Complementary and alternative medicine use decreases adherence to HAART in HIV-positive women

The use of complementary and alternative medicine (CAM) to treat chronic illnesses, especially HIV, is becoming increasingly widespread. Given this popularity, it is critical to understand how HIV-positive individuals use CAM and, more specifically, whether CAM use impacts their adherence to prescribed antiretroviral regimens (HAART). The present study examined the relationship between CAM use and HAART adherence among HIV+ women. Data were analysed from 366 HIV-positive, mostly African-American women, aged 18-50 years in Alabama and Georgia who were enrolled in an intervention to reduce high-risk sexual behaviour. At enrollment data were collected describing use of CAM and HAART use. Women were classified as CAM users if they reported taking herbal/natural immunity boosters (Chinese herbs, mushrooms, garlic, ginseng or algae) or multivitamins, or reported using religious/psychic health or bodywork to treat HIV. Women were classified as non-adherent if they reported missing any doses of their HAART medication in the 30 days preceding baseline assessment. Logistic regressions models, adjusted for potential confounders, were used to investigate the relationship between CAM use and HAART adherence. Women using CAM (immunity boosters or vitamins), relative to non-CAM users, were 1.69 times more likely to report missing HAART doses in the last 30 days (CI: 1.02-2.80; P=.041) even after adjusting for age, education, race, religion and income. The findings provide preliminary evidence that patients using CAM may be doing so as an alternative to traditional medicine as opposed to complementing prescribed HARRT treatment regimens. The inconsistent use of HAART is problematic given its association with drug resistance. Therefore, health care providers and patients should have explicit dialogues about how to effectively integrate CAM practices into traditional treatment regimens so that the safety and health of HIV-positive patients is not compromised.     

Integration of motivational interviewing and cognitive behavioral therapy to improve HIV medication adherence and reduce substance use among HIV-positive men and women: results of a pilot project

Directly addressing HIV medication adherence and substance use together is ideal in light of the research on the complex connections between these two behaviors. This paper describes the development of a pilot program in which a combined motivational interviewing and cognitive behavioral therapy intervention was used to increase adherence to highly active antiretroviral therapy (HAART) and reduce substance use in HIV-infected adults. The main goals of the pilot study were (1) to confirm the ability to recruit HIV-positive substance users taking HAART; (2) to demonstrate the ability to retain participants over the course of an eight-session intervention; and (3) to examine changes in substance use and HAART adherence from pretreatment to posttreatment. Twelve HIV-positive adults with a substance use disorder participated in an 8-week intervention, which consisted of weekly individual sessions with a trained therapist. Results showed that despite the small sample size, there was a significant reduction in substance use from pretreatment to posttreatment. No statistically significant differences were found for changes in HIV medication adherence, but the trends suggest the potential for positive results with a larger sample. Retention for all eight sessions of the treatment was 73.3%. Eighty percent completed the 3-month follow-up assessment. Participants reported high therapeutic alliance reflecting comfort with their therapists and in the treatment. Overall, the pilot demonstrated feasibility and acceptability of the treatment. Furthermore, results suggest that this may, in fact, be an effective intervention to reduce substance use and improve HIV medication adherence.     

Reasons for ART non-adherence in the Deep South: adherence needs of a sample of HIV-positive patients in Mississippi

HIV prevalence in the American Deep South has reached crisis proportions and greater numbers of patients are enrolling in clinical care and beginning antiretroviral therapy (ART). In order to gain maximum benefit from ART, patients must sustain high levels of adherence to demanding regimens over extended periods of time. Many patients are unable to maintain high rates of adherence and may need assistance to do so, which may be based upon an understanding of barriers to adherence for a given population. The current study sought to gain understanding of barriers to adherence for a mixed urban/rural HIV-positive patient population in Mississippi and to determine whether barriers to adherence may be specific to gender, employment, depressive symptoms or educational attainment status. Seventy-two patients who missed a dose of ART medication over the last three days endorsed the top five reasons for missing a dose as: (1) not having the medication with them, (2) sleeping through the dose time, (3) running out of the medication, (4) being busy with other things and (5) other. Reported barriers were fairly consistent across different groups, although women and those classified as having moderate to severe depressive symptoms reported different patterns of adherence barriers. Results suggest that adherence interventions implemented in the Deep South must take into account specific barriers faced by individuals within this region, where stigma, gender disparities and limited resources are prevalent.     

The effect of adherence on the association between depressive symptoms and mortality among HIV-infected individuals first initiating HAART

OBJECTIVE: To determine the impact of depressive symptoms on mortality among HIV/AIDS patients first initiating HAART and the potential role of patient adherence as a confounder and effect modifier in this association. METHODS: The study comprised HIV-positive individuals who were first prescribed HAART between August 1996 and June 2002. Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale. Cox proportional hazards models were used to determine the association between depressive symptoms, adherence and all-cause mortality while controlling for several baseline confounding factors. RESULTS: A total of 563 participants met the study inclusion criteria. Of these subjects, 51% had depressive symptoms at baseline and 23% of participants were less than 95% adherent in the first year of follow-up. The overall all-cause mortality rate was 10%. Multivariate analysis showed that individuals with depressive symptoms and adherence < 95% were 5.90 times (95% confidence interval, 2.55-13.68) more likely to die than adherent patients with no depressive symptoms. The estimated median model-based survival probabilities stratified by adherence and depressive symptoms levels ranged from 81% (interquartile range, 72-89%) for depressive symptoms and adherence < 95% to 97% (interquartile range, 94-98%) for no depressive symptoms and adherence > or = 95%. CONCLUSION: The results indicate that both depressive symptoms and adherence were associated with shorter survival among individuals with HIV accessing HAART. Given the high prevalence of depressive symptoms in HIV-positive patients and a strong association with adherence, the findings support improvement in the diagnosis and treatment of depression as well as adherence in order to maximize the effectiveness of HAART.     

Adherence, side effects and efficacy of stavudine plus lamivudine plus nelfinavir in treatment-experienced HIV-infected patients

OBJECTIVES: To evaluate adherence, side effects and efficacy of a modality of highly active antiretroviral therapy (HAART) in HIV-infected patients. METHODS: In a cohort, prospective study, 65 previously treated patients received stavudine plus lamivudine plus nelfinavir. Fifty-three participants (81%) had a history of intravenous drug use. Patients were evaluated at 3-month intervals. The association of adherence with demographic variables, hepatitis C virus infection, number of stopped antiretroviral regimens, HIV RNA level, CD4 cell count, and adverse effects to drugs was assessed. RESULTS: After a median follow-up of 12 months, 30 participants (46%) showed adequate adherence in all visits. An association was observed between adherence and female sex: 18 of 47 men (38%) vs. 12 of 18 women (67%) presented adequate adherence in all visits (P=0. 0416). An association was also observed between adherence and low baseline HIV RNA level (P=0.0229). Discontinuation of treatment took place because of refusal to take medication in 11 participants (17%) and because of side effects in seven participants (11%). Undetectable HIV RNA level was achieved in 26 patients (40%) at 3 months and in lower percentages at months 6, 9 and 12. CONCLUSIONS: Overall adherence to the employed HAART regimen was poor. Female sex and low baseline HIV RNA were associated with better adherence. Refusal to take medications and side effects were the main reasons to stop therapy. At 3 months' follow-up, virological efficacy was achieved in 40% of patients.     

Adherence discourse among African-American women taking HAART

Low adherence is the single most important challenge to controlling HIV through the use of high acting anti-retrovirals (HAART). Non-adherence poses an immediate threat to individuals who develop resistant forms of the virus as well as a public health threat if those individuals pass on treatment-resistant forms of the virus. To understand the concerns and perceptions that promote or deter adherence to antiretroviral medication by HIV-positive African-American women, we conducted in-depth interviews with 15 African-American women taking HAART. We focused on the discourse and narratives women use in talking about their adherence practice. Discourse analysis was utilized to identify and explore the sources of influence used by these women in describing their adherence practice. Roughly a third of the sample fell into each of the three self-assessed adherence categories: always adherent, mostly adherent and somewhat adherent. Among the 'always adherent', 80% of the sources of influence cited supported adherence, while only 48% and 47% of the authoritative sources cited by women in the 'mostly' and 'somewhat' categories supported adherence. Each self-assessed adherence group was characterized by its own distinctive discourse style. Findings suggest that adherence to HAART among African-American HIV-positive women would be improved by identifying those influences undermining adherence. Focused study of the 'always adherent' types is recommended.     

The impact of illicit drug use and substance abuse treatment on adherence to HAART

High levels of adherence to highly active antiretroviral therapy (HAART) are essential for virologic suppression and longer survival in patients with HIV. We examined the effects of substance abuse treatment, current versus former substance use, and hazardous/binge drinking on adherence to HAART. During 2003, 659 HIV patients on HAART in primary care were interviewed. Adherence was defined as > or =95% adherence to all antiretroviral medications. Current substance users used illicit drugs and/or hazardous/binge drinking within the past six months, while former users had not used substances for at least six months. Logistic regression analyses of adherence to HAART included demographic, clinical and substance abuse variables. Sixty-seven percent of the sample reported 95% adherence or greater. However, current users (60%) were significantly less likely to be adherent than former (68%) or never users (77%). In multivariate analysis, former users in substance abuse treatment were as adherent to HAART as never users (Adjusted Odds Ratio (AOR)=0.82; p>0.5). In contrast, former users who had not received recent substance abuse treatment were significantly less adherent than never users (AOR=0.61; p=0.05). Current substance users were significantly less adherent than never users, regardless of substance abuse treatment (p<0.01). Substance abuse treatment interacts with current versus former drug use status to affect adherence to HAART. Substance abuse treatment may improve HAART adherence for former substance users.     

Adherence to antiretroviral therapy in pregnancy

Successful interventions to prevent congenital HIV require adherence to highly active antiretroviral therapy (HAART) in pregnancy from mothers and agreement with other interventions including mode of delivery and infant testing. We sought to audit adherence support offered antenatally, adherence with HAART, recommendations for delivery and infant testing in women receiving HIV care at our unit and delivering a child in 2004 and 2005. Of the 32 women identified, an adherence discussion was conducted when commencing therapy in 87% and subsequent visits in 77%. Five women were non-adherent with HAART, one disagreed with recommendations for delivery, and attendance at initial post-natal tests was documented in 61%. In general, the British HIV Association guidelines with regard to adherence are followed. Although numbers in this cohort are small, age, ethnicity and pre-pregnancy HIV diagnosis did not seem to affect adherence, but being therapy na?ve and poor adherence may predict non-attendance at infant follow-up.     

Utility of therapeutic drug monitoring in the management of HIV-infected pregnant women in receipt of lopinavir

The pharmacokinetics of antiretroviral drugs in pregnancy is poorly understood. We reviewed the use of therapeutic drug monitoring (TDM) in clinical settings to document plasma concentrations of lopinavir during pregnancy and investigated how clinicians acted upon TDM results. A retrospective review was carried out of all HIV-infected pregnant women taking boosted lopinavir-based highly active antiretroviral therapy (HAART) at five National Health Service (NHS) centres in the UK between May 2004 and March 2007. Seventy-three women in receipt of lopinavir were identified, of whom 89% had plasma lopinavir concentrations above the suggested minimum recommended for wild-type HIV. Initial TDM results prompted dosage change in 10% and assessment of adherence and/or pharmacist review in 11%. TDM was repeated in 29%. TDM can play an important role in the clinical management of HIV-positive pregnant women, allowing informed dose modification and an alternative measure of adherence.     

Highly active antiretroviral therapy associated with improved anemia among HIV-infected women

Anemia is common during human immunodeficiency virus (HIV) infection and is associated with increased mortality. We conducted a study to examine the impact of highly active antiretroviral therapy (HAART) on anemia in a multicenter cohort of HIV-positive women, the Human Immunodeficiency Virus Epidemiology Research (HER) Study. Among women receiving HAART (n = 188), non-HAART monotherapy or combination antiretroviral therapy (ART) (n = 111), or who had no reported treatment (n = 62), the prevalence of anemia (hemoglobin, <120 g/L) at baseline was 38.3, 36.9, and 43.6%, respectively (p = 0.58) and at 1-year follow-up was 26.1%, 36.9%, 45.2%, respectively (p = 0.01); mean hemoglobin at baseline was 125 +/- 16, 122 +/- 16, and 122 +/- 18 g/L, respectively (p = 0.29) and at 1-year follow-up was 128 +/- 14, 123 +/- 16, and 119 +/- 20 g/L, respectively (p < 0.0001). Adjusted linear regression models showed that HAART was associated with an increase of hemoglobin of 0.20 g/L per month (p = 0.007). After 1 year of treatment, HAART was associated with a 32% reduction in anemia among HIV-infected women (p = 0.01), whereas there was no significant change in the prevalence of anemia among those on non-HAART ART or those who had no reported treatment. HAART is associated with a large reduction in anemia among HIV-infected women.     

A Preliminary Randomized Controlled Trial of a Nurse-Delivered Medication Adherence Intervention Among HIV-Positive Outpatients Initiating Antiretroviral Therapy in Beijing,China

We evaluated a nurse-delivered adherence intervention in a preliminary randomized controlled trial among 70 HIV-positive outpatients initiating antiretroviral therapy (ART) in Beijing, China. In both arms, participants received a 30-min educational session, a pillbox, and a referral to a peer support group. In the enhanced arm, participants could choose an electronic reminder device, three sessions of counseling either alone or with a treatment adherence partner, or both reminder and counseling. Survey assessments and blood draws occurred at baseline, post-intervention (13 weeks), and follow-up (25 weeks). Primary outcomes were 7-day and 30-day adherence assessed by self-report and electronic drug monitoring (EDM), and secondary outcomes were HIV-1 RNA viral load and CD4 count. The intervention was feasible and well received. It led to some improvement in self-reported and EDM-assessed adherence but not the biological outcomes. Providing counseling and facilitating the use of electronic reminders to patients initiating ART merits further investigation as a culturally viable means of promoting adherence in China.     

An investigation of why eligible patients do not receive HAART

Treatment with highly active antiretroviral therapy (HAART) decreases morbidity and mortality for persons with human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) and reduces costs of care. Yet many patients for whom HAART is indicated do not receive it. This study investigated the reasons why certain patients of a community health center with HIV/AIDS did not receive HAART between 1997 and 1998. Medical record reviews were performed to determine which patients for whom HAART was indicated (according to United States Public Health Service guidelines) were not prescribed HAART. Chart reviews and patient interviews were conducted to determine why they did not receive HAART. Of the 88 patients eligible for HAART, 60 (69%) had it prescribed in 1997-1998. Of the remaining 28 patients, 3 did not receive HAART because their provider never discussed it with them. For 6 patients (21%), the provider discussed HAART but did not recommend it; 16 patients (57%) declined HAART although their provider recommended it, and 3 (11%) accepted their provider's recommendation but never started HAART. Patients' most common reasons for refusing HAART were not being ready for strict adherence to a complex regimen (7/16) and fear of side effects (6/16). Other reasons included active drug use, religious beliefs, homelessness, confidentiality concerns, depression, and feeling well without HAART. Providers did not recommend HAART because of active drug use (4/6), lack of engagement with care (2/6) as well as homelessness, depression, and the perception that the patient was doing well without HAART. Providers should be trained to offer all patients the opportunity to develop a plan to address barriers to adherence and the support needed to implement it. Resources should also target the treatment of substance abuse and mental illness to improve the usage of HAART.     

Acceptance-based behavior therapy to promote HIV medication adherence

A significant number of adults with HIV in the USA do not maintain adherence to highly active antiretroviral therapy (HAART) at adequate levels. Although traditional cognitive behavioral interventions have shown promise in promoting HAART adherence, acceptance-based behavior therapy (ABBT) may be particularly useful in this population. ABBT has the potential to overcome common avoidance-based barriers associated with poor adherence, including denial of various illness-related factors and avoidance of stigmatization. We describe the rationale for promoting psychological and behavioral acceptance in HIV-positive populations; outline an ABBT to promote HAART adherence targeting primary care patients from urban, minority, low socioeconomic backgrounds; and report preliminary qualitative observations of treatment feasibility and acceptability.     

Antiretroviral medication adherence and persistence with respect to adherence tool usage

Adherence to complex drug regimens over an extended period is a key factor in reaping the health benefits of highly active antiretroviral therapy (HAART). Forgetting a dose is the most commonly stated reason for suboptimal adherence, indicating a potential benefit of reminder devices. We examined antiretroviral drug adherence and duration of therapy with respect to adherence tool usage. Adherence was monitored for 12 months in a cohort of patients, using pharmacy refill data. Seventy-eight subjects were administered a questionnaire with regard to tool use at least once at 6 and/or 12 months; patients who replied to the questionnaire were eligible for this study. Persistence of remaining on therapy was obtained from the subjects, charts. The tools included individualized schedules, dosettes and electronic reminder devices, which were offered free of charge to all patients. Of the 64 subjects who entered this study, 60.9% (n = 39) used at least one adherence tool. The median adherence in those using tools was 95%; three quarters showed greater than 91% adherence. Adherence rates with respect to individual tools did not differ significantly for schedules and dosettes, with medians of 95% (n = 31) and 94% (n = 13), respectively. Median adherence with electronic reminders was 76% (n = 5). Seventy-four percent of patients remained on therapy after 12 months of study. Taking into consideration previous antiretroviral treatment, actual persistence at 12 months was 87%. Employing and individualizing strategies, including adherence tools, to enhance patient adherence to complex regimens in addition to counseling and follow-up, has resulted in good adherence rates and persistence.     

Differential gender effects of depression on use of HIV medications among HIV-positive Puerto Rican drug users

Many barriers to the use of HIV medications have been identified. Research findings have also shown a gender disparity in HIV care behaviors. However, interaction effects of gender with the potential barriers to use of HIV medications among HIV-positive minority drug users remain under-studied. This study examined interaction effects of gender with potential moderating factors (i.e., individual and network characteristics) on the use of HIV medications. Analyses were based on 260 HIV-positive Puerto Rican heroin and cocaine users, recruited in New York (N=178) and Puerto Rico (N=82) in 1998-2003. HIV status was assessed using OraSure, and heroin or cocaine use was verified by urinalysis. All participants were tested and interviewed at baseline and six-month follow-up (183 males; 77 females). In predicting use of HIV medications at follow-up (HIVMEDF), use of HIV medications at baseline (HIVMED), individual characteristics (e.g., depression), network characteristics (e.g., having an intravenous drug user [IDU] sex partner), recruitment site, and interaction effects of these variables with gender, were examined in multiple logistic regression analysis. Use of HIV medications was low (29% at baseline; 40% at follow-up). HIVMED, recruitment site, gender, and depression had significant main effects on HIVMEDF. Depression also had a significant interaction effect with gender on HIVMEDF. Unlike men, women with depression were less likely than women without depression to use the medications. The findings indicate that gender-specific issues should be addressed by treatment programs for HIV-positive drug users, with particular efforts needed to enhance use of medications for depressed women.     

Adherence to antiretroviral therapy for human immunodeficiency virus/acquired immune deficiency syndrome among drug users: a systematic review

AIMS: Adherence to highly active antiretroviral therapy (HAART) is a key predictor of survival for human immunodeficiency virus (HIV)-infected people. Suboptimal adherence among marginalized populations such as HIV-positive drug users could be associated with clinical failure and the emergence of viral resistance. OBJECTIVE: To conduct a systematic review of studies assessing adherence to HAART among HIV-positive drug users (DU) and identify factors associated with non-adherence to HIV treatment. DATA SOURCES: Seven electronic databases were searched for peer-reviewed papers published in English, French, Spanish or Portuguese, from 1996 to 2007. STUDY SELECTION AND DATA ABSTRACTION: Studies were excluded if they presented only qualitative data, were reviews themselves or assessed other populations without disaggregating data on DU. Findings on adherence were extracted and summarized. DATA SYNTHESIS: Forty-one studies were considered, which studied a total of 15 194 patients, the majority of whom were HIV-positive DU (n = 11 628, 76.5%). Twenty-two studies assessed adherence using patient self-reports, eight used pharmacy records, three used electronic monitoring [i.e. Medication Event Monitoring Systems (MEMS) caps], six studies used a combination of patient self-report, clinical data and MEMS-caps, and two analyzed secondary data. Overall, active substance use was associated with poor adherence, as well as depression and low social support. Higher adherence was found in patents receiving care in structured settings (e.g. directly observed therapy) and/or drug addiction treatment (especially substitution therapy). CONCLUSION: While lower than other populations-especially among users of stimulants, incarcerated DU and patients with psychiatric comorbidities-adherence to HAART among HIV-positive DU can be achieved. Better adherence was identified among those engaged in comprehensive services providing HIV and addiction treatment with psychosocial support.     

Antiretroviral adherence and treatment outcomes among adult Ethiopian patients

Developing appropriate strategies to sustain optimal medication adherence among the increasing number of HIV-positive patients taking antiretroviral therapy (ART) in sub-Saharan Africa is a major challenge. The objective of this study was to determine patient, regimen, disease, patient-provider, and healthcare-related factors associated with adherence with ART over a one-year period, and assess the impact of adherence on treatment outcomes. We performed a prospective, observational study among 246 patients who were initiated on ART in Ethiopia. Of 172 who completed follow-up, 130 (75.6%) had ≥95% adherence. In the multivariate analyses, a higher baseline BMI (OR, 1.2; 95% CI 1.0, 1.4) and use of reminder devices (OR, 9.1; 95% CI 2.0, 41.6) remained positively associated with adherence, while a higher HIV symptom and adverse drug reaction distress score was an independent negative predictor of adherence (OR, 0.90; 95% CI 0.9, 1.0) CD4 count increase was significantly higher in the adherent patients compared to non-adherent patients at 12 months (159 cells/µL [interquartile range (IQR), 72–324 cells/µL] vs. 132 cells/µL [IQR, 43–190 cells/µL]; p?=?0.026). Our findings indicate that interventions aimed at improving adherence and thereby treatment outcomes in patients initiated on ART should promote the use of reminder devices, and monitor HIV symptoms and adverse reaction distress and nutritional status.     

Uptake and adherence to highly active antiretroviral therapy among HIV-infected people with alcohol and other substance use problems: the impact of substance abuse treatment

Aim We examined the association of substance abuse treatment with uptake, adherence and virological response to highly active antiretroviral therapy (HAART) among HIV‐infected people with a history of alcohol problems. Design Prospective cohort study. Methods A standardized questionnaire was administered to 349 HIV‐infected participants with a history of alcohol problems regarding demographics, substance use, use of substance abuse treatment and uptake of and adherence to HAART. These subjects were followed every 6 months for up to seven occasions. We defined substance abuse treatment services as any of the following in the past 6 months: 12 weeks in a half‐way house or residential facility; 12 visits to a substance abuse counselor or mental health professional; or participation in any methadone maintenance program. Our outcome variables were uptake of antiretroviral therapy, 30‐day self‐reported adherence and HIV viral load suppression. Findings At baseline, 59% (205/349) of subjects were receiving HAART. Engagement in substance abuse treatment was independently associated with receiving antiretroviral therapy (adjusted OR; 95% CI: 1.70; 1.03–2.83). Substance abuse treatment was not associated with 30‐day adherence or HIV viral load suppression. More depressive symptoms (0.48; 0.32–0.78) and use of drugs or alcohol in the previous 30 days (0.17; 0.11–0.28) were associated with worse 30‐day adherence. HIV viral load suppression was positively associated with higher doses of antiretroviral medication (1.29; 1.15–1.45) and older age (1.04; 1.00–1.07) and negatively associated with use of drugs or alcohol in the previous 30 days (0.51; 0.33–0.78). Conclusion Substance abuse treatment was associated with receipt of HAART; however, it was not associated with adherence or HIV viral load suppression. Substance abuse treatment programs may provide an opportunity for HIV‐infected people with alcohol or drug problems to openly address issues of HIV care including enhancing adherence to HAART.     

Role of the HIV/AIDS case manager: analysis of a case management adherence training and coordination program in North Carolina

Highly active antiretroviral therapy (HAART) adherence rates of 90%-95% or more are required to be effective at treating the virus and preventing drug resistance. From both a medical and public health perspective, it is essential that HIV-positive clients strictly adhere to antiretroviral treatment regimens. One promising approach to promoting optimal adherence rates among HIV-positive individuals is training and reimbursing case managers to provide adherence coordination services to HIV-positive clients. In this study, a sample of 16 HIV/ AIDS case managers from agencies across North Carolina participated in a Case Management Adherence Training and Coordination Program for a 3-month period. After case manager training, case managers enrolled 1-4 of their existing clients, who met eligibility criteria, to receive the adherence coordination program. Data were analyzed from focus group interviews and individual interviews conducted with case manager participants; their respective client care plans were also analyzed to identify primary barriers and strategies reported by case managers. Although case managers perceived themselves to be well positioned to provide adherence coordination services for their HIV-positive clients, they also identified barriers that they face in providing these services, including lack of reimbursement for their time, inadequate training, and insufficient knowledge of HIV/AIDS and medications. The findings of this study suggest that, with appropriate training and reimbursement, HIV/AIDS case managers can play a pivotal role in promoting and improving client adherence to antiretroviral medications.