A Qualitative Investigation of Antiretroviral Therapy Among Injection Drug Users

Recent advances in antiretroviral therapy for HIV/AIDS have improved the quality of life and life expectancies of many with this fatal disease. Nevertheless, a significant proportion of individuals from disadvantaged groups, which traditionally have had difficulty accessing high-quality health care in the United States, have not benefited from these treatments. For example, injection drug users (IDUs), now a principal source of new cases of AIDS, have received antiretroviral therapy at significantly lower rates than other groups. Whereas numerous studies have described this group quantitatively, few studies have examined in depth the influences that lead to IDUs' problematic relationship with HIV/AIDS treatment. The study described here is based on a longitudinal survey of 516 IDUs. A quantitative analysis was conducted with 103 HIV-positive IDUs and an in-depth qualitative analysis was performed with a subsample of 34 HIV-positive IDUs. This paper presents findings on the consequences of antiretroviral therapy use and nonuse among these individuals, focusing on their perspectives regarding this treatment regimen. Findings suggest that problematic access to, and usage of, antiretroviral therapy is related to wider societal problems of drug abuse, access to health care and housing, and the social and historical divisions that impact the lives of IDUs and their communities. Efforts to improve the availability and the adherence to antiretroviral therapy among IDUs should involve these individuals as a critical component in the design of culturally appropriate and supportive health care services.     

Adherence to Highly Active Antiretroviral Therapy (HAART): A Meta-Analysis

This meta-analysis synthesizes eighty-four observational studies, conducted across twenty countries, to determine the mean proportion of people who reported ≥90% adherence to prescribed highly active antiretroviral therapy (HAART) and to identify the factors associated with high levels of adherence. Eight electronic databases were searched to locate all relevant studies available by January 2010, which were then coded for sample characteristics and adherence levels. The average rate of reporting ≥90% adherent HAART adherence is 62%. However, this proportion varies greatly across studies. In particular, a greater proportion of individuals maintaining ≥90% adherence to HAART is more likely in studies with higher proportions of men who have sex with men (MSM) and lower proportions of injection drug users (IDU), with participants in an earlier stage of infection, and in studies conducted in countries characterized by lower Human Development Index (HDI) scores.     

Impact of HIV-Status Disclosure on Adherence to Antiretroviral Therapy Among HIV-Infected Children in Resource-Limited Settings: A Systematic Review

Pediatric HIV remains a significant global health dilemma, especially in resource-constrained nations. As access to ART increases around the world, areas of concern in pediatric HIV treatment include age-appropriate disclosure of HIV status to children and development of adherence habits over time. This review was conducted to synthesize quantitative associations reported between disclosure and adherence among children living with HIV in resource-limited settings. An electronic database search of PubMed, MEDLINE and Cochrane returned 1348 results after removal of duplicates, 14 of which were found to meet inclusion criteria. Review of these reports showed conflicting results regarding the impact of disclosure on adherence, with 5 showing no association, 4 showing a negative impact of disclosure on adherence, and 5 showing positive benefits of disclosure for adherence habits. Thus, there was no clear consensus on the effect, if any, that disclosure has on medication adherence. Longitudinal, prospective research needs to be conducted to evaluate further impacts that disclosure may have on adherence habits over time, and interventions must be structured to link the two processes together in order to maximize health benefit to the child or adolescent.     

A Meta-Analysis of Adherence to Antiretroviral Therapy and Virologic Responses in HIV-Infected Children, Adolescents, and Young Adults

The relationship between adherence to antiretroviral therapy (ART) and virologic outcomes in HIV+ children, adolescents, and young adults has been notably understudied, with much of the extant research focused on specific sub-literatures, such as resource-limited regions, specific clinical outcomes and time frames. The authors sought to better characterize the relationship between adherence to ART and virologic functioning along various sample and methodological factors. The authors conducted a meta-analysis of thirty-seven studies and utilized a random effects model to generate weighted mean effect sizes. In addition, the authors conducted meta-ANOVAs to examine potential factors influencing the relationship between adherence and three categories of clinical outcomes, specifically Viral Load (VL) <100, VL < 400, and continuously measured VL. The analyses included 5,344 HIV+ children, adolescents, and young adults. The relationship between adherence behaviors and virologic outcomes varied across different methods of measurement and analysis. The relationship between adherence and continuously measured VL was significantly larger than for dichotomously-coded VL < 400 at Qb (20.69(1), p < .0005). Caregiver self-report indices elicited very small to small magnitude effects across both VL < 100 and VL < 400 outcomes and combined informant reporting (youth/adolescent and parent) produced significantly larger effects than caregiver report alone with adherence and VL < 400 outcomes at Qb (9.28(1), p < .005). More recently published trials reported smaller relationships between adherence and categorical clinical outcomes, such that year of publication significantly negatively correlated with VL < 100 (r = ?.71(14), p < .005) and VL < 400 (r = ?.43(26), p < .02). The data suggest that the magnitude of the relationship between ART adherence and virologic outcomes among heterogeneous samples of HIV+ children, adolescents and young adults varies across virologic outcomes and may be affected by moderating sample and methodological factors. Methodological and research recommendations for the interpretation of the current findings as well as for future HIV adherence related research are presented.     

Methadone Maintenance Therapy Decreases the Rate of Antiretroviral Therapy Discontinuation Among HIV-Positive Illicit Drug Users

We sought to examine whether methadone maintenance therapy (MMT) decreased rates of antiretroviral therapy (ART) discontinuation and was associated with plasma HIV RNA responses among a cohort of illicit drug users. Cumulative ART discontinuation rates were estimated using Kaplan–Meier methods and factors independently associated with ART discontinuation were identified using Cox proportional hazards regression. Engagement in MMT was negatively and independently associated with ART discontinuation [Adjusted Relative Hazard = 0.67 (95 % CI 0.54–0.83); p < 0.001]. Among participants receiving ART and MMT, 81.6 % of plasma HIV-1 RNA assessments were <500 copies/mL, while 65.81 % of HIV-1 RNA assessments among those prescribed ART without MMT were <500 copies/mL (p < 0.001). These results demonstrate that engagement in MMT conferred a protective benefit against ART discontinuation and was associated with a significant increase in plasma HIV RNA suppression among HIV-infected opioid-dependent drug users.     

Using Electronic Drug Monitor Feedback to Improve Adherence to Antiretroviral Therapy Among HIV-Positive Patients in China

Effective antiretroviral therapy (ART) requires excellent adherence. Little is known about how to improve ART adherence in many HIV/AIDS-affected countries, including China. We therefore assessed an adherence intervention among HIV-positive patients in southwestern China. Eighty subjects were enrolled and monitored for 6 months. Sixty-eight remaining subjects were randomized to intervention/control arms. In months 7–12, intervention subjects were counseled using EDM feedback; controls continued with standard of care. Among randomized subjects, mean adherence and CD4 count were 86.8 vs. 83.8% and 297 vs. 357 cells/μl in intervention vs. control subjects, respectively. At month 12, among 64 subjects who completed the trial, mean adherence had risen significantly among intervention subjects to 96.5% but remained unchanged in controls. Mean CD4 count rose by 90 cells/μl and declined by 9 cells/μl among intervention and control subjects, respectively. EDM feedback as a counseling tool appears promising for management of HIV and other chronic diseases.     

Adherence to Antiretroviral Therapy and Acceptability of Planned Treatment Interruptions in HIV-Infected Children

There have been no paediatric randomised trials describing the effect of planned treatment interruptions (PTIs) of antiretroviral therapy (ART) on adherence, or evaluating acceptability of such a strategy. In PENTA 11, HIV-infected children were randomised to CD4-guided PTIs (n = 53) or continuous therapy (CT, n = 56). Carers, and children if appropriate, completed questionnaires on adherence to ART and acceptability of PTIs. There was no difference in reported adherence on ART between CT and PTI groups; non-adherence (reporting missed doses over the last 3 days or marking <100 % adherence since the last clinical visit on a visual analogue scale) was 18 % (20/111) and 14 % (12/83) on carer questionnaires in the CT and PTI groups respectively (odds ratios, OR (95 % CI) = 1.04 (0.20, 5.41), χ² (1) = 0.003, p = 0.96). Carers in Europe/USA reported non-adherence more often (31/121, 26 %) than in Thailand (1/73, 1 %; OR (95 % CI) = 54.65 (3.68, 810.55), χ² (1) = 8.45, p = 0.004). The majority of families indicated they were happy to have further PTIs (carer: 23/36, 64 %; children: 8/13, 62 %), however many reported more clinic visits during PTI were a problem (carer: 15/36, 42 %; children: 6/12, 50 %).     

Improved Adherence to Antiretroviral Therapy Observed Among HIV-Infected Children Whose Caregivers had Positive Beliefs in Medicine in Sub-Saharan Africa

A high level of adherence to antiretroviral treatment is essential for optimal clinical outcomes in HIV infection, but measuring adherence is difficult. We investigated whether responses to a questionnaire eliciting caregiver beliefs in medicines were associated with adherence of their child (median age 2.8 years), and whether this in turn was associated with viral suppression. We used the validated beliefs in medicine questionnaire (BMQ) to measure caregiver beliefs, and medication event monitoring system caps to measure adherence. We found significant associations between BMQ scores and adherence, and between adherence and viral suppression. Among children initiating Antiretroviral therapy (ART), we also found significant associations between BMQ ‘necessity’ scores, and BMQ ‘necessity-concerns’ scores, and later viral suppression. This suggests that the BMQ may be a valuable tool when used alongside other adherence measures, and that it remains important to keep caregivers well informed about the long-term necessity of their child’s ART.     

Predicting Adherence to Antiretroviral Therapy in HIV-Infected Older Adults: The Moderating Role of Gender

This study characterized rates and correlates of ART adherence in 242 HIV-infected persons 50+ years of age. Hierarchical regressions tested a model in which depression mediated the relationships between social support and avoidance coping with ART adherence. Results indicated low rates of consistent and timely adherence in both men (48%) and women (51%). For men and women alike, social support and avoidance coping predicted depression. Although rates of adherence and predictors of depression did not differ by gender, predictors of adherence did. Avoidance coping, social support and depression predicted ART adherence in older men, but not in older women. Contrary to expectations, depression did not mediate the relationships of coping and social support with ART adherence for either gender. These findings suggest that while HIV-infected older men and women share similar paths toward depression, they diverge in predictors of adherence. Adherence interventions may be more efficacious if they are sensitive to gender differences, although more research is first needed to identify factors related to adherence in HIV-infected older women.     

Social Factors Related to Antiretroviral Therapy Use in Injection Drug Users

This study applied a behavioral model of health services use that included health-related attitudes and indicators of social contact and support to use of antiretroviral therapy (ART) in a cross-sectional survey of 241 disadvantaged, inner-city injection drug users (IDUs). Only 44% of this sample reported taking ART despite relatively high levels of health care utilization; ART nonuse was associated with distrust of physicians (OR = 4.76, 95% CI 1.75–13.5). In a logistic regression model that controlled for severity of HIV disease and access to health care, the belief that HIV medications make the respondent feel healthier (OR = 3.24, 95% CI 1.70–6.15) and increased social isolation since becoming HIV-positive (OR = 2.60, 95% CI 1.38–4.89) were correlated with ART use. These findings underscore the importance of including social and behavioral characteristics in models that attempt to explain ART use by marginalized populations.     

Sexual Risk Behavior Among Injection Drug Users Before Widespread Availability of Highly Active Antiretroviral Therapy

HIV testing and counseling has been associated with reductions in risk behaviors in some populations. This study examined whether involvement in a long-term study, including exposure to repeated HIV testing and counseling, was associated with increased condom use among injection drug users (IDUs) through a retrospective analysis of an IDU cohort from Baltimore, MD, during 1994–1998. Eligibility included being aged 18 years or older, injecting within 10 years and not having initiated antiretroviral therapy. A logistic model of high versus low risk, based on condom use, was used. Of 322 eligible IDUs, most were male (66%) and African-American (94%). No significant change in the odds of inconsistent condom use was observed with continued study exposure. Condom use remained low, indicating a need for interventions to reduce sexual risks and HIV transmission in this population.     

Long-term Medication Adherence in Patients Receiving Antiretroviral Drug Therapy

Objective: A long-term medication adherence project was designed and implemented in an urban HIV clinic to address antiretroviral medication adherence. Design and Methods: We conducted a prospective study of patients on long-term antiretroviral therapy. Referred patients were on antiretroviral agents at least six months and had two consecutive detectable viral loads. A standarized form was utilized to assess medication adherence, including patient report, practitioner assessed barriers, and pharmacy refill history. Individualized interventions were developed to accommodate patient needs. Results: Seventy-eight patients met inclusion criteria for a total of 81 cases per study protocol. The majority of cases had an identifiable cause related to missed and/or mistimed doses. Following adherence interventions, 51 of the 81 cases (63%) experienced a successful outcome. In addition, 16 of the 27 cases (59%) without an identifiable cause became undetectable following intervention. Conclusions: This novel approach demonstrates that a proactive method for addressing barriers to long-term medication adherence yields improved patient understanding and preservation of treatment regimens.     

Adherence to Antiretroviral Therapy Among Children Living with HIV in South India

Adherence to ART, fundamental to treatment success, has been poorly studied in India. Caregivers of children attending HIV clinics in southern India were interviewed using structured questionnaires. Adherence was assessed using a visual analogue scale representing past-month adherence and treatment interruptions >48 h during the past 3 months. Clinical features, correlates of adherence and HIV-1 viral-load were documented. Based on caregiver reports, 90.9 % of the children were optimally adherent. In multivariable analysis, experiencing ART-related adverse effects was significantly associated with suboptimal adherence (p = 0.01). The proportion of children who experienced virological failure was 16.5 %. Virological failure was not linked to suboptimal adherence. Factors influencing virological failure included running out of medications (p = 0.002) and the child refusing to take medications (p = 0.01). Inclusion of drugs with better safety profiles and improved access to care could further enhance outcomes.     

Adherence to Highly Active Antiretroviral Therapy Among Children in Ethiopia: A Systematic Review and Meta-analysis

Adherence to highly active antiretroviral therapy (HAART) is the mainstay of the strategy in reducing morbidity and mortality of HIV-infected children. Different primary studies were conducted in Ethiopia. Thus, we aimed to conduct a meta-analysis of the national prevalence of optimal adherence to HAART in children. In addition, associated factors of HAART adherence were reviewed. A weighted inverse variance random-effects model was applied. The 88.7 and 93.7% of children were adhering to HAART at 07 and 03 days prior to an interview respectively. The subgroup analysis showed that HAART adherence was 93.4% in Amhara, 90.1% in Addis Ababa and 87.3% in Tigray at 07 days prior to an interview. Our study suggests that, within short window reported time, adherence to HAART in Ethiopian children may be in a good progress. Emphasis on specific adherence interventions need further based on individual predictors to improve overall HAART adherence of children.     

Polypharmacy and Risk of Antiretroviral Drug Interactions Among the Aging HIV-Infected Population

BACKGROUND

Among aging HIV-infected adults, polypharmacy and its consequences have not been well-described.

OBJECTIVE

To characterize the extent of polypharmacy and the risk of antiretroviral (ARV) drug interactions among persons of different ages.

DESIGN AND PARTICIPANTS

Cross-sectional analysis among patients within the HIV Outpatient Study (HOPS) cohort who were prescribed ARVs during 2006–2010.

MAIN MEASURES

We used the University of Liverpool HIV drug interactions database to identify ARV/non-ARV interactions with potential for clinical significance.

KEY RESULTS

Of 3,810 patients analyzed (median age 46 years, 34 % ≥ 50 years old) at midpoint of observation, 1,494 (39 %) patients were prescribed ≥ 5 non-ARV medications: 706 (54 %) of 1,312 patients ≥ 50 years old compared with 788 (32 %) of 2,498 patients < 50 years. During the five-year period, the number of patients who were prescribed at least one ARV/non-ARV combination that was contraindicated or had moderate or high evidence of interaction was 267 (7 %) and 1,267 (33 %), respectively. Variables independently associated with having been prescribed a contraindicated ARV/non-ARV combination included older age (adjusted odds ratio [aOR] per 10 years of age 1.17, 95 % CI 1.01–1.35), anxiety (aOR 1.78, 95 % CI 1.32–2.40), dyslipidemia (aOR 1.96, 95 % CI 1.28–2.99), higher daily non-ARV medication burden (aOR 1.13, 95 % CI 1.10–1.17), and having been prescribed a protease inhibitor (aOR 2.10, 95 % CI 1.59–2.76). Compared with patients < 50 years, older patients were more likely to have been prescribed an ARV/non-ARV combination that was contraindicated (unadjusted OR 1.44, 95 % CI 1.14–1.82), or had moderate or high evidence of interaction (unadjusted OR 1.29, 95 % CI 1.15–1.44).

CONCLUSIONS

A substantial percentage of patients were prescribed at least one ARV/non-ARV combination that was contraindicated or had potential for a clinically significant interaction. As HIV-infected patients age and experience multiple comorbidities, systematic reviews of current medications by providers may reduce risk of such exposures.     

Adherence to Tobacco Dependence Treatment Among HIV-Infected Smokers

High prevalence of tobacco use and low success in quitting remain significant problems for reducing disease burden among HIV-infected persons. This study’s purpose was to examine participant responsiveness and tobacco dependence treatment adherence and their influences on tobacco abstinence among HIV-infected patients. This non-randomized study included HIV-infected smokers 18 years of age or older, who smoked at least 5 cigarettes per day, and had an interest in quitting smoking in the next 30 days. HIV-infected smokers (n = 247) received a 12-week tobacco dependence treatment intervention that included pharmacotherapy and telephone counseling. Younger age and non-White race were associated with lower adherence to pharmacotherapy. Younger age, non-White race, and increased monthly binge drinking were associated with lower adherence to telephone counseling. High participant responsiveness was associated with adherence to pharmacotherapy, counseling, and abstinence. Development and testing of interventions to improve adherence to evidence-based tobacco dependence treatment is warranted.