Optimizing adherence to antiretroviral therapy

"I want to be healthy and move on": A qualitative study of barriers and facilitators to antiretroviral treatment adherence among young adult survivors with perinatal HIV in Thailand

We know that HIV treatment outcome depends on antiretroviral treatment (ART) adherence. Young adults with perinatal HIV (YPHIV) who survived have endured various adherence challenges in their adolescent years. While some of them could maintain perfect adherence with sustainable virologic suppression, many experienced one or more episodes of virologic failure. We explored factors affecting ART adherence from real-life experiences of YPHIV. A qualitative study was conducted between June and November 2022. Twenty YPHIV aged 21-29 years with a history of virologic failure and resumed virologic suppression during adolescent years were invited to share their experiences through individual in-depth interviews. Audio records were transcribed verbatim and analyzed using deductive thematic analysis. We divided excerpts into two themes: barriers and facilitators to ART adherence. The socio-ecological model was used to frame subthemes at personal, societal, and healthcare system levels. Most barriers to adherence were concentrated at the personal level, including work/study-related conditions, personal entertainment, medication issues, mental health problems, thought, and belief. At the societal level, social activities and fear of HIV disclosure were frequently mentioned as barriers. Medical care cost was the only identified barrier at the healthcare system level. The facilitators to adherence at the personal level included perceiving health deterioration, being afraid of hospitalization and medical procedures, and wishing to be healthy and move on. At the same time, perceived family support and determination to complete family without HIV transmission were identified as facilitators at the societal level. Service behaviors of healthcare providers were mentioned as facilitators to adherence at the healthcare system level. From this study, most factors associated with non-adherence in adolescents were at the personal level, and the fear of HIV disclosure was critical at the societal level. The key facilitator to adherence was the determination to be healthy and have a promising future. Our findings reinforce the importance of establishing youth-friendly services in the existing HIV care setting. More time allocation for tailored individual counseling, using other novel approaches like mHealth, online media, and involvement of social support from different sectors might be beneficial to maximize adherence self-efficacy during the transitional period of YPHIV.

Navigating the Antiretroviral Therapy Switch Conundrum: Unveiling the Dilemma of Drug Resistance and Disease Progression in HIV/AIDS

There is a need to establish consensus for harmonization in antiretroviral (ARV) therapy (ART) switch treatment strategy and address the dilemma that exists in terms of subpar immune response to therapy or an immunologic deterioration while on therapy. The purpose of this review is to identify the factors that contribute to ARV treatment failure, such as insufficient dosage, drug interactions, poor adherence, drug resistance, and poor medication absorption. It is crucial to adopt a more efficient strategy to address this challenging dilemma. After ARV treatment failure, the aim of therapy is virologic suppression, which targets plasma viral load below the limits of detection as assessed by very sensitive tests with lower limits of quantification of 20 to 75 RNA copies/ml. The therapeutic objectives when complete virologic suppression is not possible, should be to maintain or restore immunologic function, stop the progression of the clinical illness, and minimize the emergence of new drug resistance that could further restrict the options for ARV drugs. Treatment history and drug-resistance testing, including the findings of previous and ongoing resistance tests, should be considered while selecting ARV regimens. Hence, the treatment approach post-ARV failure can be personalized based on clinical, immunologic, virologic, or as a mix of the three domains on a case-to-case basis. The evaluation of projected ARV activity should be based on treatment history and previous resistance test findings.

A cross-sectional study of the factors influencing adherence to antiretroviral therapy among adults with human immunodeficiency virus infection in a tertiary care hospital in Puducherry, India

Context

Combating human immunodeficiency virus/acquired immunodeficiency syndrome epidemic has been possible due to advances in prevention strategies and Antiretroviral therapy (ART). Optimal adherence to ART is a major factor in achieving the desired immunological, virological, and patient well-being outcomes. Several socio-demographic, patient, treatment, and health-care system-related factors influence nonadherent behavior to ART.

Aims

This study was planned to assess (1) ART adherence level, (2) factors and reasons associated with nonadherence, and (3) impact of suboptimal adherence on treatment outcomes.

Settings and Design

This was a cross-sectional analytical study of 300 patients in a tertiary care hospital in Puducherry, India.

Methods

Random sampling was used to collect data from patient treatment cards and a predesigned structured questionnaire. The pill count method was used to calculate adherence level.

Statistical Analysis Used

Nonadherence was chosen as a dependent variable and factors affecting adherence were chosen as independent variables. Test for significance was carried out by Chi-square test and Fisher's exact test.

Results

Optimal adherence was seen in 68.3%. Factors significantly associated with nonadherence were lower education level, high prior CD4 count, irregular follow-up, missing doses in the past, and being late for pharmacy pill refills. Adherence was positively associated with mean increase in CD4 count over 6 months.

Conclusions

In our study, the adherence rate is suboptimal which can lead to failure of ART. Nonadherence was associated with a decrease in CD4 count overtime. Most of the factors significantly affecting ART adherence were patient behavior related. These factors can be used for target intervention during reinforcement adherence counseling.

Isoniazid preventive therapy completion and factors associated with non-completion among patients on antiretroviral therapy at Kisenyi Health Centre IV, Kampala, Uganda

BACKGROUND

Isoniazid preventive therapy (IPT) is given to HIV patients to reduce the risk of active tuberculosis (TB). However, treatment completion remains suboptimal among those that are initiated. This study aimed to determine the completion level of IPT and the factors associated with non-completion among patients on antiretroviral therapy (ART) at Kisenyi Health Center IV in Kampala, Uganda.

METHODS

A mixed-methods facility-based retrospective cohort study utilizing routinely collected data from 341 randomly selected HIV patients initiated on IPT was conducted. Data extracted from the registers was used to determine IPT completion. Robust Poisson regression was conducted to determine the associated factors of IPT non-completion, while in-depth interviews were conducted to explore barriers to IPT completion from the patient's perspective.

RESULTS

A total of 341 patients who started on isoniazid (INH) were retrospectively followed up, with 69% (236/341) being female. Overall IPT completion was 83%. Multivariate analysis revealed the prevalence of IPT non-completion among males was 2.24 times the prevalence among females (aPR 2.24, 95% CI: 1.40-3.58, p = 0.001). The prevalence of IPT non-completion among patients with a non-suppressed HIV viral load was 3.00 times the prevalence among those with a suppressed HIV viral load (aPR 3.00, 95% CI: 1.44-6.65, p = 0.007). The prevalence of IPT non-completion among patients who were married, or cohabiting was 0.31 times the prevalence among those who were single (aPR 0.31, 95% CI: 0.17-0.55, p<0.000). Lack of IPT-related health education, pill burden, distance to the health facility, and patient relocation were reported as barriers to IPT completion.

CONCLUSION

IPT completion was found to be 83% among the cohort studied. However, lower completion levels persist among males and HIV-virally non-suppressed patients. Lack of IPT-related health education, pill burden, distance to the health facility, and patient relocation were reported as barriers to IPT completion. Interventions that target these groups of people need to be intensified.

Managing household income and antiretroviral therapy adherence among people living with HIV in a low-income setting: a qualitative data from the HPTN 071 (PopART) trial in South Africa

BACKGROUND

South Africa is reported to have the highest burden of HIV with an estimated 8.2 million people living with HIV (PLHIV) in 2021- despite adopting the World Health Organisation (WHO) universal HIV test and treat (UTT) recommendations in 2016. As of 2021, only an estimated 67% (5.5 million) of all PLHIV were accessing antiretroviral therapy (ART), as per recorded clinic appointments attendance. Studies in sub-Saharan Africa show that people living in low-income households experience multiple livelihood-related barriers to either accessing or adhering to HIV treatment including lack of resources to attend to facilities and food insecurity. We describe the interactions between managing household income and ART adherence for PLHIV in low-income urban and semi-urban settings in the Western Cape, South Africa.

METHODS

We draw on qualitative data collected as part of the HPTN 071 (PopART) HIV prevention trial (2016 - 2018) to provide a detailed description of the interactions between household income and self-reported ART adherence (including accessing ART and the ability to consistently take ART as prescribed) for PLHIV in the Western Cape, South Africa. We included data from 21 PLHIV (10 men and 11 women aged between 18 and 70 years old) from 13 households. As part of the qualitative component, we submitted an amendment to the ethics to recruit and interview community members across age ranges. We purposefully sampled for diversity in terms of age, gender, and household composition.

RESULTS

We found that the management of household income interacted with people's experiences of accessing and adhering to ART in diverse ways. Participants reported that ART adherence was not a linear process as it was influenced by income stability, changing household composition, and other financial considerations. Participants reported that they did not have a fixed way of managing income and that subsequently caused inconsistency in their ART adherence. Participants reported that they experienced disruptions in ART access and adherence due to competing household priorities. These included difficulties balancing between accessing care and/or going to work, as well as struggling to cover HIV care-related costs above other basic needs.

CONCLUSION

Our analysis explored links between managing household income and ART adherence practices. We showed that these are complex and change over the course of treatment duration. We argued that mitigating negative impacts of income fluctuation and managing complex trade-offs in households be included in ART adherence support programmes.

Association Between Belief in Medicine and Adherence to Antiretroviral Therapy Among Human Immunodeficiency Virus Adults in Zaira, Kaduna State, Nigeria

BACKGROUND

Negative perceptions of antiretroviral treatment (ART)'s efficacy and consequences may operate as roadblocks to adherence. This research aimed to determine the association between belief in medicine and adherence to antiretroviral therapy among HIV adults on ART in Ahmadu Bello University Teaching Hospital, Zaria, Kaduna State, Nigeria.

METHOD

Using a cross-sectional design, a systematic random sampling method was used to select respondents aged 18-64 years on antiretroviral therapy for at least six months at Ahmadu Bello University Teaching Hospital, outpatients of the President's Emergency Plan for AIDS Relief Clinic. Socio-demographics, belief in medicine and adherence to ART were obtained using a self-administered questionnaire. Descriptive statistics, chi-square test, and multiple logistic regression were used for data analysis.

RESULTS

Among the 385 people who took part in the study, about 67.5% were females and 32.5% were males. About 54% of adults adhered to ART. More than half (55.8%) of the respondents had negative perceptions (beliefs) of personal need for ART medication and about 42.3% of the respondents had more concerns about the potential negative effects of the ART medication. Government employment (odds ratio (OR) = 2.842, p = <0.01), self-employment (OR = 2.6, p = <0.001), and being divorced or widowed (OR = 2.0, p = <0.01), negative perceptions (beliefs) of personal need for the ART medication (adjusted OR (AOR) = 1.525, p=<0.01) and more concerns about the potential negative effects of the ART medication (AOR= 1.362, p = <0.05) were all significantly associated with ART adherence.

CONCLUSION

Employment, marital status and belief in medicine were associated with adherence to ART. Therefore, during adherence counseling, healthcare personnel should address respondents' false views and fears regarding ART medication in order to strengthen proper information and the benefits of ART. This article was previously presented as a meeting poster at the 36th Scientific Conference of the Nutrition Society of Malaysia (7th and 8th September 2021).

Factors associated with anti-retroviral therapy (ART) adherence among adult people living with HIV (PLWH): A 5-year retrospective multi-centre study in Kumasi, Ghana

Background

Combined antiretroviral therapy (cART) is the recommended treatment regimen for people living with HIV (PLWH). Long-term HIV treatment of over 95% adherence inhibits increase in viral load and boosts immune system performance. On the contrary, non-adherence results in treatment failure, accelerated development of HIV drug-resistance and increased mortality. However, there is paucity of data on the prevalence of antiretroviral therapy (ART) adherence and its associated factors in Ghana. We assessed the prevalence, sociodemographic and clinical factors associated with ART adherence among registered PLWH.

Methods

In a multi-centre hospital-based retrospective study, we collected data on 720 registered PLWH 18 years and above, who attend the HIV clinic at the University Hospital (KNUST), Komfo Anokye Teaching Hospital (KATH), and the Bomso Clinic, on ART and with up-to-date medical records. They were enrolled using a multistage sampling technique. Adherence was assessed retrospectively using missed doses and prescriptions renewal. All analysis were done using SPSS Version 26.0 and GraphPad prism version 8.0.

Results

Of 720 registered PLWH, 51.8% had good ART adherence, 35.3% had fair ART adherence and 12.9% had poor ART adherence. Those diagnosed at WHO stage II (aOR = 0.45, 95% CI: (0.30-0.68); p < 0.0001) and stage III (aOR = 0.40, 95% CI: (0.27-0.59) < 0.0001) were independently associated with lower chances of good adherence to ART. Moreover, those treated with AZT/3TC/EFV (aOR = 0.33, 95% CI: (0.16-0.68); p = 0.0030), and AZT/3TC/NVP (aOR = 0.50, 95% CI: (0.26-0.98); p = 0.0410) were independently associated with lower likelihood of good ART adherence. On the contrary, PLWH who have been on treatment for 4 years (aOR = 3.56, 95% CI: (1.10-11.54); p = 0.0340) was an independent predictor of good ART adherence.

Conclusion

About half of PLWH on treatment have good adherence to ART. Being diagnosed at WHO stage II and stage III, being treated with AZT/3TC/EFV, and AZT/3TC/NVP ART combination are associated with lesser chances of good ART adherence. However, increased duration of ART among PLWH influence good ART adherence. PLWH on ART should be monitored to achieve over 95% ART adherence for effective management of HIV/AIDS.

Exploring the barriers to the antiretroviral therapy adherence among people living with HIV in Bangladesh: A qualitative approach

INTRODUCTION

Since the evolution of highly active antiretroviral therapy (ART), a near-perfect ART adherence level (>95%) is needed to control viral suppression. Non-adherence to treatment may lead to acquired immunodeficiency syndrome (AIDS) and drug resistance. Though the Bangladesh government provides free treatment and counselling services to people living with human immunodeficiency virus (PLHIV), only 22% of the identified PLHIV continue treatment. Therefore, this study aims to explore the barriers that obstruct the Bangladeshi PLHIV to ensure ART adherence.

METHODS

We conducted a qualitative study in Dhaka, Bangladesh, and recruited the sensitive study population following non-probability, mainly purposive sampling from a community-based registered organization for PLHIV. We conducted the in-depth interview using a semi-structured guideline with 15 consented respondents. We transcribed the audio-recorded interviews in the local language (Bangla) and then translated those into English for data analysis. During the data extraction process, the lead and corresponding authors independently extracted raw data to generate different themes and sub-themes and invited other authors to contribute when they could not solve any discrepancies.

RESULTS

The study identified three significant categories of barriers at the individual, community, and institutional levels that negatively interfered with ART adherence. The most dominant barriers were discrimination and rejection related to stigma, as almost all participants mentioned these barriers. Stigmatizing attitudes and the discriminatory act of the community people and healthcare providers critically affected their treatment adherence. Other leading barriers were improper inventory management of ART-related medicines and CD4 tests and lack of proper counselling. In addition, we found that a positive approach toward life and family support motivated some respondents to overcome the barriers.

CONCLUSIONS

We recommended strengthening Bangladesh's HIV/AIDS prevention, treatment, and management program with a special focus on the improvement of the supply chain of ART-related medicines and CD4 tests and ensuring proper counselling. In addition, we recommended strengthening the behaviour change communication and IEC activities at a large scale to destigmatize health facilities and community levels.

HIV care outcomes among transgender persons with HIV infection in the United States, 2006-2021

OBJECTIVES

HIV prevalence is an estimated 14% among transgender women (TW) and 3% among transgender men (TM). HIV care is vital for viral suppression but is hindered by transphobia and HIV stigma. We assessed HIV care outcomes among transgender persons (TG) with HIV in the United States.

DESIGN

Systematic review and meta-analysis of peer-reviewed journal articles.

METHODS

We searched multiple electronic databases and Centers for Disease Control and Prevention's HIV Prevention Research Synthesis database for 2006-September 2020. Eligible reports were US-based studies that included TG and reported HIV care outcomes. Random-effects models were used to calculate HIV care outcome rates. The protocol is registered with PROSPERO (CRD42018079564).

RESULTS

Few studies reported outcomes for TM; therefore, only TW meta-analysis results are reported. Fifty studies were identified having low-to-medium risk-of-bias scores. Among TW with HIV, 82% had ever received HIV care; 72% were receiving care, and 83% of those were retained in HIV care. Sixty-two percent were currently virally suppressed. Among those receiving HIV care or antiretroviral therapy (ART), 67% were virally suppressed at last test. Sixty-five percent were linked to HIV care 3 months or less after diagnosis. Seventy-one percent had ever been prescribed ART. Approximately 66% were taking ART, and 66% were ART-adherent. Only 56% were currently adherent the previous year.

CONCLUSIONS

HIV care outcomes for TW were not ideal, and research gaps exists for TM. High heterogeneity was observed; therefore, caution should be taken interpreting the findings. Integrating transgender-specific health needs are needed to improve outcomes of transgender persons across the HIV care continuum.

Study protocol: Strengthening understanding of effective adherence strategies for first-line and second-line antiretroviral therapy (ART) in selected rural and urban communities in South Africa

Multiple factors make adherence to antiretroviral therapy (ART) a complex process. This study aims to describe the barriers and facilitators to adherence for patients receiving first-line and second-line ART, identify different adherence strategies utilized and make recommendations for an improved adherence strategy. This mixed method parallel convergent study will be conducted in seven high volume public health facilities in Gauteng and one in Limpopo province in South Africa. The study consists of four phases; a retrospective secondary data analysis of a large cohort of patients on ART (using TIER.Net, an ART patient and data management system for recording and monitoring patients on ART and tuberculosis (TB)) from seven Johannesburg inner-city public health facilities (Gauteng province); a secondary data analysis of the Intensified Treatment Monitoring Accumulation (ITREMA) trial (a randomized control trial which ran from June 2015 to January 2019) conducted at the Ndlovu Medical Center (Limpopo province); in-depth interviews with people living with Human Immunodeficiency Virus (PLHIV) who are taking ART (in both urban and rural settings); and a systematic review of the impact of treatment adherence interventions for chronic conditions in sub-Saharan Africa. Data will be collected on demographics, socio-economic status, treatment support, retention in care status, disclosure, stigma, clinical markers (CD4 count and viral load (VL)), self-reported adherence information, intrapersonal, and interpersonal factors, community networks, and policy level factors. The systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) reporting and Population, Interventions, Comparisons and Outcomes (PICO) criteria. Analyses will involve tests of association (Chi-square and t-test), thematic analysis (deductive and inductive approaches) and network meta-analysis. Using an integrated multilevel socio-ecological framework this study will describe the factors associated with adherence for PLHIV who are taking first-line or second-line ART. Implementing evidence-based adherence approaches, when taken up, will improve patient's overall health outcomes. Our study results will provide guidance regarding context-specific intervention strategies to improve ART adherence.

Barriers for Antiretroviral Therapy Adherence and Viral Suppression in Members of the Key Population in Mumbai, India: Implications for Interventions

Background:

Poor adherence to antiretroviral therapy (ART) is associated with poor virologic control and drug resistance in people living with HIV/AIDS. Some barriers to ART adherence are cost, lack of information, stigma, or dissatisfaction with health services.

Aims and Objectives:

To study the association between barriers for ART adherence and viral suppression, and explore the role of "missing ART dose" as a potential mediator in high-risk groups.

Materials and Methods:

Demographic, clinical, and behavioral data from 50 "virally suppressed" (viral load [VL] <1000 copies/ml) and 48 "not suppressed" (VL > 1000 copies/ml) individuals belonging to the key population in Mumbai were collected. Sociodemographic, behavioral, and other characteristics were compared, and mediation analysis was used to identify the mediator in the pathway to viral suppression.

Results:

Those who had missed their ART at least once in the past three months (37% versus 60%, P = 0.03) and stayed alone were less likely to be virally suppressed (31% versus 69%, P = 0.002). Individuals who had negative perception about ART (adjusted odds ratio [aOR]: 0.11, 95% confidence interval [CI]: 0.02, 0.47; P = 0.002), poor ART-related knowledge/behaviors (aOR: 0.14, 95% CI: 0.03, 0.60; P = 0.007), and poor pill taking practices (aOR: 0.10, 95% CI: 0.02, 0.61; P = 0.01) were significantly less likely to be virally suppressed. The mediation pathway "adherence theme > missed ART in the past three months > viral suppression" was significant in these themes.

Conclusions:

The factors associated with low viral suppression were knowledge/behaviors, perceptions about ART, and poor pill taking practices. Thus, it is important to provide correct information about ART, its effects, side effects, and potential limitations to marginalized population. Involving brothel keepers and Gurus (head of male-to-female transgendered people/Hijras clans), and technology enabled customized counseling sessions will be helpful.

What influences adherence among HIV patients presenting with first-line antiretroviral therapy failure (ART failure)? A retrospective, cross-sectional study from a private clinic in Nagpur, India

Background:

Multiple reports show increasing occurrences of ART failure in India. Despite the fact that a significant volume of outpatient and on-going healthcare occurs in private clinics, there are very few studies on adherence from private clinics in India.

Objective:

To evaluate the factors influencing adherence to ART in patients with first-line ART failure.

Materials and Methods:

Data were collected from a convenience sample of 139 individuals diagnosed with clinical, immunological or virologic failure from a private HIV clinic in Nagpur, India. A retrospective cross-sectional study was undertaken and data were statistically analysed.

Results:

Of the 139 patients, 118 (84.9%) were male and 21 (15.1%) were female. 64 (46%) had received pre-treatment and adherence counselling. 81 (58.3%) were not told about the side effects of ART medications and 65 (46.8%) avoided friends and family. Most common reasons for suboptimal adherence by stopping treatment were high cost, alcoholism, choosing non-allopathic medications and depression. Reasons cited for suboptimal adherence due to missed doses included feeling healthy, depression, forgetfulness and busy schedule. A significant association was found between pre-treatment counselling, adherence counselling and being told the importance of lifelong treatment and decreased occurrence of complete stoppage of treatment.

Conclusion:

This study brings to light some of the predictors of ART failure. Counselling, having a strong support system as well as early identification and tackling of reasons for suboptimal adherence plays an important role in preventing ART failure.

Viral load Suppression and Associated Factors among HIV Patients on Antiretroviral Treatment in Bulambuli District, Eastern Uganda: A Retrospective Cohort Study

BACKGROUND

HIV viral load suppression (VLS) is the most important indicator of successful antiretroviral therapy. In 2016, Bulambuli District started monitoring HIV patients on ART using viral load tests in an effort to meet the third 90 of the UNAIDS 90-90-90 strategy which is VLS. The objective of this study was to determine the progress in Bulambuli District towards achievement of VLS among HIV infected patients on ART and associated factors that affect this programme.

METHODS

A retrospective cohort study design was used. One thousand, one hundred and one medical records of HIV infected patients on ART who attended HIV clinic at Muyembe Health Centre IV from June 2016 to April 2018 were reviewed. A data abstraction tool was used for data collection. Chi Square was used to determine factors associated with VLS and logistic regression was used to determine the magnitude by which the ART and clinical factors influence VLS. Data were summarized using descriptive statistics for categorical variables and by computing proportions, means and standard deviation for continuous variables.

RESULTS

Of the patients (n = 944, 85.7%) had attained VLS. Adjusting for known confounders, only adherence to ART was a significant predictor of VLS. Individuals with fair adherence (80%-95%) had 2.667 times the odds of VLS, CI = 1.122-9.370, P-value of <.002 compared to individuals with good (>95%) adherence which was used as the reference while those with poor (<80%) adherence had 4.553 times the odds of attaining VLS, CI = 1.31-13.930, P-value of <.001 compared to individuals with good adherence.

CONCLUSION

These findings suggest that Bulambuli District, at 85.7% VLS is on track to attaining the third 90 of the 90, 90, 90 global targets by 2020. It further reveals that adherence is the only significant predictor of VLS in the District.

Socioeconomic and Demographic Statuses as Determinants of Adherence to Antiretroviral Treatment in HIV Infected Patients: A Systematic Review of the Literature

BACKGROUND

Socioeconomic and demographic statuses are associated with adherence to the treatment of patients with several chronic diseases. However, there is a controversy regarding their impact on adherence among HIV/AIDS patients. Thus, we performed a systematic review of the evidence regarding the association of socioeconomic and demographic statuses with adherence to antiretroviral therapy (ART) among HIV/AIDS patients.

METHODS

The PubMed database was used to search and identify studies concerning about socioeconomic and demographic statuses and HIV/AIDS patients. Data were collected on the association between adherence to ART and varies determinants factors of socioeconomic (income, education, and employment/occupation) and socio-demographic (sex and age).

FINDINGS

From 393 potentially-relevant articles initially identified, 35 original studies were reviewed in detail, which contained data that were helpful in evaluating the association between socioeconomic/ demographic statuses and adherence to ART among HIV patients. Two original research study has specifically focused on the possible association between socioeconomic status and adherence to ART. Income, level of education, and employment/occupational status were significantly and positively associated with the level of adherence in 7 studies (36.8%), 7 studies (28.0%), and 4 studies (23.5%) respectively out of 19, 25, and 17 studies reviewed. Sex (being male), and age (per year increasing) were significantly and positively associated with the level of adherence in 5 studies (14.3%), and 9 studies (25.7%) respectively out of 35 studies reviewed. However, the determinant of socioeconomic and demographic statuses was not found to be significantly associated with adherence in studies related to income 9(47.4%), education 17(68.0%), employment/ occupational 10(58.8%), sex 27(77.1%), and age 25(71.4%).

CONCLUSION

The majority of the reviewed studies reported that there is no association between socio- demographic and economic variables and adherence to therapy. Whereas, some studies show that age of HIV patients (per year increasing) and sex (being male) were positively associated with adherence to ART. Among socio-economic factors, the available evidence does not provide conclusive support for the existence of a clear association with adherence to ART among HIV patients. There seems to be a positive trend between socioeconomic factors and adherence to ART in some of the reviewed studies.

Adherence to antiretroviral therapy and associated factors among Human immunodeficiency virus positive patients accessing treatment at Nekemte referral hospital, west Ethiopia, 2019

BACKGROUND

Antiretroviral therapy has a remarkable clinical effect in reducing the progress of Acquired Immune Deficiency Syndrome. The clinical outcome of Anti-Retroviral therapy depends on strict adherence. Poor adherence reduces the effectiveness of antiretroviral therapy and increases viral replication. With changes in service delivery over time and differences in socio-demographic status from region to region, it is essential to measure adherence. Therefore, this study aimed to assess adherence to antiretroviral therapy and its associated factors among HIV/AIDS patients accessing treatment at Nekemte referral hospital, West Ethiopia.

METHODS

Institutional based cross-sectional study was conducted on 311 HIV/AIDS patients from March 01 to March 30, 2019. The study participants were selected by a simple random sampling method and interviewed using structured questionnaires. Bivariable logistic regression was conducted to find an association between each independent variable and adherence to antiretroviral medication. Multivariable logistic regression was used to find the independent variables which best predict adherence. The statistical significance was measured using odds ratio at a 95% confidence interval with a p-value of less than 0.05.

RESULTS

Out of a total of 311 patients sampled, 305 were participated in the study, making a response rate of 98.07%. From these 305 study participants,73.1% (95% CI = 68.2, 78.0) were adherent to their medication. Having knowledge about HIV and its treatment (AOR = 8.24, 95% CI: 3.10, 21.92), having strong family/social support (AOR = 6.21, 95% CI: 1.39, 27.62), absence of adverse drug reaction (AOR = 5.33, 95% CI: 1.95, 14.57), absence of comorbidity of other chronic diseases (AOR = 5.72, 95% CI: 1.91, 17.16) and disclosing HIV status to the family (AOR = 5.08, 95% CI: 2.09, 12.34) were significantly associated with an increased likelihood of adherence to antiretroviral medication.

CONCLUSION

The level of adherence to antiretroviral therapy was found low compared to WHO recommendation. The clinician should emphasize reducing adverse drug reaction, detecting and treating co-morbidities early, improving knowledge through health education, and encouraging the patients to disclose their HIV status to their families.

Reliability, validity and measurement invariance of the Simplified Medication Adherence Questionnaire (SMAQ) among HIV-positive women in Ethiopia: a quasi-experimental study

BACKGROUND

Adherence to antiretroviral therapy is critical to the achievement of the third target of the UNAIDS Fast-Track Initiative goals of 2020-2030. Reliable, valid and accurate measurement of adherence are important for correct assessment of adherence and in predicting the efficacy of ART. The Simplified Medication Adherence Questionnaire is a six-item scale which assesses the perception of persons living with HIV about their adherence to ART. Despite recent widespread use, its measurement properties have yet to be carefully documented beyond the original study in Spain. The objective of this paper was to conduct internal consistency reliability, concurrent validity and measurement invariance tests for the SMAQ.

METHODS

HIV-positive women who were receiving ART services from 51 service providers in two sub-cities of Addis Ababa, Ethiopia completed the SMAQ in a HIV treatment referral network study between 2011 and 2012. Two cross-sections of 402 and 524 female patients of reproductive age, respectively, from the two sub-cities were randomly selected and interviewed at baseline and follow-up. We used Cronbach's coefficient alpha (α) to assess internal consistency reliability, Pearson product-moment correlation (r) to assess concurrent validity and multiple-group confirmatory factor analysis to analyze factorial structure and measurement invariance of the SMAQ.

RESULTS

All participants were female with a mean age of 33; median: 34 years; range 18-45 years. Cronbach's alphas for the six items of the SMAQ were 0.66, 0.68, 0.75 and 0.75 for T1 control, T1 intervention, T2 control, and T2 intervention groups, respectively. Pearson correlation coefficients were 0.78, 0.49, 0.52, 0.48, 0.76 and 0.80 for items 1 to 6, respectively, between T1 compared to T2. We found invariance for factor loadings, observed item intercepts and factor variances, also known as strong measurement invariance, when we compared latent adherence levels between and across patient-groups.

CONCLUSIONS

Our results show that the six-item SMAQ scale has adequate reliability and validity indices for this sample, in addition to being invariant across comparison groups. The findings of this study strengthen the evidence in support of the increasing use of SMAQ by interventionists and researchers to examine, pool and compare adherence scores across groups and time periods.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

A study of adherence to antiretroviral therapy in a tertiary care hospital at Allahabad, India

Introduction:

India has a large proportion of the global HIV-infected patients. Antiretroviral therapy (ART) is the cornerstone of HIV treatment. Antiretroviral drugs are highly toxic and lead to diverse adverse drug reactions (ADRs). Adherence to medications plays a prominent role in success of the therapy. This prospective study was done to study the adherence and analyze its associated factors.

Methodology:

The present study was conducted at ART Centre, Swarup Rani Hospital, Allahabad, Uttar Pradesh, India. Selection of the patients was done based on systematic random sampling method. Baseline enrollment was done over 2 months and follow-up was done monthly over 6 months. Information regarding sociodemographic profile, ART regimen, occurrence of ADRs, adherence to ART and factors affecting adherence was collected. Bivariate logistic regression was done to analyze the association of selected variables with adherence.

Results:

This study enrolled 163 participants among which 152 participants completed the study. During the study period, 94 participants reported the occurrence of at least one ADR. Nonadherence to ART therapy was seen in 31.6% of patients. The most common reason was forgetting to take the medicine (21.8%) followed by occurrence of ADRs (18.3%). No statistically significant association of nonadherence was found with the selected variables.

Conclusion:

Comprehensive research to assess nonadherence to ART therapy is the need of the hour. Policy formulations ought to be made to assess and promote effective adherence to enhance the longevity and quality of life of people living with HIV/AIDS. Concerted efforts by government and intersectoral collaboration are further needed to sustain promotive measures.

Social and economic barriers to adherence among patients at Livingstone General Hospital in Zambia

BACKGROUND

 Zambia is one of the countries hardest hit by the human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) pandemic with a national HIV prevalence estimated at 14% among those aged 15-49 years in 2012. Antiretroviral therapy (ART) has been available in public health facilities in Zambia since 2003. By early 2016, 65% of the 1.2 million Zambians living with HIV were accessing ART. While access to ART has improved the lives of people living with HIV globally, the lack of adherence to ART is a major challenge to treatment success globally.

AIM

 This article reports on social and economic barriers to ART adherence among HIV patients being attended to at Livingstone General Hospital in Zambia.

SETTING

 Livingstone General Hospital is located in the Southern province of Zambia, and had over 7000 patients enrolled for HIV care of whom 3880 patients were on ART.

METHODS

 An explorative, qualitative study was conducted with 42 patients on ART where data were collected through six focus group discussions (3 male and 3 female groups) and seven in-depth interviews. Data were audio-recorded and transcribed verbatim and subjected to thematic content analysis.

RESULTS

 Economic factors such as poverty and unemployment and the lack of food were reported as major barriers to adherence. Furthermore, social factors such as traditional medicine, religion, lack of family and partner support, and disclosure were also reported as critical barriers to adherence to ART.

CONCLUSION

 Interventions to improve adherence among ART patients should aim to redress the socio-economic challenges at community and individual levels.

Quality of life among HIV-tuberculosis co-infected patients

Background:

India is the world's third leading country in terms of people living with human deficiency virus (HIV) (2.1 million) with 0.4 million deaths due to HIV-associated tuberculosis (TB). Physical and mental stress degrades the quality of life (QOL) in these patients. Studies have been done in HIV patients but very few on HIV-TB co-infected patients. Our study aims at assessing and comparing the QOL in HIV patients with and without TB.

Materials and Methods:

It was a cross-sectional study done at Antiretroviral Treatment Center of KMC, Mangalore and District Wenlock Hospital, Mangalore, over 6 months. A sample size was 104. Semi-structured questionnaire to collect clinico-demographic data, World Health Organization QOL (WHOQOL)-HIV BREF to assess the QoL, and Beck's Depression Inventory Scale (Physical health, psychological well-being, social relationship, environmental health, level of independence, and spiritual health) to identify depression were used. The Cronbach's alpha was used to measure the internal consistency for each domain of the WHOQOL-HIV instrument.

Results:

HIV-TB co-infected patients had a lower mean score in all domains as compare to only HIV patients, suggesting that HIV-TB co-infected patients had a poor QOL (P < 0.05). Internal consistency of each domain was good (α >0.7).

Conclusion:

To improve the QOL in HIV patients, it is important to identify the determinants of QOL and work toward its improvement.

Availability of HIV services along the continuum of HIV testing, care and treatment in Ghana

BACKGROUND

Ghana has been providing HIV and AIDS services since the identification of the first case in 1986 and added highly active antiretroviral therapy to its comprehensive care in 2003.This study aimed at assessing availability of HIV services along the continuum of HIV care in Ghana.

METHOD

A cross sectional study was conducted among 172 (87%) of the total 197 ART canters in Ghana. Data was collected by self-administered questionnaire and analysed using STATA version 13.

RESULTS

Of the 172 health facilities surveyed, 165 (96%) were offering HIV testing Services (HTS) during the survey period. More than 90% of the surveyed facilities reported to offer Anti-Retroviral Treatment (ART), patient counselling, TB screening and Prevention of Mother to Child Transmission (PMTCT) services. Viral load and Early Infant Diagnosis (EID) and laboratory testing services were reported at 10 (5.8%) and 23 (13.4%) respectively. HIV testing services (HTS), PMTCT, ART, patient counselling and opportunistic infections (OI) prophylaxis services were offered at all Tertiary and Regional hospitals surveyed. EID sample collection and testing services was reported at 2 out of 27 (7.4%) of the Health Centre and/or clinics in Ghana. The common adherence assessment methodology being implemented varied by facilities which included: asking patients if they took their drugs 154 (89.5%), pill counting 131 (76.2%), use of follow-up visit 79(45.9%) and use of CD4 counts, viral loads and clinical manifestation 76 (44.2%). Challenges encountered by facilities included shortage of test reagents and drugs 122 (71%), 111 (65%) respectively and patient compliance 101 (59%).

CONCLUSION

This study showed ART services to be available in most facilities. Methods used to assess patients adherence varied across facilities. Shortage of test reagents and drugs, EID sample collection and testing were major challenges. A standardised approach to assessing patient's adherence is recommended. Measures should be put in place to ensure availability of HIV commodities at all levels.

Factors associated with adherence to antiretroviral therapy among HIV infected children in Kabale district, Uganda: a cross sectional study

Objectives

This study was set out to assess the level of adherence to antiretroviral therapy (ART) and its determinants among children receiving HIV treatment in Kabale district, south western Uganda, in order to inform interventions for improving pediatric ART adherence.

Results

Overall, 79% (121/153) of the children did not miss ART doses over the 7 days. Caregiver forgetfulness was the major reason for missing ART doses, 37% (13/35). Other reasons included transportation costs to the health facilities, 17%, (6/35) and children sitting for examinations in schools. Older children (11–14 years) were more likely to adhere to ART than the younger ones (0–10 years) (AOR = 6.41, 95% CI 1.31–31.42). Caregivers, who knew their HIV status, had their children more adherent to ART than the caregivers of unknown HIV status (AOR = 21.64: 95% CI 1.09–428.28). A significant proportion of children in two facilities 21.5% (32/153) missed ART doses within the previous week. Support for providers to identify clues or reminders to take drugs, extending HIV testing to caregivers and innovative models of ART delivery that alleviate transport costs to caregivers and allow sufficient drugs for children in school could enhance drug adherence among children.

HIV treatment and monitoring patterns in routine practice: a multi-country retrospective chart review of patient care

Background: A study of patient records in four HIV clinics in three sub-Saharan African countries examined routine clinical care patterns and variations.

Methods: Clinic characteristics were described, and patient data extracted from a sample of medical records. Data on treatment, CD4 count and viral load (VL) were obtained for the last visit in the records, dates mainly between 2015 and 2017, patient demographic data were obtained from the first clinic visit.

Results: Four clinics, two in Nigeria, one in Zambia and one in Uganda, all public facilities, using national HIV treatment guidelines were included. Numbers of patients and health professionals varied, with some variation in stated frequency of testing for CD4 count and VL. Clinical guidelines were available in each clinic, and most drugs were available free to patients. The proportion of patients with a CD4 count in the records varied from 84 to 100 percent, the latest median count varied from 269 to 593 between clinics. 35% had a record of a VL test, varying from 1% to 63% of patients. Lamivudine (3TC) was recorded for more than 90% of patients in each clinic, and although there was variation between clinics in the choice of antiretroviral therapy (ART), the majority were on first line drugs consistent with guidelines.  Only about 2% of the patients were on second-line ARTs. In two clinics, 100% and 99% of patients were prescribed co-trimoxazole, compared with 7% and no patients in the two other clinics.

Conclusions: The wide variation in available clinic health work force, levels and frequency of CD4 counts, and VL assessment and treatment indicate sub-optimal adherence to current guidelines in routine clinical care. There is room for further work to understand the reasons for this variation, and to standardise record keeping and routine care of HIV positive patients.

Use of an android phone application for automated text messages in international settings: A case study in an HIV clinical trial in St. Petersburg, Russia

BACKGROUND/AIMS

Reproducible outcomes in clinical trials depend on adherence to study protocol. Short message service (also known as text message) reminders have been shown to improve clinical trial adherence in the United States and elsewhere. However, due to systematic differences in mobile data plans, languages, and technology, these systems are not easily translated to international settings.

METHODS

To gauge technical capabilities for international projects, we developed SMSMessenger, an automated Android application that uses a US server to send medication reminders to participants in a clinical trial in St. Petersburg, Russia (Zinc for HIV disease among alcohol users-a randomized controlled trial in the Russia Alcohol Research Collaboration on HIV/AIDS cohort). The application is downloaded once onto an Android study phone. When it is time for the text message reminders to be sent, study personnel access the application on a local phone, which in turn accesses the existing clinical trial database hosted on a US web server. The application retrieves a list of participants with the following information: phone number, whether a message should be received at that time, and the appropriate text of the message. The application is capable of storing multiple outgoing messages. With a few clicks, text messages are sent to study participants who can reply directly to the message. Study staff can check the local phone for incoming messages. The SMSMessenger application uses an existing clinical trial database and is able to receive real-time updates. All communications between the application and server are encrypted, and phone numbers are stored in a secure database behind a firewall. No sensitive data are stored on the phone, as outgoing messages are sent through the application and not by messaging features on the phone itself. Messages are sent simultaneously to study participants, which reduces the burden on local study staff. Costs and setup are minimal. The only local requirements are an Android phone and data plan.

CONCLUSION

The SMSMessenger technology could be modified to be applied anywhere in the world, in any language, script, or alphabet, and for many different purposes. The novel application of this existing low-cost technology can improve the usefulness of text messaging in advancing the goals of international clinical trials.

Use of Non-Prescription Remedies by Ghanaian Human Immunodeficiency Virus-Positive Persons on Antiretroviral Therapy

Background

Inappropriate use of non-prescription remedies by persons living with human immunodeficiency virus (PLHIV) may result in adverse events or potentiate non-adherence to prescribed medications. This study investigated the use of non-prescription remedies among PLHIV receiving antiretroviral therapy (ART) from four treatment centers in southern Ghana.

Methods

A mixed method design using quantitative and qualitative methods was used. This article focuses on the quantitative survey of 540 respondents. Univariate analysis was used to generate descriptive tabulations of key variables. Bivariate analysis and logistic regression modeling, respectively, produced unadjusted and adjusted associations between background attributes of PLHIV and the use of non-prescription remedies. A p-value of < 0.05 was considered statistically significant. All analyses were performed using IBM SPSS Statistics for Windows, Version 20.0.

Results

One out of three respondents reported the use of non-prescription remedies at least once within 3 months of the survey. Most of these were locally made and included “Angel natural bitters, concoctions from the Christian prayer centers, garlic, and mahogany syrups.” These remedies were used concomitantly with antiretroviral medications (ARVs)—46% or administered with ARVs but at different times during the day (43%). Some of the remedies were reportedly prescribed by health workers, or self-initiated during periods of ARVs shortage. Others took them based on their perception of their efficacy. Bivariate level analysis identified ART clinic site, place of residence, and ARV adherence monitoring to be significantly associated with the use of non-prescription remedies (p < 0.05). Multiple logistic regression analysis controlling for covariates confirmed the location of ART clinic as the only predictor of the use of non-prescription remedies. Compared to clients at the large urban teaching hospital (Korle-Bu Fevers Unit ART center), those at the district level (Atua ART center) were ninefold more likely to use non-prescription remedies [adjusted odds ratio (AOR) = 8.84; 95% confidence interval (CI) 2.83–33.72]. Those from a district level mission hospital (St. Martin’s ART center) were threefold as likely to use these remedies (AOR = 2.610; 95% CI 1.074–9.120).

Conclusion

The use of non-prescription remedies by PLHIV on ART is common in southern Ghana. Usage is mostly self-initiated because of perceived efficacy of remedy, and was more common among clients attending rural ART clinics.

Exploring 'generative mechanisms' of the antiretroviral adherence club intervention using the realist approach: a scoping review of research-based antiretroviral treatment adherence theories

Background

Poor retention in care and non-adherence to antiretroviral therapy (ART) continue to undermine the success of HIV treatment and care programmes across the world. There is a growing recognition that multifaceted interventions – application of two or more adherence-enhancing strategies – may be useful to improve ART adherence and retention in care among people living with HIV/AIDS. Empirical evidence shows that multifaceted interventions produce better results than interventions based on a singular perspective. Nevertheless, the bundle of mechanisms by which multifaceted interventions promote ART adherence are poorly understood. In this paper, we reviewed theories on ART adherence to identify candidate/potential mechanisms by which the adherence club intervention works.

Methods

We searched five electronic databases (PubMed, EBSCOhost, CINAHL, PsycARTICLES and Google Scholar) using Medical Subject Headings (MeSH) terms. A manual search of citations from the reference list of the studies identified from the electronic databases was also done. Twenty-six articles that adopted a theory-guided inquiry of antiretroviral adherence behaviour were included for the review. Eleven cognitive and behavioural theories underpinning these studies were explored. We examined each theory for possible ‘generative causality’ using the realist evaluation heuristic (Context-Mechanism-Outcome) configuration, then, we selected candidate mechanisms thematically.

Results

We identified three major sets of theories: Information-Motivation-Behaviour, Social Action Theory and Health Behaviour Model, which explain ART adherence. Although they show potential in explaining adherence bebahiours, they fall short in explaining exactly why and how the various elements they outline combine to explain positive or negative outcomes. Candidate mechanisms indentified were motivation, self-efficacy, perceived social support, empowerment, perceived threat, perceived benefits and perceived barriers. Although these candidate mechanisms have been distilled from theories employed to explore adherence to ART in various studies, the theories by themselves do not provide an explanatory model of adherence based on the realist logic.

Conclusions

The identified theories and candidate mechanisms offer possible generative mechanisms to explain how and why patients adhere (or not) to antiretroviral therapy. The study provides crucial insights to understanding how and why multifaceted adherence-enhancing interventions work (or not). These findings have implications for eliciting programme theories of group-based adherence interventions such as the adherence club intervention.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4322-8) contains supplementary material, which is available to authorized users.

Factors Influencing Adherence to Antiretroviral Therapy among People Living with HIV in Coastal South India

BACKGROUND

Antiretroviral Therapy (ART) has transformed life threatening HIV/AIDS scenario into chronic manageable disease.

METHODOLOGY

In this cross-sectional, 409 People Living with Human Immunodeficiency Virus (PLHIV) aged ≥ 18 years, who were on ART, were assessed regarding the adherence to ART and factors affecting adherence using semi-structured questionnaire. The association between factors affecting adherence and the level of adherence were analyzed using multiple logistic regression model and odds ratio (OR) with 95% confidence intervals (CI) were reported.

RESULTS

Among 409 PLHIV, 70.4% showed adherence to ART (≥95%). Univariate analysis yielded many factor associated with adherence (P < 0.05). However, on multivariate analysis, PLHIV who do not forget to take ART and not consuming alcohol were the factors consistent with adherence to ART (P < 0.05).

CONCLUSION

Regular patient education and counseling regarding the usage of memory aids and abstinence from alcohol could be useful for adherence and long term success of ART among PLHIV.

Adherence to anti-retroviral therapy & factors associated with it: A community based cross-sectional study from West Bengal, India

BACKGROUND & OBJECTIVES

Failure to adhere to anti-retroviral therapy (ART) can lead to a range of unfavourable consequences impacting upon people living with HIV (PLH) and society. It is, therefore, paramount that ART adherence is measured in a reliable manner and factors associated with adherence are identified. Lack of such data from West Bengal necessitated undertaking the current study.

METHODS

Participants were included during August-October, 2011 from three Drop-In-Centres (DICs) from the three districts of West Bengal, India. ART-adherence was calculated by using formula based on pill-count and records collected from ART-card in possession of each of the 128 consenting adult PLH. Information on self-reported adherence, socio-demography, and adherence influencing issues was also collected through interviewer-administered questionnaire.

RESULTS

Of the 128 PLH, 99 (77%) and 93 (73%) PLH had ≥90 per cent and ≥95 per cent adherence, respectively to ART. Conversely, subjective reporting captured much higher proportion of PLH as 'well adherent'; a finding having implications for ongoing ART programme. Factors, independently associated with poor adherence (<90%), were '7 th to 12 th month period of ART intake' (adjusted OR=9.5; 90% CI 1.9 - 47.3; p0 =0.02) and 'non-disclosure of HIV status to family members' (adjusted OR=4; 90% CI 1.3 - 13; P=0.05. Results at 95 per cent adherence cut-off were similar.

INTERPRETATION & CONCLUSIONS

Enabling environment, which would encourage people to disclose their HIV status and in turn seek adherence partners from families and beyond and ongoing adherence-counselling appear to be important issues in the programme. Relevance of these study findings in wider context is conceivable.

Realist evaluation of the antiretroviral treatment adherence club programme in selected primary healthcare facilities in the metropolitan area of Western Cape Province, South Africa: a study protocol

INTRODUCTION

Suboptimal retention in care and poor treatment adherence are key challenges to antiretroviral therapy (ART) in sub-Saharan Africa. Community-based approaches to HIV service delivery are recommended to improve patient retention in care and ART adherence. The implementation of the adherence clubs in the Western Cape province of South Africa was with variable success in terms of implementation and outcomes. The need for operational guidelines for its implementation has been identified. Therefore, understanding the contexts and mechanisms for successful implementation of the adherence clubs is crucial to inform the roll-out to the rest of South Africa. The protocol outlines an evaluation of adherence club intervention in selected primary healthcare facilities in the metropolitan area of the Western Cape Province, using the realist approach.

METHODS AND ANALYSIS

In the first phase, an exploratory study design will be used. Document review and key informant interviews will be used to elicit the programme theory. In phase two, a multiple case study design will be used to describe the adherence clubs in five contrastive sites. Semistructured interviews will be conducted with purposively selected programme implementers and members of the clubs to assess the context and mechanisms of the adherence clubs. For the programme's primary outcomes, a longitudinal retrospective cohort analysis will be conducted using routine patient data. Data analysis will involve classifying emerging themes using the context-mechanism-outcome (CMO) configuration, and refining the primary CMO configurations to conjectured CMO configurations. Finally, we will compare the conjectured CMO configurations from the cases with the initial programme theory. The final CMOs obtained will be translated into middle range theories.

ETHICS AND DISSEMINATION

The study will be conducted according to the principles of the declaration of Helsinki (1964). Ethics clearance was obtained from the University of the Western Cape. Dissemination will be done through publications and curation.

Migration as a risk and a livelihood strategy: HIV across the life course of migrant families in India

Migrant workers are understood to be vulnerable to HIV. However, little is known about the experience of migration-based households following HIV infection. This qualitative study examined the migration-HIV relationship beyond the point of infection, looking at how it affects livelihood choices, household relationships and the economic viability of migrant families. We conducted semi-structured interviews with 33 HIV-positive migrant men and women recruited from an anti-retroviral therapy (ART) centre in north India. Following infection among the migrant men, contact with free, public-sector HIV services was often made late, after the development of debilitating symptoms, abandonment of migrant work and return to native villages. After enrolment at the ART centre participants’ health eventually stabilised but they now faced serious economic debt, an inflexible treatment regimen and reduced physical strength. Insecure migrant job markets, monthly drug collection and discriminatory employment policies impeded future migration plans. HIV-positive wives of migrants occupied an insecure position in the rural marital household that depended on their husbands’ health and presence of children. The migration-HIV relationship continued to shape the life course of migrant families beyond the point of infection, often exposing them again to the economic insecurity that migration had helped to overcome, threatening their long-term survival.

Elevation of Brain Magnesium Potentiates Neural Stem Cell Proliferation in the Hippocampus of Young and Aged Mice

In the adult brain, neural stem cells (NSCs) can self-renew and generate all neural lineage types, and they persist in the sub-granular zone (SGZ) of the hippocampus and the sub-ventricular zone (SVZ) of the cortex. Here, we show that dietary-supplemented - magnesium-L-threonate (MgT), a novel magnesium compound designed to elevate brain magnesium regulates the NSC pool in the adult hippocampus. We found that administration of both short- and long-term regimens of MgT, increased the number of hippocampal NSCs. We demonstrated that in young mice, dietary supplementation with MgT significantly enhanced NSC proliferation in the SGZ. Importantly, in aged mice that underwent long-term (12-month) supplementation with MgT, MgT did not deplete the hippocampal NSC reservoir but rather curtailed the age-associated decline in NSC proliferation. We further established an association between extracellular magnesium concentrations and NSC self-renewal in vitro by demonstrating that elevated Mg(2+) concentrations can maintain or increase the number of cultured hippocampal NSCs. Our study also suggests that key signaling pathways for cell growth and proliferation may be candidate targets for Mg(2+) 's effects on NSC self-renewal. J. Cell. Physiol. 231: 1903-1912, 2016. © 2016 Wiley Periodicals, Inc.

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.

Adherence to Antiretroviral Therapy and Its Effect on Survival of HIV-Infected Individuals in Jharkhand, India

Introduction

Research in India has extensively examined the factors associated with non-adherence to antiretroviral therapy (ART) with limited focus on examining the relationship between adherence to ART regimen and survival status of HIV infected patients. This study examines the effect of optimal adherence to ART on survival status of HIV infected patients attending ART centers in Jharkhand, India.

Materials and Methods

Data from a cohort of 239 HIV infected individuals who were initiated ART in 2007 were compiled from medical records retrospectively for 36 months. Socio-demographic characteristics, CD4 T cell count, presence of opportunistic infections at the time of ART initiation and ART regimen intake and survival status was collected periodically. Optimal adherence was assessed using pill count methods; patients who took <95% of the specified regimens were identified as non-adherent. Cox-proportional hazard model was used to determine the relative hazards of mortality.

Results

More than three-fourths of the patients were male, on an average 34 year old and median CD4 T cell count was 118 cells/cmm at the time of ART registration. About 57% of the patients registered for ART were found to be adherent to ART. A total of 104 patients died in 358.5 patient-years of observation resulting in a mortality rate of 29 per 100 patient-years (95% confidence interval (CI): 23.9–35.2) and median survival time of 6.5 months (CI: 2.7–10.9). The mortality rate was higher among patients who were non-adherent to ART (64.5, CI: 50.5–82.4) than who were adherent (15.4, CI: 11.3–21.0). The risk of mortality was fourfold higher among individuals who were non-adherent to ART than who were adherent (Adjusted hazard ratio: 3.9, CI: 2.6–6.0).

Conclusion

Adherence to ART is associated with a higher chance of survival of HIV infected patients, ascertaining the need for interventions to improve the ART adherence and early initiation of ART.

Adherence to Antiretroviral Therapy Among People Living with HIV

BACKGROUND

Acquired immune deficiency syndrome (AIDS) is now considered as a manageable chronic illness. There has been a dramatic reduction in human immunodeficiency virus (HIV) related morbidity and mortality due to antiretroviral therapy. A high level of adherence (>95%) is required for antiretroviral therapy to be effective. There are many barriers to adherence in both developed and developing countries.

AIM

The aim of our study was to determine adherence levels and factors influencing adherence to antiretroviral therapy among people living with HIV.

MATERIALS AND METHODS

Using a cross-sectional study design, 116 HIV positive patients receiving antiretroviral therapy for at least 1 year were interviewed using a semi structured questionnaire. The collected data was analyzed using Statistical Product and Service Solutions (SPSS) version 11.5. Chi-square test was done. A P value of < 0.05 was considered statistically significant.

RESULTS

Of 116 participants, 63.7% reported adherence ≥ 95%. Mean adherence index was 91.25%. Financial constraints, forgetting to take medication, lack of family care, depression, alcohol use, social stigma and side effects to antiretroviral therapy were barriers for adherence in our study.

CONCLUSION

Adherence to antiretroviral therapy in south India is suboptimal. Intensive adherence counseling should be provided to all patients before initiation ofantiretroviral therapy. Health care providers must identify possible barriers to adherence at the earliest and provide appropriate solutions.

Comparative evaluation of the Abbott HIV-1 RealTime™ assay with the Standard Roche COBAS® Amplicor™ HIV-1 Monitor® Test, v1.5 for determining HIV-1 RNA levels in plasma specimens from Pune, India

The implementation of cost effective HIV-1 viral load assays in resource-limited settings have been an impediment for monitoring HIV-1 therapy. A study involving the comparative analytical performance of two HIV-1 viral load assays - Standard Roche COBAS(®) Amplicor™ HIV-1 Monitor(®) Test, version 1.5 (Roche Diagnostics, Basel, Switzerland) and Abbott HIV-1 RealTime™ assay (Abbott Molecular, Wiesbaden, Germany) was performed using 125 specimens in Pune, India. A strong correlation was observed between the manual endpoint reverse transcriptase polymerase chain reaction assay and the recent real time polymerase chain reaction assay (r=0.989, p value<0.0001) and agreement was 94.4%. Results of the study indicate a higher sensitivity of the Abbott HIV-1 RealTime™ assay for HIV-1 Virology Quality Assurance copy controls as compared to the Standard Roche COBAS(®) Amplicor™ HIV-1 Monitor(®) Test, version 1.5. Furthermore, features of the Abbott m2000rt RealTime™ PCR assay platform such as higher analytical sensitivity, automated/manual extraction platforms for high/low sample throughputs and ability to quantify a variety of infectious agents (Hepatitis B virus, Hepatitis C virus, Human Papillomavirus and Neisseria gonorrhoeae/Chlamydia trachomatis) justify its suitability in resource-limited Indian settings. Besides, the study also highlights utility of the precise Virology Quality Assurance validation template in performance evaluation of various quantitative viral load assays.

Scoring satisfaction among patients, attending ART Centre of a medical college in North-West India

Patient satisfaction is a measurable concept comprising multidimensional elements such as access to care, quality of the provider patient interpersonal relationship and affordability of care. This further influences the decisions to seek care and outcomes of diseases. Although stigma and discrimination are potential barriers to effective implementation of the antiretroviral therapy (ART) programme, higher satisfaction levels of patients are also crucial for treatment adherence. A hospital-based cross-sectional study was conducted at the ART centre of IG Medical College, Shimla from November 2008 through May 2009. Three hundred and eighty four consecutive adult (≥18 years) patients attending the ART centre and on ART who consented to participate in the study were enrolled. Of the 384 patients, 209 (54.4%) were males. Majority were in the age bracket of 25-44 years. About 61.6% of the patients were satisfied to the services being provided. Mean Patient Satisfaction Questionnaire (PSQ) scores were the highest for technical quality of care and lowest for financial aspects. About 69.4% of the patients were satisfied towards their care provider. Although a majority of the patients were satisfied, several areas of patient care need improvement.

Causes of mortality among inpatients with systemic lupus erythematosus in a tertiary care hospital in North India over a 10-year period

INTRODUCTION

Systemic lupus erythematosus (SLE) is a systemic autoimmune disorder with significant morbidity and mortality. The present study was undertaken to identify the causes of in-hospital mortality of patients with SLE.

METHODS

This was a retrospective study. The hospital records of patients with SLE who died between 1998 and 2007 were reviewed. Demographic details, organ involvement, treatment received and evidence of infection were recorded. Disease activity was calculated using the SLE Disease Activity Index. The cause of death of each patient was determined and this information was classified into either deaths caused primarily due to SLE, deaths caused due to infection or those that were multi-factorial.

RESULTS

Seventeen patients with SLE who were diagnosed according to the revised American College of Rheumatology criteria died between 1998 and 2007. Fifteen of these patients were female and two were male. The median age was 25 years. The average duration of hospital stay was 10.29 days. Seven patients (41%) died of active SLE (three from pulmonary hemorrhage, two had renal failure, one had myocarditis and one had severe thrombocytopenia with upper gastrointestinal bleed), three patients (18%) died from infections (one contracted Staphylococcal septicemia, another contracted tuberculous meningitis and the third patient had Pseudomonas septicemia) and in seven patients (41%) the etiology was multi-factorial (these showed both active SLE and evidence of infection). In total 10 patients had evidence of infection, two of these were community-acquired and the rest were hospital-acquired.

CONCLUSION

Active SLE and/or infection are the major causes of death in hospitalised patients with SLE. To reduce patient mortality improvements in supportive care for patients with active SLE and measures to prevent hospital-acquired infections are required.

Caring for caregivers of people living with HIV in the family: a response to the HIV pandemic from two urban slum communities in Pune, India

INTRODUCTION

In low resource settings, the vast majority of 'Person/people Living with HIV' (PLHIV/s) and inadequate healthcare delivery systems to meet their treatment and care needs, caregivers play a vital role. Home based caregivers are often unrecognized with limited AIDS policies and programs focusing on them. We explored the perceptions and norms regarding care being provided by family caregivers of PLHIVs in India.

METHODOLOGY

A community based qualitative study to understand the issues pertaining to home based care for PLHIV was conducted in urban settings of Pune city, in Maharashtra, India. Eight Focus Group Discussions (FGDs) among men, women and peer educators were carried out. A total of 44 in-depth Interviews (IDIs) with PLHIVs (20) and their caregivers (24), were conducted using separate guides respectively. Data was analyzed thematically.

RESULTS

Home based care was perceived as economically viable option available for PLHIVs. 'Care' comprised of emotional, adherence, nursing and financial support to PLHIV. Home based care was preferred over hospital based care as it ensured confidentiality and patient care without hampering routine work at home. Women emerged as more vital primary caregivers compared to men. Home based care for men was almost unconditional while women had no such support. The natal family of women also abandoned. Their marital families seemed to provide support. Caregivers voiced the need for respite care and training.

DISCUSSION

Gender related stigma and discrimination existed irrespective of women being the primary family caregivers. The support from marital families indicates a need to explore care and support issues at natal and marital homes of the women living with HIV respectively. Home based care training and respite care for the caregivers is recommended. Gender sensitive interventions addressing gender inequity and HIV related stigma should be modeled while designing interventions for PLHIVs and their family caregivers.

Enhancing HIV medication adherence in India

BACKGROUND

This pilot study evaluated an intervention designed to enhance adherence among those new to antiretroviral therapy.

METHODS

Participants (n = 80) were recruited from a hospital clinic in Chandigarh, India, and randomized to a 3-month group intervention or individual enhanced standard of care followed by crossover of condition and assessed over 6 months. Adherence was measured by prescription refill, pill count, and self-report.

RESULTS

At baseline, 56% of group condition (immediate intervention) and 54% of individual condition (delayed intervention) participants were nonadherent by pill count and 23% of group and 26% of individual condition participants self-reported skipping medication at least once over the last 3 months. From the postintervention to long-term follow-up, adherence in the group condition (immediate intervention) improved in comparison with adherence in the individual condition (delayed intervention; χ(2) = 5.67, P = .02).

CONCLUSIONS

Results support the use of interventions early in treatment to provide information and social support to establish long-term healthy adherence behaviors.