Pharmacy Refill Research Articles

Adherence and outcomes to direct oral anticoagulants among patients with atrial fibrillation: findings from the veterans health administration

BackgroundThe direct oral anticoagulants (DOACs) reduce the risk of stroke in moderate to high-risk patients with non-valvular atrial fibrillation (AF). Yet, concerns remain regarding its routine use in real world practice. We sought to describe adherence patterns and the association between adherence and outcomes to the DOACs among outpatients with AF.MethodsWe performed a retrospective cohort study of patients in the VA Healthcare System who initiated pharmacotherapy with dabigatran, rivaroxaban, or apixaban between November 2010 and January 2015 for non-valvular AF with CHA2DS2-VASc score ≥ 2. Adherence was determined using pharmacy refill data and estimated by the proportion of days covered (PDC) over the first year of therapy. Clinical outcomes, including all-cause mortality and stroke, were measured at 6 months and used to assess measures of adherence for each DOAC.ResultsA total of 2882 patients were included. Most were prescribed dabigatran (72.7%), compared with rivaroxaban (19.8%) or apixaban (7.5%). The mean PDC was 0.84 ± 0.20 for dabigatran, 0.86 ± 0.18 for rivaroxaban, and 0.89 ± 0.14 for apixaban (p < 0.01). The proportion of non-adherent patients, PDC <0.80, was 27.6% for all and varied according DOAC. Lower adherence to dabigatran was associated with higher risk of mortality and stroke (HR 1.07; 1.03–1.12 per 0.10 decline in PDC).ConclusionsIn a real-world VA population being prescribed anticoagulation for AF, more than one quarter had sub-optimal adherence. Lower adherence was associated with a higher risk of mortality and stroke. Efforts identifying non-adherent patients, and targeted adherence interventions are needed to improve outcomes.

The Effectiveness of a Pharmaceutical Care Model on Adherence to Antiretroviral Therapy: A SAME-Based Cohort Study in Brazil.

Purpose: To verify the effectiveness of a pharmaceutical care model developed by the Specialized Municipal Assistance Service in Sorocaba, Brazil, on adherence to ART among patients infected with HIV.Methods: A cohort study compared adherence to ART in two groups of patients: intervention group (patients assisted with pharmaceutical care, n=130) and non-intervention group (patients attended by the habitual dispensing process, n=229). Antiretroviral adherence was measured by the number of pharmacy refill records in a six-month period. The relationship between the use of other drugs for the treatment of opportunistic infections and the adherence rate in the intervention group and the correlation between adherence and viral load and CD4 lymphocytes were also assessed.Results: Higher adherence rates were observed in the intervention group (p<0.05). The use of others drugs did not influence adherence to ART (p=0.30). There was a positive correlation between adherence and the percentage of patients in the intervention group with undetectable viral loads (p=0.0004) and higher levels of CD4 lymphocytes (p=0.0024).Conclusion: The pharmaceutical care model developed by the SAME improved patient adherence to ART as well as clinical outcomes.

Longitudinal Patterns of Medication Nonadherence and Associated Health Care Costs.

Nonadherence to treatment recommendations is associated with poorer outcomes in inflammatory bowel disease and may increase the cost of care. We examined the longitudinal relationship between nonadherence and health care costs and hypothesized that at least 3 distinct trajectories of nonadherence would be observed and that increasing nonadherence would account for significantly greater health care costs after controlling for disease activity. Ninety-nine patients aged 2 to 21 years with inflammatory bowel disease were recruited into this 2-year longitudinal study. Medication possession ratios were calculated from pharmacy refill data, disease activity ratings were obtained from medical charts, and hospital and physician charges associated with an International Classification of Diseases, Ninth Revision code for ulcerative colitis or Crohn's disease were obtained from the hospital's accounting database. An average total cost effect size of d = 0.68 was observed between the increasing severity and stable low severity groups, but the confidence intervals overlap. Conversely, patients with increasing nonadherence demonstrated significantly higher health care costs than patients with stable ≤10%, stable 11% to 20%, or decreasing nonadherence. Medication nonadherence is related to increased health care costs after controlling for disease severity. Patients with increasing nonadherence over time demonstrate more than a 3-fold increase in costs compared with adherent patients. In addition, patients whose adherence improves over time incur approximately the same costs as those who are consistently adherent. This suggests that, in addition to leveraging prevention efforts to keep patients from becoming more nonadherent as treatment continues, efforts aimed at modifying adherence behavior may result in significant cost savings over time.

Improved Retention With 6-Month Clinic Return Intervals for Stable Human Immunodeficiency Virus-Infected Patients in Zambia.

Extending appointment intervals for stable HIV-infected patients in sub-Saharan Africa can reduce patient opportunity costs and decongest overcrowded facilities. We analyzed a cohort of stable HIV-infected adults (on treatment with CD4 >200 cells/μL for more than 6 months) who presented for clinic visits in Lusaka, Zambia. We used multilevel, mixed-effects logistic regression adjusting for patient characteristics, including prior retention, to assess the association between scheduled appointment intervals and subsequent missed visits (>14 days late to next visit), gaps in medication (>14 days late to next pharmacy refill), and loss to follow-up (LTFU; >90 days late to next visit). A total of 62084 patients (66.6% female, median age 38, median CD4 438 cells/μL) made 501281 visits while stable on antiretroviral therapy. Most visits were scheduled around 1-month (25.0% clinical, 44.4% pharmacy) or 3-month intervals (49.8% clinical, 35.2% pharmacy), with fewer patients scheduled at 6-month intervals (10.3% clinical, 0.4% pharmacy). After adjustment and compared to patients scheduled to return in 1 month, patients with six-month clinic return intervals were the least likely to miss visits (adjusted odds ratio [aOR], 0.20; 95% confidence interval [CI], 0.17-0.24); miss medication pickups (aOR, 0.47; 95% CI 0.39-0.57), and become LTFU prior to the next visit (aOR, 0.41; 95% CI, 0.31-0.54). Six-month clinic return intervals were associated with decreased lateness, gaps in medication, and LTFU in stable HIV-infected patients and may represent a promising strategy to reduce patient burdens and decongest clinics.

The Use of Electronic Personal Health Records to Improve Medication Adherence and Patient Engagement: A Randomized Study of Non-valvular Atrial Fibrillation Patients.

Embolic stroke is a major complication of atrial fibrillation (AF) that frequently results in disability or death. The administration of oral anticoagulation can reduce stroke risk in AF patients; however, medication non-adherence can eliminate this benefit. To date, reported patient adherence rates to oral anticoagulation regimens vary. The objective of the current study was to examine the impact of medication-specific education delivered via a personal health record (PHR) system on medication adherence. A randomized, prospective study was conducted from February 2014 to June 2014 at Parkview Health, a not-for-profit, community-based health care clinic that serves a northeastern Indiana population of more than 820,000. AF patients receiving dabigatran (Pradaxa®; Boehringer Ingelheim GmbH, Ingelheim am Rhein, Germany) to prevent stroke participated in this study. The study participants were predominantly Caucasian males over 65 years of age who were educated, insured, and living above the poverty level. Patients were allowed to view online, download, and transmit health information via a PHR. The intervention group received PHR training and dabigatran education via the PHR. The control group received standard care and PHR access without training. A longitudinal survey pertaining to medication knowledge, medication adherence, and patient engagement was administered at baseline and at the end of the study. Medication-dispensing data collected from pharmacy refill prescriptions were used for calculating the medication possession ratio (MPR). Ninety patients were included in this study, and were randomly assigned to either the intervention group (n = 46) or the control group (n = 44). All participants completed the baseline survey, and 95.6% of patients finished the follow-up survey. The mean score for knowledge increased significantly in the intervention group (from 3.77 to 4.23, p = 0.005), but not in the control group (from 3.70 to 3.95, p = 0.72).The MPR was significantly higher in the intervention group (97.47% vs. 87.67%, p = 0.001). Both groups had similar levels of improvement in Patient Activation Measure scores (from 63.0 to 65.8, p = 0.078 vs. from 63.1 to 63.6, p = 0.814). Patients who used the PHR achieved greater medication knowledge, resulting in improved medication adherence. To our knowledge, no published randomized trial has reported on the use of PHRs to improve medication adherence and knowledge. This study is the first to demonstrate a positive impact on anticoagulation adherence with PHR use.

Relationship Between Single Tablet Antiretroviral Regimen and Adherence to Antiretroviral and Non-Antiretroviral Medications Among Veterans' Affairs Patients with Human Immunodeficiency Virus.

Several antiretrovirals (ART) have been coformulated as single tablet regimens (STR). Study objectives were to compare ART and non-ART adherence between STR and multiple tablet regimens (MTR) recipients, determine whether STR independently predicts ART adherence, and determine whether ART adherence influences non-ART adherence. A retrospective cohort study was performed among Upstate New York Veterans' Healthcare Administration (VISN-2) patients from 2000 to 2013. Inclusion criteria were age ≥18 years, human immunodeficiency virus (HIV) infection, receipt of ≥3 ART medications for ≥3 months, and available pharmacy refill records. The two study outcomes were adherence to ART medications and non-ART medications. Adherence was determined with pharmacy refill records that were used to calculate medication possession ratios. Among the 1202 subjects, there were 165 (13.7%) STR and 1037 (86.3%) MTR recipients. Mean ± standard deviation (SD) ART adherence was significantly higher for STR recipients (81.5% ± 15.3%) than MTR recipients (66.1% ± 21.1%), p < 0.001. Use of STR [adjusted odds ratio (aOR): 5.76, 95% confidence interval (CI): 3.84-8.65, p < 0.001] was independently associated with optimal (≥90%) adherence to ART. Mean ± SD non-ART adherence did not differ between STR (78.8% ± 15.6%) and MTR recipients (80.8% ± 16.0%), p = 0.17. Optimal adherence to ART medications (aOR: 2.30, 95% CI: 1.57-3.38, p < 0.001) was independently associated with optimal adherence to non-ART medications. The use of STRs are associated with optimal adherence to ART medications, but not directly associated with adherence to non-ART medications.

Transitioning to Second-line Antiretroviral Therapy Among Adolescents in Copperbelt Province, Zambia: Predictors of Treatment Switching and Adherence to Second-line Regimens.

Adolescents living with HIV (ALHIV) experience less favorable antiretroviral therapy (ART) outcomes than other age groups. First-line treatment failure complicates ART management as second-line regimens can be costlier and have greater pill burdens. Understanding predictors of switching ART regimens and adherence among adolescents on second-line ART may help to prevent poor treatment outcomes. A quantitative survey was administered to 309 ALHIV attending 3 ART clinics in the Copperbelt Province, Zambia. Medical chart data, including pharmacy refill data, were abstracted. Associations between being on second-line ART and sociodemographic, psychosocial and ART adherence characteristics were tested. Cox proportional hazards models were used to estimate the effect of baseline ART variables on time to switching. Ten percent of participants were on second-line regimens. Compared with ALHIV on first-line ART, adolescents on second-line regimens were older (P = 0.02), out of school due to completion of secondary studies (P = 0.04) and on ART longer (P = 0.03). Adolescents on second-line regimens were more likely to report missing ≥48 consecutive hours of drugs in the last 3 months (P = 0.01). Multivariable analysis showed that adolescents who initiated ART with efavirenz-based regimens were more likely to switch to second-line than those put on nevirapine-based regimens (hazard ratio = 2.6; 95% confidence interval: 1.1-6.4). Greater support is needed for ALHIV who are on second-line regimens. Interventions for older adolescents that bridge the gap between school years and young adulthood would be helpful. More research is needed on why ALHIV who start on efavirenz-based regimens are more likely to switch within this population.

Relationship between alcohol consumption, whether linked to other substance use or not, and antiretroviral treatment adherence in HIV+ patients.

Hazardous alcohol consumption is a common diagnosis among people living with HIV infection. The relationship between alcohol consumption and poor adherence to antiretroviral therapy has been highlighted in different studies, yet few of them performed a parallel analysis of other substance use. In Spain, alcohol consumption is frequently associated with other substance use, mainly cannabis and cocaine. The aim of this study is to assess the influence of hazardous alcohol consumption both combined with other substances (cocaine, heroin, methadone and/or cannabis) or alone on antiretroviral therapy adherence in our social environment. We performed an observational case-control study including 119 HIV+ individuals. We recruited 40 non-adherent patients, defined by less than 90% compliance according to hospital pharmacy refill data, and corroborated by the Simplified Medication Adherence Questionnaire (SMAQ) and referring professional's opinion. Control cases (n=79) were defined as those patients with similar characteristics but considered adherent according to the same parameters. Data collection took place between May 2013 and September 2015. Statistical analysis was performed using a binary logistic regression model. Our results indicate that alcohol consumption decreases adherence to antiretroviral therapy. The use of methadone represents a statistically significant increased risk of poor adherence. No significant differences were found between adherent and non-adherent groups regarding cocaine, heroin or cannabis use in this study. In summary, the detection of substance use and especially alcohol consumption in HIV+ patients can improve the effectiveness of antiretroviral therapy by identifying and treating at-risk individuals for a poor therapeutic adherence.

Low levels of viral suppression among refugees and host nationals accessing antiretroviral therapy in a Kenyan refugee camp

BackgroundRefugees and host nationals who accessed antiretroviral therapy (ART) in a remote refugee camp in Kakuma, Kenya (2011–2013) were compared on outcome measures that included viral suppression and adherence to ART.MethodsThis study used a repeated cross-sectional design (Round One and Round Two). All adults (≥18 years) receiving care from the refugee camp clinic and taking antiretroviral therapy (ART) for ≥30 days were invited to participate. Adherence was measured by self-report and monthly pharmacy refills. Whole blood was measured on dried blood spots. HIV-1 RNA was quantified and treatment failures were submitted for drug resistance testing. A remedial intervention was implemented in response to baseline testing. The primary outcome was viral load <5000 copies/mL. The two study rounds took place in 2011-2013.ResultsAmong eligible adults, 86% (73/85) of refugees and 84% (86/102) of Kenyan host nationals participated in the Round One survey; 60% (44/73) and 58% (50/86) of Round One participants were recruited for Round Two follow-up viral load testing. In Round One, refugees were older than host nationals (median age 36 years, interquartile range, IQR 31, 41 vs 32 years, IQR 27, 38); the groups had similar time on ART (median 147 weeks, IQR 38, 64 vs 139 weeks, IQR 39, 225). There was weak evidence for a difference in the proportion of refugees and host nationals who were virologically suppressed (<5000 copies/mL) after 25 weeks on ART (58% vs 43%, p = 0.10) and no difference in the proportions suppressed at Round Two (74% vs 70%, p = 0.66). Mean adherence within each group in Round One was similar. Refugee status was not associated with viral suppression in multivariable analysis (adjusted odds ratio: 1.69, 95% CI 0.79, 3.57; p = 0.17). Among those not suppressed at either timepoint, 69% (9/13) exhibited resistance mutations.ConclusionsVirologic outcomes among refugees and host nationals were similar but unacceptably low. Slight improvements were observed after a remedial intervention. Virologic monitoring was important for identifying an underperforming ART program in a remote facility that serves refugees alongside host nationals. This work highlights the importance of careful laboratory monitoring of vulnerable populations accessing ART in remote settings.

Development and validation of CF-Medication Beliefs Questionnaire: A mixed-methods approach

BackgroundBeliefs about medication have been associated with adherence in other diseases but there are no existing disease-specific medication beliefs questionnaires for CF. This mixed-methods validated the Cystic Fibrosis Medication Belief Questionnaire (CF-MBQ), based on social cognitive theory. MethodsBased on previous research, items were developed for five domains: motivation, self-efficacy, perceived importance, and decisional balance to take or miss medications. Cognitive interviews were conducted with 15 adult patients with CF to refine item development. 128 patients with CF completed an online survey and objective medication adherence was measured using pharmacy refill data. ResultsThe five subscales demonstrated strong psychometric properties, with adequate-to-good internal consistency scores. More importantly, each domain demonstrated construct validity with adherence. ConclusionsThese theoretically-derived measures may be important for clinical purposes to provide guidance on appropriate interventions to improve adherence and for research to provide enhanced understanding on patient determinants of medication adherence.

Reduced adherence to antiretroviral therapy is associated with residual low-level viremia.

The source and significance of residual low-level viremia (LLV) during combinational antiretroviral therapy (cART) remain a matter of controversy. It is unclear whether residual viremia depends on ongoing release of HIV from the latent reservoir or if viral replication contributes to LLV. We examined the relationship between adherence and LLV. Adherence was estimated by pharmacy refill and dichotomized as ≥95% or <95%. Plasma HIV-RNA was determined, with an ultrasensitive test having a limit of detection of 3 copies/mL at least 2 times over the follow-up period. Patients were grouped according to HIV-RNA over time as K<3: constantly <3 copies/mL; V<3: sometimes below or above the cutoff limit but always <50 copies/mL; K>3: constantly between 3 and 50 copies/mL; and V>50: a measure of >50 copies/mL minimum. Overall, 2789 patients were included. At each time point approximately 92% of the patients presented an HIV-RNA <50 copies/mL and two-thirds of those <3 copies/mL, 34.6% of patients had <3 copies/mL constantly, 32.7% sometimes below or above the cutoff limit but always <50 copies/mL, 9.5% constantly between 3 and 50 copies/mL, and 23.2% a measure of >50 copies/mL minimum. The mean adherence rate was 92.1% (95% confidence interval [CI] from 91.1% to 93.1%) in K<3 patients, similar in V<3 patients (91.9%), but lowered to 88.8% in K>3 patients and to 88.4% in V>50 patients (P<0.0001). Approximately 55% of patients in groups K<3 and V<3 showed an adherence rate ≥95%; this proportion lowered to ~51% in K>3 and to 48% in V>50. Moreover, 34% of patients with a steady adherence <95% were categorized as K>3, whereas 21.7% of those with a drug holiday (21.7%) were observed in the V>50 group (P=0.002). A steady viral suppression can occur despite moderate cART non-adherence, but reduced adherence is associated with low-level residual viremia, which could reflect new rounds of HIV replication. However, a detectable HIV-RNA could also be detected in patients with optimal cART adherence, indicating additional mechanisms favoring HIV persistence.

Comparison of six methods to estimate adherence in an ART-na\xefve cohort in a resource-poor setting: which best predicts virological and resistance outcomes?

BackgroundIncomplete adherence to antiretroviral therapy (ART) results in virologic failure and resistance. It remains unclear which adherence measure best predicts these outcomes. We compared six patient-reported and objective adherence measures in one ART-naïve cohort in South Africa.MethodsWe recruited 230 participants from a community ART clinic and prospectively collected demographic data, CD4 count and HIV-RNA at weeks 0, 16 and 48. We quantified adherence using 3-day self-report (SR), clinic-based pill count (CPC), average adherence by pharmacy refill (PR-average), calculation of medication-free days (PR-gaps), efavirenz therapeutic drug monitoring (TDM) and an electronic adherence monitoring device (EAMD). Associations between adherence measures and virologic and genotypic outcomes were modelled using logistic regression, with the area under the curve (AUC) from the receiver operator characteristic (ROC) analyses derived to assess performance of adherence measures in predicting outcomes.ResultsAt week 48 median (IQR) adherence was: SR 100% (100–100), CPC 100% (95–107), PR-average 103% (95–105), PR-gaps 100% (95–100) and EAMD 86% (59–94), and efavirenz concentrations were therapeutic (>1 mg/L) in 92%. EAMD, PR-average, PR-gaps and CPC best predicted virological outcome at week 48 with AUC ROC of 0.73 (95% CI 0.61–0.83), 0.73 (95% CI 0.61–0.85), 0.72 (95% CI 0.59–0.84) and 0.64 (95% CI 0.52–0.76) respectively. EAMD, PR-gaps and PR-average were highly predictive of detection of resistance mutations at week 48, with AUC ROC of 0.92 (95% CI 0.87–0.97), 0.86 (0.67–1.0) and 0.83 (95% CI 0.65–1.0) respectively. SR and TDM were poorly predictive of outcomes at week 48.ConclusionEAMD and both PR measures predicted resistance and virological failure similarly. Pharmacy refill data is a pragmatic adherence measure in resource-limited settings where electronic monitoring is unavailable.Trial registration The trial was retrospectively registered in the Pan African Clinical Trials Registry, number PACTR201311000641402, on the 13 Sep 2013 (www.pactr.org). The first participant was enrolled on the 12th July 2012. The last patient last visit (week 48) was 15 April 2014

Barriers and facilitators of antiretroviral therapy adherence in rural Eastern province, Zambia: the role of household economic status

In Zambia, more people living with HIV now have access to lifesaving antiretroviral therapy than ever before. However, progress in HIV treatment and care has not always resulted in lower mortality. Adherence remains a critical barrier to treatment success. The objective of this study was to examine the barriers and facilitators of antiretroviral therapy adherence, particularly the role of household economic status. The study included a cross-sectional sample of 101 people living with HIV (PLHIV) in two rural communities in eastern Zambia. Adherence was measured using patient self-assessment and pharmacy information. Household economic status included components such as occupation, income, assets, food security, and debt. Multivariable logistic regression was conducted to examine the associations between household economic factors and adherence. Our findings suggest that the role of economic status on adherence appears to be a function of the economic component. Debt and non-farming-related occupation were consistently associated with non-adherence. The association between assets and adherence depends on the type of asset. Owning more transportation-related assets was consistently associated with non-adherence, whereas owning more livestock was associated with self-reported adherence. Additionally, living in a community with fewer economic opportunities was associated with non-adherence. The associations between place of residence and pharmacy refill adherence and between transportation assets and self-reported adherence were statistically significant. Improving adherence requires a multifaceted strategy that addresses the role of economic status as a potential barrier and facilitator. Programmes that provide economic opportunities and life-skills training may help PLHIV to overcome economic, social, and psychological barriers.

The adherence gap: a longitudinal examination of men's and women's antiretroviral therapy adherence in British Columbia, 2000-2014.

The aim of this study was to observe the effect of sex on attaining optimal adherence to combination antiretroviral therapy (cART) longitudinally while controlling for known adherence confounders - IDU and ethnicity. Using the population-based HAART Observational Medical Evaluation and Research cohort, data were collected from HIV-positive adults, aged at least 19 years, receiving cART in British Columbia, Canada, with data collected between 2000 and 2014. cART adherence was assessed using pharmacy refill data. The proportion of participants reaching optimal (≥95%) adherence by sex was compared per 6-month period from initiation of therapy onward. Generalized linear mixed models with logistic regression examined the effect of sex on cART adherence. Among 4534 individuals followed for a median of 65.9 months (interquartile range: 37.0-103.2), 904 (19.9%) were women, 589 (13.0%) were Indigenous, and 1603 (35.4%) had a history of IDU. A significantly lower proportion of women relative to men were optimally adherent overall (57.0 vs. 77.1%; P < 0.001) and in covariate analyses. In adjusted analyses, female sex remained independently associated with suboptimal adherence overall (adjusted odds ratio: 0.55; 95% confidence interval: 0.48-0.63). Women living with HIV had significantly lower cART adherence rates then men across a 14-year period overall, and by subgroup. Targeted research is required to identify barriers to adherence among women living with HIV to tailor women-centered HIV care and treatment support services.

Nonadherence to antiretroviral therapy among HIV-infected patients in Zambia is concentrated among a minority of patients and is highly variable across clinics.

The distribution of adherence to antiretroviral therapy (ART) can indicates whether barriers are concentrated or more distributed. We quantified the medication possession ratio (MPR) and characterized the distribution of medication nonpossession in a network of clinics in Zambia to identify 'hotspots' and predictors of poorer adherence. We analyzed a population of adults on ART for more than 3 months who made at least one clinic visit between 1 January 2013 and 28 February 2015. Pharmacy refill and clinical information were obtained through the electronic medical record system used in routine care. We constructed a Lorenz curve to visualize the distribution of poor adherence and used a multilevel logistic regression model to examine factors associated with MPR. Among 131 767 patients in 56 clinics [64% women, median age 34 years (interquartile range (IQR) 29-41), median CD4 cell count at ART initiation 351 cells/μl (IQR 220-517)], the median MPR was 85.8% (IQR 70.8-96.8). During months 7-12 on ART, 45.6% of patients had 100% MPR and 10.5% accounted for 50% of medication nonpossession. Across clinics, median MPR ranged from 49.1 to 98.5, and clinic accounted for 12% of the variability in adherence after adjusting for individual and clinic-level characteristics. A small fraction of patients account for the majority of days of medication nonpossession. Further characterization of these subpopulations is needed to target interventions. Clinic also accounted for much variability in MPR. Health systems interventions targeting clinic 'hot spots' may represent an efficient use of resources to improve ART adherence.

FACTORS AFFECTING ANTIRETROVIRAL DRUG ADHERENCE AMONG HIV ADULT PATIENTS ATTENDING HIV CLINIC AT THE UNIVERSITY TEACHING HOSPITAL IN LUSAKA

BackgroundEffectiveness of anti-retroviral therapy (ART) requires strict adherence. Adherence ≥95% achieves optimum therapeutic levels and reduces drug resistance. We sought to determine factors associated with ART adherence within the context...

Pharmacy refill data can be used to predict virologic failure for patients on antiretroviral therapy in Brazil.

Introduction: Pharmacy adherence measures such as pharmacy dispensing ratios (PDRs) have previously been shown to be predictive of virologic outcomes. We aimed to determine the optimal interval of PDR assessment for predicting virologic failure for HIV-infected patients on antiretroviral therapy (ART).Methods: Using national Brazilian ART pharmacy refill data, we examined PDRs for patients ≥18 years of age with at least one HIV RNA level ≥180 days after ART initiation on or after 1 January 2011. Patients with a documented ART change ≤270 days prior to viral load test date were excluded. Logistic regression models were used to describe associations between virologic failure, defined as an HIV RNA level ≥400 copies/mL and PDRs, defined as the number of days index drug dispensed (non-nucleoside reverse-transcriptase inhibitor or protease inhibitor) per 180- and 90-day, interval preceding viral load testing, adjusting for sex, age, race, time since ART initiation and index drug. Backward elimination of insignificant variables was performed after adjusting for PDR. A predictive probability of virologic failure was calculated using the corresponding odds ratios for the PDR and any other significant variables. The diagnostic performance of the PDR interval was assessed by calculating the area under the receiver operating characteristic curve (AUROC) for the predictive probability with respect to virologic failure.Results and Discussion: A total of 1,025 patients were included (68% were male, median age 40 years, median time on ART 3.4 years). The PDR was found to be significantly associated with virologic failure for all of the PDR intervals (p < 0.001). There was an increased risk of virologic failure for all PDRs <0.95. The 90–180 days interval had a AUROC of 0.842, compared to 0.841 and 0.829 for the 0–180 days and 0–90 days intervals, respectively. The PDR performed well as a predictive tool to identify patients in virologic failure with the 90–180-days interval prior to viral load testing being marginally more predictive.Conclusions: The validation and use of the pharmacy dispensing ratio using public pharmacy refill data could aid in early identification of patients with poor adherence and prevent development of treatment failure and drug resistance in Brazil.

Evaluating Adherence to Antiretroviral Therapy Using Pharmacy Refill Records in a Rural Treatment Site in South Africa

Optimal adherence to combination antiretroviral therapy (cART) is critical to maintain virologic suppression, thereby ensuring the global success of HIV treatment. We evaluated adherence to cART using pharmacy refill records and determined the adherence threshold resulting in >90% virologic suppression in a community run treatment site in South Africa. Additionally, we analysed factors associated with adherence using univariable and multivariable logistic regression models. Logistic regression was also performed to determine the relationship between adherence and virologic suppression and the adherence threshold resulting in <10% virologic failure. The overall median (interquartile range) adherence was 95% (88.6–98.4%). Out of the study participants, 210/401 (52.4%) had optimal (≥95%) adherence while only 37/401 (9.2%) had poor (≤80%) adherence. The majority (90.5%) of patients with optimal adherence had virologic suppression. Having TB at registration into care was found to be negatively associated with adherence (adjusted odds ratio [AOR], 0.382; p ≤ .05). Compared to nonadherent individuals, optimally adherent participants were more likely to achieve virologic suppression (OR 2.92; 95% CI: 1.63–5.22). Only adherence rates above 95% were observed to lead to <10% virologic failure. cART adherence measured by pharmacy refill records could serve as a useful predictor of virologic failure; adherence rates >95% are needed to maintain optimal virologic suppression.

Adherence to Antiretroviral Therapy and Associated Factors Among Adult ARV Users in Arba Minch Hospital, Southern Ethiopia

The provision of Antiretroviral Therapy (ART), HIV/AIDS is becoming a chronic manageable disease; therefore to manage chronic disease, adherence to HIV medication is very important but a variety of other factors may complicate ART adherence that needs devotion from patients, provisions of health services and health care professionals, and having social support from the society. The purpose of this study was to determine the level of adherence to ART and associated factors among adult antiretroviral drugs (ARV) users. A cross sectional study was carried out at Arba Minch Hospital from March 5 to May 5, 2015. One month patients’ self-report and pharmacy refill records were used to assess adherence. Data were collected by a standard questionnaire after pre-tested and data abstraction format. The collected data were entered in to Epi-Info and it was exported in to SPSS for data analysis. Multiple logistic regressions analysis was applied and statistical significance test was declared at P-value &lt;0.05 and OR with 95% CI. Based on patients’ self-report dose adherence, among the 428 study participants, the magnitude of adherence to ART in a month before interview was 77.10%. Multivariable analysis showed that, adherence was positively associated with sex (male) (AOR=3.03, CI (1.69-5.42)), free from substance uses (AOR=3.49, CI (1.80-6.77)), absence of side effect of drugs (AOR =2.61, CI (1.19-5.73)), ART schedule fit to daily routines (AOR= 2.93, CI (1.24-6.91)) and feeling comfort on taking ART drug in front of others (AOR=3.32, CI (1.54-7.16)). The ART adherence rate of this study was relatively low compared with WHO standard and others study in Ethiopia. Sex, feeling comfort on taking the ART drugs, ART schedule fit to daily routines, substance use and drug side effects were strong predictors of adherence.

Can a Multifaceted Intervention Including Motivational Interviewing Improve Medication Adherence, Quality of Life, and Mortality Rates in Older Patients Undergoing Coronary Artery Bypass Surgery? A Multicenter, Randomized Controlled Trial with 18-Month Follow-Up.

Patients undergoing coronary artery bypass graft (CABG) surgery are required to take a complex regimen of medications for extended periods, and they may have negative outcomes because they struggle to adhere to this regimen. Designing effective interventions to promote medication adherence in this patient group is therefore important. The present study aimed to evaluate the long-term effects of a multifaceted intervention (psycho-education, motivational interviewing, and short message services) on medication adherence, quality of life (QoL), and mortality rates in older patients undergoing CABG surgery. Patients aged over 65years from 12 centers were assigned to the intervention (EXP; n=144) or treatment-as-usual (TAU; n=144) groups using cluster randomization at center level. Medication adherence was evaluated using the Medication Adherence Rating Scale (MARS), pharmacy refill rate, and lipid profile; QoL was evaluated using Short Form-36. Data were collected at baseline; 3, 6, and 18months after intervention. Survival status was followed up at 18months. Multi-level regressions and survival analyses for hazard ratio (HR) were used for analyses. Compared with patients who received TAU, the MARS, pharmacy refill rate, and lipid profile of patients in the EXP group improved 6months after surgery (p<0.01) and remained so 18months after surgery (p<0.01). QoL also increased among patients in the EXP group as compared with those who received TAU at 18months post-surgery (physical component summary score p=0.02; mental component summary score p=0.04). HR in the EXP group compared with the TAU group was 0.38 (p=0.04). The findings suggest that a multifaceted intervention can improve medication adherence in older patients undergoing CABG surgery, with these improvements being maintained after 18months. QoL and survival rates increased as a function of better medication adherence. ClinicalTrials.gov NCT02109523.