100% Adherence Study: Educational Workshops vs. Video Sessions to Improve Adherence Among ART-Naïve Patients in Salvador,Brazil

We conducted a randomized trial to test an intervention aimed at increasing adherence to antiretroviral therapy (ART) among HIV-positive, ART-naïve patients in Salvador, Brazil. Participants (N = 107) were randomized to either educational workshops based on the information-motivation-behavioral skills model (n = 52) or a control video session (n = 55). Changes in self-reported ART adherence, viral load, CD4 cell counts and ART pharmacy records were measured periodically over 12 months. After 3–6 months, ART adherence (≥95%) was 77.8% in the workshop group and 85.7% in video group (as treated) and 53.8% and 65.5%, respectively, using intention-to-treat (ITT) analysis (both P > 0.05) At 9–12 months, ART adherence decreased to 73.7% in the workshop group and 79.1% in the video group (as treated) and 53.8% and 61.8% using ITT, respectively. No differences were found in self-reported adherence, viral load or pharmacy records between groups. We found that the educational workshop intervention does not increase adherence to ART.     

Direct and Indirect Effects of Heavy Alcohol Use on Clinical Outcomes in a Longitudinal Study of HIV Patients on ART

In a cohort of patients receiving care for HIV, we examined longitudinally the impact of past 30-day frequency of heavy drinking (consuming 5+ drinks on one occasion) on HIV-related (detectable viral load and CD4+ T cell count) and non-HIV-related (hemoglobin and biomarkers of kidney function and liver fibrosis) clinical outcomes and the extent to which these effects were due to reduced antiretroviral therapy (ART) adherence. Data came from the Study to Understand the Natural History of HIV/AIDS in the Era of Effective Therapy. Between March 2004 and June 2006, 533 individuals receiving ART were recruited and followed every 6 months for six years. Using longitudinal mediation analysis, we estimated natural direct effects (NDE) of heavy drinking frequency (never, 1–3 times, or 4+ times in the past 30 days) on clinical outcomes and natural indirect effects (NIE) mediated via ART adherence. A one-level increase in heavy drinking frequency had a significant negative NDE on CD4+ T-cell counts (-10.61 cells/mm³; 95 % CI [-17.10, -4.12]) and a significant NIE through reduced ART adherence of -0.72 cells/mm³ (95 % CI [-1.28, -0.15]), as well as a significant NIE on risk of detectable viral load (risk ratio = 1.03; 95 % CI [1.00, 1.05]). Heavy drinking had a significant detrimental NIE on a combined index of 5-year mortality risk and detrimental NDE and total effect on a biomarker of liver fibrosis. Heavy drinking has deleterious effects on multiple clinical outcomes in people living with HIV, some of which are mediated through reduced ART adherence.     

<Emphasis Type="Italic">Abriendo Puertas</Emphasis>: Feasibility and Effectiveness a Multi-Level Intervention to Improve HIV Outcomes Among Female Sex Workers Living with HIV in the Dominican Republic

Female sex workers (FSW) are disproportionately affected by HIV. Yet, few interventions address the needs of FSW living with HIV. We developed a multi-level intervention, Abriendo Puertas (Opening Doors), and assessed its feasibility and effectiveness among a cohort of 250 FSW living with HIV in the Dominican Republic. We conducted socio-behavioral surveys and sexually transmitted infection and viral load testing at baseline and 10-month follow-up. We assessed changes in protected sex and adherence to antiretroviral therapy (ART) with logistic regression using generalized estimating equations. Significant pre-post intervention changes were documented for adherence (72–89 %; p < 0.001) and protected sex (71–81 %; p < 0.002). Higher intervention exposure was significantly associated with changes in adherence (AOR 2.42; 95 % CI 1.23–4.51) and protected sex (AOR 1.76; 95 % CI 1.09–2.84). Illicit drug use was negatively associated with both ART adherence and protected sex. Abriendo Puertas is feasible and effective in improving behavioral HIV outcomes in FSW living with HIV.     

Impact of Physical Activity on Reporting of Childhood Asthma Symptoms

This study aims to determine the impact of physical activity on asthma symptom reporting among children living in an inner city. Among 147 children aged 5–12 years with physician-diagnosed asthma, we assessed asthma symptoms using twice-daily diaries and physical activity using the physical activity questionnaire for children during three 8-day periods (baseline, 3 and 6 months). Linear, logistic, and quasi-poisson regression models were used to determine the association between physical activity and asthma symptoms; adjusting for age, sex, race, BMI, caregiver’s education, asthma severity, medication use, and season. A 1-unit increase in PAQ score was significantly associated with reporting more nocturnal symptoms [risk ratio (RR): 1.03; 95% CI 1.00–1.06], daytime symptoms (RR: 1.04; 95% CI 1.00–1.09), being bothered by asthma (RR: 1.05; 95% CI 1.00–1.09), and trouble breathing (RR: 1.05; 95% CI 1.00–1.10). Level of physical activity should be taken into account in clinical management of asthma and epidemiological studies of asthma symptom burden.     

A Randomized Controlled Trial of Personalized Text Message Reminders to Promote Medication Adherence Among HIV-Positive Adolescents and Young Adults

HIV-positive adolescents and young adults often experience suboptimal medication adherence, yet few interventions to improve adherence in this group have shown evidence of efficacy. We conducted a randomized trial of a two-way, personalized daily text messaging intervention to improve adherence to antiretroviral therapy (ART) among N = 105 poorly adherent HIV-positive adolescents and young adults, ages 16–29. Adherence to ART was assessed via self-reported visual analogue scale (VAS; 0–100 %) at 3 and 6-months for mean adherence level and proportion ≥90 % adherent. The average effect estimate over the 6-month intervention period was significant for ≥90 % adherence (OR = 2.12, 95 % CI 1.01–4.45, p < .05) and maintained at 12-months (6 months post-intervention). Satisfaction scores for the intervention were very high. These results suggest both feasibility and initial efficacy of this approach. Given study limitations, additional testing of this intervention as part of a larger clinical trial with objective and/or clinical outcome measures of adherence is warranted.     

Adherence to On-Time ART Drug Pick-Up and Its Association with CD4 Changes and Clinical Outcomes Amongst HIV Infected Adults on First-Line Antiretroviral Therapy in Nigerian Hospitals

Medication adherence is a major determinant of antiretroviral treatment (ART) success. Promptness in medication refill pick-ups may give an indication of medication adherence. This study determined medication refill adherence among HIV positive patients on ART and its association with treatment outcomes in HIV treatment centers in Nigeria. This retrospective multi-center cohort study involved a review of ART refill records for 3534 HIV-positive patients aged 18–60 years who initiated first-line ART between January 2008 and December 2009 and were on therapy for ≥18 months after ART initiation. Drug refill records of these patients for 10 consecutive refill visits after ART initiation were analyzed. The first ten consecutive refill appointment-keeping rates after ART initiation ranged from 64.3 % to 76.1 % which decreased with successive visits. Altogether, 743 (21.1 %) patients were deemed adherent, meaning they picked up their drugs within 7 days of the drug refill appointment date on at least nine out of ten refill visits. The adherent group of patients had a mean CD4 cells increase of 206 ± 6.1 cells/dl after 12 months of ART compared to 186 ± 7.1 cells/dl reported among the nonadherent group (p = 0.0145). The proportion of patients in the adherent category who showed no OIs after 12 months on ART (81 %) was significantly higher when compared to the proportion in the non-adherent category (23.5 %), (p = 0.008). The multivariate analysis showed that the odds of being adherent was 2–3 times more in patients who had a baseline CD4 count of less than 200 cells/dl compared to those with a baseline CD4 of >350 cells/dl. (AOR 2.43, 95 % CI 1.62–3.66). In addition, for patients with baseline CD4 cell count of 201–350 cells/dl, the odds of being adherent was found to be 1.9 compared to those with baseline CD4 of greater than 350 cells/dl (AOR 1.93, 95 % CI 1.27–2.94). Pharmacy refill data can serve as an adherence measure. Adherence to on-time drug pickup on ≥90 % of refill appointments was associated with a better CD4 count response and a reduction in the presence of opportunistic infections in ART patients after 12 months of treatment.     

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.     

Multiple Dimensions of Stigma and Health Related Factors Among Young Black Men Who Have Sex with Men

This study is among the first to examine the association between multiple domains of HIV-related stigma and health-related correlates including viral load and medication adherence among young Black men who have sex with men (N = 92). Individual logistic regressions were done to examine the hypothesized relationships between HIV-related stigma and various health and psychosocial outcomes. In addition to examining total stigma, we also examined four domains of HIV stigma. Findings revealed the various domains of stigma had differential effects on health-related outcomes. Individuals who reported higher levels of total stigma and personalized stigma were less likely to be virally suppressed (OR 0.96, 95 % CI 0.91–1.00 and OR 0.50, 95 % CI 0.25–1.02, respectively). Concerns about public attitudes toward HIV were positively related to medication adherence (OR 2.18, 95 % CI 1.20–3.94) and psychological distress (OR 5.02, 95 % CI 1.54–16.34). The various domains of HIV stigma differentially affected health and psychosocial outcomes, and our findings suggest that some forms of HIV stigma may significantly affect viral load and medication adherence among this population. Stigma-informed approaches to care and treatment are needed, along with incorporated psychological and social supports.     

High prevalence of non-adherence to antiretroviral therapy among undisclosed HIV-infected children in Ghana

Adherence to antiretroviral therapy (ART) remains one of the greatest obstacles in pediatric HIV care. We sought to determine the prevalence of adherence to ART among undisclosed HIV-infected children and adolescents in Ghana. We analyzed baseline data from HIV-infected children and adolescents aged 7–18 years old enrolled in the SANKOFA Pediatric HIV disclosure intervention study in Ghana. Antiretroviral medication adherence was measured using caregiver 3-day recall; child 3-day recall; and pharmacy records for antiretroviral time-to-refill. Four hundred and twenty child-caregiver dyads were enrolled from January 2013 to June 2016. The median adherence (interquartile range), as measured by time-to-refill, was 93.2% (68.0%–100.0%). However, only 47.5% of children had ≥95% adherence (“good adherence”) using time-to-refill data. Children of caregivers who had received secondary or higher level of education versus no school (aOR, 2.90, 95% Confidence Interval, CI 1.29–6.56), p?=?0.010) or elementary education only (aOR, 2.20, CI, 1.24–3.88, p?=?0.007) were more likely to have “good adherence” (≥95%). In this cohort of children unaware of their HIV positive status, median ART adherence rate was sub-optimal (by World Health Organization definition) while 38% had poor adherence (<85%).     

Residential Eviction and Risk of Detectable Plasma HIV-1 RNA Viral Load Among HIV-Positive People Who Use Drugs

We examined the relationship between residential eviction and exhibiting detectable plasma HIV-1 RNA viral load (VL) among a prospective cohort of antiretroviral therapy (ART)-exposed HIV-seropositive people who use illicit drugs (PWUD) in Vancouver, Canada. We used multivariable generalized estimating equations to estimate the effect of residential eviction on detectable VL and examine ART adherence as a mediating variable. Between June 2007 and May 2014, 705 ART-exposed participants were included in the study, among whom 500 (70.9 %) experienced at least one period of detectable VL. In a time-updated multivariable model, eviction independently increased the odds of detectable VL among those who were homeless [adjusted odds ratio (AOR) = 2.25; 95 % confidence interval (CI) 1.18–4.29] as well as not homeless (AOR = 1.76; 95 % CI 1.17–2.63) post eviction. The results of mediation analyses suggest that this association was mediated by incomplete ART adherence. These findings suggest the need for further development and evaluation of interventions to prevent evictions and promote ART adherence among PWUD facing eviction.     

The effectiveness of treatment supporter interventions in antiretroviral treatment adherence in sub-Saharan Africa: a systematic review and meta-Analysis

ABSTRACT

This systematic review and meta-analysis evaluated the effectiveness of treatment supporter interventions (TSI) in improving ART adherence and viral suppression among adults living with HIV (PLWH) in sub-Saharan Africa. This review included ten randomized controlled trials (RCT) and six cohort studies comparing treatment support interventions to the standard of care (SOC). Primary outcomes include pill count ART adherence and viral load suppression (VLS). Pooled relative risk ratios (PRR) with 95% confidence intervals were generated using random-effects models. Stratified analyses and meta-regressions were conducted to determine the effect of study type, follow-upperiod, and patient treatment supporters on ART adherence. Treatment supporters included partners, friends, family members, trained community health workers, and HIV positive peers. TSIs were associated with a 7.6% higher ART adherence compared to the SOC group (PRR = 1.076, [95% CI = 1.005, 1.151]). VLS was 5% higher in the treatment group compared to the SOC group (PRR = 1.05, [95% CI = 1.061, 1.207]). There was a significant, positive association between TSIs and VLS in community-based delivery settings but not in facility-based settings. TSIs were statistically significant for VLS in cohort study designs (RR = 1.073, [95% CI = 1.028, 1.121]) but not in RCTs. Findings suggest that TSIs critical in facilitating optimal ART adherence and VLS among PLWHs.     

Alcohol Interactive Toxicity Beliefs and ART Non-adherence Among HIV-Infected Current Drinkers in Mbarara,Uganda

Interactive toxicity beliefs regarding mixing alcohol and antiretroviral therapy (ART) may influence ART adherence. HIV-infected patients in Uganda completed quarterly visits for 1 year, or one visit at 6 months, depending on study randomization. Past month ART non-adherence was less than daily or <100 % on a visual analog scale. Participants were asked if people who take alcohol should stop taking their medications (belief) and whether they occasionally stopped taking their medications in anticipation of drinking (behavior). Visits with self-reported alcohol use and ART use for ≥30 days were included. We used logistic regression to examine correlates of the interactive toxicity belief and behavior, and to determine associations with ART non-adherence. 134 participants contributed 258 study visits. The toxicity belief was endorsed at 24 %, the behavior at 15 %, and any non-adherence at 35 % of visits. In multivariable analysis, the odds of non-adherence were higher for those endorsing the toxicity behavior [adjusted odds ratio (AOR) 2.06; 95 % confidence interval (CI) 0.97–4.36] but not the toxicity belief (AOR 0.63; 95 % CI 0.32–1.26). Clear messaging about maintaining adherence, even if drinking, could benefit patients.     

Adherence to antiretroviral therapy and its determinants in children with HIV infection – Experience from Paediatric Centre of Excellence in HIV Care in North India

The objective of this study is to assess adherence to antiretroviral therapy (ART) in HIV-infected children using the pill count method, and determine factors leading to adherence failure. Records of 106 children living with HIV (CLHIV) age <15 years and on ART for >6 months were reviewed. Average adherence to ART by pill count method over preceding six months was calculated and re-assessed by 3-day recall method. The caregivers of 105 children and one child himself were interviewed about the problems encountered while giving ART. Median age of enrolled children was 104 (inter-quartile range [IQR] 77.3–133.8) months. Median duration of ART was 25 (IQR 16–35) months. The desired adherence level of >95% during six months of review assessed by pill count was achieved in 95.3% children. The 3-day recall method yielded >95% adherence in 99% children (p ≤ .001). Caregivers of 59 children (56.2%) reported multiple problems while administering drugs. In most instances, problems encountered were related to family/caregivers, the commonest being multiple caregivers, job constraints and death/illness in the family. In conclusion, we found a very high level of adherence to ART in CLHIV. Poor adherence was mainly associated with issues related to the family/caregivers.     

Psychological and social determinants of health,antiretroviral therapy (ART) adherence,and viral suppression among HIV-positive black women in care

Black women are disproportionately affected by HIV, accounting for 61% of women diagnosed in 2016. Black women with HIV are less likely to be adherent to antiretroviral therapy (ART) and virally suppressed compared to women of other racial/ethnic groups. We analyzed 2013–2014 data from 1703 black women patients in the Centers for Disease Control and Prevention’s Medical Monitoring Project to examine whether select psychological and social determinants of health (SDH) factors were associated with ART adherence and viral suppression. We calculated weighted estimates and used multivariable logistic regression with adjusted prevalence ratios (aPR) and 95% confidence intervals (CI) to examine correlates of ART adherence and viral suppression. Women who had not been incarcerated in the past 12 months (aPR?=?1.24; CI: 1.04–1.48) and had not experienced discrimination in a health care setting since their HIV diagnosis (aPR?=?1.06; 1.00–1.11) were slightly more likely to be adherent to ART. Women who lived above the federal poverty level were more likely to be virally suppressed during the past 12 months (aPR?=?1.09; CI: 1.01–1.18). More research is warranted to identify the best strategies to create health care settings that encourage black women’s HIV care engagement, and to address other key SDH and/or psychological factors.     

Improved long-term antiretroviral treatment outcomes amongst patients receiving community-based adherence support in South Africa

Retaining high levels of patients in care who are virally suppressed over long treatment periods has been an important challenge for antiretroviral treatment (ART) programmes in sub-Saharan Africa, the region having the highest HIV burden globally. Clinic-linked community-based adherence support (CBAS) programmes provide home-based adherence and psychosocial support for ART patients. However, there is little evidence of their longer-term impact. This study assessed the effectiveness of CBAS after eight years of ART. CBAS workers are lay healthcare personnel providing regular adherence and psychosocial support for ART patients and their households through home visits addressing household challenges affecting adherence. A multicentre cohort study using routinely collected data was undertaken at six public ART sites in a high HIV-prevalence South African district. Patient retention, loss to follow-up (LTFU), viral suppression and CD4 cell restoration were compared between patients with and without CBAS, using competing-risks regression, linear mixed models and log-binomial regression. 3861 patients were included, of whom 1616 (41.9%) received CBAS. Over 14,792 patient-years of observation, the cumulative incidence of LTFU was 37.3% and 46.2% amongst patients with and without CBAS, respectively, following 8 years of ART; adjusted subhazard ratio (CBAS vs. no CBAS)?=?0.74 (95% CI: 0.66–0.84; P?P?=?.015). Annual CD4 cell increases from baseline were 62.8 cells/µL/year and 51.5 cells/µL/year amongst patients with and without CBAS, respectively, after 6.5 years or more (P?=?.034). After adjustment, annual CD4 cell recovery was 15.1 cells/µL/year (95% CI: 2.7–27.6) greater in CBAS patients (P?=?.017). ART patients who received CBAS had improved long-term patient retention, viral suppression and immunological restoration. CBAS is an intervention that can improve longer-term ART programme outcomes in resource-limited settings.     

Laparoscopic lavage versus surgical resection for acute diverticulitis with generalised peritonitis: a systematic review and meta-analysis

This systematic review and meta-analysis investigates current evidence on the therapeutic role of laparoscopic lavage in the management of diverticular peritonitis. A systematic review of the literature was performed on PubMed until June 2016, according to preferred reporting items for systematic reviews and meta-analyses guidelines. All randomised controlled trials comparing laparoscopic lavage with surgical resection, irrespective of anastomosis or stoma formation, were analysed. After assessment of titles and full text, 3 randomised trials fulfilled the inclusion criteria. Overall the quality of evidence was low because of serious concerns regarding the risk of bias and imprecision. In the laparoscopic lavage group, there was a statistically significant higher rate of postoperative intra-abdominal abscess (RR 2.54, 95% CI 1.34–4.83), a lower rate of postoperative wound infection (RR 0.10, 95% CI 0.02–0.51), and a shorter length of postoperative hospital stay during index admission (WMD = ?2.03, 95% CI ?2.59 to ?1.47). There were no statistically significant differences in terms of postoperative mortality at index admission or within 30 days from intervention in all Hinchey stages and in Hinchey stage III, postoperative mortality at 12 months, surgical reintervention at index admission or within 30–90 days from index intervention, stoma rate at 12 months, or adverse events within 90 days of any Clavien–Dindo grade. The surgical reintervention rate at 12 months from index intervention was significantly lower in the laparoscopic lavage group (RR 0.57, 95% CI 0.38–0.86), but these data included emergency reintervention and planned intervention (stoma reversal). This systematic review and meta-analysis did not demonstrate any significant difference between laparoscopic peritoneal lavage and traditional surgical resection in patients with peritonitis from perforated diverticular disease, in terms of postoperative mortality and early reoperation rate. Laparoscopic lavage was associated with a lower rate of stoma formation. However, the finding of a significantly higher rate of postoperative intra-abdominal abscess in patients who underwent laparoscopic lavage compared to those who underwent surgical resection is of concern. Since the aim of surgery in patients with peritonitis is to treat the sepsis, if one technique is associated with more postoperative abscesses, then the technique is ineffective. Even so, laparoscopic lavage does not appear fundamentally inferior to traditional surgical resection and this technique may achieve reasonable outcomes with minimal invasiveness.     

Young age predicts poor antiretroviral adherence and viral load suppression among injection drug users

Previous studies of adherence to antiretroviral therapy (ART) for HIV among young injection drug users (IDU) have been limited because financial barriers to care disproportionately affect youth, thus confounding results. This study examines adherence among IDU in a unique setting where all medical care is provided free-of-charge. From May 1996 to April 2008, we followed a prospective cohort of 545 HIV-positive IDU of 18 years of age or older in Vancouver, Canada. Using generalized estimating equations (GEE), we studied the association between age and adherence (obtaining ART≥95% of the prescribed time), controlling for potential confounders. Using Cox proportional hazards regression, we also studied the effect of age on time to viral load suppression (<500 copies per milliliter), and examined adherence as a mediating variable. Five hundred forty-five participants were followed for a median of 23.8 months (interquartile range [IQR]=8.5-91.6 months). Odds of adherence were significantly lower among younger IDU (adjusted odds ratio [AOR]=0.76 per 10 years younger; 95% confidence interval [CI], 0.65-0.89). Younger IDU were also less likely to achieve viral load suppression (adjusted hazard ratio [AHR]=0.75 per 10 years younger; 95% CI, 0.64-0.88). Adding adherence to the model eliminated this association with age, supporting the role of adherence as a mediating variable. Despite absence of financial barriers, younger IDU remain less likely to adhere to ART, resulting in inferior viral load suppression. Interventions should carefully address the unique needs of young HIV-positive IDU.     

The Influence of Medication Attitudes on Utilization of Antiretroviral Therapy (ART) in Indonesian Prisons

Negative attitudes toward HIV medications may restrict utilization of antiretroviral therapy (ART) in Indonesian prisons where many people living with HIV (PLH) are diagnosed and first offered ART. This mixed-method study examines the influence of medication attitudes on ART utilization among HIV-infected Indonesian prisoners. Randomly-selected HIV-infected male prisoners (n = 102) completed face-to-face in-depth interviews and structured surveys assessing ART attitudes. Results show that although half of participants utilized ART, a quarter of those meeting ART eligibility guidelines did not. Participants not utilizing ART endorsed greater concerns about ART efficacy, safety, and adverse effects, and more certainty that ART should be deferred in PLH who feel healthy. In multivariate analyses, ART utilization was independently associated with more positive ART attitudes (AOR = 1.09, 95 % CI 1.03–1.16, p = 0.002) and higher internalized HIV stigma (AOR = 1.03, 95 % CI 1.00–1.07, p = 0.016). Social marketing of ART is needed to counteract negative ART attitudes that limit ART utilization among Indonesian prisoners.