Provide Adherence Support Research Articles

Clinician Specialty and HIV PrEP Prescription Reversals and Abandonments

Clinicians are a key component of preexposure prophylaxis (PrEP) care. Yet, no prior studies have quantitatively investigated how PrEP adherence differs by clinician specialty. To understand the association between prescribing clinician specialty and patients not picking up (reversal/abandonment) their initial PrEP prescription. This cross-sectional study of patients who were 18 years or older used pharmacy claims data from 2015 to 2019 on new insurer-approved PrEP prescriptions that were matched with clinician data from the US National Plan and Provider Enumeration System. Data were analyzed from January to May 2022. Clinician specialties included primary care practitioners (PCPs), infectious disease (ID), or other specialties. Reversal was defined as a patient not picking up their insurer-approved initial PrEP prescription. Abandonment was defined as a patient who reversed and still did not pick their prescription within 365 days. Of the 37 003 patients, 4439 (12%) were female and 32 564 (88%) were male, and 77% were aged 25 to 54 years. A total of 24 604 (67%) received prescriptions from PCPs, 3571 (10%) from ID specialists, and 8828 (24%) from other specialty clinicians. The prevalence of reversals for patients of PCPs, ID specialists, and other specialty clinicians was 18%, 18%, and 25%, respectively, and for abandonments was 12%, 12%, and 20%, respectively. After adjusting for confounding, logistic regression models showed that, compared with patients who were prescribed PrEP by a PCP, patients prescribed PrEP by ID specialists had 10% lower odds of reversals (odds ratio [OR], 0.90; 95% CI, 0.81-0.99) and 12% lower odds of abandonment (OR, 0.88; 95% CI, 0.78-0.98), while patients prescribed by other clinicians had 33% higher odds of reversals (OR, 1.33; 95% CI, 1.25-1.41) and 54% higher odds of abandonment (OR, 1.54; 95% CI, 1.44-1.65). The results of this cross-sectional study suggest that PCPs do most of the new PrEP prescribing and are a critical entry point for patients. PrEP adherence differs by clinician specialties, likely due to the populations served by them. Future studies to test interventions that provide adherence support and education are needed.

Evaluation of a peer-support, ‘mentor mother’ program in Gaza, Mozambique; a qualitative study

BackgroundRetention in prevention of mother-to-child transmission of HIV programs is critical to reduce vertical transmission. To addresses challenges with retention, Mozambique launched a peer-support program in 2018, in which HIV-positive mothers provide adherence support as mentor mothers (MMs) for HIV-positive pregnant and lactating women and HIV-exposed and infected children.MethodsA descriptive qualitative evaluation was conducted across nine facilities in Gaza Province to assess the acceptability and barriers to implementation of the mentor mother program (MMP) among those receiving services and providing services. In-depth interviews and focus group discussions were conducted with MMs, MM supervisors, health care workers (HCWs), HIV-positive mothers enrolled in the MMP, HIV-positive mothers who declined MMP enrollment, and key informants involved in the implementation of the program. Thematic analysis identified emerging recurrent themes and patterns across the participants’ responses. Data were collected between November-December 2020.ResultsThere were initial challenges with acceptability of the MMP, especially regarding confidentiality concerns and MM roles. Sharing additional information about MMs and making small changes during the beginning of the MMP resulted in generally high acceptance of the MMP. HIV-positive mothers reported that counseling from MMs improved their understanding of the importance of anti-retroviral treatment (ART) and how to take and administer ART. HIV-positive mothers reported having reduced guilt and shame about their HIV-status, feeling less alone, and having more control over their health. MMs shared that their work made them feel valued and decreased their self-stigmatization. However, MMs also reported feeling that they had inadequate resources to perform optimal job functions; they listed inadequate transportation, insufficient stipends, and false addresses of clients among their constraints. Overall, HCWs felt that their workload was significantly reduced with MM support and wanted more MMs in the community and health facility.ConclusionsThis study found that the MMP was considered a substantive and highly valued support to HIV-positive mothers, resulting in increased ART literacy among patients, improved self-reported well-being and sense of community and reduced feelings of isolation. Recommendations include strengthening MM training, increasing financial and materiel resources, additional information provided to newly enrolled mothers and support for the male partners.

Management of Pelvic Inflammatory Disease in Clinical Practice.

Pelvic inflammatory disease (PID) is a common reproductive health disorder among women of reproductive age. The treatment of PID has slowly evolved, reflecting changing antibiotic susceptibility and advancements in therapeutics and research; however, it has been largely unchanged over the last several decades. The most recent treatment recommendations consider the severity of infection, clinical presentation, and the polymicrobial nature of the disease. In addition, the role of novel organisms like Mycoplasma genitalium in PID is of emerging significance. PID treatment guidance offers oral and parenteral treatment options based on the patient's clinical status; however, deviations from the published guidelines are a general concern. Point of care (POC) testing for precision care, provision of adherence support, optimizing self-management and prevention strategies, and other alternative or synergistic approaches that maximize treatment outcomes will be instrumental for addressing the current challenges in PID diagnosis and management.

Perceptions and Attitudes Toward an Interactive Voice Response Tool (Call for Life Uganda) Providing Adherence Support and Health Information to HIV-Positive Ugandans: Qualitative Study

The continuing decline in AIDS-related deaths in the African region is largely driven by the steady scale-up of antiretroviral therapy. However, there are challenges to retaining people living with HIV on treatment. Call for Life Uganda (CFLU) is an interactive voice response tool using simple analogue phones. CFLU supports patients with daily pill reminders, preappointment reminders, symptom reporting and management, and weekly health promotion tips. Mobile health tools are being increasingly used in resource-limited settings but are often adopted without rigorous evaluation. This qualitative study conducted at 12 months after enrollment assessed patients' experiences, perceptions, and attitudes regarding CLFU. We conducted a qualitative substudy within an open-label randomized controlled trial titled "Improving outcomes in HIV patients using mobile phone based interactive software support." Data were collected through 6 focus group discussions with participants sampled based on proportion of calls responded to-<25%, between 25% and 50%, and >50%-conducted at the Infectious Diseases Institute, Mulago, and the Kasangati Health Centre IV. NVivo (version 11; QSR International) was used in the management of the data and in the coding of the emerging themes. The data were then analyzed using content thematic analysis. There was consensus across all groups that they had more positive than negative experiences with the CFLU system. Participants who responded to >50% of the calls reported more frequent use of the specific elements of the CFLU tool and, consequently, experienced more benefits from the system than those who responded to calls less frequently. Irrespective of calls responded to, participants identified pill reminders as the most important aspect in improved quality of life, followed by health promotion tips. The most common challenge faced was difficulty with the secret personal identification number. Findings showed participants' appreciation, high willingness, and interest in the intervention, CFLU, that demonstrated great perceived potential to improve their access to health care; adherence to treatment; health awareness; and, consequently, quality of life. ClinicalTrials.gov NCT02953080; https://clinicaltrials.gov/ct2/show/NCT02953080.

Attitudes and practices of health care providers towards improving adherence to smoking cessation medications in Australia: A descriptive study.

Adherence to smoking cessation medications is low and predicts the success of quit attempts. Health care providers (HCPs) role in delivering smoking cessation support is crucial. HCPs support to improve adherence to smoking cessation medication has not been evaluated in Australia. This study describes the attitudes and practices of HCPs in Australia towards adherence to smoking cessation medications (nicotine replacement therapies, varenicline and bupropion) and intervention options. A descriptive cross-sectional study was conducted using a convenience sample of 70 HCPs in Australia. Participants were recruited through the social media platforms of professional societies in Australia. Data was collected in the periods between November 2020 and September 2021. Descriptive statistics were performed using SPSS statistical software version 27.0 and data was presented using proportions and percentages. The majority of participants were doctors, nurses and midwives (82.8%). Almost two-thirds of the participants (68.6%) self-reported that they provided adequate adherence support to individuals taking smoking cessation medications. The majority of participants (87.1%) identified adherence support service as part of their professional role. Only 11.1% of the participants who did not believe supporting medication adherence to be their role reported providing adherence support. The main perceived barriers to adherence support are lack of skill, knowledge, time and resources. HCPs believed that providing additional counselling and monitoring of adherence can improve adherence rates. In an online survey conducted in Australia, HCPs indicated multiple barriers to providing adherence support and intervention strategies that should be considered for smoking cessation programs. A higher proportion of participants who perceived adherence support as their professional role reported supporting adherence to smoking cessation medications. SO WHAT?: Considerations should be given to improve HCPs attitudes and practices towards smoking cessation medications adherence support. Smoking cessation programs should consider the issue of adherence support. Further studies with a larger sample size across a broader range of HCPs are needed to extensively understand adherence service provision among HCPs in Australia.

Mapping modifiable determinants of medication adherence in bipolar disorder (BD) to the theoretical domains framework (TDF): a systematic review.

Around 40% of people with bipolar disorder (BD) are non-adherent to medication leading to relapse, hospitalisation and increased suicide risk. Limited progress in addressing non-adherence may be partly attributable to insufficient understanding of the modifiable determinants of adherence that require targeting in interventions. We synthesised the modifiable determinants of adherence in BD and map them to the theoretical domains framework (TDF). We searched CINAHL, Cochrane Library, Embase, LILACS, Medline, PsychINFO and PubMed until February 2020. We included studies reporting modifiable determinants of adherence in BD. Two reviewers independently screened studies, assessed quality, extracted modifiable determinants and mapped them to TDF. We included 57 studies involving 32 894 participants. Determinants reported by patients spanned 11 of the 14 TDF domains compared to six domains represented by clinician/researcher. The TDF domains most commonly represented (% and example) in studies were: 'Environmental context and resources' (63%, e.g. experiencing side effects), 'Beliefs about consequences' (63%, e.g. beliefs about medication effects), 'Knowledge' (40%, e.g. knowledge about disorder), 'Social influences' (33%, e.g. support from family/clinicians), 'Memory, attention and decision processes' (33%, e.g. forgetfulness), 'Emotion' (21%, e.g. fear of addiction) and 'Intentions' (21%, e.g. wanting alternative treatment). 'Intentions', 'Memory, attention and decision processes' and 'Emotion' domains were only reported by patients but not clinicians. Clinicians may be underappreciating the full range of modifiable determinants of adherence and thus not providing adherence support reflective of patients' needs. Reporting of modifiable determinants in behavioural terms facilitates developing theory-based interventions to address non-adherence in BD.

Improved adherence with Medicines Use Review service in Slovenia: a randomized controlled trial

BackgroundBased on several existing patient-oriented activities, Medicines Use Review (MUR) service was standardized and officially adopted in Slovenia in 2015. Service aims to provide adherence support and ensure safe and effective medicines use. Therefore, the aim of the study was to evaluate the benefits of MUR in Slovenia, primarily the impact on medication adherence.MethodsA randomised controlled trial was performed in community pharmacies to compare MUR with standard care. Patients were randomised into either the test (patients received MUR by a certified MUR provider at visit 1), or control group. The study primary outcome was self-reported adherence to multiple medications, assessed by electronic ©Morisky Widget MMAS-8 Software at the first visit (V1) and after 12 weeks (V2). A sub-analysis of intentional and unintentional non-adherence was performed. MUR impact was defined as the relative difference in ©MMAS-8 score after 12 weeks between the test and control group. A multiple linear regression model was used to predict MUR impact based on baseline adherence (low versus medium and high). Several secondary outcomes (e.g. evaluation of drug-related problems (DRPs)) were also assessed.ResultsData from 153 (V1) and 140 (V2) patients were analysed. Baseline adherence was low, moderate and high in 17.6, 48.4 and 34.0% patients, respectively. In the low adherence subpopulation, test group patients showed a 1.20 point (95% CI = 0.16–2.25) increase in total ©MMAS-8 score (p = 0.025) compared to control group patients. A 0.84 point (95% CI = 0.05–1.63) increase was due to intentional non-adherence (p = 0.038), and a 0.36 point (95% CI = − 0.23-0.95) was due to unintentional non-adherence (p = 0.226). Additionally, statistically significant decrease in the proportion of patients with manifested DRPs (p < 0.001) and concerns regarding chronic medicines use (p = 0.029) were revealed.ConclusionMUR service in Slovenia improves low medication adherence and is effective in addressing DRPs and concerns regarding chronic medicines use.Trial registrationClinicalTrials.gov - NCT04417400; 4th June 2020; retrospectively registered.

The Comparison of Teen Clubs vs. Standard Care on Treatment Outcomes for Adolescents on Antiretroviral Therapy in Windhoek, Namibia.

Background Adolescents living with HIV (ALHIV) are challenged to adhere to antiretroviral therapy (ART) and achieve and maintain virologic suppression. Group-based adherence support interventions, such as adherence clubs, have been shown to improve long-term adherence in ART patients. The teen club intervention was introduced in 2010 in Namibia to improve treatment outcomes for ALHIV by providing adherence support in a peer-group environment. Adolescents who have completed the full HIV disclosure process can voluntarily join the teen clubs. The current study compared treatment outcomes of ALHIV receiving ART at a specialized paediatric HIV clinic between 1 July 2015 and 30 June 2017 in Windhoek, Namibia. Methods A retrospective cohort analysis was conducted on routine patient data extracted from the electronic Patient Monitoring System, individual Patient Care Booklets, and teen club attendance registers. A sample of 385 adolescents were analysed: 78 in teen clubs and 307 in standard care. Virologic suppression was determined at 6, 12, and 18 months from study start date, and compared by model of care, age, sex, disclosure status, and ART regimen. Comparisons between adolescents in teen clubs and those receiving standard care were performed using the chi-square test, and risk ratios were calculated to analyze differences in ART adherence and virologic suppression. Results The average clinician-measured ART adherence was 89% good, 6% fair, and 5% poor amongst all adolescents, with no difference between teen club members and adolescents in standard care (p = 0.277) at 3 months. Virologic suppression over the 2-year observation period was 87% (68% fully suppressed <40 copies/ml and 19% suppressed between 40–999 copies/ml), with no difference between teen club members and those in standard care. However, there were statistically significant differences in virologic suppression levels between the younger (10–14 years) adolescents and older (15–19 years) adolescents at 6 months (p = 0.015) and at 12 months (p = 0.021) and between adolescents on first-line and second-line ART regimen at 6 months (p = 0.012), 12 months (p = 0.004), and 18 months (p = 0.005). Conclusion The teen club model delivering psychosocial support only did not improve adherence and virologic suppression levels for adolescents in a specialized paediatric ART clinic, neither were they inferior to standard care. Considering the limitations of this study, teen clubs may still hold potential for improving adherence and virologic suppression levels for older adolescents, and more robust research on adherence interventions for adolescents with higher methodological quality is required.

Cryptococcal Meningitis Screening and Community-based Early Adherence Support in People With Advanced Human Immunodeficiency Virus Infection Starting Antiretroviral Therapy in Tanzania and Zambia: A Cost-effectiveness Analysis.

BackgroundA randomized trial demonstrated that among people living with late-stage human immunodeficiency virus (HIV) infection initiating antiretroviral therapy, screening serum for cryptococcal antigen (CrAg) combined with adherence support reduced all-cause mortality by 28%, compared with standard clinic-based care. Here, we present the cost-effectiveness.MethodsHIV-infected adults with CD4 count <200 cells/μL were randomized to either CrAg screening plus 4 weekly home visits to provide adherence support or to standard clinic-based care in Dar es Salaam and Lusaka. The primary economic outcome was health service care cost per life-year saved as the incremental cost-effectiveness ratio (ICER), based on 2017 US dollars. We used nonparametric bootstrapping to assess uncertainties and univariate deterministic sensitivity analysis to examine the impact of individual parameters on the ICER.ResultsAmong the intervention and standard arms, 1001 and 998 participants, respectively, were enrolled. The annual mean cost per participant in the intervention arm was US$339 (95% confidence interval [CI], $331–$347), resulting in an incremental cost of the intervention of US$77 (95% CI, $66–$88). The incremental cost was similar when analysis was restricted to persons with CD4 count <100 cells/μL. The ICER for the intervention vs standard care, per life-year saved, was US$70 (95% CI, $43–$211) for all participants with CD4 count up to 200 cells/μL and US$91 (95% CI, $49–$443) among those with CD4 counts <100 cells /μL. Cost-effectveness was most sensitive to mortality estimates.ConclusionsScreening for cryptococcal antigen combined with a short period of adherence support, is cost-effective in resource-limited settings.

PG-11 Characteristics of a nationwide cohort of Nigerian adolescents living with HIV on ART

Background: At an estimated 240,000, Nigeria has the second highest number of adolescents living with HIV (ALHIV) globally. Treatment outcomes for ALHIV have been poorer than for adults and younger children living with HIV. In order to improve outcomes for this population, comprehensive profile information is needed for programming innovations and differentiated care. We collated patient-level data from a large cohort of Nigerian ALHIV on ART to facilitate high-level decision-making for better outcomes. Methods: Between April and September 2017, data from all sites supported by 6 of the largest member organizations of the Nigeria Implementation Science Alliance were collected from the relevant State Health agencies. These 6 PEPFAR-implementing partners (IPs) supported healthcare facilities across all 6 of Nigeria's geopolitical zones. Data from 10 to 19 year old ALHIV enrolled in care and on ART during the review period were targeted. Data collected were extracted from IP-verified de-identified programmatic databases that included socio-demographic and clinical treatment information. Data from each partner were merged into a single Microsoft Excel database and descriptive analysis conducted using STATA 13. Results: A total of 22,551 unique ALHIV entries were identified, from 29 of Nigeria's 37 states and the Federal Capital Territory. The highest proportion of ALHIV (34.1%) came from the North-Central Zone, and the lowest proportion (9.3%) from the South-West. ALHIV in this cohort comprised 13,473 (59.7%) females, and were spread at 30.5%, 33.5% and 36.0% across early (10–13 years), mid (14–16 years) and late (17–19 years) adolescence, respectively. The greatest proportion of females (77.5%) was in the 19 year age group, with the lowest proportion (∼50%) across the 10–14 year age group. After excluding 4% missing data, approximately 91% of adolescents in the cohort were documented as being currently on first line NNRTI-based adult or pediatric combination ART. The remaining 5% of ALHIV were on PI-based second-line regimens. Facility-based ART refills for the majority (59.4%) of this cohort were on a two-monthly cycle; 29.7% on a one-monthly cycle and 10.2% on a three-monthly schedule. There were significant data gaps, with little to no information available on source of HIV infection and point of service entry into care, marital or sexual activity status, HIV disclosure status, or viral suppression. Conclusions: This ALHIV cohort represents nearly 10% of the estimated 240,000 ALHIV in Nigeria, and offers an opportunity to understand and program for impactful differentiated ALHIV care in the country. Questions remain on the relative absence of older adolescent males in care, regimen adjustments and switching based on weight and viral load data, and the best schedule and approach for delivering ART to this challenging population. Missing and non-prioritized data is an issue, specifically that needed to provide adherence support and comprehensive sexual and reproductive health services, including PMTCT and partner notification. Data collection for relevant indicators need to be incorporated into routine programming for improved service delivery. Longitudinal monitoring for this cohort can potentially yield valuable data to improve treatment outcomes.

Feasibility and acceptability of adherence support for direct acting antiviral therapy for hepatitis C in a low-threshold primary health-care opioid agonist treatment program.

To maximise the benefits of direct acting antivirals in Australia, innovative options for marginalised populations to receive daily or weekly medication may be beneficial. This study evaluated the feasibility and acceptability of direct acting antivirals provision by leveraging an opioid agonist treatment program to support adherence regardless of opioid agonist treatment enrolment. Feasibility was evaluated by monitoring selection of dosing options by clients initiating direct acting antivirals during the first 6 months. Client acceptability was assessed using a cross-sectional survey after 6 months. Pre- and post-implementation surveys of attitudes and concerns regarding the program were compared to evaluate staff acceptability. Among 79 clients commencing direct acting antivirals, 30 (38%) chose adherence support. Among these, 12 (40%) were not simultaneously enrolled in opioid agonist treatment. Clients were satisfied with service provision and access despite introducing daily dosing. All highly marginalised clients receiving direct acting antivirals with adherence support found this helpful. Staff concerns identified prior to the program proved unfounded. This study demonstrates providing adherence support for direct acting antivirals regardless of client participation in opioid agonist treatment is both feasible and acceptable with minimal impact on service provision. Availability of direct acting antivirals in opioid agonist treatment or primary health-care settings expands the pool of people who may receive effective treatment for hepatitis C virus and reduces treatment barriers.

Self-Efficacy and Adherence Behaviors in Rheumatoid Arthritis Patients.

IntroductionRheumatoid arthritis (RA) is a common disease that requires patient self-management with chronic medications. Adherence rates for RA medications are suboptimal. This study explores medication adherence and self-efficacy behaviors among RA patients.MethodsWe conducted a qualitative study comprising focus groups and individual interviews. Nineteen participants were recruited and screened to participate in three 90-minute focus groups (n = 13) and six 60-minute individual interviews. We created and maintained a codebook to analyze data. Interviews were analyzed by using NViVo qualitative analysis software.ResultsKey points in participant interviews were 1) self-efficacy as influenced by the ability to establish routines, and having an understanding relationship with their healthcare provider; 2) self-efficacy to adjust medications depended on having permission from providers to adjust medications, perceptions of the effectiveness of medications, and confidence in self-knowledge to make appropriate adjustments; and 3) changes in self-efficacy over time were influenced by initial denial and later acceptance of the diagnosis. Participant interviews revealed that medication adherence is a spectrum that ranges from adherent to nonadherent.ConclusionParticipants’ experience with RA medications revealed varied underlying reasons for adherence behaviors. Recognizing adherence as a dynamic behavior has important implications for how adherence interventions are designed. For example, participants reported adjusting medications in response to the unpredictable nature of RA. Interventions could collect information about RA symptoms and be tailored to provide adherence support at times when patients need it most. The importance of self-efficacy in influencing participants’ adherence behaviors is an area for continuing research among patients and providers.

Use of strategies to improve antihypertensive medication adherence within United States outpatient health care practices, DocStyles 2015-2016.

Patients' adherence to antihypertensive medications is key to controlling high blood pressure. Evidence-based strategies to improve adherence exist, but their use, individually and in combination, has not been described. 2015-2016 DocStyles data were analyzed to describe health care professionals' and their practices' use of 10 strategies to improve antihypertensive medication adherence across 3 categories: prescribing, education, and tracking/encouragement. Among 1590 respondents, a mean of using 5 strategies was reported, with individual strategy use ranging from 17.2% (providing patients adherence-related rewards) to 69.4% (prescribing once-daily regimens). Those with higher odds of using ≥7 strategies and strategies across all 3 categories included: (1) nurse practitioners compared to family practitioners/internists and (2) health care professionals in practices with standardized hypertension treatment protocols who routinely recommend home blood pressure monitor use compared to respondents without those characteristics. Despite using an array of evidence-based adherence-promoting strategies, additional opportunities exist for health care professionals to provide adherence support among hypertensive patients.

Do Persons Living with HIV Continue to Fill Prescriptions for Antiretroviral Drugs during a Gap in Care? Analysis of a Large Commercial Claims Database.

The significance of a gap in HIV care depends, at least partially, on whether patients continue to fill prescriptions for antiretroviral (ARV) drugs during the gap in care. We used a billing claims database to determine the proportion of persons who filled ≥1 prescription for ARV drugs during a gap in care (no clinic visit in >6 months). Persons were stratified into 3 groups: "never" (prescriptions never filled), "sometimes" (prescriptions filled >0%-<100% of months), and "always" (prescriptions filled monthly). Logistic regression analyses were conducted to determine factors associated with "never" filling ARV drugs. Of 14 308 persons, 69% (n = 9817), 13% (n = 1928), and 18% (n = 2563) "never," "sometimes," and "always" filled ARV drugs during the gap in care. Persons aged 18 to 29 years (odds ratio [OR] = 1.56, 95% confidence interval [CI] 1.39-1.74), women (OR = 1.67, CI 1.52-1.83), and persons from the Northeast region of the United States (OR = 1.86, CI 1.69-2.03) were more likely to never fill ARV drugs than persons aged ≥30 years, men, and persons outside the Northeast, respectively. Efforts should be made to minimize gaps in care, emphasize importance of therapy, and provide adherence support.

Emergent drug resistance with integrase strand transfer inhibitor-based regimens.

To estimate the incidence of and risk factors for emergent resistance to integrase strand transfer inhibitor (INSTI) and nucleoside(-tide) reverse transcriptase inhibitors (NRTI) in HIV-1-infected adults receiving an INSTI and two NRTIs. Retrospective cohort study. Persons aged at least 19 years were included if they received their first prescription for raltegravir, elvitegravir or dolutegravir in British Columbia, Canada in 2012-2014 and were followed to 31 December 2015. Emergent resistance was defined as new mutations conferring intermediate-high level NRTI or INSTI resistance (score ≥30, Stanford HIV Drug Resistance Algorithm v.7.0.1). First-year resistance rates and 95% confidence intervals (95% CI) were estimated for 'any' (INSTI or NRTI) resistance using Poisson regression. The relationship between any emergent resistance and explanatory variables was modeled by Cox proportional hazards. There were 270 raltegravir, 323 elvitegravir and 392 dolutegravir-treated persons who were predominantly male (77%), antiretroviral therapy (ART)-experienced (81%), with low prevalence of preexisting drug resistance (16%). INSTI and NRTI resistance emerged in both ART-experienced and ART-naive persons (including dolutegravir-treated ART-naive), with no statistically significant differences in 'any' resistance rates (95% CI) between INSTIs: raltegravir 3.80 (1.90, 7.60), elvitegravir 2.37 (1.06, 5.27) and dolutegravir 1.48 (0.62, 3.55)/100 person-years. The strongest factors associated with emergent resistance were CD4 less than 200 cells/μl, adjusted hazard ratio (95% CI) 10.46 (4.67, 23.41) and less than 80% adherence to the INSTI regimen hazard ratio 2.52 (1.11, 5.71). Incident drug resistance rates were low with 'real-world' use of INSTI-based regimens. However, incomplete ART adherence and low CD4 cell count were associated with increased resistance rates regardless of which INSTI was prescribed. Provide adherence support and monitor for drug resistance.

Mortality among people living with HIV on antiretroviral treatment in Bali, Indonesia: incidence and predictors.

Indonesia has the third highest number of people living with HIV/AIDS (PLWH) and the greatest increase in proportion of AIDS-related mortality in the Asia Pacific region between 2005 and 2013. Longitudinal mortality data among PLWH in Indonesia are limited. We conducted a retrospective cohort study from medical records of antiretroviral treatment (ART) recipients attending Badung General Hospital (BGH) and Bali Medica Clinic (BMC) between 2006 and 2014. We explored incidence of mortality by Kaplan-Meier analysis and identified predictors using a Cox proportional hazard model. In total, 575 patients were included in the analysis; the majority were male. The overall mortality rate was 10% per year. Multivariate analysis suggested that being male (adjusted hazard ratio [aHR]: 2.74; 95% confidence interval [CI]: 1.34-5.59), having a lower education (aHR: 2.17; 95%CI: 1.31-3.61), having heterosexual (aHR: 7.40; 95% CI: 2.61-21.00) or injecting drug use (aHR: 13.20; 95% CI: 3.17-55.00) as the likely transmission risk category, starting treatment with low CD4 cell counts (aHR: 3.18; 95% CI: 1.16-8.69), and not having a treatment supervisor (aHR: 4.02; 95% CI: 2.44-6.65) were independent predictors of mortality. The mortality was high, particularly in the first three months after initiating ART. These findings highlight the need to encourage HIV testing and early diagnosis and prompt treatment. Applying aspects of BMCs targeted HIV services model in more generalised services such as BGH may be beneficial. Providing adherence support as part of ART services is key to promoting adherence to ART.

Correlates of Combination Antiretroviral Adherence Among Recently Diagnosed Older HIV-Infected Adults Between 50 and 64years.

Optimal adherence to combination antiretroviral therapy is essential to the health of older people living with HIV (PLWH), however, the literature on adherence and aging is limited. Using Medicaid data from 29 states (N=5177), we explored correlates of optimal adherence among older PLWH. The prevalence of optimal adherence was low (32%) in this study. Males were more adherent than females (APR=1.11, 95% CI 1.02-1.21, P=0.0127); persons with three or more co-morbidities (APR=0.67, 95% CI 0.60-0.74, P<0.001), two co-morbidities (APR=0.86, 95% CI 0.75-0.98, P=0.0319) and one co-morbidity (APR=0.82, 95% CI 0.73-0.92, P=0.0008) were less adherent than those without any co-morbidity; and residents of rural areas (APR=0.90, 95% CI 0.63-0.98, P=0.0385) and small metropolitan areas (APR=0.82, 95% CI 0.72-0.94, P=0.0032) were less adherent than residents of large metropolitan areas. There were no racial differences in optimal adherence. Targeted interventions that provide adherence support, case management, and peer navigation services may be of benefit in achieving optimal adherence in this population.

A study on determinants of adherence to highly active anti-retroviral therapy in a tertiary care hospital

Background: Acquired immunodeficiency syndrome (AIDS) caused by human immunodeficiency virus (HIV) is a major global health problem. A major concern with scaling up of antiretroviral treatment in resource limited settings is the emergence of drug resistant viral strains due to sub-optimal adherence and the transmission of these resistant viral strains in the population. Adherence is the second largest predictor of progression to AIDS and death after CD4 count. Hence the aim of the present study was to evaluate adherence to HAART and its determinants among HIV/AIDS patients on first line HAART. Methods: This study was cross-sectional, observational in nature carried out among two hundred and seventy (270) HIV/AIDS patients on HAART during December 2013 to November 2014 at ART centre. Frequencies, Proportions and logistic regression analysis were applied and statistical analysis was done using (SPSS) 17.0 version. Results: Among the study population, 52.6% of the patients were male, 81.5% of them were adherent to HAART in the last 7 days recall. Most common reasons for missing HAART regimen in this study were simply forgetting (70%). On Bivariate analysis, Adherence levels was less among Female (p <0.025) compared to male patients, Adherence levels were more among patients who were Employed (p <0.01) compared to unemployed, patients taking only HAART medications (p <0.000) when compared to patients taking more than or equal to four medications, those taking two to three medications (p <0.000) when compared to patients taking more than or equal to four medications, patients in WHO stage I (p <0.00) compared to patients in WHO stage III, patients in WHO stage II (p <0.032) compared to patients in stage III and lastly patients who were never admitted to hospital (p <0.008) due to HIV related illness in the previous year of HAART medication compared to those admitted more than once. Conclusions: Several demographic and treatment related factors influence adherence to HAART. Hence, addressing these factors and providing adherence support services are main strategies to decrease non-adherence and its consequences.

Adherence to antiretroviral therapy among HIV-infected adults in the United States.

National estimates of antiretroviral therapy (ART) adherence and adherence support services utilization are needed to inform efforts to improve the health of HIV-infected persons in the United States. In a nationally representative sample of HIV-infected adults receiving medical care, 86% self-reported taking all ART doses in the past 72 hours. Overall, 20% reported using adherence support services and 2% reported an unmet need for services. If all nonadherent persons not receiving adherence support and all persons with a self-perceived unmet need for adherence support accessed services, resources to support ∼42,673 additional persons would be needed. Factors associated with lower adherence included younger age, female gender, depression, stimulant use, binge alcohol use, greater than once-daily dosing, longer time since HIV diagnosis, and patient beliefs. Predictors of adherence are multifactorial so multiple targeted strategies to improve adherence are warranted. Providing adherence support services to all those in need may require additional resources.

Delivery of patient adherence support: a systematic review of the role of pharmacists and doctors

Delivery of patient adherence support: a systematic review of the role of pharmacists and doctors Malin Andersson,1,2 Sara Garfield,1,2 Lina Eliasson,3,4 Christina Jackson,3 David K Raynor5 1The Centre for Medication Safety and Service Quality, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, 2UCL School of Pharmacy, London, 3Atlantis Healthcare, London, 4Centre for Haematology, Imperial College London, Hammersmith Hospital, London, 5School of Healthcare, University of Leeds, Leeds, UK Abstract: We conducted a systematic review of adherence support programs involving doctors and pharmacists. We searched MEDLINE&reg;, Embase, International Pharmaceutical Abstracts, PsycINFO&reg;, and CINAHL using the keywords &quot;pharmacist&quot; or &quot;doctor&quot; and &quot;adhere*&quot; or &quot;compli*&quot; and &quot;randomized controlled trials&quot;. We found 89 studies involving pharmacists; in contrast, only 14 studies involved doctors. The roles of pharmacists and doctors ranged from providing education and counseling to adjusting treatment. Most interventions that specified a patient group were carried out with patients with chronic conditions (n=79) and only six included short-term treatments. The majority of interventions improved adherence and clinical outcomes to some extent, although the size of effect size was sometimes small. Resource utilization (eg, hospitalization rates, visits to doctors) did not change in the majority of studies that reported it. Few studies included cost analyses. All but one study had high risk of performance bias due to the nature of the interventions, which made it impossible to blind the participants. The majority of studies did not report tailoring the interventions to patient needs and the vast majority of papers did not report taking a concordant patient-centered approach or considering patients&#39; own views and experiences when providing adherence support. In addition, the majority of studies did not describe training for the health care professionals involved in providing adherence support. Providing training for doctors and pharmacists to take a more patient-centered concordant approach would be expected to increase the effectiveness of adherence support further. Keywords: interventions, patient views, patient experiences, patient-centered approach, resource utilization