Testing a nurse-tailored HIV medication adherence intervention

BACKGROUND: The relationship between patient adherence and treatment outcomes has been documented across chronic health conditions, but the evidence base for effective adherence interventions in human immunodeficiency virus (HIV) and acquired immune deficiency syndrome (AIDS) requires more rigorous research and reporting. OBJECTIVES: The aims of this study were to determine whether a tailored, nurse-delivered adherence intervention program--Client Adherence Profiling and Intervention Tailoring (CAP-IT)--improved adherence to HIV medications, compared with standard care, and to identify the relationship among adherence measures. METHODS: A randomized controlled trial (RCT) with repeated measures was used to test the efficacy of CAP-IT over a 6-month period. A convenience sample of 240 participants was recruited from a freestanding public HIV/AIDS clinic in Houston, TX, that provides medical, psychological, and pharmaceutical services for over 5,000 clients. Study instruments and measures included demographics; chart audit to capture CD4 count, viral load, and prescribed medications; health literacy; and five measures of adherence (AIDS Clinical Trial Group-Revised Reasons for Missing Medications, Morisky Self-Report of Medication Non-Adherence, Pill Count, Medication Event Monitoring System [MEMS] caps, and Pharmacy Refill). RESULTS: A logistic regression using generalized estimating equations method showed no significant differences over time on the five medication-adherence measures between the experimental and control groups. Little correlation was documented among the five different adherence measures, and there was minimal correlation with clinical markers. DISCUSSION: It is unclear why the tailored adherence intervention was not efficacious in improving medication adherence. The findings suggest that these measures of medication adherence did not perform as expected and that, perhaps, they are not adequate measures of adherence. Effective and efficient adherence interventions are needed to address the barriers to medication adherence in HIV/AIDS.     

Using motivational interviewing to promote adherence to antiretroviral medications: a pilot study.

This report describes a pilot study of a nursing intervention to increase adherence to combination therapy. The intervention was based on motivational interviewing (MI). Participants completed a baseline assessment using the computer-administered self-interview with audio (ACASI) data collection method and then were randomly assigned to the MI intervention or control condition. Nurse counselors met with participants in the MI intervention group for three adherence sessions. Two months following baseline, participants completed a follow-up assessment. Mean scores on ratings of missed medications were lower for participants in the intervention group than those in the control group. Although there were no significant differences in the number of medications missed during the past 4 days, participants in the MI group reported being more likely to follow the medication regimen as prescribed by their health care provider. The pilot study provided useful information about the acceptability of ACASI and the adequacy of intervention procedures. The results of this pilot study show promise for the use of MI as an intervention to promote adherence to antiretroviral medications.     

Sleep disturbance and depression as barriers to adherence

This study examined the relationships among subjective sleep disturbance, depressive symptoms, and adherence to medications among HIV-infected women. HIV-infected women (N = 173) were recruited through community AIDS service organizations throughout South Carolina. Participants completed the Pittsburgh Sleep Quality Index (PSQI), the Centers for Epidemiological Studies Depression Scale (CES-D), and a modified version of the Adults AIDS Clinical Trials Group Adherence Baseline Questionnaire. Women who reported greater sleep disturbance also reported a higher level of depressive symptoms and reported poor adherence to their medication regimen. Depression helped to explain the relationship between sleep quality and adherence. Results indicate that assessment and management of sleep disturbance and depressive symptoms in women with HIV disease is important to promote medication adherence.     

A randomized controlled trial to enhance antiretroviral therapy adherence in patients with a history of alcohol problems

OBJECTIVE: To assess the effectiveness of an individualized multicomponent intervention to promote adherence to antiretroviral therapy (ART) in a cohort of HIV-infected individuals with a history of alcohol problems. DESIGN: We conducted a randomized controlled trial to compare the usual medical follow-up with an adherence intervention. SETTING: The principal enrolment site was Boston Medical Center, a private, not-for-profit, academic medical institution. SUBJECTS: HIV-infected patients with a history of alcohol problems on ART. A total of 151 were enrolled and 141 (93%) were assessed at follow-up. Intervention: A nurse, trained in motivational interviewing, completed the following over 3 months in four encounters: addressed alcohol problems; provided a watch with a programmable timer to facilitate pill taking; enhanced perception of treatment efficacy; and delivered individually tailored assistance to facilitate medication use. MAIN OUTCOME MEASURES: Prior 30-day adherence > or =95%, prior 3-day adherence of 100%, CD4 cell count, HIV RNA and alcohol consumption, each at both short- and long-term follow-up. RESULTS: At follow-up, no significant differences in medication adherence, CD4 cell count, HIV RNA or alcohol consumption were found (all P values >0.25). CONCLUSIONS: A multicomponent intervention to enhance adherence among HIV-infected individuals with a history of alcohol problems was not associated with changes in medication adherence, alcohol consumption or markers of HIV disease progression. The failure to change adherence in a group at high risk for poor adherence, despite utilizing an intensive individual-focused patient intervention, supports the idea of addressing medication adherence with supervised medication delivery or markedly simplified dosing regimens.     

Factors affecting medication adherence in hypertensive patients

BACKGROUND: Adherence to medication is a critical factor in the continued health and well-being of patients with hypertension. Patients' acceptance of medical advice and information may be influenced by their subjective beliefs about their health condition; therefore, it is essential that their beliefs be taken into account when giving health advice or medical treatment. OBJECTIVE: To determine whether a relationship exists between illness attribution, perceived control, and adherence to antihypertensive medications. METHODS: A prospective, cross-sectional survey of hypertensive patients was conducted at the University of Michigan Medical Centers, Hypertension Clinic, Ann Arbor, MI. One hundred two patients with a goal to reduce their blood pressure were included in the study. Written and follow-up telephone survey questions assessing patients' illness attributions, perceived control, and medication adherence were administered. Associations between these variables were analyzed using correlation analyses. RESULTS: The majority of patients (67.7%) were adherent with their hypertensive medications. Patients indicated that modifiable variables were the most common attribution believed to cause hypertension; however, there was no significant relationship to medication adherence. A significant inverse relationship was found between perceived control over hypertension and medication adherence (p < 0.01). CONCLUSIONS: The findings suggest that patients' greater perception of control over trying to reduce blood pressure may result in decreased reliance on medications and subsequent nonadherence to drug therapy. Implications of these findings on pharmacy practice are discussed.     

Stages of change for adherence with medication regimens for chronic disease: development and validation of a measure

BACKGROUND: The stages-of-change (SOC) model has been used to explain and predict how behavior change occurs, but it is new as an approach to understanding why patients fail to take their medications as prescribed. OBJECTIVE: This study validated a 2-item measure of SOC for adherence with medication regimens in 2 groups of patients prescribed pharmacologic therapy for chronic conditions. METHODS: Two cross-sectional studies of attitudes toward medication adherence included the same measure of SOC for medication adherence. One was a sample of 161 HIV-positive patients in the United States, and the other was an international sample of 731 patients with hypertension. The validity of the measure of SOC for medication adherence was examined in both convenience samples using previously validated self-reported measures of adherence (the Medication Adherence Scale and a measure of adherence from the Medical Outcomes Study), and in the HIV sample using electronic monitoring of adherence behavior in 85 patients. RESULTS: Construct validity was demonstrated in both samples by associations between SOC and the previously validated measures of adherence (P < 0.001), and predictive validity was supported by significant associations between SOC for medication adherence and electronically monitored medication-taking behavior during the next 30 days (P < 0.03). CONCLUSIONS: Behavior-change theory suggests that stage-tailored communication strategies are more effective than uniform health-promotion messages. Our results provide a foundation for the development of interventions for medication adherence that are tailored to patients' readiness for change. Our validated 2-item measure of SOC for medication adherence can be used to match communication strategies to individual motivation and readiness for adherence with chronic disease medication regimens.     

Mediating roles of medication-taking self-efficacy and depressive symptoms on self-reported medication adherence in persons with HIV: a questionnaire survey

BACKGROUND: To date, only a few studies have examined the mediating role of self-efficacy on the relationship between depressive symptoms or perceived social support and medication adherence in persons with HIV. OBJECTIVES: The purpose of this study was to examine the impact of perceived social support, depressive symptoms and medication-taking self-efficacy on self-reported medication adherence in persons with HIV. A proposed comprehensive model included three mediation hypotheses in order to examine the mediating roles of medication-taking self-efficacy and depressive symptoms. METHOD: Baseline data from "Adherence to Protease Inhibitors" were used. The 215 persons with HIV aged 19-61 (mean=40.7, S.D.=7.58) were recruited from multiple sites in Pittsburgh, PA (USA) and through self-referral. The participants were assessed using the Beck Depression Inventory, Interpersonal Support Evaluation List, the Medication Taking Self-Efficacy Scale, and the modified Morisky Self-report Medication Taking Scale. Structural equation modeling (EQS version 6.1) was used. The Satorra-Bentler Scaled chi(2) test statistics (S-B chi(2)), Comparative Fit Index (CFI), and the Standardized Root Mean Squared Residual (SRMR) were used to assess the fit of a comprehensive model including three mediation hypotheses. RESULTS: A comprehensive model with the three hypotheses showed a good model fit (S-B chi(2) (24, N=215)=69.06, p<.001; CFI=.95; SRMR=.057). Medication adherence self-efficacy fully mediated the prediction of self-reported medication adherence by perceived social support and depressive symptoms. Depressive symptoms partially mediated the prediction of medication-taking self-efficacy by perceived social support. CONCLUSIONS: The findings of this study provide researchers with increased understanding of the mediating role of medication-taking self-efficacy beliefs between selected psychological variables and self-reported medication adherence in persons with HIV. Future studies need to test the moderating effect of gender, ethnicity and risk factors for HIV on this model and the intervention effect of self-efficacy beliefs using longitudinal data.     

A programme of symptom management for improving quality of life and drug adherence in AIDS/HIV patients

AIM: This paper reports an evaluation of the effect of symptom management programmed on drug adherence, CD4 count and virus load and the quality of life of patients with HIV/AIDS. BACKGROUND: Patients with HIV/AIDS have to face the long-term side effects caused by highly active antiretroviral therapy regimens. There has been little research to evaluate the influence of drug intervention side effects on self-care. METHODS: Sixty-seven patients with HIV/AIDS were randomly assigned to one-on-one teaching, group teaching, or control groups. All those in the one-on-one and group teaching groups attended a symptom management programme once a week, followed by 3 weeks of continuity and telephone counselling. Those in the control group were offered experimental intervention at the conclusion of data collection. The Customized Adherence Self-Report Questionnaire, CD4 count and virus load, and Quality of Life Index were used to evaluate the effectiveness of the symptom management programme before and at 3 months after the intervention. RESULTS: Median differences on the Customized Adherence Self-Report Questionnaire, CD4 count and virus load, and quality of life in both experimental groups were statistically significantly better than in the control group. CONCLUSIONS: The symptom management programme can increase self-care ability in managing medication side effects in patients with HIV/AIDS.     

Adherence to latent tuberculosis infection therapy among latino immigrants

BACKGROUND: One third of the world population is infected with Mycobacterium tuberculosis. In the United States, a key component for eliminating tuberculosis (TB) is treating latent TB infection (LTBI) in high-risk persons such as immigrants. OBJECTIVE: Examine the prevalence of adherence to LTBI therapy and the influence of basic conditioning factors on adherence among Latino immigrants, guided by Orem's Self-Care Deficit Theory. Adherence was treated as a health deviation self-care requisite; the self-care practice of taking daily medication for 9 months is essential to LTBI adherence. Conditioning factors include gender, age, sociocultural factors, environment, and health state. DESIGN: Exploratory, cross-sectional. SAMPLE: Nonprobability sample (n=53) of Latino immigrants attending an urban public health clinic in the Washington, DC metropolitan area. METHODS: Participants completed a brief questionnaire documenting selected conditioning factors, and 9-month adherence to LTBI therapy was determined from their medical records. RESULTS: Adherence dropped from 98% in month 2 to 72% at 9 months. The mean number of months adherent was 7.4. Adherence was not significantly associated with gender, country of origin, languages spoken, age, education, or years in the United States. Adherence was slightly lower (t=2.059, p=.059) in persons who knew someone with TB. CONCLUSIONS: Nurses should emphasize the importance of adherence for the full 9 months to this population.