence for persons living with HIV in China. Based on 20 qualitative interviews with persons living with HIV and their family caregivers and a cross-sectional survey with 113 adults receiving HIV care at Beijing's Ditan outpatient clinic, this mixed-methods study examines family caregivers' role in promoting adherence to ART. Building upon a conceptual model of adherence, this article explores the role of family members in supporting four key components enhancing adherence (i.e., access, knowledge, motivation, and proximal cue to action). Patients with family caregiving support report superior ART adherence. Also, gender (being female) and less time since ART initiation are significantly related to superior adherence. Since Chinese cultural values emphasize family care, future work on adherence promotion in China will want to consider the systematic incorporation of family members.

Adherence to tablet and liquid formulations of antiretroviral medication for paediatric HIV treatment at an urban clinic in Uganda

BACKGROUND

Major obstacles remain in scaling up paediatric HIV treatment, including limited paediatric anti-retroviral drug options for resource-limited settings, challenges with adherence to liquid formulations and treatment fatigue with lifelong therapy.

AIM

To determine levels of adherence to HAART in HIV-infected children at 12, 24, 36 and 48 weeks of follow-up and to compare adherence levels before and after switching from syrup to fixed-dose combination (FDC)-tablet anti-retroviral formulations.

METHODS

HIV-infected children aged between 6 months and 12 years were initiated on anti-retroviral therapy at Makerere University-Johns Hopkins University Care Clinic, Kampala. Good adherence to HAART was defined as taking ≥95% of prescribed medications. Adherence levels were measured using pharmacy refill data, quarterly unannounced home-visit pill counts and caregiver self-reports. Data were analysed using STATA(®) version 10.0.

RESULTS

A total of 129 HIV-infected children were initiated on HAART with 14.7% on syrups and 85.3% on tablet formulations at enrollment. According to caregiver self-reporting, 99.2%, 100%, 100% and 99.2% achieved ≥95% adherence at 12, 24, 36 and 48 weeks, respectively. Using pharmacy refill data, the proportions were 89.9%, 95.4%, 93.8% and 93.0% and for unannounced home visits were 89.8%, 92.4%, 88.9% and 86.2%, respectively. Median adherence to syrup formulations (97%, IQR 93-98) was significantly lower than for tablets (100%, IQR 97-100, p = 0.012, n = 28) using pharmacy refill data. Viral suppression correlated with home visit and pharmacy refill adherence data.

CONCLUSION

The majority of children initiating HAART had good adherence when estimated by caregiver self-report and pharmacy refill data but lower adherence when measured by home-visit pill counts. Adherence to tablet formulation of HAART was significantly better than syrup formulation. Medication formulation did not significantly affect viral suppression.

Matching social support to individual needs: a community-based intervention to improve HIV treatment adherence in a resource-poor setting

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in Lima, Peru to receive community-based accompaniment with supervised antiretrovirals (CASA), consisting of 12 months of DOT-HAART, as well as microfinance assistance and/or psychosocial support group according to individuals' need. We matched 60 controls from a neighboring district, and assessed final clinical and psychosocial outcomes at 24 months. CASA support was associated with higher rates of virologic suppression and lower mortality. A comprehensive, tailored adherence intervention in the form of community-based DOT-HAART and matched economic and psychosocial support is both feasible and effective for certain individuals in resource-poor settings.

Beliefs and practices about antiretroviral medication: a study of poor urban Kenyans living with HIV/AIDS

Interest in medication-taking as a social behaviour is growing. Drawing on qualitative data, this study interrogates beliefs and practices related to antiretroviral therapy (ART) use among urban poor Kenyan people living with HIV/AIDS (PLWHA). Responding PLWHA relied on a range of ingenious strategies to remember to take their medications but did not necessarily perceive compliance with medical instructions as key to treatment efficacy. They also believed that compliance can even hurt some patients. PLWHA relied on both compliance and non-compliance to seek social acceptance, maintain a reputation of being healthy, dispel rumours about one's status, and minimise economic vulnerability. Compliance was further used to mark gratitude to supportive caregivers and providers, and non-compliance to appraise the efficacy of other treatments which promise permanent cure. The medication-taking practices of poor Kenyan PLWHA reflect their struggles with deprived livelihoods and stigma.

Revisiting long-term adherence to highly active antiretroviral therapy in Senegal using latent class analysis

BACKGROUND

Adherence is one of the main predictors of antiretroviral treatment success. A governmental initiative was launched in 1998 for HIV-infected patients in Senegal to provide access to highly active antiretroviral therapy.

METHODS

Between August 1998 and April 2002, 404 adult patients were enrolled. Adherence measurements, defined as pills taken/pills prescribed, were assessed between November 1999 and April 2009 using a pill count along with a questionnaire for 330 patients. Predictors of adherence were explored through a random-intercept Tobit model and a latent class analysis (LCA) was performed to identify adherence trajectories. We also performed a survival analysis taking into account gender and latent adherence classes.

RESULTS

Median treatment duration was 91 months (interquartile range, 84-101). On average, adherence declined by 7% every year, was 30% lower for patients taking indinavir, and 12% higher for those receiving cotrimoxazole prophylaxis. Based on the predicted probability of having an adherence ≥ 95%, LCA revealed 3 adherence behaviors and a better adherence for women. A quarter of patients had a high adherence trajectory over time and half had an intermediate one. Male gender and low adherence behavior over time were independently associated with a higher mortality rate.

CONCLUSIONS

This study shows that an overall good adherence can be obtained in the long term in Senegal. LCA suggests a better adherence for women and points out a large subsample of patients with intermediate level of adherence behavior who are at risk for developing resistance to antiretroviral drugs. This study warrants further research into gender issues.

Barriers to antiretroviral therapy adherence in rural Mozambique

BACKGROUND

HIV is treated as a chronic disease, but high lost-to-follow-up rates and poor adherence to medication result in higher mortality, morbidity, and viral mutation. Within 18 clinical sites in rural Zambézia Province, Mozambique, patient adherence to antiretroviral therapy has been sub-optimal.

METHODS

To better understand barriers to adherence, we conducted 18 community and clinic focus groups in six rural districts. We interviewed 76 women and 88 men, of whom 124 were community participants (CP; 60 women, 64 men) and 40 were health care workers (HCW; 16 women, 24 men) who provide care for those living with HIV.

RESULTS

While there was some consensus, both CP and HCW provided complementary insights. CP focus groups noted a lack of confidentiality and poor treatment by hospital staff (42% CP vs. 0% HCW), doubt as to the benefits of antiretroviral therapy (75% CP vs. 0% HCW), and sharing medications with family members (66% CP vs. 0%HCW). Men expressed a greater concern about poor treatment by HCW than women (83% men vs. 0% women). Health care workers blamed patient preference for traditional medicine (42% CP vs. 100% HCW) and the side effects of medication for poor adherence (8% CP vs. 83% CHW).

CONCLUSIONS

Perspectives of CP and HCW likely reflect differing sociocultural and educational backgrounds. Health care workers must understand community perspectives on causes of suboptimal adherence as a first step toward effective intervention.

Livelihood security and adherence to antiretroviral therapy in low and middle income settings: a systematic review

INTRODUCTION

We sought to examine the association between livelihood security and adherence to antiretroviral therapy (ARVs) in low- and middle-income countries (LIMC).

METHODS

Performing a systematic review, we searched, independently and in duplicate, 7 electronic databases and 2 conference websites for quantitative surveys that examined the association between indicators of livelihood security and adherence to ARVs in LIMC between 2000-2010. Criteria for relevance were applied to complete papers (quantitative study with estimates of associations) and quality assessment was conducted on those deemed relevant. We performed three regressions to measure the association between each type of livelihood and adherence.

RESULTS

Twenty original studies and 6 conference abstracts were included, the majority from Africa (n = 16). Seventeen studies and 3 conference abstracts were cross-sectional and 3 studies and 3 abstracts were prospective clinical cohort studies, with considerable variation in quality for studies of each design type. Among the diverse populations represented, we observed considerable variation in associations between measurements of livelihood indicators and increasingly accepted adherence measures, irrespective of study design or quality. A financial capital indicator, financial constraints/payment for ARV medication, was more commonly associated with non-adherence (3/5 studies). A human capital indicator, educational level, was most commonly associated with adherence (11/20 studies).

DISCUSSION

Additional better quality research examining livelihood security is required to inform provision of optimal supports for adherence and mitigation of the impacts of HIV/AIDS.

How does directly observed therapy work? The mechanisms and impact of a comprehensive directly observed therapy intervention of highly active antiretroviral therapy in Peru

From December 2005 through August 2008, we provided community-based accompaniment with supervised antiretroviral therapy (CASA) to impoverished individuals starting highly active antiretroviral therapy. Adherence support was provided for 18 months by a community-based team comprised of several nurses and two types of community health workers: field supervisors and directly observed therapy (DOT) volunteers. To complement our quantitative data collection in 2008 using purposive sampling, we conducted two gender-mixed focus group discussions with 13 CASA patient participants and 13 DOT volunteers from Lima, Peru to identify the mediating mechanisms by which CASA improved well-being, and to understand the benefits of the intervention, as perceived by these individuals. Using standard qualitative methods for the review and analysis of transcripts and interview notes, we identified central themes and developed a coding scheme for categorising participants' statements. Two individuals blinded to each other's coding, coded interview transcripts for theme and content from which a third reviewer compared their coding to arbitrate discrepancies. Additional domains were added if necessary and all domains were integrated into a theoretical scheme. Among the forms of support delivered by the CASA team, DOT volunteers reported emotional support, instrumental support, directly observed therapy, building trust, education, advocacy, exercise of moral authority and preparation for transition off CASA support. CASA participants described outcomes of improved adherence, ability to resume social roles, increased self-efficacy, hopefulness, changes in non-HIV-related behaviour, reduced internalised and externalised stigma, as well as ability to disclose. Both sets of focus group participants highlighted remaining challenges after completion of CASA support: stigma in the community, difficulties achieving economic recovery and persistent barriers to health services. Based on our prior quantitative and qualitative outcomes reported here, we argue that DOT of highly active antiretroviral therapy could be designed to optimise psychosocial recovery during the period of DOT.

Mobile phone technologies improve adherence to antiretroviral treatment in a resource-limited setting: a randomized controlled trial of text message reminders

OBJECTIVE

There is limited evidence on whether growing mobile phone availability in sub-Saharan Africa can be used to promote high adherence to antiretroviral therapy (ART). This study tested the efficacy of short message service (SMS) reminders on adherence to ART among patients attending a rural clinic in Kenya.

DESIGN

A randomized controlled trial of four SMS reminder interventions with 48 weeks of follow-up.

METHODS

Four hundred and thirty-one adult patients who had initiated ART within 3 months were enrolled and randomly assigned to a control group or one of the four intervention groups. Participants in the intervention groups received SMS reminders that were either short or long and sent at a daily or weekly frequency. Adherence was measured using the medication event monitoring system. The primary outcome was whether adherence exceeded 90% during each 12-week period of analysis and the 48-week study period. The secondary outcome was whether there were treatment interruptions lasting at least 48 h.

RESULTS

In intention-to-treat analysis, 53% of participants receiving weekly SMS reminders achieved adherence of at least 90% during the 48 weeks of the study, compared with 40% of participants in the control group (P = 0.03). Participants in groups receiving weekly reminders were also significantly less likely to experience treatment interruptions exceeding 48 h during the 48-week follow-up period than participants in the control group (81 vs. 90%, P = 0.03).

CONCLUSION

These results suggest that SMS reminders may be an important tool to achieve optimal treatment response in resource-limited settings.

Outcomes of antiretroviral treatment: a comparison between hospitals and health centers in Ethiopia

OBJECTIVE

the objective of this study was to compare the outcomes of antiretroviral therapy (ART) between hospital and health center levels in Ethiopia.

METHODS

medical records of 1709 ART patients followed for 24 months at 2 hospitals and 3 health centers in the Oromia region of Ethiopia were reviewed. Noted outcomes of ART were currently alive and on treatment; lost to follow-up (LTFU); transferred out (TO); and died (D).

RESULTS

of 1709 HIV-positive patients started on ART between September 2006 and February 2007, 1044 (61%) remained alive and were on treatment after 24-month follow-up. In all, 835 (57%) of ART patients at hospitals and 209 (83%) at health centers were retained in the program. Of those who were alive and receiving ART, 79% of patients at health centers and 72% at hospitals were clinically or immunologically improving. In addition, 331 (23%) patients at hospitals were LFTU as compared to 24 (10%) of patients at health centers (relative risk [RR] at 95% confidence interval [CI]: .358 [.231-.555]). While 11% was the mortality rate at hospitals, 5% of patients at health centers also died (RR at 95% CI: .360 [.192-.673]).

CONCLUSION

antiretroviral therapy at health centers was associated with more favorable outcomes than at hospitals.

Anthropological Perspectives on Structural Adjustment and Public Health

Thirty years since its first public use in 1980, the phrase structural adjustment remains obscure for many anthropologists and public health workers. However, structural adjustment programs (SAPs) are the practical tools used by international financial institutions (IFIs) such as the International Monetary Fund (IMF) and the World Bank to promote the market fundamentalism that constitutes the core of neoliberalism. A robust debate continues on the impact of SAPs on national economies and public health. But the stories that anthropologists tell from the field overwhelmingly speak to a new intensity of immiseration produced by adjustment programs that have undermined public sector services for the poor. This review provides a brief history of structural adjustment, and then presents anthropological analyses of adjustment and public health. The first section reviews studies of health services and the second section examines literature that assesses broader social determinants of health influenced by adjustment.

Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco

Background

At the individual level, higher HIV viral load predicts sexual transmission risk. We evaluated San Francisco's community viral load (CVL) as a population level marker of HIV transmission risk. We hypothesized that the decrease in CVL in San Francisco from 2004–2008, corresponding with increased rates of HIV testing, antiretroviral therapy (ART) coverage and effectiveness, and population-level virologic suppression, would be associated with a reduction in new HIV infections.

Methodology/Principal Findings

We used San Francisco's HIV/AIDS surveillance system to examine the trends in CVL. Mean CVL was calculated as the mean of the most recent viral load of all reported HIV-positive individuals in a particular community. Total CVL was defined as the sum of the most recent viral loads of all HIV-positive individuals in a particular community. We used Poisson models with robust standard errors to assess the relationships between the mean and total CVL and the primary outcome: annual numbers of newly diagnosed HIV cases. Both mean and total CVL decreased from 2004–2008 and were accompanied by decreases in new HIV diagnoses from 798 (2004) to 434 (2008). The mean (p = 0.003) and total CVL (p = 0.002) were significantly associated with new HIV cases from 2004–2008.

Conclusions/Significance

Reductions in CVL are associated with decreased HIV infections. Results suggest that wide-scale ART could reduce HIV transmission at the population level. Because CVL is temporally upstream of new HIV infections, jurisdictions should consider adding CVL to routine HIV surveillance to track the epidemic, allocate resources, and to evaluate the effectiveness of HIV prevention and treatment efforts.

Community-based DOT-HAART accompaniment in an urban resource-poor setting

From December 2005 to April 2007, we enrolled 60 adults starting antiretroviral therapy (ART) in a health district of Lima, Peru to receive community-based accompaniment with supervised antiretroviral (CASA). Paid community health workers performed twice-daily home visits to directly observe ART and offered additional medical, social and economic support to CASA participants. We matched 60 controls from a neighboring district by age, CD4 and primary referral criteria (TB status, female, neither). Using validated instruments at baseline and 12 months (time of DOT-HAART completion) we measured depression, social support, quality of life, HIV-related stigma and self-efficacy. We compared 12 month clinical and psychosocial outcomes among CASA versus control groups. CASA participants experienced better clinical and psychosocial outcomes at 12 months, including proportion with virologic suppression, increase in social support and reduction in HIV-associated stigma.

Adherence to antiretroviral therapy in Nigeria: an overview of research studies and implications for policy and practice

Both Human Immunodeficiency Virus (HIV) infection and AIDS remain major public health crises in Nigeria, a country which harbors more people living with HIV/AIDS than any country in the world, with the exception of South Africa and India. In response to the HIV pandemic, global and international health initiatives have targeted several countries, including Nigeria, for the expansion of antiretroviral therapy (ART) programs for the increasing number of affected patients. The success of these expanded ART initiatives depends on the treated individual's continual adherence to antiretroviral (ARV) drugs. Thirteen peer-reviewed studies concerning adherence to ART in Nigeria were reviewed with very few pediatric and adolescent studies being found. Methodologies of adherence measurement were analyzed and reasons for nonadherence were identified in the geopolitical zones in the federal republic of Nigeria. The results of the literature review indicate that adherence to ART is mixed (both high and low adherence) with patient self-recall identified as the common method of assessment. The most common reasons identified for patient nonadherence include the cost of therapy (even when the drugs are heavily subsidized), medication side effects, nonavailability of ARV drugs, and the stigma of taking the drugs. This manuscript highlights the policy and practice implications from these studies and provides recommendations for future ART program management.

High levels of psychosocial readiness for ART in an African population at the onset of treatment

Adherence at the earliest stages of treatment is likely to be influenced by prior illness trajectories and future expectations, best captured (and addressed) before treatment begins. We examined the influence of illness trajectories and treatment expectations on psychosocial readiness to start antiretroviral therapy (ART) in Jinja, Uganda. In-depth interviews were conducted between October 2005 and April 2006 with 41 members of an AIDS support organisation on their first day of treatment. Transcribed texts were translated, coded and analysed thematically using NVIVO-7 software. Results indicated that acute fear of death and progressive withdrawal from social, economic and sexual roles narrowed focus on survival, while efficacy-enhancing experiences with septrin prophylaxis and trust in counsellors reinforced belief in HIV diagnosis and importance of adherence. Most enjoyed supportive home environments after disclosing their serostatus. Lack of money for food and transport was anticipated as the main barriers to future adherence, particularly among women. Integrating strong counselling support with ART provision helped channel the power of shared illness experience into positive motivation to adhere at the onset of treatment.

Explaining adherence success in sub-Saharan Africa: an ethnographic study

BACKGROUND

Individuals living with HIV/AIDS in sub-Saharan Africa generally take more than 90% of prescribed doses of antiretroviral therapy (ART). This number exceeds the levels of adherence observed in North America and dispels early scale-up concerns that adherence would be inadequate in settings of extreme poverty. This paper offers an explanation and theoretical model of ART adherence success based on the results of an ethnographic study in three sub-Saharan African countries.

METHODS AND FINDINGS

Determinants of ART adherence for HIV-infected persons in sub-Saharan Africa were examined with ethnographic research methods. 414 in-person interviews were carried out with 252 persons taking ART, their treatment partners, and health care professionals at HIV treatment sites in Jos, Nigeria; Dar es Salaam, Tanzania; and Mbarara, Uganda. 136 field observations of clinic activities were also conducted. Data were examined using category construction and interpretive approaches to analysis. Findings indicate that individuals taking ART routinely overcome economic obstacles to ART adherence through a number of deliberate strategies aimed at prioritizing adherence: borrowing and "begging" transport funds, making "impossible choices" to allocate resources in favor of treatment, and "doing without." Prioritization of adherence is accomplished through resources and help made available by treatment partners, other family members and friends, and health care providers. Helpers expect adherence and make their expectations known, creating a responsibility on the part of patients to adhere. Patients adhere to promote good will on the part of helpers, thereby ensuring help will be available when future needs arise.

CONCLUSION

Adherence success in sub-Saharan Africa can be explained as a means of fulfilling social responsibilities and thus preserving social capital in essential relationships.

Making Sense of Qualitative and Quantitative Findings in Mixed Research Synthesis Studies

The synthesis of qualitative and quantitative research findings is increasingly promoted, but many of the conceptual and methodological issues it raises have yet to be fully understood and resolved. In this article, we describe how we handled issues encountered in efforts to synthesize the findings in forty-two reports of studies of antiretroviral adherence in HIV-positive women in the course of an ongoing study to develop methods to synthesize qualitative and quantitative research findings in common domains of health-related research. Working with these reports underscored the importance of looking past method claims and ideals and directly at the findings themselves, differentiating between aggregative syntheses in which findings are assimilated and interpretive syntheses in which they are configured, and understanding the judgments involved in designating relationships between findings as confirmatory, divergent, or complementary.

Adherence as therapeutic citizenship: impact of the history of access to antiretroviral drugs on adherence to treatment

A dramatic increase in the use of antiretroviral drugs in Africa has increased focus on adherence to treatment, which has so far been equivalent if not superior to that in northern contexts. The reasons for this exceptional adherence are poorly understood. In this paper, we examine adherence in the historical and ethnographic context of access to treatment in Burkina Faso, Côte d'Ivoire and Mali. Living where there is no social security and minimal, if any, medical care, individuals diagnosed with HIV are faced with the threat of illness, death, ostracism and destitution, and were obliged to negotiate conflicting networks of obligation, reciprocity, and value. HIV and AIDS programmes value efforts to address social, and indeed biological, vulnerability. In contrast, kinship-based social relationships may value individuals in other ways. These conflicting moral economies often intersect in the worlds of people living with HIV. HIV status can be used to claim resources from the public or non-governmental organization programmes. This may interfere with social networks that are the most stable source of material and emotional support. Self-help and empowerment techniques provided effective tools for people living with HIV to fashion themselves into effective advocates. In the early years of the use of antiretroviral therapy (ART), access to treatment was thus mediated by confessional practices and forms of social triage. We introduce the term 'therapeutic citizenship' to describe the way in which people living with HIV appropriate ART as a set of rights and responsibilities to negotiate these at times conflicting moral economies. Exemplary adherence should be viewed through the lens of therapeutic citizenship.

Gender, sexuality, and antiretroviral therapy: using social science to enhance outcomes and inform secondary prevention strategies

OBJECTIVES

To explore how, within the context of antiretroviral therapy (ART) uptake and adherence, social science research on gender and sexuality could complement existing epidemiological and behavioral research on uptake, adherence, disinhibition and reproduction.

METHODS

Bibliographical database searches on ART uptake and adherence, the sexual practices of HIV-positive individuals, and fertility management among HIV-positive men and women were conducted over a 6-month period using ISI Web of Science and Medline. Articles were sorted by main topic and then analysed to reveal the unarticulated assumptions that have framed research to date.

RESULTS

The adoption of more social scientific theoretical frameworks would move research on uptake, adherence, disinhibition, and reproduction among HIV-infected and affected individuals beyond the current overemphasis on how cognitive and ideological factors shape behavior and towards an understanding of how culture and inequality shapes the way people engage with ART and craft their sexual and reproductive lives. Research that pays greater attention to the social processes that create differentials in uptake and adherence, rather than just the quantification of those differentials, will open up new possibilities for community-based interventions. Similarly, social science research on gender and sexuality can provide insight into the social factors shaping reproductive and sexual behavior, and thus enhance our ability to manage the potentially competing priorities of limiting marital sexual risk and increasing access to reproductive choice among HIV-affected couples.

CONCLUSION

The ability to produce good clinical outcomes and to develop effective policies for secondary prevention will be enhanced by a deeper understanding of how gender inequality and the social organization of sexuality shape the sexual and reproductive behavior of individuals using ART.

HIV Medication Adherence

The unique nature of the HIV/AIDS epidemic and the needs of people living with HIV disease have required the expertise of clinicians and biomedical, clinical, behavioral, and social scientists. The successes achieved in the past 25 years are the collective product of committed individuals from within all these disciplines. This is particularly true in HIV care and therapeutics and, specifically, in medication adherence, where biologic, clinical, behavioral, and social issues converge and each has been critically important in achieving the stunning therapeutic benefit for individuals and populations with HIV disease. There has been growing acceptance and success of interdisciplinary collaboration to address HIV medication adherence in the past 2 decades. Nevertheless, there remain real and perceived impediments obstructing collaboration among biomedical, behavioral, and social scientists and important differences between all these research domains and clinical practice. Differences in training and expertise, perceived mission, orientation, culture, and personal and professional skills can thwart meaningful collaboration or be used synergistically to move understanding and improvement of HIV medication adherence forward. This article explores these relations and differences from the perspective of an HIV clinician and clinical researcher with a background in biology and an inclination toward behavioral and social science and suggests some approaches for their resolution.

How do intellectual property law and international trade agreements affect access to antiretroviral therapy?

Westerhaus and Castro argue that US-negotiated bilateral, regional, and multilateral trade agreements are hindering access to essential HIV medicines in poor countries.