Electronic Drug Monitoring Research Articles

Heterogeneity Among Studies in Rates of Decline of Antiretroviral Therapy Adherence Over Time

To use electronic drug monitoring to determine if adherence to HIV antiretroviral therapy (ART) changes over time, whether changes are linear, and how the declines vary by study.We conducted a longitudinal study of pooled data from 11 different studies of HIV-infected adults using ART. The main outcome was ART adherence (percent of prescribed doses taken) measured by electronic drug monitoring. We modeled and compared changes in adherence over time using repeated measures linear mixed effects models and generalized additive mixed models (GAMMs). Indicator variables were used to examine the impact of individual studies, and the variation across studies was evaluated using study-specific parameter estimates calculated by using interaction terms of study and time.The mean age of the subjects was 41 years, 35% were female, most had high school education or less, and 46% were African American. In GAMMs, adherence declined over time. The GAMMs further suggested that the decline was nonlinear, and in both sets of models, there was considerable study-to-study variability in how adherence changed over time.Findings may not be generalizable to non-US populations or to patients not in clinical studies.Although overall ART adherence declined with time, not all studies showed declines, and a number of patterns of change were seen. Studies that identify clinical and organizational factors associated with these different patterns are needed. Models of changes in adherence with time should take account of possible nonlinear effects.

A novel ingestible electronic drug delivery and monitoring device

We developed an ingestible electronic drug delivery and monitoring system. This system includes an electronic capsule comprising a drug reservoir, a pH and temperature sensor, a microprocessor and wireless transceiver, a stepper motor, and batteries. The location of the capsule in the gut derived from pH data can be monitored in real time. The stepper motor can be remotely actuated to expel the contents of the drug reservoir. First human study. Two consecutive observational studies. University medical center. Twenty healthy volunteers. Study I: Ingestion and passage of the capsule. Study II: Ingestion and passage of the capsule, loaded with (99m)technetium-pertechnetate ((99m)Tc); remotely actuated expulsion of (99m)Tc in the gut. Study I: Safety, tolerability, and functionality (wireless pH and temperature recording). Study II: Tracing of the capsule and expulsion and distribution of (99m)Tc from the drug reservoir by scintigraphy. Correlating location pH with scintigraphy. Study I: Ingestion and passage of the capsule was safe and well tolerated. Transmitted pH and temperature data were received by the recorder in 96.5% ± 3%. Study II: pH-determined passage of the esophagogastric, gastroduodenal, and ileocolonic junction correlated well with scintigraphy. Expulsion of (99m)Tc from the capsule was successful in 9 of 10 subjects. Subjects with relatively low body mass index. This electronic drug delivery and monitoring system may be a promising tool for targeted delivery of substances to well-defined areas of the GI tract.

Cost of Behavioral Interventions Utilizing Electronic Drug Monitoring for Antiretroviral Therapy Adherence

To provide data on the actual costs associated with behavioral ART adherence interventions and electronic drug monitoring used in a clinical trial to inform their implementation in future studies and real-world practice. Direct and time costs were calculated from a multisite 3-arm randomized controlled ART adherence trial. HIV-positive participants (n = 204) were randomized to standard care, enhanced counseling (EC), or EC and modified directly observed therapy (mDOT) interventions. Electronic drug monitoring (EDM) was used. Costs were calculated for various components of the 24-week adherence intervention. This economic evaluation was conducted from the perspective of an agency that may wish to implement these strategies. Sensitivity analyses were conducted to examine costs and savings associated with different scenarios. Total direct costs were $126,068 ($618 per patient). Initial time costs were $53,590 ($262 per patient). Base cost of labor was $0.36/min. EC costs for 134 patients were $18,427 ($137 per patient) and mDOT for 64 patients cost $18,638 ($291 per patient). Total per patient costs were as follows: standard care = $880, EC = $1018, EC/mDOT = $1309. Removing driving costs evidenced the most variable impact on savings between the 3 study arms. The tornado diagram (sensitivity analysis) showed a graphical representation of how each sensitivity assumption reduced costs compared with each other and the resulting comparative costs for each group. This novel economic analysis provides valuable cost information to guide treatment implementation and research design decisions.

Can technology change the work of nurses? Evaluation of a drug monitoring system for ambulatory chronic disease patients

ObjectiveTo evaluate the impact of an electronic drug monitoring system (eDMS) for ambulatory rheumatology patients on time nurses spent on, and the process of, drug monitoring. MethodsThe study was conducted in the Rheumatology Department of a large metropolitan hospital. The eDMS, a module of the Hospital Clinical Information System (HCIS), was designed to allow electronic ordering and subsequent monitoring of ambulatory patients on long-term, immunosuppressive rheumatology medications. Quantitative measures collected before and after the intervention were: time spent on specific nursing activities; who nurses spent time with; format and location of documentation monitoring; and patient throughput. Qualitative data from interviews and observations were collected to ascertain the impact of the eDMS on nurses’ monitoring activities. ResultsNurses spent significantly less time on medication monitoring tasks (33.1% versus 26.4%, P=0.003) and significantly more time on patient care (6.5–18.1%, P<0.0001) following implementation of the eDMS. Nurses also spent significantly more time with patients (7.7–19.8%, P<0.0001) and relatives (0.4–3.7%, P=0.01) after the system was implemented. The time saved on monitoring allowed the number of nurse directed clinics and patient throughput to increase following eDMS implementation. Qualitative data supported results from the timing study with nurses reporting that the monitoring process was more standardised, safer, took less time and simplified documentation. ConclusionsThe eDMS was associated with a reduction in time spent on the complex task of medication monitoring allowing nurses to spend a greater proportion of their time on other patient care activities.

A dynamic assessment of medication‐taking behavior during pregnancy and postpartum: should cART adherence be reinforced during postpartum?

This study compared adherence (persistence and execution) during pregnancy and postpartum in HIV‐positive women having taken part in the adherence‐enhancing program of the Community Pharmacy of the Department of Ambulatory Care and Community Medicine in Lausanne between 2004 and 2012. This interdisciplinary program combined electronic drug monitoring and semi‐structured, repeated motivational interviews. This was a retrospective, observational study. Observation period spread over from first adherence visit after last menstruation until 6 months after childbirth. Medication‐taking was recorded by electronic drug monitoring. Socio‐demographic and delivery data were collected from Swiss HIV Cohort database. Adherence data, barriers and facilitators were collected from pharmacy database. Electronic data were reconciled with pill‐count and interview notes in order to include reported pocket‐doses. Execution was analyzed over 3‐day periods by a mixed effect logistic model, separating time before and after childbirth. This model allowed us to estimate different time slopes for both periods and to show a sudden fall associated with childbirth. Twenty‐five pregnant women were included. Median age was 29 (IQR: 26.5, 32.0), women were in majority black (n = 17,68%) and took a cART combining protease and nucleoside reverse transcriptase inhibitors (n = 24,96%). Eleven women (44%) were ART‐naïve at the beginning of pregnancy. Twenty women (80%) were included in the program because of pregnancy. Women were included at all stages of pregnancy. Six women (24%) stopped the program during pregnancy, 3 (12%) at delivery, 4 (16%) during postpartum and 12 (48%) stayed in program at the end of observation time. Median number of visits was 4 (3.0, 6.3) during pregnancy and 3 (0.8, 6.0) during postpartum. Execution was continuously high during pregnancy, low at beginning of postpartum and increased gradually during the 6 months of postpartum.imageMajor barriers to adherence were medication adverse events and difficulties in daily routine. Facilitators were motivation for promoting child‐health and social support. The dramatic drop and very slow increase in cART adherence during postpartum might result in viral rebound and drug resistance. Although much attention is devoted to pregnant women, interdisciplinary care should also be provided to women in the community during first trimester of postpartum to support them in sustaining cART adherence.

Racial/Ethnic Disparities in ART Adherence in the United States

Minority race/ethnicity is generally associated with antiretroviral therapy nonadherence in US-based studies. Limitations of the existing literature include small samples, subjective adherence measures, and inadequate control for potential confounders such as mental health and substance use, which have been consistently associated with poorer adherence. Individual-level data were pooled from 13 US-based studies employing electronic drug monitoring to assess adherence. Adherence was operationalized as percent of prescribed doses taken from the first 12 (monthly) waves of data in each study. Depression symptoms were aggregated from several widely used assessments, and substance use was operationalized as any use of cocaine/stimulants, heroin/opiates, ecstasy, hallucinogens, or sedatives in the 30-365 days preceding baseline. The final analytic sample of 1809 participants ranged in age from 18 to 72 years and was 67% male. Participants were 53% African American, 14% Latino, and 34% White. In a logistic regression adjusting for age, gender, income, education, and site, race/ethnicity was significantly associated with adherence (P < 0.001) and persisted in a model that also controlled for depression and substance use (P < 0.001), with African Americans having significantly lower adherence than Latinos [odds ratio (OR) = 0.72, P = 0.04] and whites (OR = 0.60, P < 0.001). Adherence did not differ between whites and Latinos (OR = 0.84, P = 0.27). Racial/ethnic differences in demographics, depression, and substance abuse do not explain the lower level of antiretroviral therapy adherence in African Americans observed in our sample. Further research is needed to explain the persistent disparity and might examine factors such as mistrust of providers, health literacy, and inequities in the health care system.

Patient communication tools to enhance ART adherence counseling in low and high resource settings

ObjectiveFew articles have examined specific counseling tools used to increase antiretroviral therapy (ART) adherence. We present communication tools used in the context of Project MOTIV8, a randomized clinical trial. MethodsWe developed, piloted, and evaluated pictorial images to communicate the importance of consistent dose timing and the concept of drug resistance. Electronic drug monitoring (EDM) review was also used to provide visual feedback and facilitate problem solving discussions. Adherence knowledge of all participants (n=204) was assessed at baseline and 48 weeks. Participant satisfaction with counseling was also assessed. ResultsAdherence knowledge did not differ at baseline, however, at 48 weeks, intervention participants demonstrated significantly increased knowledge compared to controls F(1, 172)=10.76, p=0.001 (12.4% increase among intervention participants and 1.8% decrease among controls). Counselors reported that the tools were well-received, and 80% of participants felt the counseling helped them adhere to their medications. ConclusionsCounseling tools were both positively received and effective in increasing ART adherence knowledge among a diverse population. Practice implicationsWhile developed for research, these counseling tools can be implemented into clinical practice to help patients; particularly those with lower levels of education or limited abstract thinking skills to understand medical concepts related to ART adherence.

Characteristics of HIV patients referred to a medication adherence program in Switzerland

Since August 2004, HIV patients who encounter -or are at risk of -problems with their antiretroviral treatment (ART) are referred by their physician to a medication adherence program at the community pharmacy of the Department of Ambulatory Care and Community Medicine in Lausanne (Switzerland). The program combines motivational interviewing and electronic drug monitoring. To compare the demographic and clinical characteristics as well as ART of HIV patients referred to the adherence program versus those of the entire HIV population followed in the same infection disease department in the same time frame. Retrospective descriptive cross-sectional study. Study time frame was defined according to the period with the highest number of HIV patients visiting the adherence program. Subjects included in the adherence program had more often a protease inhibitor-based regimen (64 %; 95 % CI [52-75 %] vs. 37 %) and lower CD4 cell counts (419 (252.0, 521.0); 95 % CI [305-472] vs. 500 (351.0, 720.0)) than the entire HIV population. A majority of women were included in the adherence program (66 %; 95 % CI [54-76 %] vs. 39% in the entire HIV population). Subjects referred to the adherence program were different from the entire HIV population and showed worse clinical outcomes and were more often under salvage therapy. More women than men were included. Reasons for such a difference need to be further explored.

Use of an electronic drug monitoring system for ambulatory patients with chronic disease: how does it impact on nurses' time spent documenting clinical care?

Medication monitoring of ambulatory rheumatology patients on Disease Modifying Anti-Rheumatic Drugs (DMARDS) is time consuming and complex, with possibilities for error. Electronic systems have the potential to improve the process. The aim of this study was to evaluate the impact of an electronic Drug Monitoring System (eDMS) on the time nurses' spent on clinical documentation associated with monitoring. The study was conducted with all nurses (n=4) in the Rheumatology Department of a large metropolitan Australian teaching hospital. The eDMS was designed as a module of the Hospital Clinical Information System (HCIS) to assist clinicians in monitoring rheumatology patients on DMARDS. Timing data were collected using a modified time and motion work measurement technique using software on a handheld computer. Data included the time nurses spent on documentation regarding medication monitoring before and after the implementation of the eDMS. Results showed that following implementation of the eDMS nurses spent significantly less time documenting medication monitoring information (13.6% to 7.2%, P&lt;.0001). The cumbersome paper-based Drug Monitoring Patient List was replaced entirely by the eDMS. Consequently, there was a significant decrease in the time nurses spent using the HCIS (13.01% to 2.8%, p&lt;.0001) for monitoring and the use of loose-leaf paper also decreased (7.6% to 5.0%, p = 0.002). The eDMS made the process of drug monitoring quicker and simpler for nurses and thus permitted them to increase their time spent in direct patient care.

First in Human Study With a Novel Ingestible Electronic Drug Delivery and Monitoring Device: The Intellicap

BACKGROUND: Highly predictable intraluminal delivery of drugs to a well-defined area of the gut may be beneficial for the development and testing of new drugs as well as for clinical use in luminal diseases of the gut and diseases requiring high drug concentrations in the portal system. We developed an ingestible electronic drug delivery and monitoring device, the IntelliCap, to meet these demands. The IntelliCap comprises a 300 μl drug reservoir, a pHand temperature sensor, a stepper motor, and a transceiver for 2-way real time wireless communication. Data are relayed via a data recorder to a computer. Changes in pH and temperature can be used to indicate the location of the IntelliCap in the gut and control drug delivery.

The Madison Avenue effect: How drug presentation style influences adherence and outcome in patients with asthma

Little is known about how drug presentation influences medication adherence. To examine the effect of an educational program aimed at increasing expectations of treatment benefit on medication adherence. Data are analyzed from 99 participants who underwent electronic drug monitoring during the Trial of Asthma Patient Education, a randomized, placebo-controlled, multicenter trial. Participants with suboptimally controlled asthma were randomized to placebo or montelukast in conjunction with a presentation mode that was either neutral or designed to increase outcome expectancy. Adherence was monitored electronically over 4 weeks and was defined as ≥ 80% use of prescribed doses. Outcome expectancy, peak expiratory flow, prebronchodilator FEV₁, asthma control (Juniper asthma control questionnaire), and asthma-related quality of life were assessed at baseline and at the 4-week follow-up. Average electronic medication adherence was 69.9%. There was a significant interaction between presentation mode and drug assignment, with participants in the enhanced/montelukast group having a higher change in outcome expectancy (Δ 2.1 points; P < .001) and better medication adherence (odds ratio, 4.0; 95% CI, 1.1-14.3) compared with those in the neutral/placebo group. There was no difference in asthma symptoms, quality of life, or clinical outcomes on the basis of presentation mode. Rather, increased outcome expectancy was associated with modest improvements in asthma symptoms after adjusting for presentation mode, drug assignment, and medication adherence. The use of an enhanced presentation aimed at increasing outcome expectancy may lead to improved medication adherence.

An interdisciplinary HIV-adherence program combining motivational interviewing and electronic antiretroviral drug monitoring

To ensure successful treatment, HIV patients must maintain a high degree of medication adherence over time. Since August 2004, patients who are (or are at risk of) experiencing problems with their HIV antiretroviral therapy (ART) have been referred by their physicians to an interdisciplinary HIV-adherence program. The program consists of a multifactorial intervention along with electronic drug monitoring (MEMSTM). The pharmacists organize individualized semi-structured motivational interviews based on cognitive, emotional, behavioral, and social issues. At the end of each session, the patient brings an adherence report to the physician. This enables the physician to use the adherence results to evaluate the treatment plan. The aim of this study was to retrospectively analyze this on-going interdisciplinary HIV-adherence program. All patients who were included between August 2004 and the end of April 2008 were analyzed. One hundred and four patients were included (59% women, median age 39 (31.0, 46.0) years, 42% black ethnicity). Eighty (77%) patients were ART-experienced patients and 59% had a protease inhibitor-based treatment. The retention rate was high (92%) in the program. Patient inclusion in this HIV-adherence program was determined by patient issues for naive patients and by nonadherence or suboptimal clinical outcomes for ART-experienced patients. The median time spent by a subject at the pharmacy was 35 (25.0, 48.0) minutes, half for the medication handling and half for the interview. The adherence results showed a persistence of 87% and an execution of 88%. Proportion of undetectable subjects increased during study. In conclusion, retention and persistence rates were high in this highly selected problematic population.

A Preliminary Randomized Controlled Trial of a Nurse-Delivered Medication Adherence Intervention Among HIV-Positive Outpatients Initiating Antiretroviral Therapy in Beijing, China

We evaluated a nurse-delivered adherence intervention in a preliminary randomized controlled trial among 70 HIV-positive outpatients initiating antiretroviral therapy (ART) in Beijing, China. In both arms, participants received a 30-min educational session, a pillbox, and a referral to a peer support group. In the enhanced arm, participants could choose an electronic reminder device, three sessions of counseling either alone or with a treatment adherence partner, or both reminder and counseling. Survey assessments and blood draws occurred at baseline, post-intervention (13 weeks), and follow-up (25 weeks). Primary outcomes were 7-day and 30-day adherence assessed by self-report and electronic drug monitoring (EDM), and secondary outcomes were HIV-1 RNA viral load and CD4 count. The intervention was feasible and well received. It led to some improvement in self-reported and EDM-assessed adherence but not the biological outcomes. Providing counseling and facilitating the use of electronic reminders to patients initiating ART merits further investigation as a culturally viable means of promoting adherence in China.

How Long Is the Right Interval for Assessing Antiretroviral Pharmacy Refill Adherence?

How Long Is the Right Interval for Assessing Antiretroviral Pharmacy Refill Adherence?

Peer Support and Pager Messaging to Promote Antiretroviral Modifying Therapy in Seattle: A Randomized Controlled Trial

To determine the relative efficacy of peer support and pager messaging strategies versus usual care to improve medication adherence and clinical outcomes among HIV-positive outpatients initiating or switching to a new highly active antiretroviral therapy regimen. A 2 3 2 factorial randomized controlled trial of a 3-month intervention with computer-assisted self-interviews and blood draws administered at baseline, 3, 6, and 9 months. HIV-positive patients at a public HIV specialty clinic in Seattle,WA (N = 224) were randomly assigned to peer support, pager messaging, both strategies, or usual care. The main outcomes were adherence according to self-report and electronic drug monitoring, CD4 count, and HIV-1 RNA viral load. Intent-to-treat analyses suggested the peer intervention was associated with greater self-reported adherence at immediate postintervention. However, these effects were not maintained at follow-up assessment; nor were there significant differences in biological outcomes. The pager intervention, on the other hand, was not associated with greater adherence but was associated with improved biological outcomes at postintervention that were sustained at follow-up. Analyses indicate the potential efficacy of peer support and pager messaging to promote antiretroviral adherence and biological outcomes, respectively. More potent strategies still are needed.

An examination of the psychometric properties of the Antiretroviral General Adherence Scale (AGAS) in two samples of HIV-infected individuals.

This article reports on the development and psychometric properties of the Antiretroviral General Adherence Scale (AGAS) in two National Institutes of Health-funded projects: the Get Busy Living Project, a behavioral clinical trial to promote consistent use of antiretroviral therapy, and the KHARMA (Keeping Healthy and Active with Risk Reduction and Medication Adherence) Project, which addressed issues of adherence and risk reduction behavior in women. AGAS assesses the ease and ability of participants to take antiretroviral therapy according to a health care provider's recommendations. Data were analyzed from completed baseline assessments of the two studies. The AGAS was internally consistent in both samples. Content, construct, and criterion validity were established using factor analysis and correlations of total AGAS scores with two measures of adherence: electronic drug monitoring and an Adult AIDS Clinical Trials Group adherence scale. Viral load, CD4 cell counts, and depression scores were also examined. Reliability and validity of the AGAS were supported in both samples.

Lack of Association between Retrospectively Collected Pharmacy Refill Data and Electronic Drug Monitoring of Antiretroviral Adherence

Antiretroviral medication refill adherence has not been compared directly to electronic drug monitoring (EDM) in any identifiable published study. We retrospectively studied adults with undetectable HIV titers on highly active antiretroviral therapy. We used Pearson correlation coefficients and receiver operating characteristic curves to relate the two adherence measures, and we used the Wilcoxon rank-sum test to assess the relation between adherence and viral load. In sixty-five subjects, the majority of whom were African American and male with median age of 44 years, pharmacy refill adherence was difficult to collect retrospectively, was not significantly correlated with EDM adherence, and was not significantly related to viral load. Ninety-day supply pharmacy refill adherence correctly classified 95% EDM adherence maximally at 94 days between refills, and the measure was most sensitive for non-adherence at <90 days. Reassessment of the relation between pharmacy refill data and EDM would be warranted when pharmacy refill data is collected as soon as feasible from sources with complete data capture.

Letter to the Editor: Modified Directly Observed Therapy: Sustained Self-Reported Adherence and HIV Health Status

AIDS Patient Care and STDsVol. 21, No. 12 Letter to the Editor: Modified Directly Observed Therapy: Sustained Self-Reported Adherence and HIV Health StatusJennifer A. Mitty, Delphine Huang, Helen G. Loewenthal, Cynthia MacLeod, Lara Thompson, and Lauri B. BazermanJennifer A. MittySearch for more papers by this author, Delphine HuangSearch for more papers by this author, Helen G. LoewenthalSearch for more papers by this author, Cynthia MacLeodSearch for more papers by this author, Lara ThompsonSearch for more papers by this author, and Lauri B. BazermanSearch for more papers by this authorPublished Online:21 Dec 2007https://doi.org/10.1089/apc.2007.0066AboutSectionsPDF/EPUB ToolsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited byChallenges in the Evaluation of Interventions to Improve Engagement Along the HIV Care Continuum in the United States: A Systematic Review24 January 2017 | AIDS and Behavior, Vol. 21, No. 7Cost of Behavioral Interventions Utilizing Electronic Drug Monitoring for Antiretroviral Therapy AdherenceJAIDS Journal of Acquired Immune Deficiency Syndromes, Vol. 63, No. 1Peer Knowledge and Roles in Supporting Access to Care and Treatment19 March 2010 | Journal of Community Health, Vol. 35, No. 6Persistence of Virological Benefits Following Directly Administered Antiretroviral Therapy Among Drug Users: Results From a Randomized Controlled TrialJAIDS Journal of Acquired Immune Deficiency Syndromes, Vol. 50, No. 2Strategies for promoting adherence to antiretroviral therapy: A review of the literature23 November 2008 | Current Infectious Disease Reports, Vol. 10, No. 6Short- and Long-Term Efficacy of Modified Directly Observed Antiretroviral Treatment in Mombasa, Kenya: A Randomized TrialJAIDS Journal of Acquired Immune Deficiency Syndromes, Vol. 48, No. 5Safer Sexual Behaviors after 12 Months of Antiretroviral Treatment in Mombasa, Kenya: A Prospective Cohort Stanley Luchters, Avina Sarna, Scott Geibel, Matthew F. Chersich, Paul Munyao, Susan Kaai, Kishorchandra N. Mandaliya, Khadija S. Shikely, Naomi Rutenberg, and Marleen Temmerman22 July 2008 | AIDS Patient Care and STDs, Vol. 22, No. 7 Volume 21Issue 12Dec 2007 InformationMary Ann Liebert, Inc.To cite this article:Jennifer A. Mitty, Delphine Huang, Helen G. Loewenthal, Cynthia MacLeod, Lara Thompson, and Lauri B. Bazerman.Letter to the Editor: Modified Directly Observed Therapy: Sustained Self-Reported Adherence and HIV Health Status.AIDS Patient Care and STDs.Dec 2007.897-899.http://doi.org/10.1089/apc.2007.0066Published in Volume: 21 Issue 12: December 21, 2007PDF download

A randomized controlled trial of a peer support intervention targeting antiretroviral medication adherence and depressive symptomatology in HIV-positive men and women.

To determine the efficacy of a peer-led social support intervention involving support groups and telephone contacts compared with standard clinical care to enhance antiretroviral medication adherence. Randomized controlled trial with follow-up. Participants were 136 HIV-positive indigent mainly African American and Puerto Rican men and women recruited from an outpatient clinic in the Bronx, New York. The 3-month intervention was delivered by other HIV-positive clinic patients trained in addressing barriers to adherence and sensitively providing appraisal, spiritual, emotional, and informational adherence-related social support. Medical chart-abstracted HIV-1 RNA viral load, antiretroviral adherence according to electronic drug monitoring and participant self-report, and social support and depressive symptomatology. All assessments conducted at baseline, 3 months, and 6 months. Intent-to-treat and as-treated analyses indicated no between-conditions intervention effects on the primary outcome of HIV-1 RNA viral load or any of the secondary outcomes at immediate postintervention or follow-up. Post hoc analyses within the intervention condition indicated greater intervention exposure was associated with higher self-reported adherence, higher social support, and lower depressive symptomatology at follow-up, even after controlling for baseline adherence. Null findings, consistent with the limited literature on efficacious highly active antiretroviral therapy (HAART) adherence interventions, may be due to insufficient exposure to the intervention, its low intensity, or the nature of the sample-a heterogeneous HAART-experienced group of patients with high levels of substance use and multiple other competing stressors. Overall, findings highlight the need for more comprehensive and intensive efforts to battle nonadherence.

Practical and conceptual challenges in measuring antiretroviral adherence.

Accurate measurement of antiretroviral adherence is essential for targeting and rigorously evaluating interventions to improve adherence and prevent viral resistance. Across diseases, medication adherence is an individual, complex, and dynamic human behavior that presents unique measurement challenges. Measurement of medication adherence is further complicated by the diversity of available measures, which have different utility in clinical and research settings. Limited understanding of how to optimize existing adherence measures has hindered progress in adherence research in HIV and other diseases. Although self-report is the most widely used adherence measure and the most promising for use in clinical care and resource-limited settings, adherence researchers have yet to develop evidence-based standards for self-reported adherence. In addition, the use of objective measures, such as electronic drug monitoring or pill counts, is limited by poor understanding of the source and magnitude of error biasing these measures. To address these limitations, research is needed to evaluate methods of combining information from different measures. The goals of this review are to describe the state of the science of adherence measurement, to discuss the advantages and disadvantages of common adherence measurement methods, and to recommend directions for improving antiretroviral adherence measurement in research and clinical care.