Adherence is not a barrier to successful antiretroviral therapy in South Africa

OBJECTIVE: To determine adherence of an indigent African HIV-infected cohort initiating antiretroviral therapy (ART); to identify predictors of incomplete adherence (< 95%) and virologic failure (> 400 HIV RNA copies/ml). DESIGN: Prospective monitoring of adherence in a poor HIV-positive cohort, attending a public sector hospital and receiving ART through phase III studies. METHODS: Adherence to ART was determined over 48 weeks by counting tablet-returns. Logistic regression models including age, WHO HIV stage, home language, socio-economic status, complexity and type of regimen were fitted to determine predictors of incomplete adherence and virologic failure at 48 weeks. RESULTS: 289 patients were recruited between January 1996 and May 2001. Median (mean) adherence of the cohort was 93.5% (87.2%). Three times daily dosing [risk ratio (RR), 3.07; 95% confidence interval (CI), 1.40-6.74], speaking English (RR, 0.41; 95% CI, 0.21-0.80) and age (RR, 0.97; 95% CI, 0.94-0.99) were independent predictors of incomplete adherence. Socio-economic status, sex and HIV stage did not predict adherence. Independent predictors of virologic failure included baseline viral load (RR, 2.57; 95% CI, 1.57-4.22) and three times daily dosing (RR, 2.64; 95% CI, 1.23-5.66), incomplete adherence (RR, 1.92; 95% CI, 1.10-3.57), age (RR, 0.96; 95% CI, 0.92-0.99) and dual nucleoside therapy (RR, 2.69; 95% CI, 1.17-6.15). CONCLUSION: The proportion of individuals achieving viral suppression matched results from the developing world. Speaking the same language as site staff and simplified dosing frequency were beneficial. Socio-economic status had no impact on adherence and should not be used as a limitation to ART access.     

Adherence to antiretroviral therapy in HIV-infected children in Italy

Adherence to antiretroviral therapy is a major problem in children with HIV infection, who depend on parents or foster parents for receiving drugs. During an ongoing investigation on intestinal function in children with symptomatic HIV infection who were treated with zidovudine, blood samples were obtained six hours after the administration of zidovudine as reported by the parents and, again, one and six hours after its administration in the hospital, and drug concentration was measured by radioimmunoassay. Both peak and steady state zidovudine levels were within the expected concentration ranges after administration in the hospital. In contrast, they were below the effective concentration in five of the 10 children that reportedly had received the drug at home by the parents. These data directly show poor compliance with antiretroviral therapy in children. Compliance with antiretroviral therapy should be carefully checked in children and strategies are needed to increase full and permanent adherence with antiretroviral therapy by people in charge to administer drugs to HIV-infected children.     

Adherence to highly active antiretroviral therapy in HIV-infected inmates

Adherence to highly active antiretroviral therapy (HAART) has been scarcely studied in correctional settings. Our study aims to evaluate the relationship between adherence and virological outcome and to determine factors related to adherence in correctional settings. A cross-sectional retrospective study was performed in Topas prison (Salamanca, Spain). 50 inmates starting HAART were studied. Adherence was estimated through a self-report questionnaire and variables related to adherence (covering individual factors, the illness itself and the therapeutic regimen) were recorded. HIV-RNA levels and CD4 lymphocyte count were measured before starting therapy and six months after. Statistical analysis was performed using univariate and multivariate methods. 21 inmates (42%) were considered adherent and 29 (58%) were non-adherent. Adherence to treatment, as measured by our questionnaire, was the only significant and independent factor associated with an undetectable viral load at six months of therapy. Five variables were significantly associated with adherence to treatment, four of them as predictor factors for good adherence: an active occupation inside prison, the absence of HIV-related symptoms, a good or average acceptance of treatment, and a higher academic background; previous injection drug use as a risk factor for HIV transmission was associated with non-adherence. A simple self-report questionnaire may be useful for assessing adherence in prison inmates. Recognizing variables associated with adherence is essential to identify prisoners at high risk of being non-adherents in order to develop strategies for improving compliance.     

Adherence with isoniazid for prevention of tuberculosis among HIV-infected adults in South Africa

Background  

Tuberculosis (TB) is the most common opportunistic infection in HIV-infected adults in developing countries. Isoniazid (INH) is recommended for treatment of latent TB infection, however non-adherence is common. The purpose of this study was to apply in-house prepared isoniazid (INH) urine test strips in a clinical setting, and identify predictors of positive test results in an adherence questionnaire in HIV-infected adults taking INH for prevention of TB.     

Factors affecting first-month adherence to antiretroviral therapy amongHIV-positive adults in South Africa

This study explores the influence of baseline factors on first-month adherence to highly active antiretroviral therapy (HAART) among adults. The study design involved a review of routinely collected patient information in the CAPRISA AIDS Treatment (CAT) programme, at a rural and an urban clinic in KwaZulu-Natal Province, South Africa. The records of 688 patients enrolled in the CAT programme between June 2004 and September 2006 were analysed. Adherence was calculated from pharmacy records (pill counts) and patients were considered adherent if they had taken at least 95% of their prescribed drugs. Logistic regression was used to analyse the data and account for confounding factors. During the first month of therapy, 79% of the patients were adherent to HAART. HAART adherence was negatively associated with a higher baseline CD4 count. Women had better adherence if they attended voluntarily testing and counselling or if they had taken an HIV test because they were unwell, while men had higher adherence if they were tested due to perceived risk of HIV infection. HAART adherence was positively associated with higher age among patients who possessed cell phones and among patients who provided a source of income in the urban setting, but not in the rural setting. Though long-term data from this cohort is required to fully evaluate the impact of non-adherence in the first month of treatment, this study identifies specific groups of patients at higher risk for whom adherence counselling should be targeted and tailored. For example, first-month HAART adherence can be improved by targeting patients initiated on treatment with a high CD4 count.     

HIV disclosure and other factors that impact on adherence to antiretroviral therapy: the case of Soweto,South Africa

Some authors argue that there are no predictors of adherence to medication, while others proffer indicators of likely adherence. These contextual factors are wide-ranging and may be interdependent. There are few studies of adherence in resource-poor settings. Of these, many were linked to particular trials whose conditions were highly controlled. For instance, the number of participants in the trial was small, the participants were strictly selected and they were offered much adherence support. These conditions will largely fall away with wider access to antiretroviral drugs (ARVs) such as South Africa is undertaking. Poor adherence remains one of the challenges to scaling-up access to ARVs, and, as such, the likely barriers to adherence need to be understood and countered. This study explores contextual factors — such as disclosure, preparation for treatment, treatment meaning and treatment acceptance — as aspects of lifestyle that can bear on adherence. Those who had disclosed were largely supported at household level, and after initial problems with adherence, participants adjusted and were able to include ARV treatment in their daily repertoire. Although the anticipation of stigma remains an obstacle to wide disclosure, antiretroviral therapy offers new hope and has the potential to impact on stigma.     

Adherence to antiretroviral therapy among HIV-infected prison inmates (Spain)

This cross-sectional study was carried out in two Spanish prisons. A group of 177 HIV-infected prison inmates were interviewed. Standardized personal interviews using a structured questionnaire were conducted to assess sociodemographic features and prison setting characteristics, clinical variables, social support and drug consumption. A simplified four-item questionnaire for self-reported adherence was used. A total of 24.3% were non-adherent. Predictors of non-adherence in the multivariate analysis included poor or lack of ability to follow the prescribed treatment regimen, no visits in a month, anxious and/or depressed mood, difficulty in taking medication, receiving methadone treatment, cannabis consumption and robbery as the reason for imprisonment. Adherence to antiretroviral therapy was higher than in the wider community. However, other variables related to the correctional setting, such as assignments within the facility, adaptability of the prison system to authorize the cell being opened in the event of missed medication, or legal situation had no effect on adherence for inmates with HIV disease.     

Treatment outcomes in HIV-infected adolescents attending a community-based antiretroviral therapy clinic in South Africa

Background  

Very few data are available on treatment outcomes of adolescents living with HIV infection (whether perinatally acquired or sexually acquired) in sub-Saharan Africa. The present study therefore compared the treatment outcomes in adolescents with those of young adults at a public sector community-based ART programme in Cape Town, South Africa.     

Adherence to antiretroviral therapy,stigma and behavioral risk factors in HIV-infected adolescents in Asia

We studied behavioral risks among HIV-infected and uninfected adolescents using an audio computer-assisted self-interview. A prospective cohort study was initiated between 2013 and 2014 in Malaysia, Thailand, and Vietnam. HIV-infected adolescents were matched to uninfected adolescents (4:1) by sex and age group (12–14 and 15–18 years). We enrolled 250 HIV-infected (48% male; median age 14.5 years; 93% perinatally infected) and 59 uninfected (51% male; median age 14.1 years) adolescents. At enrollment, HIV-infected adolescents were on antiretroviral therapy (ART) for a median (IQR) of 7.5 (4.7–10.2) years, and 14% had HIV-RNA >1000?copies/mL; 19% reported adherence <80%. Eighty-four (34%) HIV-infected and 26 (44%) uninfected adolescents reported having ever smoked cigarettes or drunk alcohol (p?=?0.13); 10% of HIV-infected and 17% of uninfected adolescents reported having initiated sexual activity; 6 of the HIV-infected adolescents had HIV-RNA >1000?copies/mL. Risk behaviors were common among adolescents, with few differences between those with and without HIV.     

Adherence, sexual risk, and viral load in HIV-infected women prescribed antiretroviral therapy

Abstract The purpose of this study was to determine if there was a connection between adherence to antiretroviral therapy (ART) and use of risk reduction behaviors (RRB) in HIV-infected women who were prescribed antiretroviral therapy. The sample consisted of 193 predominately African American women with an average age of 44 who had been on ARV for approximately 9 years and had low annual incomes. All women were participating in a behavioral clinical trial focused on these dual outcomes. Using a risk index developed for this study, we examined the relationship of a composite of risk behaviors to electronically measured and self-reported adherence over the approximately 13-month study period. Women were categorized based on levels of adherence and risky behaviors, and we sought to determine if these classifications were associated with clinical outcomes of HIV viral load and CD4 counts. High levels of adherence were correlated with low risk behaviors (abstinence, consistent use of condoms, etc.). Those classified as high adherence and low-risk behavior (HALR) as well as those classified as high adherence and high-risk behavior (HAHR) had lower mean viral loads and higher CD4 counts than those in the other categories. Women in the low adherence and high-risk category (LAHR) had detectable viral loads and the lowest CD4 counts and are at higher risk for transmitting HIV to partners and unborn children. Our findings underscore the importance of addressing adherence to both ART and RRB in HIV clinical settings to improve clinical outcomes and reduce HIV transmission.     

Suboptimal antiretroviral therapy adherence among HIV-infected adults in Guangzhou,China

Despite China's free antiretroviral therapy (ART) program, there are high rates of treatment failure, large sociodemographic disparities in care outcomes and emerging medication resistance. Understanding patient medication adherence behaviors and challenges could inform adherence interventions to maximize the individual and prevention benefits of ART. This study assessed recent nonadherence and treatment interruption among 813 HIV-infected adult outpatients in Guangzhou, China. Participants completed a behavioral survey, underwent chart review, and were tested for syphilis, gonorrhea, and chlamydia. Factors associated with suboptimal adherence were identified using univariate and multivariate logistic regression. Among 721 HIV-infected adults receiving ART, 18.9% reported recent nonadherence (any missed ART in the past four weeks) and 6.8% reported treatment interruption (four or more weeks of missed ART in the past year). Lower education, living alone, alcohol use, and being on ART one to three years were associated with recent nonadherence. Male gender, lower education, and being on ART one to three years were associated with treatment interruption. ART medication adherence interventions are needed in China that include individualized, long-term adherence plans sensitive to patients' educational and economic situations. These interventions should also consider possible gender disparities in treatment outcomes and address the use of alcohol during ART. Successful ART medication adherence interventions in China can inform other international settings that face similar adherence challenges and disparities.     

Adherence to antiretroviral therapy in HIV-infected pediatric patients improves with home-based intensive nursing intervention

Adherence to combination antiretroviral therapy (ART) has been shown to be a determining factor in controlling viral replication, maintaining immunologic function and long-term survival in HIV-positive individuals. Little information is available on strategies to improve adherence in pediatric HIV-infected patients. We conducted a randomized, nonblinded, pilot study to determine if a home-based nursing intervention would improve medication adherence. The study was offered to all eligible HIV-positive patients receiving care at Connecticut Children's Medical Center's (CCMC) Pediatric and Youth HIV Program. Sixty-seven percent (37/55) of the patients and their caretakers participated. We randomized participants to either standard of care or the intervention trial. The intervention was designed to improve knowledge and understanding of HIV infection and HIV medications and to resolve or modify barriers to adherence. Both groups completed pre- and post-intervention questionnaires, assessing their knowledge and understanding of HIV, ART, and adherence. Adherence was estimated objectively from medication refill history and subjectively from a self-report score. We also inferred adherence from pre- to post-test plasma viral load and CD4+ T-cell percentages. The knowledge score (p = 0.02) and medication refill history (p = 0.002) improved significantly in the intervention group. The adherence self-report score improved, although not significantly (p = 0.07). We did not observe statistical differences in CD4+ T-cell counts or viral load between groups. We conclude that our home-based nursing intervention helped HIV-positive children and their families in better adhering to prescribed medication regimens.     

Adherence to antiretroviral therapy among HIV-infected prisoners: a systematic review and meta-analysis

Data on antiretroviral therapy (ART) adherence among prison inmates are limited and not previously synthesized in a systematic manner. The objective of this study was to provide accurate and up-to-date ART adherence estimates among prison inmates. We searched electronic databases for all studies reporting adherence as a primary or secondary outcome among prison inmates. A random-effects model was used to pool adherence rates; sensitivity, heterogeneity and publication bias were assessed. Eleven studies involving 2895 HIV-infected prison inmates were included. The studies were carried out between 1992 and 2011 and reported between 1998 and 2013. A pooled analysis of all studies indicated a pooled estimate of 54.6% (95% confidence interval 48.1–60.9%) of prison inmates had adequate (≥95%) ART adherence. The adherence estimates were significantly higher among cross-studies and studies that used self-reported measures. In summary, our findings indicate that optimal adherence remains a challenge among prison inmates. It is crucial to monitor ART adherence and develop appropriate interventions to improve adherence among these population.     

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.     

Effectiveness of antiretroviral therapy among HIV-infected children in sub-Saharan Africa

Assessment of antiretroviral treatment programmes for HIV-infected children in sub-Saharan Africa is important to enable the development of effective care and improve treatment outcomes. We review the effectiveness of paediatric antiretroviral treatment programmes in sub-Saharan Africa and discuss the implications of these findings for the care and treatment of HIV-infected children in this region. Available reports indicate that programmes in sub-Saharan Africa achieve treatment outcomes similar to those in North America and Europe. However, progress in several areas is required to improve the care of HIV-infected children in sub-Saharan Africa. The findings emphasise the need for low-cost diagnostic tests that allow for earlier identification of HIV infection in infants living in sub-Saharan Africa, improved access to antiretroviral treatment programmes, including expansion of care into rural areas, and the integration of antiretroviral treatment programmes with other health-care services, such as nutritional support.     

Pneumococcal bacteremia in adults in Soweto, South Africa, during the course of a decade.

We retrospectively reviewed 414 episodes of pneumococcal bacteremia that occurred in adults from July 1986 through June 1987 (1986/1987) and from July 1996 through June 1997 (1996/1997) to monitor the incidence and clinical and laboratory characteristics and to assess the influence of human immunodeficiency virus (HIV) infection on any changes. The incidence increased from 26 per 100,000 persons in 1986/1987 to 36 per 100,000 persons in 1996/1997; the increase was most marked among patients who were aged 25-44 years (24 cases per 100,000 persons to 45 per cases 100,000 persons) and > or =65 years (43 cases per 100,000 persons to 50 cases per 100,000 persons). Of 161 patients who were tested for HIV in 1996/1997, 108 (67%) were HIV seropositive. Among the general population, the prevalence of other underlying diseases and smoking decreased from 45% and 67%, respectively, in 1986/1987 to 23% (P<.0001) and 35% (P<.0001) in 1996/1997. Strains of pneumococci that were not susceptible to penicillin were found in 4% patients in 1986/1987 and 12% in 1996/1997 (P=.005). This increase occurred exclusively among the HIV-infected patients (22% of the HIV-seropositive patients versus 4% of HIV-seronegative patients; P=.008), and there was a parallel increase for childhood serotypes (51% of HIV-seropositive patients versus 17% of HIV-seronegative patients; P<.0001).     

Thymopoiesis in HIV-infected adults after highly active antiretroviral therapy.

The thymus of HIV-seropositive patients can enlarge as CD4+ T cell counts increase on highly active anti-retroviral therapy (HAART). This may indicate development of new T cells or represent mature peripheral T cells recirculating to the thymus. To define the etiology of the enlargement, the thymuses of two HIV-infected individuals on HAART were biopsied. For more than 3 years before initiation of HAART, both patients (38 and 41 years of age) had documented CD4+ T lymphopenia. Peripheral blood samples were obtained to assess circulating CD4+ CD45RA+ CD62L+ T cells, which were thought to have recently developed in the thymus. Peripheral blood T cells from both patients and thymocytes from the second patient were also tested for levels of DNA episomes formed during T cell receptor gene rearrangement (T cell receptor rearrangement excision circles, TRECs). With HAART, peripheral blood CD4+ T cell counts increased from approximately 60/mm(3) to 552/mm(3) and 750/mm(3) for patients 1 and 2, respectively. Thymic biopsies from both patients showed normal thymus histology with active thymopoiesis. Percentages of peripheral blood CD4+ CD45RA+ CD62L+ T cells and quantitation of T cell TRECs also reflected active thymopoiesis in both patients. Thus, in these two HIV-seropositive adults examined after initiation of HAART, thymic enlargement represented active thymopoiesis. Thymopoiesis in adult AIDS patients may contribute to immune reconstitution even after prolonged CD4+ T lymphopenia.     

Hypoglycaemic Admissions Among Diabetic Patients in Soweto,South Africa

An audit of hypoglycaemic admissions among diabetic patients to Baragwanath Hospital, Soweto, South Africa was carried out prospectively during a recent 5-month period. A total of 51 episodes of biochemically confirmed hypoglycaemia (blood glucose < 2.2 mmol I^?1 with coma or pre-coma, and requiring intravenous glucose) were observed in 43 patients. There was a wide range of ages (22–88 years) and an excess of males (27M:16F). Fourteen (33%) cases were associated with sulphonylurea (gliclazide) treatment. Doses of insulin or sulphonylureas were not excessive. The major cause precipitating the event was a missed meal (36 %), though alcohol (22 %), gastrointestinal upset (20%), and inappropriate treatment (18%) were also important contributory factors. Following recovery from the event, doses of drugs or insulin were frequently reduced, and three patients were successfully taken off insulin, and six off gliclazide. There was no mortality in this series, and no obvious long-term morbidity. We conclude that severe hypoglycaemia is a frequent and important acute diabetic complication in Soweto. Patient education and care in prescribing for Type 2 diabetic patients may help reduce its occurrence and severity.