A Fluctuating Pattern of Over- and Under-Adherence for HAART: A Case Study from a Videophone Intervention Project

Highly Active Antiretroviral Therapy (HAART) has transformed HIV from a terminal illness to a chronic condition. While disagreement remains regarding the level of medication adherence required to achieve and maintain viral suppression, the highest possible rate is preferable. This article discusses the case study of "Bob," a 54 year-old man living with HIV for 25 years. At baseline, Bob evinced fluctuating patterns of medication over- and under-adherence and reported numerous negative side effects. Bob participated in eight videophone-administered adherence intervention sessions. His adherence improved to a high of 97.9% at one-month follow-up; his negative treatment side effects subsided considerably. This case study demonstrates that videophone technology is a potential medium by which to assess and intervene upon HIV medication adherence.     

Methamphetamine abuse as a barrier to HIV medication adherence among gay and bisexual men

Medication adherence among persons with HIV infection is important not only because of the effect of non-adherence on an individual's health but also because non-adherence can lead to medication-resistant viral strains. However, adherence to HIV medications is difficult due to complex dosing regimens and side effects. This paper is a qualitative analysis of HIV medication adherence among gay and bisexual methamphetamine-abusing men enrolled in an outpatient drug treatment research project. As part of an open-ended, semi-structured interview, 23 HIV-infected men discussed the effects of their methamphetamine use on their medication adherence. Substance-use barriers to adherence were coded into two main themes: (1) planned non-adherence and (2) unplanned non-adherence. Planned non-adherence was a strategy for coping with demanding HIV medication schedules, or was linked to sexual behaviours while using methamphetamine or to fears of interaction effects from mixing methamphetamine with HIV medications. Participants did not define their medication regimen adjustments as non-adherence but as a way to achieve a sense of control over their lives. Unplanned non-adherence was linked to methamphetamine-related disruptions in food and sleep schedules. Findings are helpful in designing culturally specific HIV medication adherence interventions for this population.     

The impact of neurobehavioral features on medication adherence in HIV: Evidence from longitudinal models

Effective antiretroviral therapy has led to substantial improvements in health-related outcomes among individuals with HIV. Despite advances in HIV pharmacotherapy, suboptimal medication adherence remains a significant barrier to successful treatment. Although several factors have been associated with medication adherence in the extant literature, study assessing the effects of some of the neurobehavioral features specific to HIV has been limited. Moreover, although there is a growing body of literature measuring medication adherence in HIV prospectively, few employ advanced statistical methodologies suited to handle advanced models with multiple predictors that would strengthen our understanding of medication adherence trajectories in HIV. This study sought to integrate traditionally assessed predictors of medication adherence with neurobehavioral features of HIV in a longitudinal study of medication adherence to combined antiretroviral therapy (cART). The current study used multilevel modeling to examine a wide arrangement of categories of factors – demographic, medication related, psychosocial, and neurobehavioral – on medication adherence. The sample consisted of 235 HIV+ individuals whose medication adherence was monitored over the course of six months using electronic monitoring devices. After controlling for the effects of demographic, medication, and psychosocial factors, neurobehavioral features added predictive validity to the model. In the final model, simultaneously controlling for the effects of each of the predictors within all the categories, age, self-efficacy, executive functioning, apathy, and frequency of stimulant use emerged as unique individual predictors of average medication adherence across the 6-month study. Self-efficacy and irritability predicted changes in medication adherence over time. Adherence behavior is multidetermined. Adequate assessment of these factors, combined with timely intervention, appears to be warranted in order to boost adherence rates.     

HIV patient insight on adhering to medication: a qualitative analysis

Research on HIV medication adherence has relied mainly on quantitative methods. The objective of this study was to explore factors associated with adherence from the HIV-infected patient's perspective. Six focus groups were convened with treatment-experienced HIV-positive individuals. The discussions focused on issues that make it easy or difficult to adhere to HIV regimens. Thirty-five patients participated in the focus groups, which were conducted in Washington, D.C., and Los Angeles. The mean age was 48; 66% were male; 63% were black; and 40% contracted HIV through heterosexual contact. Six major themes emerged from the data that influenced adherence to medication: regimen complexity/medication features (including number of pills), lifestyle fit, emotional impacts (including worry, anger, stress and anxiety), side effects, medication effectiveness, and communication (including information from friends, physicians, and published sources). The data informed a conceptual framework, illustrating the possible interactions among these themes that can potentially be used by clinicians when discussing HIV treatment options with patients. This is potentially one of the first focus group studies concentrating on HIV medication adherence. The findings highlight specific factors that should be considered when trying to improve adherence and may be helpful in clinical decision-making.     

Side effects,adherence self-efficacy,and adherence to antiretroviral treatment: a mediation analysis in a Chinese sample

Antiretroviral therapy (ART) is a lifelong treatment. To date, ART adherence is suboptimal for most patients in resource-poor settings. Previous research indicates that medication side effects are perceived to be a significant barrier of high ART adherence. Data regarding the role of adherence self-efficacy in mediating the relationship between side effects from ART and adherence to ART are limited; thus, this study examines this potential mediational role of self-efficacy. A cross-sectional survey of 2987 people living with HIV aged ≥18 years was conducted in 2012–2013 in Guangxi Autonomous Region (Guangxi) which has one of the fastest-growing HIV rates in China. Of the total sample, 2146 (72.1%) participants had initiated ART. Participants reported the number of days of completing the daily dose of ART in the past month; adherence was defined as completing the daily dose at least 28 days in the last month (≥90%). Side effects were significantly negatively related to adherence to ART. Mediation analyses indicated that adherence self-efficacy significantly mediated the side effects–adherence relationship. Future interventions to increase adherence self-efficacy and effective coping with side effects among HIV patients are needed in order to improve their ART adherence.     

Gender differences in factors associated with adherence to antiretroviral therapy

OBJECTIVE: To identify gender differences in social and behavioral factors associated with antiretroviral adherence. DESIGN: Prospective cohort study. SETTING: Methadone maintenance program. PARTICIPANTS: One hundred thirteen HIV-seropositive current or former opioid users. MEASUREMENTS AND MAIN RESULTS: Participants were surveyed at baseline about social and behavioral characteristics and at monthly research visits about drug and alcohol use and medication side effects. Electronic monitors (MEMS) were used to measure antiretroviral adherence. Median adherence among women was 27% lower than among men (46% vs. 73%; P < .05). In gender-stratified multivariate models, factors associated with worse adherence in men included not belonging to an HIV support group (P < .0001), crack/cocaine use (P < .005), and medication side effects (P = .01). Among women, alcohol use (P = .005), heroin use (P < .05), and significant medication side effects (P < .005) were independently associated with worse adherence. In a model including both men and women, worse adherence was associated with lack of long-term housing (P < .005), not belonging to any HIV support groups (P < .0005), crack or cocaine use (P < .01), and medication side effects (P < .0005). In addition, worse adherence was associated with the interaction between female gender and alcohol use (P < or = .05). CONCLUSIONS: In this cohort of current and former opioid users, gender-stratified analysis demonstrated that different social and behavioral factors are associated with adherence in men and women. Among both men and women, worse adherence was associated with lack of long-term housing, not belonging to an HIV support group, crack/cocaine use, and medication side effects. Among women only, alcohol use was associated with worse adherence.     

Medication Adherence Mediates the Relationship between Adherence Self-efficacy and Biological Assessments of HIV Health among those with Alcohol Use Disorders

The current study examines the relationship between negative consequences of alcohol use, adherence self-efficacy, medication adherence, and biological markers of HIV health (CD4 count and viral load). A total of 275 HIV-positive men and women with alcohol use disorders were surveyed using Audio-CASI measures and time line followback interviews. Findings from a structural equation model suggest that negative consequences related to alcohol use did not directly impact HIV health. Adherence self-efficacy had direct effects on viral load, but not CD4 count. Mediation analyses indicated that self-reported adherence partially mediated the relationship between adherence self-efficacy and viral load. Cognitive-oriented interventions aimed at facilitating adherence self-efficacy may be effective in improving both medication adherence and HIV health. If facilitating confidence improves HIV health, then health care providers can make a strong impact by spending a few short minutes themselves and/or partnering with behavioral health clinicians using techniques like motivational enhancement.     

Medication adherence practices of HIV/AIDS case managers: a statewide survey in North Carolina

The primary objective of this study was to examine the adherence-related practices and attitudes of HIV/AIDS case managers in North Carolina. All North Carolina HIV/AIDS case managers (n = 111) employed by agencies that were state certified to provide HIV case management were sent an adherence counseling survey. Negative binomial regression was used to examine the relationship of case managers' characteristics and attitudes with their medication adherence counseling practices. Of the 94 HIV/AIDS case managers who responded to the survey, the majority (65%) reported discussing medications with almost every client. The adherence-related behaviors that case managers most frequently provided were related to monitoring medication usage rather than providing medication instruction. Most case managers believed that medication adherence counseling is part of their role (77%); however, a substantial minority, (36%) did not believe that their adherence counseling skills were adequate. Multivariate analysis revealed that case managers who provided more adherence counseling services reported greater confidence in their adherence counseling skills, believed that adherence counseling is a HIV/AIDS case management role, and had a higher proportion of substance-abusing clients in their caseload. The adherence counseling activities of HIV/AIDS case managers can potentially supplement the counseling provided by other health professionals and promote greater adherence to medications. However, variability in perceived skills and adherence-related activities suggests that the role of case managers in medication adherence counseling needs to be better defined and appropriate training provided to meet the expectations of this role.     

Psychological and behavioral barriers to ART adherence among PLWH in China: role of self-efficacy

Globally, optimal adherence to antiretroviral therapy (ART) is insufficient despite it is critical for maximum clinical benefits and treatment success among people living with HIV (PLWH). Many factors have been evidenced to influence medication adherence, including perceived barriers and self-efficacy. However, limited data are available regarding to psychological and behavioral barriers to ART adherence in China. Moreover, few studies have examined the mechanism of these two factors underlying HIV medication adherence. The aim of the current study is to examine the mediating role of adherence self-efficacy between perceived barriers and ART adherence among PLWH. Cross-sectional data were obtained from 2095 PLWH in Guangxi China who provided data on ART adherence. Participants reported their medication adherence, self-efficacy, barriers to ART adherence, as well as background characteristics. Results indicated a significant indirect effect from perceived barriers to medication adherence through adherence self-efficacy. Higher perceived psychological and behavioral barriers to ART adherence were related to lower adherence self-efficacy, which in turn was related to lower ART adherence. Self-efficacy could buffer the negative effects of perceived barriers on ART adherence. Future interventions to promote HIV medication adherence are recommended to focus on eliminating psychological and behavioral barriers, as well as increasing adherence self-efficacy.     

Relationship of depression and catastrophizing to pain, disability, and medication adherence in patients with HIV-associated sensory neuropathy

Few studies have examined how patients with chronic HIV infection cope with pain and how pain relates to medication adherence. Pain coping strategies such as catastrophizing are often associated with increased pain and disability and may also influence adherence to medications. The goal of our study is to assess the relationship of catastrophizing and depression to pain, disability, and medication adherence through questionnaires administered to a cross-section of patients with HIV-associated sensory neuropathy. In our study, 46 HIV-seropositive subjects completed questionnaires evaluating neuropathic pain severity, pain catastrophizing, pain-related disability, depressive symptoms, severity of antiretroviral therapy (ART) side effects, and common reasons for medication nonadherence. Hierarchical regression analysis indicated that pain catastrophizing correlated with severity of neuropathic pain independent of depressive symptoms. Furthermore, depressive symptoms were not associated with multiple factors independent of pain catastrophizing such as severity of neuropathic pain and pain-related disability. Pain catastrophizing, but not depressive symptoms, correlated with increased pain disability even after controlling for the effects of age and neuropathic pain. We also found that poor adherence attributed to fear of side effects or forgetfulness was associated with increased severity of neuropathic pain, while depressive symptoms but not catastrophizing correlated with ART side effects. These findings suggest that both catastrophizing and depressive symptoms are important factors to consider in the management of pain from HIV neuropathy and adherence to ART.     

Adherence to Medication Treatment: A Qualitative Study of Facilitators and Barriers Among a Diverse Sample of HIV+ Men and Women in Four U.S. Cities

Most studies examining HIV antiretroviral medication treatment adherence involve quantitative surveys. Although these studies have identified factors associated with medical adherence, no single variable or combination of variables is sufficiently consistent to apply to any individual or group of people. Using qualitative methods, an ethnically diverse sample (N = 110) of HIV+ women, men who have sex with men, and male injecting drug users in four U.S. cities were interviewed in depth to elicit their experiences, perspectives, and life contexts regarding knowledge, attitudes, beliefs, and experiences with HIV medication adherence. Most described multiple influences on medication-taking behavior, describing adherence as a dynamic phenomenon that changes over time with their changing beliefs, attitudes, emotions, and daily and larger life events. Prevalent themes include ambivalence toward HIV medication and intentional nonadherence, usually to address physical side effects. Factors from different domains (e.g., cognitive, emotional, interpersonal) can have compensatory influences on behavioral outcomes. Findings are discussed in terms of social action theory, contributing to our theoretical understanding of the phenomenon of adherence.     

A structural equation model of HIV-related stigma, depressive symptoms, and medication adherence

HIV-related stigma has a damaging effect on health outcomes among people living with HIV (PLWH), as studies have associated it with poor HIV medication adherence and depressive symptoms. We investigated whether depressive symptoms mediate the relationship between stigma and medication adherence. In a cross-sectional study, 720 PLWH completed instruments measuring HIV-related stigma, depressive symptoms, and HIV medication adherence. We used structural equation modeling (SEM) to investigate associations among these constructs. In independent models, we found that poorer adherence was associated with higher levels of stigma and depressive symptoms. In the simultaneous model that included both stigma and depressive symptoms, depression had a direct effect on adherence, but the effect of stigma on adherence was not statistically significant. This pattern suggested that depressive symptoms at least partially mediated the association between HIV-related stigma and HIV medication adherence. These findings suggest that interconnections between several factors have important consequences for adherence.     

Predictors of antiretroviral adherence

This study was conducted in order to help determine the key factors that predict adherence to antiretroviral medications. A total of 115 HIV/AIDS patients who were having trouble adhering to their antiretroviral regimens completed face-to-face interviews in which adherence levels, medication side effects, mental health, social support, patient-provider relationship characteristics, substance use and health anxiety were assessed. Three measures of adherence were used: adherence over the past three days, adherence over the past week, and adherence over the past month. Logistic regression analyses indicated strongest prediction of three-day adherence, with mental health, social support, patient-provider relationship characteristics and side effects contributing to prediction. Past week adherence was associated with age and social support measures, and showed a marginal association with side effects. Past month adherence was less strongly predicted, with social support and alcohol use contributing to prediction. Thus, a variety of factors were found to determine adherence, and implications of the findings for adherence models and interventions are discussed.     

Changes in Attitudes Toward Antiviral Medication: A Comparison of Women Living with HIV/AIDS in the Pre-HAART and HAART Eras

To examine potential changes in attitudes toward antiviral medication since the advent of highly active antiretroviral therapy (HAART), focused interviews were conducted with two samples of women living with HIV/AIDS; one in the pre-HAART era (1994–1996) and a second matched sample in the HAART era (2000–2003). Women in the pre-HAART era held highly negative attitudes toward antiviral medications, perceived them as ineffective with few benefits and viewed side effects as intolerable. In contrast, women in the HAART era were less likely to report negative attitudes, which were balanced by more frequent reports of perceived benefits and more likely to view side effects as temporary and manageable. African American women in both eras were more likely to hold negative attitudes and less likely to perceive benefits than White and Puerto Rican women. These findings suggest that views of antiviral medication have improved since the advent of HAART, but that negative attitudes and side-effect concerns remain which should be addressed in interventions to promote treatment acceptance and adherence.     

Influence of side effect information on patient willingness to take medication: consequences for informed consent and medication adherence

Medication side effect information can create negative patient expectations of side effects, but such information is considered crucial to informed consent. The current study investigated the effect of informing participants of different numbers of medication side effects. Willingness to take the medication was highest for those informed of one or four compared with none or 26 side effects, and memory of side effects was also more accurate. Findings suggest that informing patients of some, but not several, side effects may optimise both medication adherence and accuracy of informed consent.     

Prediction of adherence to antiretroviral therapy: a one-year longitudinal study

The aim of this longitudinal study was to identify the determinants of adherence to antiretroviral therapy (ART) in HIV patients over a period of 12 months. A total of 376 individuals living with HIV treated with ART participated in the study. Data were collected at baseline and at three, six, nine and 12 months. Variables assessed were adherence, attitude, outcome expectancies, self-efficacy, patient satisfaction with the relationship with their physician, provision of social support, optimism, CD4 cell count, viral load and side effects. Predictors of adherence in the Generalized Estimated Equation (GEE) were: high perception of self-efficacy (OR=1.68; 95%CI 1.27-2.22), positive attitude towards taking medication (OR=1.56; 95%CI 1.18-2.06), not living alone (OR=1.47; 95%CI 1.04-2.08) and being a male (OR=2.81; 95%CI 1.47-5.34). Subsequent analysis showed that a positive attitude towards taking medication was associated with a high level of patient satisfaction with their physician, high perceived social support, being optimistic, living with HIV for five years or less and experiencing no side effects. Also, a strong sense of self-efficacy was associated with positive perception of social support, high level of patient satisfaction with their physician and not living alone. These results suggest that interventions aimed at improving adherence to ART should focus on reinforcing self-efficacy and developing a positive attitude towards taking medication.     

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.     

Training Substance Abuse Counselors About HIV Medication Adherence

Abstract

High levels of medication adherence are crucial to the success of HIV treatment. Consequently, substance abuse counselors (SACs), social service and other care providers can best support their HIV positive clients when they understand adherence and related interventions. This paper describes a training program that was designed to increase counselor knowledge of HIV medications, adherence strategies and enhance counseling skills specific to HIV adherence. For substance abuse counselors the training needs included: better understanding of medication interactions, relapse, recovery, and interdisciplinary communication. Thirty-six SACs from three agencies completed the 11/2-day training, which included lecture discussions, case discussion and interactive client case simulations. Success in accomplishing training objectives was evaluated at three points: preintervention training, post-intervention, and six month follow-up to determine changes in participants' knowledge, attitudes and behaviors related to adherence counseling. Three case scenarios measuring counselor comfort levels indicated SACs felt significantly more comfortable discussing relapse and medication issues with their HIV affected clients than they would in discussing medication issues with the client's physician. However, they felt slightly more comfortable about physician discussions after training. Open-ended comments by SACs at six-month follow-up provided insights into recovery issues their clients faced. The findings suggest ways medication adherence could fit the reality of serving clients with co-occurring HIV and substance use to better meet their health and support needs.     

Factors associated with adherence to antiretroviral therapy among HIV + Patients in Guangxi,China

This study employed logistic regression to examine the factors that predict medication adherence among a total of 2,146 HIV-infected individuals who were receiving antiretroviral therapy (ART) in Guangxi, China. Of these participants, 1,388 patients (64.7%) did not miss any medication dose. Medication-specific social support (OR = 1.50, 95% CI: 1.05–2.13), no/less experience of influential side effects (OR = 1.38, 95% CI: 1.05–1.81), and direct coping (OR = 1.11, 95% CI: 1.01–1.22) are significant predictors of never missing doses. However, longer duration of receiving ART (OR = 1.60, 95% CI: 1.00–2.57), ever use of synthetic drugs (OR = 2.70, 95% CI: 1.58–4.61), and actively social support seeking (OR?=?.95, 95% CI: .90–.99) are significant predictors of ever missing adherence. HIV treatment and care in Guangxi should address potential treatment fatigue, offer medication-specific social support, and help patients to prevent, reduce, or manage side effects of treatment. Continuing research is greatly needed on the influence of coping strategies on medication adherence.