Can Short-Term Use of Electronic Patient Adherence Monitoring Devices Improve Adherence in Patients Failing Second-Line Antiretroviral Therapy? Evidence from a Pilot Study in Johannesburg, South Africa.

Denise Evans,Matthew P Fox,Arthemon Nguweneza,Faith Moyo,Rebecca Berhanu,Lawrence Long

doi:10.1007/s10461-016-1417-7

Denise Evans, Matthew P Fox + Show 4 more

Open Access

https://doi.org/10.1007/s10461-016-1417-7

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Abstract

High levels of adherence are required to achieve the full benefit of ART. We assess the effectiveness of electronic adherence monitoring devices among patients failing second-line ART, as measured by viral load suppression. Cohort study of Wisepill™ real-time adherence monitoring in addition to intensified adherence counselling over 3 months in adults with a viral load ≥400 copies/ml on second-line ART in Johannesburg, South Africa between August 2013 and January 2014. Patients were sent SMS reminders upon missing a scheduled dose. We compared outcomes to earlier historical cohorts receiving either intensified adherence counselling or adherence counselling alone. Overall, 63 % of the participants (31/49) took >80 % of their prescribed medication; this dropped from 76 to 53 and 49 % at 1, 2 and 3 months post-enrolment respectively. Compared to those with good adherence (>80 %), participants with poor adherence (≤80 %) had a higher risk for a subsequently elevated viral load ≥400 copies/ml (relative risk (RR) 1.47 95 % CI 0.97–2.23). Participants found the intervention “acceptable and useful” but by 6 months after eligibility they were only slightly more likely to be alive, in care and virally suppressed compared to those who received intensified adherence counselling (44.9 vs. 38.5 %; RR 1.19; 95 % CI 0.85–1.67) or adherence counselling alone (44.9 vs. 40.9 %; RR 1.12; 95 % CI 0.81–1.56). In patients with an elevated viral load on second-line ART electronic adherence monitoring was associated with a modest, but not significant, improvement in viral suppression.

Highlights

The advent of antiretroviral therapy (ART) has led to significant reductions in morbidity and mortality [1,2,3]
Compared to participants in the intervention cohort, those who were in the standard adherence cohort and intensified adherence cohort differed in terms of gender, had higher median CD4 counts at eligibility
When testing the association between the three groups and our primary outcome we found that patients receiving a combination of Electronic adherence monitoring device (EAMD) and intensified adherence counselling demonstrated small differences in proportions alive, in care and virally suppressed at 6 months after an elevated viral load on second-line ART when compared to intensified adherence counselling (RR 1.19; 95 % confidence intervals (CI) 0.85–1.67; risk difference 0.06) or adherence counselling alone (RR 1.12; 95 % CI 0.81–1.56; risk difference 0.04)

Summary

Introduction

The advent of antiretroviral therapy (ART) has led to significant reductions in morbidity and mortality [1,2,3]. Despite the huge successes in increasing HIV treatment coverage, most patients who experience virologic failure on second-line ART in low-middle income countries fail due to poor adherence rather than resistance to a class of ART drugs [4, 5]. For patients on second-line protease inhibitor-based ART, high levels (C80 %) of adherence are required for viral suppression and poorer outcomes are observed when adherence drops [6, 7]. Some patients demonstrating poor adherence go on to fail therapy, develop resistance and require more expensive subsequent treatment regimens [8,9,10,11,12]. In South Africa, second-line treatment is readily available but comes at a significantly higher cost compared to first-line therapy, which forces a shift of resources away from initiating new patients onto treatment [11]. Delaying the need for secondand third-line therapy through improved treatment

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