Preventing Medication Nonadherence of Youth (13-24 Years) With HIV Initiating Antiretroviral Therapy

PURPOSE

The objective of this study was to evaluate the feasibility and acceptability of a dynamic, behavioral intervention to optimize medication adherence of adolescents and young adults (AYAs) with HIV newly initiating highly active antiretroviral therapy (HAART) and explore its efficacy on adherence and disease outcomes.

METHODS

The two-arm randomized controlled trial piloted a brief, individualized intervention designed for direct integration into standard clinical care. In total, 32 AYAs with a confirmed HIV diagnosis, reportedly horizontally acquired, and recommended to initiate HAART completed a two-week placebo trial before HAART initiation and were subsequently randomized to standard of care or the individualized intervention. Adherence and disease outcomes were measured over the first six months of HAART.

RESULTS

Results supported the primary study aim regarding feasibility (recruitment = 89%, attendance = 81%-100%, intervention exercise completion = 100%) and acceptability (average favorable response = 89%). Data also supported the positive effect of the intervention on select HAART adherence measures and disease outcomes. Adherence (by pharmacy refill) declined in both groups; however, adherence declined more slowly in the intervention group versus standard of care (p < .001). In addition, 100% of participants receiving the intervention obtained an undetectable viral load by 3 months and maintained an undetectable viral load at 6 months (vs. 68.8% standard of care).

CONCLUSIONS

This is one of the first interventions to target adherence for AYAs with HIV newly initiating HAART and designed for delivery in existing clinical care settings. Future research will help confirm efficacy and the potential utility of the intervention in promoting HAART adherence from medication initiation and preventing the decrease in adherence often observed over time.

The Role of Pharmacy Refill Measures in Assessing Adherence and Predicting HIV Disease Markers in Youth with Perinatally-Acquired HIV (PHIV)

Antiretroviral (ARV) adherence is critical in monitoring disease response in youth with perinatally-acquired HIV (PHIV). We used pharmacy refill (PR) information for PHIV youth from the PHACS Memory Sub-study to calculate medication availability over 2, 4, and 6 months. PR, a proxy of adherence, was compared with self-reported 7-day adherence in predicting suppressed viral load (SVL < 400 copies/mL) and higher CD4% (≥ 25%). Among 159 PHIV youth, 79% were adherent by 7-day recall, and 62, 55, and 48% by PR over 2, 4, and 6 months, respectively. Agreement between 7-day recall and PR adherence was weak (Kappa = 0.09-0.25). In adjusted logistic regression models, adherence showed associations with SVL for 7-day recall (OR 2.78, 95% CI 1.08, 7.15) and all PR coverage periods (6-month: OR 3.24, 95% CI 1.22, 8.65). Similar associations were observed with higher CD4%. PR measures were predictive of study retention. Findings suggest a possibly independent role of PR adherence measures.

Paediatric advance care planning survey: a cross-sectional examination of congruence and discordance between adolescents with HIV/AIDS and their families

OBJECTIVES

To identify patient-reported paediatric advance care planning (pACP) needs of adolescents living with HIV and to examine the congruence with their family's perception of their needs.

METHODS

A cross-sectional survey among six paediatric hospital-based outpatient HIV specialty clinics. Participants included 48 adolescent/family dyads (n=96 participants) within a larger study facilitating pACP. The main outcome measure was the Lyon Advance Care Planning Survey - Adolescent and Surrogate Versions-Revised.

RESULTS

Adolescents' mean age was 18 years (range ≥14-<21); 54% male; 92% African-American; 27% with prior AIDS diagnosis. If dying, 92% believed in completing an advance directive; 85% preferred to die at home;88% knowing how to say good bye; 71% being off machines that extend life and 77% dying a natural death. Best timing for end-of-life (EOL) decisions was while healthy (38%), when first diagnosed (17%), when first sick from a life-threatening illness (4%), when first hospitalised (8%), if dying (4%) and all of the above (19%). Prevalence-adjusted bias-adjusted Kappa (PABAK) measured congruence in pACP needs within adolescent/family dyads. There was substantial congruence in that being free from pain (PABAK=0.83), and understanding your treatment choices (PABAK=0.92) were very important or important. There was discordance about being off machines that extend life (PABAK=0.08) and when is the best time to bring up EOL decisions (PABAK=0.32).

CONCLUSIONS

Areas of discordance were associated with life-sustaining choices and when to have the EOL conversation. Targeted, adolescent/family-centred, evidence-based pACP interventions are needed to improve family understanding of youth's EOL wishes.

TRIAL REGISTRATION NUMBER

NCT01289444; Results.

A randomized clinical trial of adolescents with HIV/AIDS: pediatric advance care planning

The objective of this study is to determine if pediatric advance care planning (pACP) increases adolescent/family congruence in end-of-life (EOL) treatment preferences longitudinally. Adolescents aged 14-21 years with HIV/AIDS and their families were randomized (N = 105 dyads) to three-60-minute sessions scheduled one week apart: either the pACP intervention (survey administered independently, facilitated conversation with adolescent and family present, completion of legal advance directive document with adolescent and family present) or an active control (developmental history, safety tips, nutrition and exercise education). This longitudinal, single-blinded, multi-site, randomized controlled trial was conducted in six pediatric hospital-based HIV-clinics, located in high HIV mortality cities. The Statement of Treatment Preferences measured adolescent/family congruence in EOL treatment preferences at immediately following the facilitated pACP conversation (Session 2), and at 3-month post-intervention. The mean age of adolescent participants was 18 years (range 14-21 years); 54% were male; and 93% were African-American. One-third had an AIDS diagnosis. Immediately post-intervention the Prevalence Adjusted Bias Adjusted Kappa showed substantial treatment preference agreement for pACP dyads compared to controls (High burden/low chance of survival, PABAK = 0.688 vs. 0.335; Functional impairment, PABAK = 0.687 vs. PABAK= 0.34; Mental impairment, PABKA = 0.717 vs. 0.341). Agreement to limit treatments was greater among intervention dyads than controls (High burden: 14.6% vs. 0%; Functional impairment = 22.9% vs. 4.4%; and Mental impairment: 12.5% vs. 4.4%). Overall treatment preference agreement among pACP dyads was high immediately post-intervention, but decreased over time. In contrast, treatment agreement among control dyads was low and remained low over time. As goals of care change over time with real experiences, additional pACP conversations are needed.

Use of Placebo Pills Before Treatment Initiation in Youth with HIV: Are They Ready?

Highly active antiretroviral therapy (HAART) nonadherence is related to negative health outcomes and is well-documented in adolescents and young adults (AYAs) with behaviorally acquired HIV. Few studies describe methods to improve adherence in this population. This retrospective study describes placebo pill trial use (ie, pills with inert substance prescribed to practice taking HAART) in AYAs initiating HAART and its relation to disease outcomes. Sixty-two AYAs initiated HAART during the review period. Disease outcomes during the first year of standard clinical care were abstracted from medical records. In all, 72.6% of participants received ≥1 pill trial and 27.4% received ≥2 trials. Placebo trial use was not independently related to adherence post-HAART initiation. "Prescription" of a second trial was related to less optimal disease status over the first 6 months of treatment. Placebo trials have the potential to inform clinical care, aid in identifying AYAs at risk for nonadherence, and may provide a novel intervention strategy before/after HAART initiation.

Body Image and Risk Behaviors in Youth with HIV

Body image concerns are common among people living with HIV. Among adults with HIV, body image concerns have been shown to be related to risky sexual behaviors; little research has been conducted among youth living with HIV (YLWH). The current study examined the predictors, including body image, of sexual risk behaviors among YLWH. Adolescents from a single clinic (n = 143; age range, 16-24 years; 69% male; 95% African American) completed a computerized self-report survey to assess demographic, behavioral, and body image domains. Demographic and clinical data were abstracted from the medical record. Logistic regression analyses assessed associations between risk factors and risky sexual behaviors. Results indicated that YLWH who reported less favorable body image perceptions (p = 0.04) and more sexual partners (p = 0.05) were less likely to use condoms during their last sexual encounter. YLWH with six or more sexual partners were more likely to use drugs or alcohol during their last sexual encounter (p = 0.03). A belief that their HIV medications changed their body physically (p = 0.05), history of HIV-related complications (p = 0.03), an undetectable viral load at their most recent clinical laboratory draw (p = 0.01), and having a high school diploma or equivalent (p = 0.001) were independently associated with disclosure of participant's HIV status to a romantic/sexual partner. Findings suggest that body image perceptions may influence risky sexual behavior in YLWH. Further study is warranted to understand and intervene upon this relationship to improve individual and public health outcomes.

Acceptability of Family-Centered Advanced Care Planning for Adolescents With HIV

BACKGROUND AND OBJECTIVE

Small pilot studies support the appropriateness of engaging adolescents with chronic or life-limiting illnesses in pediatric advance care planning (pACP). We do not yet know if pACP is acceptable, feasible, and worthwhile, even if emotionally intense, in a fully powered randomized controlled trial.

METHODS

We conducted a prospective 2-arm randomized controlled trial at 6 US urban hospitals. Adolescent/family member dyads were randomized to receive the 1-session-a-week 3-session FAmily-CEntered Advance Care Planning (FACE) pACP intervention (1, ACP Survey; 2, Goals of Care Conversation/Treatment Preferences; 3, Completion of Advance Directive) or active comparator (1, Developmental History; 2, Safety Tips; 3, Nutrition/Exercise). The Satisfaction Questionnaire was administered to participants independently after each session by a blinded research assistant.

RESULTS

We enrolled 53% of eligible participants and intervened with 97 adolescent/family dyads. Adolescents ranged in age from 14 to 21 years; 54% were male individuals; 93% African American; and 73% perinatally infected. Attendance was 99% for all 3 sessions in each arm. At session 3, FACE adolescents and family dyad members, respectively, found the session useful (98%, 98%) and helpful (98%, 100%), despite feelings of sadness (25%, 17%). FACE adolescents' improvement in the total subscale A score (useful, helpful, like a load off my mind, satisfied, something I needed to do, courageous, worthwhile) was better than control adolescents at session 3 (β = 1.16, P = .02). There were no adverse events.

CONCLUSIONS

FACE enabled worthwhile conversations, while simultaneously eliciting intense emotions. No participants withdrew, 99% of those enrolled completed each session, and there were no adverse events, evidence of pACP's feasibility, acceptability, and safety.

Pediatric palliative care for youth with HIV/AIDS: systematic review of the literature

Improvement in treatment has led to decreased death in youth with human immunodeficiency virus (HIV) in developed countries. Despite this, youth with HIV are still at risk for increased mortality and morbidity compared with their uninfected counterparts. In developing countries, high numbers of youth die from acquired immune deficiency syndrome (AIDS)-related illnesses due to lack of access to consistent antiretroviral treatment. As a result, pediatric palliative care is a relevant topic for those providing care to youth with HIV. A systematic review was conducted to gather information regarding the status of the literature related to pediatric palliative care and medical decision-making for youth with HIV. The relevant literature published between January 2002 and June 2012 was identified through searches conducted using PubMed, CINAHL, Scopus, and PSYCInfo databases and a series of key words. Articles were reviewed by thematic analysis using the pillars of palliative care set out by the National Consensus Project. Twenty-one articles were retained after review and are summarized by theme. In general, few empirically based studies evaluating palliative care and medical decision-making in youth with HIV were identified. Articles identified focused primarily on physical aspects of care, with less attention paid to psychological, social, ethical, and cultural aspects of care. We recommend that future research focuses on broadening the evaluation of pediatric palliative care among youth with HIV by directly evaluating the psychological, social, ethical, and cultural aspects of care and investigating the needs of all involved stakeholders.

Who to report to the coroner? A survey of intensive care unit directors and Her Majesty's Coroners in England and Wales

We performed a postal survey to assess the ability of intensive care unit directors and Her Majesty's Coroners to recognise deaths that should be reported to the local coroner. The survey questionnaire consisted of 12 hypothetical case scenarios. Coroners were significantly better at identifying reportable deaths than intensive care unit directors (median correct recognition scores of 11 (interquartile range 9.25-11) vs. 8 (interquartile range 7-10), respectively, p < 0.01). Deaths associated with an accident, medical treatments, industrial disease, neglect and substance abuse were significantly under-reported by intensive care unit directors (p < 0.01). Results show that significant numbers of deaths on intensive care units in England and Wales may not be being referred for further investigation, and that wide variation in local coroners' practices exists. Improvements in postgraduate medicolegal education about deaths reportable to a coroner are required. National regulations need to be more detailed and standardised so that regional variation is eliminated.

Validating the Sedation-Agitation Scale with the Bispectral Index and Visual Analog Scale in adult ICU patients after cardiac surgery

OBJECTIVE

To validate the Sedation-Agitation Scale (SAS) with the Visual Analog Scale (VAS) and Bispectral Index (BIS) in adult ICU patients after cardiac surgery.

DESIGN

Prospective study comparing blinded evaluations of the SAS, VAS and BIS.

SETTING

Forty-two-bed multidisciplinary ICU.

PATIENTS AND PARTICIPANTS

Convenience sample of 39 adults after cardiac surgery.

MEASUREMENTS AND RESULTS

Bispectral Index 3.2 was continuously recorded using the Aspect A-1000 and evaluators were blinded to this value. The bedside nurse and a trained researcher independently rated wakefulness using a 100 mm VAS upon patient arrival on the ICU, at first awakening, when ventilator weaning was started and after extubation; the researcher also evaluated patients using SAS. Upon arrival on the ICU, the median SAS score was 2 (interquartile range = 1-3), the mean VAS was 26+/-30 and the mean BIS was 70+/-16. Twenty-four patients underwent a trial of weaning from mechanical ventilation with a SAS of 4 (IQR = 4), VAS of 86+/-12 and BIS of 87+/-10. SAS correlated well with VAS performed by one researcher (r = 0.91, p < 0.001) or by 19 different bedside nurses (r = 0.43, p < 0.001) and with BIS 3.2 (r = 0.60, p < 0.001). The correlation between SAS and BIS was reduced in patients with above average electromyogram (EMG) power. As a measure of construct validity, significant differences were noted for the BIS, SAS, VAS and EMG between ICU arrival and extubation (all p < 0.001).

CONCLUSIONS

Sedation-Agitation Scale and BIS are valid measures of wakefulness after cardiac surgery, but EMG interference may affect the accuracy of BIS for a small percentage of patients not receiving neuromuscular blockade.

The frequency and cost of patient-initiated device removal in the ICU

OBJECTIVE

To determine the frequency and pattern with which patients in the intensive care unit (ICU) remove medical devices on their own, and the costs associated with this problem.

DESIGN

Prospective observational study.

SETTING

Two 10-bed sections of a multidisciplinary ICU in a tertiary care teaching hospital.

PATIENTS

Adults admitted to the ICU for longer than 24 hours during October 1998.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Medical records were reviewed prospectively for the occurrence of patient-initiated device removal and the responses to those events by health care providers. Associated costs were estimated using hospital databases and Medicare physician reimbursement schedules. Annual cost estimates were calculated using 1997 admission statistics for 1211 adults in an ICU for more than 24 hours. Thirty-six patients were studied for 199 patient-days. Ten patients (28%) removed 42 devices: 88% of these events involved gastrointestinal tubes and vascular catheters. Significant agitation was documented within 2 hours before 74% of the events. Estimated cost associated with device removal was $7606, or $181/event. The estimated annual cost in this 42-bed ICU was more than $250,000.

CONCLUSIONS

Patients commonly remove medical devices on their own, and this represents significant consumption of health care resources.

Frequency, severity, and treatment of agitation in young versus elderly patients in the ICU

STUDY OBJECTIVE

To study the frequency, duration, severity, and treatment of agitation in patients in the intensive care unit (ICU) to determine if the elderly represent a distinct population.

DESIGN

Prospective cohort study

SETTING

Tertiary care, 10-bed, multidisciplinary ICU.

PATIENTS

All patients older than 18 years of age admitted for longer than 24 hours during a 4-month period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

One hundred thirty patients were studied for 916 patient-days; 63 (48%) were elderly (> 65 yrs). Nurses and physicians described agitated behavior in 92 patients (70.8%) during 534 (58.3%) patient-days, and it was severe or dangerous in 60 patients (46.1%) during 273 (30%) patient-days. There were no age-related differences in frequency, severity, and duration of agitation. Opiates, benzodiazepines, and haloperidol were administered during 72%, 62%, and 29% of agitated patient-days, respectively. Haloperidol was administered more often to elderly patients (p=0.015); otherwise no between-group differences were noted. Daily dosing requirements were less in the elderly for intermittent intravenous lorazepam, haloperidol, and morphine but not for midazolam (p=0.15). When these dosages were corrected for body mass, no statistical differences between young and old were found.

CONCLUSION

In the ICU, the elderly are not a distinct population for agitation.

Combined historical and electrocardiographic timing of acute anterior and inferior myocardial infarcts for prediction of reperfusion achievable size limitation

The historical time of acute symptom onset is not always an accurate indication of the timing of onset of an acute myocardial infarction (AMI). Consideration of electrocardiographic (ECG) timing parameters could supplement historical timing alone as a clinical guide for decisions regarding the use of reperfusion therapy. Three hundred ninety-five patients from 4 trials of thrombolytic therapy conducted in the northwestern United States and western Canada are included in the present study. A total of 316 patients received either streptokinase or tissue plasminogen activator, and 79 received no reperfusion therapy. Historical time of symptom onset was acquired by emergency or cardiology department personnel and recorded on patient report forms. An ECG method for estimating the timing of the AMI, the Anderson-Wilkins (AW) acuteness score, was calculated from the initial standard 12-lead recording by investigators blinded to the knowledge of symptom duration or any other study variables. Tomographic thallium-201 imaging 7 weeks after hospital admission was used to measure final AMI size. The ECG timing method achieved a relation with final AMI size similar to that previously reported for historical timing. The AW acuteness score proved most useful for anterior AMI location when there was a > or = 2 hour delay following symptom onset, but was most useful for the inferior AMI location when there was a < 2 hour delay. Despite a longer delay, patients with high AW acuteness scores had 50% lower final anterior AMI size than those with low scores; and despite a shorter delay, those with low ECG acuteness scores had 50% greater final inferior AMI size than those with high scores. The AW acuteness score combined with the historical estimation of symptom duration should provide a more accurate basis for predicting the potential for limitation of final AMI size than either method alone. These results could potentially provide the basis for developing a new method for noninvasive guidance of clinical decisions regarding administration of reperfusion therapy in the initial evaluation of patients with AMI.

Admission prediction of expected final myocardial infarct size using weighted ST-segment, Q wave, and T wave measurements

Formulas for predicting final acute myocardial infarction (MI) size from ST-segment deviation on an initial electrocardiogram were proposed by Aldrich et al. for anterior and inferior infarct locations. This study of 529 patients who did not receive thrombolytic therapy was performed to determine the effectiveness of the Aldrich formulas for predicting final QRS MI size; to propose new formulas for predicting final MI size using ST-segment deviation, Q wave, and T wave information in a development population of 322 patients; and to evaluate the new formulas in a randomly selected population of 207 patients. The Aldrich formulas achieved correlations with final infarct size of r = .40 for anterior and r = .43 for inferior MI locations in the present population which are weaker than those previously reported. Formulas that consider electrocardiographic parameters in addition to ST-segment deviation were proposed for both anterior and inferior final MI size. In the test set of 207 patients, these models explained 16.9% and 15.2% of the variation in final MI size for anterior and inferior locations respectively. They may prove useful in assessing the extent of myocardial salvage where interventions are to be tested.

T wave amplitudes in normal populations. Variation with ECG lead, sex, and age

Consideration of increased T wave amplitude (tall T waves), either alone or in association with other electrocardiographic (ECG) parameters, may be beneficial for the early detection of acute transmural ischemia, and quantification of the increase might be used in quantifying the ischemic area. The primary purpose of this study was to quantify normal T wave amplitude limits according to ECG lead, sex, and age. One thousand nine hundred thirty-five subjects in two normal populations were analyzed, and the 98th percentile of the positive T wave amplitude for each ECG lead (including -aVR) was considered the upper limit of normal. Normal T wave amplitude was two times greater in the precordial than in the limb leads, and it was approximately 25% greater in men than in women in all leads. There was approximately a 10% decrease in normal T wave amplitude between 18-39- and 40-59-year-old patients and a 15% decrease between 40-59- and 60-79-year-old patients. The upper limit of normal T wave amplitudes identified in this study confirm those developed by Lepeschkin for use as means for each lead when age and sex are not considered. These limits might be incorporated into both normograms and automated ECG analysis systems to determine the presence or absence of tall T waves in patients presenting with symptoms of acute transmural ischemia.

Comparison of continuous ST-segment recovery analysis with methods using static electrocardiograms for noninvasive patency assessment during acute myocardial infarction. Thrombolysis and Angioplasty in Myocardial Infarction (TAMI) 7 Study Group

Continuous ST-segment recovery analysis and 5 static methods using ST-segment comparison between a pre- and post-treatment electrocardiogram were compared for their ability to predict infarct-related artery patency in 82 patients with acute myocardial infarction who underwent angiography a median of 124 minutes after onset of thrombolytic treatment. Accuracy at the moment of angiography was 85% (95% confidence interval [CI] 77% to 93%) for the continuous method, and 68% (CI 57% to 78%), 78% (CI 69% to 87%), 83% (CI 74% to 91%), 82% (CI 73% to 90%), and 80% (CI 71% to 89%) for the static methods. At the moment of angiography the most accurate static method and the continuous method agreed in patency assessment in 90% of the patients (CI 84% to 97%). Agreement was reduced to 83% (CI 75% to 91%) of patients when a patency assessment was performed earlier at 90 minutes after treatment onset, and was only 77% (CI 68% to 86%), at 60 minutes. Early disagreement was mainly seen when the continuous ST recording showed ST recovery from a delayed peak ST elevation after the pretreatment static electrocardiogram or when dynamic ST changes suggesting cyclic reperfusion occurred. Continuous ST-segment recovery analysis appears to be as accurate as the most accurate static methods. Continuously updated reference points appear to give important additional information when ST recovery follows a delayed peak ST elevation or when re-elevation occurs, suggesting cyclic flow changes. Such findings appear to affect about half of patients with acute myocardial infarction treated with intravenous thrombolysis, particularly early after administration of therapy.