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Adherence to combination antiretroviral therapy: Synthesis of the literature and clinical implications
Abstract
Adherence to combination antiretroviral therapy has a strong impact on virologic response and emergence of viral resistance. However, monitoring adherence in the clinic is difficult. What a patient says or a clinician believes about a patient's adherence may be misleading. Patients with suboptimal adherence may have reduced or undetectable viral loads. On the other hand, viral load may not decrease in patients with perfect adherence because of pretreatment resistance, poor drug metabolism, or other factors. A multidisciplinary approach involving patients, health care professionals, family, and friends may optimize adherence. This article reviews the literature on adherence to antiretroviral therapy, critiques the various adherence measures used by researchers and clinicians, and discusses the clinical implications of adherence to antiretroviral therapy.
... The median age of the 307 women was 44 years [IQR: [33][34][35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51], the majority of whom identified as African, Caribbean, or Black [n ¼ 58, 56.3% with suboptimal adherence; n ¼ 123, 63.1% with optimal adherence]. Among the 307 participants, 201 (65.5%) reported optimal adherence defined as !95% ART adherence (Table 1). ...
... Adherence over 4 weeks may not reflect adherence over a longer period thus longitudinal analyses are required. Further, women in our study are young (44 years IQR [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] suboptimal adherence and 43 years IQR [36][37][38][39][40][41][42][43][44][45][46][47][48][49][50] optimal adherence) and with increasing life expectancy more comorbidities along with comedications are expected and this has been shown to increase the risk of ART non-adherence. 74 The NPHS has not been validated and affirmative/negative response options may have resulted in misclassification as it does not capture perceived stress which may differ between individuals. ...
... Adherence over 4 weeks may not reflect adherence over a longer period thus longitudinal analyses are required. Further, women in our study are young (44 years IQR [35][36][37][38][39][40][41][42][43][44][45][46][47][48][49][50][51] suboptimal adherence and 43 years IQR [36][37][38][39][40][41][42][43][44][45][46][47][48][49][50] optimal adherence) and with increasing life expectancy more comorbidities along with comedications are expected and this has been shown to increase the risk of ART non-adherence. 74 The NPHS has not been validated and affirmative/negative response options may have resulted in misclassification as it does not capture perceived stress which may differ between individuals. ...
Background: We aimed to identify the association between stress and antiretroviral therapy (ART) adherence among women in HIV care in Toronto, Ontario participating in the Ontario HIV Treatment Network Cohort Study (OCS) between 2007 and 2012.
Materials and methods: We conducted cross-sectional analyses with women on ART completing the AIDS Clinical Trial Group (ACTG) Adherence Questionnaire. Data closest to, or at the last completed interview, were collected from medical charts, through record linkage with Public Health Ontario Laboratories, and from a standardized self-reported questionnaire comprised of socio-demographic and psycho-socio-behavioral measures (Center for Epidemiologic Studies Depression Scale (CES-D), Alcohol Use Disorders Identification Test (AUDIT)), and stress measures (National Population Health Survey). Logistic regression was used to quantify associations with optimal adherence (≥95% adherence defined as missing ≤ one dose of ART in the past 4 weeks).
Results: Among 307 women, 65.5% had optimal adherence. Women with suboptimal compared to optimal adherence had higher median total stress scores (6.0 [interquartile range (IQR): 3.0–8.1] vs. 4.1 [IQR: 2.0–7.1], p = 0.001), CES-D scores (16 [IQR: 6–28] vs. 12 [IQR: 3–22], p = 0.008) and reports of hazardous and harmful alcohol use (31.1% vs. 17.9%, p = 0.008). In our multivariable model, we found an increased likelihood of optimal adherence with the absence of hazardous and harmful alcohol use (Adjusted Odds Ratio (AOR)=2.20, 95% confidence interval (CI): 1.12–4.32) and a decreased likelihood of optimal adherence with more self-reported stress (AOR = 0.56, 95% CI: 0.33–0.94).
Conclusions: Interventions supporting optimal ART adherence should address stress and include strategies to reduce or eliminate hazardous and harmful alcohol use for women living with HIV.
... 5 Poor adherence to ART has serious consequences for HIV-infected patients-their sexual partners, children and community at large, including failure to prevent viral replication, an increased likelihood of developing viral resistance, the development of clinical complications, and shortened survival. [6][7][8] In order to seamlessly support the adherence to ART amongst recipients of care, reaching impact saturation and epidemic control (RISE) of HIV/AIDs in Akwa Ibom state, a five (5) years USAID funded project jointly implemented by ICAP and Jhpiego instituted several interventions at the beginning of FY 21 (October, 2020) that included the use of cost-effective behavioral models. stage of change model (transtheoretical model) by Prochaska and DiClemente was utilized to evolve the behaviors of recipients of care from pre-contemplation, contemplation, preparation to action and preferably, maintenance phases and having systems in place that will prevent relapse. ...
Background: There has been limited use of stage of change model in scaling up self-care for optimal adherence to ART. The study aimed to assess the pattern of behavior and its associated factors among recipients of care (RoC) receiving treatment in Akwa Ibom state, Nigeria. Methods: A descriptive cross-sectional study was conducted among 423 RoC between August and October 2022. The pattern of behavior of RoC was determined using descriptive statistics, and factors associated with behavior were assessed using chi-square analysis and subsequently binary logistic regression at an alpha level of <0.05 at a 95% confidence interval using SPSS version 25. Results: Out of 423 recipients on care interviewed, 85% were in maintenance phase, and 13% in action phase. The correlates of behaviors of RoC were HIV diagnosis and on ART for over a year (p<0.001), residing in rural settings (p<0.001), and those in clinically stable DSD models (p<0.001). Over 87% of those in maintenance phase were adherent to ART, however, this was not statistically significant (p=0.21). Conclusions: Almost all the RoC were in good behavior and majority of them were adherent to ART. The factors associated with behavior of recipients of care were those diagnosed and on ART for over a year, residing in rural settings, and those in clinically stable differentiated service delivery (DSD) models. Interventions that utilize stage of change model to scale up the self-care of RoC particularly among those in the urban settings is highly imperative.
... Viral load is one of the most objective surrogate endpoints in measuring the progress of HIV/AIDS and treatment success, and every recipient on care need to be supported with several strategies including behavioral models to improve adherence to ART aimed at the achievement of this goal. Poor adherence to ART has serious consequences for HIV-infected patients, including failure to prevent viral replication, an increased likelihood of developing viral resistance, the development of clinical complications, and shortened survival [5][6][7]. ...
Background: Globally the benefits of undetectable viremia in preventing the transmission of HIV/AIDS have been established. Objective: The study aimed to assess the prevalence and determinants of undetectable viral load amongst HIV/AIDS clients receiving care and treatment in RISE-supported facilities in Akwa Ibom State, Nigeria. Methods: A descriptive cross-sectional study was conducted using secondary data from a validated Retention and Audit Determination Tool (RADET) file generated in September 2021. This was cleaned, imported into, and analyzed using a statistical package for social sciences (IBM SPSS) statistical package version 25. The prevalence of undetectable viremia was determined using descriptive statistics, and factors associated with undetectable viremia were assessed using chi-square analysis. Binary logistic regression was used to identify the determinants of undetectable viremia at an alpha level of <0.05 at a 95% confidence interval. Results: out of 47,575 recipients on care, 85.7% had undetectable viremia. Residing in rural areas (p<0.001, OR=1.3), respondents aged 25-49 years (p=0.008, OR=1.32), and those placed on Multi-Month Dispensing (MMD 6) (p<0.001, OR=1.45) were more likely to have undetectable viremia. While students (p=0.035, OR=1.2), and those employed (p=0.001, OR=1.102) were less likely to have undetectable viremia. Conclusion: This study reported a high prevalence of undetectable viremia. The determinants were occupation, residing in rural areas, productive age group, and being on MMD 6. Multiple interventions that include phone reminders and behavioral models to support self-care amongst urban dwellers are imperative. Differentiated interventions that include operation Triple Zero (OTZ) and Community Adolescent Treatment Supports (CATs) targeting the pediatric age group are needed to support the adherence to ART and undetectable viremia.
... The oldest indirect method for assessing adherence is physician perception. This method has low sensitivity between 24 and 62% depending on the definition of nonadherence [16]. ...
Non-adherence to antihypertensive treatment is frequent, complicates the care of hypertensive patients, represents one of the major causes of treatment failure and is linked with the increased risk of cardiovascular events. Identifying a non-adherent patient is one of the recent daily-practice tasks for which the ideal solution has not yet been found. Presence of certain clinical red flags should prompt the clinician to consider non-adherence. Chemical adherence testing using serum or urine antihypertensive levels is regarded as the best method so far and should be used if available. Alternatively, the check for prescription refills in the patient electronic medical records, or directly observed therapy with subsequent ambulatory blood pressure monitoring may be used. We suggest a simple algorithm to guide the clinicians to detect non-adherence in the practice.
... Patients may have guessed that their doctor was going to check the questionnaire and therefore more concerned about completing it "correctly" so as not to disappoint their doctor and perhaps could not freely write that they did not comply with the doctor's prescriptions all the time. Indeed, more generally, patients tend to respond to what their doctors want to hear and therefore overestimate their adherence [32]. Further studies may be needed to make the administration procedure more anonymous (e.g., using a closed, anonymous box to collect the questionnaire outside the physician's office). ...
Background
The Generic Adherence for Chronic Diseases Profile is a French generic scale (GACID-P) developed to measure adherence in several disease areas such as cardiology, rheumatology, diabetes, cancer and infectiology.
Method
We aimed to study the measurement invariance of the Generic Adherence for Chronic Diseases Profile by an item response model, optimize the new instrument version from item response model and qualitative content analyses results, and validate the instrument. The metric properties of the optimized version were studied according to classical test theory and item response model analysis.
Results
A sample of 397 patients consulting at two French hospitals (in diabetes, cardiology, rheumatology, cancerology and infectiology) and in four private practices was recruited; 314 (79%) patients also completed the questionnaire 15 days later. Factor analyses revealed four dimensions: “Forgetting to take medication”, “Intention to comply with treatment”, “Limitation of risk-related consumer habits” and “Healthy lifestyle”. The item response model and content analyses optimized these four dimensions, regrouping 32 items in four dimensions of 25 items, including one item conditioned on tobacco use. The psychometric properties and scale calibration were satisfactory. One score per dimension was calculated as the sum of the items for the dimensions “Forgetting to take medication” and “Intention to comply with treatment” and as a weighted score according to the item response model analysis for the two other dimensions because of differential item functioning found for two items.
Conclusion
Four adherence profile scores were obtained. The instrument validity was documented by a theoretical approach and content analysis. The Generic Adherence for Chronic Diseases Profile is now available for research targeting adherence in a broad perspective.
... Third, this study shares with many others some of the general methodological problems related to adherence assessment based on patients' self-reports, which may be affected by social desirability and recall bias [19]. Various studies of HAART-treated patients have indeed shown that self-reports tend to estimate adherence as slightly higher than alternative methods of measurement (such as unannounced pill counts and electronic medication monitors) [4,20], especially among some specific populations such as drug users [21]. ...
Objective
To assess the impact of different patterns of adherence to highly active antiretroviral therapy (HAART), in particular, the relative impact of early and late adherence, on long-term immuno-virological response in HIV-infected individuals started on a protease inhibitor-containing regimen.
Design
Clinical, immuno-virological and self-reported adherence data were collected at 4 (M4), 12 (M12), 20 (M20), 28 (M28) and 36 (M36) months after HAART initiation in the French APROCO cohort.
Methods
A standardized self-administered questionnaire classified patients as non-adherent, moderately or highly adherent at each visit. Stable viral suppression at both M28 to M36, and a CD4 cell increase >200 between M0 and M36 were used as outcome measures.
Results
Of the 582 patients followed regularly through M36, 360 patients had complete adherence data. Although 59.2% were highly adherent at M4, only 25.8% maintained consistent high adherence throughout the follow-up. High adherence at M4 was independently associated with both stable viral suppression at M28–M36 [OR (95% CI): 2.8 (1.4–5.5)] and a CD4 cell increase >200 during the same period [OR (95% CI): 3.9 (1.7–9.7)]. However, ‘moderately adherent’ patients between M12 and M36 had the same likelihood [OR (95% CI): 1.9 (1.1–3.2)] as patients who were always high adherent [OR (95% CI): 1.9 (1.1–3.2)] of achieving stable viral load suppression, relative to those who reported non-adherence episodes.
Conclusion
Optimizing adherence in the early months of treatment is crucial to ensure long-term immuno-virological success. Moderate deviations from high adherence during follow-up have a less negative impact. Priority should be given to interventions aimed to improve adherence in the early months of HAART.
... L'observance est d'autant plus importante que, dans le cas du VIH, le standard actuel reconnu est une adhésion à au moins 95% de la prise de médication (Paterson, et al., 2000). Les résultats de recherches actuelles laissent voir, cependant, qu'en moyenne, les personnes ont un taux d'observance qui se situe autour de 71% à 80% (Golin, Liu, Hays, Miller, Beck, Ickovies, Kaplan & Wenger, 2002;Miller & Hays, 2000). ...
... The effective use of anti-retroviral therapy (ART) among people living with HIV (PLHIV) has dramatically reduced AIDS-related morbidity and mortality [1][2][3], while simultaneously reducing sexual transmission of the virus to others [4,5]. Despite the promise of increased access to and use of ART across settings and populations over time, both HIV treatment and prevention outcomes remain suboptimal due in part to barriers related to consistent adherence to daily oral ART [6][7][8][9]. Switching from multiple tablets, often several times a day, to a single tablet regimen has been found to improve adherence and virologic suppression, however optimal adherence remains a problem for many people currently on daily oral ART [10]. Lack of ART adherence can also lead to viral resistance, making HIV infection more difficult to treat. ...
Background:
Long-acting (LA) injectable antiretroviral therapy (ART) has been found non-inferior to daily oral ART in Phase 3 trials. LA ART may address key barriers to oral ART adherence and be preferable to daily pills for some people living with HIV. To date, women have been less represented than men in LA ART research. Using longitudinal data from the Women's Interagency HIV Study (WIHS) cohort of women living with HIV in the United States, we examined barriers and facilitators of daily oral ART adherence that may be related to or addressed by LA ART.
Methods:
We conducted a secondary analysis of WIHS cohort data from 1998 to 2017 among participants seen for at least 4 visits since 1998 who reported using ART at least once (n = 2601). Two dichotomous outcomes, patient-reported daily oral ART adherence and viral suppression were fit using generalized linear models, examining the role of socio-demographic and structural factors.
Results:
At study enrollment, the median age was 40.5 years, 63% of participants were African American and 22% were Latina. The majority (82%) reported taking ART more than 75% of the time and 53% were virally suppressed. In multivariate analysis, several sub-groups of women had lower odds of reported adherence and viral suppression: 1) younger women (adherence aOR: 0.71; viral suppression aOR: 0.63); 2) women who inject drugs (adherence aOR: 0.38; viral suppression aOR: 0.50) and those with moderate (adherence aOR: 0.59; viral suppression aOR: 0.74) and heavy alcohol consumption (adherence aOR: 0.51; viral suppression aOR: 0.69); 3) those with depressive symptoms (adherence aOR: 0.61; viral suppression aOR: 0.76); and 4) those with a history of going on and off ART (adherence aOR: 0.62, viral suppression aOR: 0.38) or changing regimens (adherence aOR: 0.83, viral suppression aOR: 0.56).
Conclusions:
Current injectable contraceptive users (vs. non-users) had greater odds of oral ART adherence (aOR: 1.87) and viral suppression (aOR: 1.28). Findings identify profiles of women who may benefit from and be interested in LA ART. Further research is warranted focused on the uptake and utility of LA ART for such key subpopulations of women at high need for innovative approaches to achieve sustained viral suppression.
La perte de vue (PDV) est l’un des obstacles majeurs au succès thérapeutique. Au Mali, l’accès au traitement antirétroviral (TARV) s’est élargi avec l’instauration de la gratuité des soins pour les PVVIH de 2004 à nos jours. L’objectif était d’évaluer chez les PVVIH sous TARV, la PDV avant la clôture de la base (absence de visites cliniques et/ou biologiques pendant au moins 6 mois), et le retour dans le soin des PVVIH PDV au cours du suivi (1 visite clinique et/ou biologique au décours de la PDV), puis d’identifier les facteurs de risque associés à ces évènements. Les données de PVVIH âgées ≥18 ans, débutant un TARV entre 2006-2013, et suivies dans l’un des 16 centres disposant d‘ESOPE ont été utilisées. Parmi les 9 821 PVVIH inclues, l’incidence de la PDV est passée de 15,7% à 1 an à 35,2% à 5 ans de TARV. Les facteurs de risque associés à la PDV étaient : le fait d’être un homme ou jeune, d’avoir initier le TARV dans les périodes 2010-2012 ou 2013, d’avoir un faible niveau socio-économique et d’être suivi dans des hôpitaux situés >5 km du domicile ou dans des cliniques régionales situées <5 km du domicile. L’incidence du retour dans le soin estimée chez les PVVIH ayant initié un TARV entre 2006-2012 et ayant été PDV au cours du suivi avant le 31/12/2013 (n=3 650) est passée de 39,0% à 1 an à 47,0% à 3 ans après PDV. Les facteurs associés au retour dans le soin étaient le fait d’être enceinte à l’initiation du TARV, d'avoir reçu un TARV pendant 6 à 12 mois avant la PDV ou de l'avoir reçu pendant au moins 12 mois avec un gain de CD4 sur 12 mois ≥50 cells/µL avant la PDV par rapport à avoir reçu un TARV pendant moins de 6 mois, ou d’être suivi à Bamako.
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