Peer Adherence Research Articles

Randomized Controlled Trial of 60 minutes for Health With Rapid Antiretroviral Therapy to Reengage Persons With HIV Who Are Out of Care.

Many persons with HIV remain out of care (PWH-OOC). We evaluated InstaCare, a complex intervention integrating the brief behavioral intervention 60 minutes for Health with the rapid restart of antiretroviral therapy (rapid ART). Prospective open-label randomized controlled trial among PWH-OOC in San Diego, USA. PWH-OOC were randomized 1:1 to InstaCare or a time-and-attention control integrating a diet-and-nutrition behavioral intervention also with rapid ART initiation (restart ≤7 days from enrollment). All participants had access to support services (free transport, HIV peer navigation, adherence counseling, and linkage to care) and primary care services (mental health, case management, social work, medication-assisted treatment, and specialist pharmacy). The primary outcomes were viral suppression (<50 copies/mL) and re-engagement with care (≥2 HIV care visits >90 days apart) by 24 weeks. Outcomes were reported on an intention-to-treat basis. Between November 2020 and August 2022, 52 PWH-OOC were enrolled. Baseline substance use in the preceding month (49%), unstable housing (51%), moderate/severe depression (49%), and moderate/severe anxiety (41.7%) were prevalent. Rapid ART was provided for all participants. At week 24, the proportion with HIV viral load <50 copies/mL was 37.3% (19/51) (InstaCare 28.0%, control 46.2%, P = 0.25). Fourteen (27.5%) were engaged with care (InstaCare 7/25 [28.0%], control 7/26 [26.9%], P = 1.00). Most participants (94%) reported low or very low emotional distress associated with rapid ART. Study lost to follow-up by week 24 was high (23/51, 45%). The InstaCare complex intervention did not improve viral suppression or reengagement with care among PWH-OOC. Investigation of high-intensity, individually adapted interventions is needed among PWH-OOC.

Motivating and Maintaining Ethics, Equity, Effectiveness, Efficiency, and Expertise in Peer Review

Scientists who engage in science and the scientific endeavor should seek truth with conviction of morals and commitment to ethics. While the number of publications continues to increase, the number of retractions has increased at a faster rate. Journals publish fraudulent research papers despite claims of peer review and adherence to publishing ethics. Nevertheless, appropriate ethical peer review will remain a gatekeeper when selecting research manuscripts in scholarly publishing and approving research applications for grant funding. However, this peer review must become more open, fair, transparent, equitable, and just with new recommendations and guidelines for reproducible and accountable reviews that support and promote fair citation and citational justice. We should engineer this new peer-review process with modern informatics technology and information science to provide and defend better safeguards for truth and integrity, to clarify and maintain the provenance of information and ideas, and to rebuild and restore trust in scholarly research institutions. Indeed, this new approach will be necessary in the current post-truth era to counter the ease and speed with which mis-information, dis-information, anti-information, caco-information, and mal-information spread through the internet, web, news, and social media. The most important question for application of new peer-review methods to these information wars should be ‘Who does what when?’ in support of reproducible and accountable reviews. Who refers to the authors, reviewers, editors, and publishers as participants in the review process. What refers to disclosure of the participants' identities, the material content of author manuscripts and reviewer commentaries, and other communications between authors and reviewers. When refers to tracking the sequential points in time for which disclosure of whose identity, which content, and which communication at which step of the peer-review process for which audience of readers and reviewers. We believe that quality peer review, and peer review of peer review, must be motivated and maintained by elevating their status and prestige to an art and a science. Both peer review itself and peer review analyses of peer reviews should be incentivised by publishing peer reviews as citable references separately from the research report reviewed while crossreferenced and crosslinked to the report reviewed.

Exploring the relationships between rule-governed behavior and adherence to guidelines aiming to reduce the spread of COVID-19

Research demonstrates that socially mediated consequences impact adherence to health mandates during pandemics. However, no published research has examined whether adherence varies based on the extent to which an individual relies on arbitrary social approval (i.e., displays generalized pliance). The present study explored the relationships between adherence to COVID-19 public health measures, two types of rule-following (pliance and tracking), and perceived peer behavior in a sample of adults (n = 288). Findings revealed that adherence was negatively correlated with generalized pliance and tracking was unrelated to adherence. Pliance did not moderate the relationship between peer adherence and individual adherence. Findings are discussed with reference to the need to develop easily adaptable and context sensitive measures of types of rule-following, in addition to a measure of social tracking.

Effect of peer-mother interactive programme on prevention of mother-to-child HIV transmission outcomes among pregnant women on anti-retroviral treatment in routine healthcare in Dar es Salaam, Tanzania.

Peer support services are increasingly being integrated in programmes for the prevention of mother-to-child HIV transmission (PMTCT). We aimed to evaluate the effect of a peer-mother interactive programme on PMTCT outcomes among pregnant women on anti-retroviral treatment (ART) in routine healthcare in Dar es Salaam, Tanzania. Twenty-three health facilities were cluster-randomized to a peer-mother intervention and 24 to a control arm. We trained 92 ART experienced women with HIV to offer peer education, adherence and psychosocial support to women enrolling in PMTCT care at the intervention facilities. All pregnant women who enrolled in PMTCT care at the 47 facilities from 1st January 2018 to 31st December 2019 were identified and followed up to 31st July 2021. The primary outcome was time to ART attrition (no show >90 days since the scheduled appointment, excluding transfers) and any difference in one-year retention in PMTCT and ART care between intervention and control facilities. Secondary outcomes were maternal viral suppression (<400 viral copies/mL) and mother-to-child HIV transmission (MTCT) by ≥12 months post-partum. Analyses were done using Kaplan Meier and Cox regression (ART retention/attrition), generalized estimating equations (viral suppression) and random effects logistic regression (MTCT); reporting rates, proportions and 95% confidence intervals (CI). There were 1957 women in the peer-mother and 1384 in the control facilities who enrolled in routine PMTCT care during 2018-2019 and were followed for a median [interquartile range (IQR)] of 23 [10, 31] months. Women in both groups had similar median age of 30 [IQR 25, 35] years, but differed slightly with regard to proportions in the third pregnancy trimester (14% versus 19%); advanced HIV (22% versus 27%); and ART naïve (55% versus 47%). Peer-mother facilities had a significantly lower attrition rate per 1000 person months (95%CI) of 14 (13, 16) versus 18 (16, 19) and significantly higher one-year ART retention (95%CI) of 78% (76, 80) versus 74% (71, 76) in un-adjusted analyses, however in adjusted analyses the effect size was not statistically significant [adjusted hazard ratio of attrition (95%CI) = 0.85 (0.67, 1.08)]. Viral suppression (95%CI) was similar in both groups [92% (91, 93) versus 91% (90, 92)], but significantly higher among ART naïve women in peer-mother [91% (89, 92)] versus control [88% (86, 90)] facilities. MTCT (95%CI) was similar in both groups [2.2% (1.4, 3.4) versus 1.5% (0.7, 2.8)]. In conclusion, we learned that integration of peer-mother services in routine PMTCT care improved ART retention among all women and viral suppression among ART naïve women but had no significant influence on MTCT.

Hepatitis C treatment uptake among patients who have received methadone substitution treatment in the Republic of Georgia

ObjectivesThere is a dearth of research on hepatitis C virus (HCV) treatment uptake among people who inject drugs (PWIDs) and receive methadone substitution treatment (MST) in Eastern Europe and Central Asia countries. This study contributed to addressing that gap. We examined and identified factors that may affect HCV treatment uptake among PWID who received MST in the Republic of Georgia. Study designThe design of the study is retrospective cohort study. MethodsWe conducted HCV care cascade analysis by matching the data from the web-based national hepatitis C program registry (ELIM C) and the MST treatment database between January 1, 2015, and December 31, 2018. Using the World Health Organization's (WHO) Consensus HCV cascade of care (CoC) global instrument, we assessed the progress made toward the country's 2020 and WHO's 2030 hepatitis C elimination targets for the subpopulation of MST patients. ResultsOverall, 10,498 individuals have been dispensed methadone during the study period. A total of 6828 MST beneficiaries had HCV screening, of whom 5843 (85.6%) tested positive; 5476 (93.7%) were tested for HCV viremia, and 5275 (96.3%) were confirmed with chronic HCV infection. More than 75% (n = 4000) of HCV-infected MST patients initiated HCV treatment, and 3772 (94.3%) completed the treatment. Of those eligible for sustained virologic response assessment, 71.0% (2641/3715) were evaluated, and the reported cure rate was 96.1% (2537). The study found the odds of patients starting HCV treatment differed by the type of facility they were screened at and whether they were registered as PWID at the screening sites. The patients screened at centers with integrated HCV treatment services had higher treatment uptake rates than those screened at other centers. ConclusionsAs the cumulative HCV treatment uptake and cure rates among MST patients with HCV infection are high (75.8% and 96.1%, respectively), the MST patients might become the first microelimination target population in which hepatitis C elimination will be achieved in Georgia. The study found the type of screening facility and whether MST patients registered themselves as PWID or not had significant effects on MST patients starting HCV treatment. At the same time, the study did not find gender and age to be significant predictors of MST patients starting HCV treatment. MST patients used different types of health facilities to get screened for HIV. Many of them did not register themselves as PWID when screened for HIV. The existence of only a few harm reduction sites with integrated HCV treatment services, a high level of stigma, and the criminalization of drug use might have incentivized MST patients to self-navigate across the HCV care continuum with the rest of the population. The implementation of focused, harm reduction, integrated HCV treatment with good peer and professional adherence support at treatment sites could help reach the hepatitis C elimination goals among MST patients.

Understanding early uptake of PrEP by female sex workers in Zimbabwe

ABSTRACT Female sex workers (FSW) are prioritised for increased access to pre-exposure prophylaxis (PrEP), although rates of uptake remain sub-optimal, particularly across Southern Africa. In the first two years of its availability in Zimbabwe, 37.1% of FSW in trial sites initiated PrEP and received at least one re-supply. We conducted a qualitative study on perceptions of PrEP among 19 early users selected from sites with varying rates of PrEP initiation. Narrative interviews examined the pathways taken by FSW from hearing about PrEP, through their decision to start taking it, and early experiences. FSW appreciated PrEP’s introduction within familiar and trusted “friendly” services tailored for sex workers and valued positive encouragement from clinic staff and peers over negative influence from family members. They also found PrEP difficult to understand at first, and feared side effects and rare adverse complications described in information leaflets. While FSW identified individual strategies for remembering to take their medication, they also relied on structured peer adherence support, leading some FSW to actively promote the method to other FSW as “PrEP champions”. Information on how early users experience a new prevention technology such as PrEP can inform design of interventions that leverage existing support structures and target key barriers.

A randomized controlled trial study of the acceptability, feasibility, and preliminary impact of SITA (SMS as an Incentive To Adhere): a mobile technology-based intervention informed by behavioral economics to improve ART adherence among youth in Uganda

BackgroundStudies report serious adherence problems among youth (individuals age 15–24 years of age) in Uganda. Recent growth in mobile phone ownership has highlighted the potential of using text-based interventions to improve antiretroviral treatment (ART) adherence among Ugandan youth. We piloted a randomized controlled trial of a text-based intervention providing weekly real-time antiretroviral adherence feedback, based on information from a smart pill box, to HIV-positive Ugandan youth. In this paper, we report the acceptability, feasibility, and preliminary impact of the intervention.MethodsWe randomized participants to a control group, or to receive messages with information on either their own adherence levels (Treatment 1 - T1), or their own adherence and peer adherence levels (Treatment 2 – T2). We conducted six focus groups from December 2016 to March 2017 with providers and youth ages 15–24, double coded 130 excerpts, and achieved a pooled Cohen’s Kappa of 0.79 and 0.80 based on 34 randomly selected excerpts.ResultsThe quantitative and qualitative data show that the intervention was deemed acceptable and feasible. After controlling for baseline adherence, the T1 group had 3.8 percentage point lower adherence than the control group (95% CI -9.9, 2.3) and the T2 group had 2.4 percentage points higher adherence than the control group (95% CI -3.0, 7.9). However, there was an increasing treatment effect over time for the T2 group with the largest effect towards the end of the study; a 2.5 percentage point increase in the initial 9-weeks that grows steadily to 9.0 percentage points by the last 9-weeks of the study. We find negative treatment effects for T1 in 3 of the 4 9-week intervals. This pilot study was not designed to detect statistically significant differences.ConclusionsImproving youth’s adherence by supplementing information about their adherence with information about the adherence of peers is a promising new strategy that should be further evaluated in a fully-powered study. Providing one’s own adherence information alone appears to have less potential.Trial registrationNCT02514356 07/30/2015.

Perceived peer support and diabetes management from adolescence into early emerging adulthood.

The objective of the study was to examine longitudinal associations of perceived diabetes-specific peer support with adherence and glycemic control among late adolescents with type 1 diabetes as they transition out of high school and into early emerging adulthood. As part of a larger study, 211 high school seniors with type 1 diabetes completed confidential online surveys and were reassessed 1 year later. Perceived diabetes-specific peer support and adherence were assessed in each survey. Glycemic control was measured with HbA1c assay kits. Perceived diabetes-specific peer support in high school predicted better adherence across the subsequent year while controlling for initial levels of adherence. Perceived peer support during early emerging adulthood was also associated with better adherence across time, after controlling for initial levels of both adherence and peer support. Perceived diabetes-specific peer support may be a protective factor as late adolescents with type 1 diabetes transition out of high school. Building strong peer support during the transition into early emerging adulthood may facilitate better diabetes management during this high-risk time of development. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Improving antiretroviral therapy adherence in resource-limited settings at scale: a discussion of interventions and recommendations.

Introduction: Successful population‐level antiretroviral therapy (ART) adherence will be necessary to realize both the clinical and prevention benefits of antiretroviral scale‐up and, ultimately, the end of AIDS. Although many people living with HIV are adhering well, others struggle and most are likely to experience challenges in adherence that may threaten virologic suppression at some point during lifelong therapy. Despite the importance of ART adherence, supportive interventions have generally not been implemented at scale. The objective of this review is to summarize the recommendations of clinical, research, and public health experts for scalable ART adherence interventions in resource‐limited settings. Methods: In July 2015, the Bill and Melinda Gates Foundation convened a meeting to discuss the most promising ART adherence interventions for use at scale in resource‐limited settings. This article summarizes that discussion with recent updates. It is not a systematic review, but rather provides practical considerations for programme implementation based on evidence from individual studies, systematic reviews, meta‐analyses, and the World Health Organization Consolidated Guidelines for HIV, which include evidence from randomized controlled trials in low‐ and middle‐income countries. Interventions are categorized broadly as education and counselling; information and communication technology‐enhanced solutions; healthcare delivery restructuring; and economic incentives and social protection interventions. Each category is discussed, including descriptions of interventions, current evidence for effectiveness, and what appears promising for the near future. Approaches to intervention implementation and impact assessment are then described. Results and discussion: The evidence base is promising for currently available, effective, and scalable ART adherence interventions for resource‐limited settings. Numerous interventions build on existing health care infrastructure and leverage available resources. Those most widely studied and implemented to date involve peer counselling, adherence clubs, and short message service (SMS). Many additional interventions could have an important impact on ART adherence with further development, including standardized counselling through multi‐media technology, electronic dose monitoring, decentralized and differentiated models of care, and livelihood interventions. Optimal targeting and tailoring of interventions will require improved adherence measurement. Conclusions: The opportunity exists today to address and resolve many of the challenges to effective ART adherence, so that they do not limit the potential of ART to help bring about the end of AIDS.

Use of peers to improve adherence to antiretroviral therapy: a global network meta-analysis.

IntroductionIt is unclear whether using peers can improve adherence to antiretroviral therapy (ART). To construct the World Health Organization's global guidance on adherence interventions, we conducted a systematic review and network meta-analysis to determine the effectiveness of using peers for achieving adequate adherence and viral suppression.MethodsWe searched for randomized clinical trials of peer-based interventions to promote adherence to ART in HIV populations. We searched six electronic databases from inception to July 2015 and major conference abstracts within the last three years. We examined the outcomes of adherence and viral suppression among trials done worldwide and those specific to low- and middle-income countries (LMIC) using pairwise and network meta-analyses.Results and discussionTwenty-two trials met the inclusion criteria. We found similar results between pairwise and network meta-analyses, and between the global and LMIC settings. Peer supporter+Telephone was superior in improving adherence than standard-of-care in both the global network (odds-ratio [OR]=4.79, 95% credible intervals [CrI]: 1.02, 23.57) and the LMIC settings (OR=4.83, 95% CrI: 1.88, 13.55). Peer support alone, however, did not lead to improvement in ART adherence in both settings. For viral suppression, we found no difference of effects among interventions due to limited trials.ConclusionsOur analysis showed that peer support leads to modest improvement in adherence. These modest effects may be due to the fact that in many settings, particularly in LMICs, programmes already include peer supporters, adherence clubs and family disclosures for treatment support. Rather than introducing new interventions, a focus on improving the quality in the delivery of existing services may be a more practical and effective way to improve adherence to ART.

The impact of community support initiatives on the stigma experienced by people living with HIV/AIDS in South Africa.

In the current context of human resource shortages in South Africa, various community support interventions are being implemented to provide long-term psychosocial care to persons living with HIV/AIDS (PLWHA). However, it is important to analyze the unintended social side effects of such interventions in regards to the stigma felt by PLWHA, which might threaten the successful management of life-long treatment. Latent cross-lagged modeling was used to analyze longitudinal data on 294 PLWHA from a randomized controlled trial (1) to determine whether peer adherence support (PAS) and treatment buddying influence the stigma experienced by PLWHA; and (2) to analyze the interrelationships between each support form and stigma. Results indicate that having a treatment buddy decreases felt stigma scores, while receiving PAS increases levels of felt stigma at the second follow up. However, the PAS intervention was also found to have a positive influence on having a treatment buddy at this time. Furthermore,a treatment buddy mitigates the stigmatizing effect of PAS, resulting in a small negative indirect effect on stigma. The study indicates the importance of lookingbeyond the intended effects of an intervention, with the goal of minimizing any adverse consequences that might threaten the successful long-term management of HIV/AIDS and maximizing the opportunities created by such support.

A peer adherence support intervention to improve the antiretroviral treatment outcomes of HIV patients in South Africa: The moderating role of family dynamics

Given the severe shortage of human resources in the healthcare sector in many countries with high HIV prevalence, community-based peer adherence support is being increasingly cited as an integral part of a sustainable antiretroviral treatment (ART) strategy. However, the available scientific evidence on this topic reports discrepant findings on the effectiveness of peer adherence support programmes. These conflicting findings to some extent can be attributed to the lack of attention to the social contexts in which peer adherence support programmes are implemented.This study explores the potential moderating role of family dynamics by assessing the differential impact of peer adherence support in different types of families, based on the theoretical underpinnings of the family functioning framework. These relationships were explored with the aid of multivariate statistical analysis of cross-sectional, post-trial data for a sample of 340 patients interviewed as part of the Effectiveness of Aids Treatment and Support in the Free State (FEATS) study conducted in the public-sector ART programme of the Free State Province of South Africa.The analysis reveals no significant overall differences in CD4 cell count between the intervention group accessing additional peer adherence support and the control group receiving standard care. When controlling for the potential moderating role of family dynamics, however, the outcomes clearly reveal a significant interaction effect between the adherence intervention and the level of family functioning with regard to treatment outcomes. Multi-group analysis demonstrates that peer adherence support has a positive effect on immunological restoration in well-functioning families, while having a negative effect in dysfunctional families.The study outcomes stress the need for peer adherence interventions that are sensitive to the suboptimal contexts in which they are often implemented. Generic, broad-based interventions do not necessarily facilitate the treatment adherence of the most vulnerable patient groups, particularly those without supportive family contexts. Tailoring interventions aimed at creating a health-enabling environment to the needs of these at-risk patients should therefore be a priority for both research and policy.

Families as catalysts for peer adherence support in enhancing hope for people living with HIV/AIDS in South Africa

IntroductionHope is an essential dimension of successful coping in the context of illnesses such as HIV/AIDS, because positive expectations for the future alleviate emotional distress, enhance quality of life and have been linked to the capacity for behavioural change. The social environment (e.g. family, peers) is a regulator of hope for people living with HIV/AIDS (PLWHA). In this regard, the dual aim of this article is (1) to analyze the influence of a peer adherence support (PAS) intervention and the family environment on the state of hope in PLWHA and (2) to investigate the interrelationship between the two determinants.MethodsThe Effective AIDS Treatment and Support in the Free State study is a prospective randomized controlled trial. Participants were recruited from 12 public antiretroviral treatment (ART) clinics across five districts in the Free State Province of South Africa. Each of these patients was assigned to one of the following groups: a control group receiving standard care, a group receiving additional biweekly PAS or a group receiving PAS and nutritional support. Latent cross-lagged modelling (Mplus) was used to analyse the impact of PAS and the family environment on the level of hope in PLWHA.ResultsThe results of the study indicate that neither PAS nor the family environment has a direct effect on the level of hope in PLWHA. Subsequent analysis reveals a positive significant interaction between family functioning and PAS at the second follow-up, indicating that better family functioning increases the positive effect of PAS on the state of hope in PLWHA.ConclusionsThe interplay between well-functioning families and external PAS generates higher levels of hope, which is an essential dimension in the success of lifelong treatment. This study provides additional insight into the important role played by family dynamics in HIV/AIDS care, and it underscores the need for PAS interventions that are sensitive to the contexts in which they are implemented.

The mediating role of extreme peer orientation in the relationships between adolescent–parent relationship and diabetes management.

The study examined whether the quality of the adolescent-parent relationship was associated with better diabetes management in adolescents with Type 1 diabetes by decreasing adolescents' extreme peer orientation. Adolescents (n = 252; 46% male and 54% female) aged 10 to 14 years with Type 1 diabetes completed assessments of extreme peer orientation (i.e., tendency to ignore parental advice and diabetes care to fit in with friends), adolescent-parental relationship, and adherence; HbA1c scores indexed metabolic control. Adolescents with higher quality relationships with parents reported less peer orientation and better diabetes care. The mediational model revealed that adolescents' high quality relationships with their parents (mother and father) were associated with better treatment adherence and metabolic control through less peer orientation. It is likely that high quality adolescent-parent relationships may be beneficial to adolescent diabetes management through a healthy balance between peer and parental influence.

Serials as a Public Service: We're One Big Happy Family

ABSTRACT Jennifer Duncan and Sylvia McAphee exemplify career paths that differ from traditionally defined job descriptions and assigned responsibilities. In the course of their careers, both of these librarians have assumed simultaneous roles in Technical and Public Services departments. In this presentation, they challenge librarians working in traditional roles to embrace opportunities to serve in positions outside their assigned job descriptions in spite of barriers imposed by peer or administrative adherence to narrowly defined roles.

Cost of a dedicated ART clinic.

The provision of antiretroviral therapy (ART) is being rolled out across South Africa. Little evidence exists on the cost of running clinics for ART provision. To determine the cost per patient-month enrolled in an ART programme and per patient-visit for a dedicated, public-sector ART clinic in a South African peri-urban setting in 2004/05 and 2005/06, as the clinic moved from a temporary to a permanent site. A retrospective costing study was performed from a programme perspective. Two years of expenditure data for the clinic were collected from primary sources. Costs per patient visit and per patient-month were calculated in Rand and converted to 2004 US$ (R6.4347 = US$1). The total cost of running the site, excluding patient-specific items (medicines and medical tests), was $174,072 in 2004/05 and $421,872 in 2005/06. Cost per patient-month fell from $40.29 to $36.47, a 9% decrease; cost per patient-visit fell from $54.79 to $41.62, a 24% decrease. In 2005/06, 68% of all expenditure was on medical and pharmacy staff (versus 62% in 2004/05), 23% was on the employment of peer adherence counsellors (versus 35%), and the remaining 9% was on capital costs and supplies (versus 3%). The increase in scale of operation for the provision of ART at this clinic allowed economies of scale to be reaped. Staff costs, both medical and support, comprised the large majority of total clinic costs, such that the erection of a dedicated building for the clinic had little impact on the economic cost of care.

Problem solving and diabetes regimen adherence by children and adolescents with IDDM in social pressure situations: a reflection of normal development.

Investigated problem-solving ability and reported regimen adherence among children, early adolescents, and middle adolescents with IDDM in response to hypothetical social situations where a choice between diabetes regimen adherence and peer desires must be made. Sixty-seven 8- to 17-year-olds with IDDM from two distinct U.S. geographical areas participated. Results indicated that compared to children with IDDM, adolescents with IDDM had better problem-solving abilities in response to social pressure situations, possibly reflecting their greater cognitive maturity. However, adolescents were also more likely to choose behaviors that are less regimen adherent. Differences in levels of problem-solving ability and adherence between the two regional subsamples were also found. Similar developmental patterns were found in both groups, showing the robust nature of the observed age-related trend of decreasing adherence in social situations despite increasing problem-solving abilities. Findings were interpreted in the context of normal adolescent development. Results are conceptually important for those interested in the transaction between peer and social influences and adherence for children and adolescents with IDDM, as well as other health behaviors.