Treatment Adherence Strategies Research Articles

Evaluating the Effectiveness of “I LIKE VST” Digital Technology in Enhancing Tuberculosis Treatment Adherence in Moldova

This study assessed the acceptance and feasibility of the implementation of Video Supported Treatment (VST) “I LIKE VST” digital application as an approach to increase tuberculosis (TB) treatment adherence in the Republic of Moldova. It employed mixed quantitative and qualitative method among TB patients and healthcare providers. The analysis encompasses socio-demographic factors, adherence levels, technological accessibility, and user experiences with the VST app. Results indicate that VST app method is acceptable and feasible to implement for people who find it convenient, regardless of their level of education. Adherence data from the I LIKE VST system shows that 75% of participants have over 90% adherence rate, due to VST app’s digital nature offering convenience and flexibility. No cases of less than 50% adherence were found. Challenges include technological, financial barriers and the need for patient-centric customization. Less than 2% of TB patients have their own phones which support the app work. Moreover, 13.3% of TB patients and 19.7% medical staff stated that they did not have own resources to cover mobile internet costs, until they were covered by the project. This study demonstrates the effectiveness of digital health interventions in resource-limited settings. The findings are particularly relevant for policymakers and health practitioners aiming to innovate TB treatment adherence strategies.

Quantitative Study of Physical, Social, Psychological, and Environmental Challenges Faced by Patients With Drug-Resistant Tuberculosis.

Background This study chronicles the socioeconomic and emotional challenges experienced by patients suffering from drug-resistant tuberculosis (DR-TB) in India, the country with the highest tuberculosis (TB) burden globally. Current government measures under the National TB Elimination Programme (NTEP) that include widely available molecular diagnostic methods, well-defined DR-TB regimens, free drug distribution, treatment adherence strategies, etc. need to expand to cover socioeconomic and emotional aspects of the disease. Objective The objective of this study was to assess the effects of DR-TB and its treatment on the quality of life of patients in the psychological, social, environmental, and physical domains using validated scales. Method Conducted at a tertiary care center in Pune, this quantitative study utilized the World Health Organization Quality of Life (WHOQOL-BREF) questionnaire to objectively assess the quality of life of 64 DR-TB patients. The questionnaire was self-administered but assisted by the investigator to understand the meaning of the questions, and it covered four domains: psychological, social, environmental, and physical. Results The results indicated significant psychological distress, with the psychological domain scoring the lowest mean (33.41), followed by social (35.52), environmental (41.27), and physical domains (41.88). These findings underscore the profound impact of DR-TB on the mental health, social interactions, and overall well-being of these patients. Furthermore, substantial employment challenges, financial constraints, and fears of disease transmission were prevalent among patients, highlighting socioeconomic disparities. Conclusion The study emphasizes the necessity of holistic interventions that include psychological support, socioeconomic empowerment, and public health campaigns to improve the quality of life and treatment adherence for DR-TB patients. Future research should explore integrated care models that address both the clinical and psychosocial needs of patients. The insights from this study suggest a need for policy enhancements and resource allocation to better support this vulnerable population, ultimately aiming for more comprehensive and sustainable DR-TB management, thus focusing not only on the outcome but also on morbidity.

Predictors of quality of life (QOL) and treatment adherence among children with nephrotic syndrome.

Any significant changes in the growth and development of any aspect of life will ultimately affect the health-related quality of life (HRQOL) of children with nephrotic syndrome. Various factors can influence treatment adherence, which can promote or decline the child's quality of life (QOL). Objective: To assess the quality of life and adherence to treatment regimen and to identify the predictors of QOL and adherence to treatment regimen among children with nephrotic syndrome. A cross-sectional study was conducted among 59 children with nephrotic syndrome who attended the Paediatric Department of AIIMS, Bhubaneswar, using the PedsQL 4.0 generic core scale to assess the quality of life and adherence response scale. Both descriptive and inferential statistics were performed using the SPSS 20 version. The overall QOL median score was 93.48, with an IQR of 18.48, which indicated good QOL. A median score of treatment adherence was 16 with IQR 5, which indicated that the overall treatment adherence was good. Type of nephrotic syndrome (P = 0.014), developmental stage (P = 0.018), education of mother (P = 0.026), and occupation of mother (P = 0.026) were the variables predicted QOL. Duration of disease (P = 0.006) and duration of therapy (P = 0.005) significantly predicted treatment adherence. Children need continuous reinforcement on treatment adherence strategies to attain and maintain good QOL so that it can help to reduce the disease severity. Controlling the predictors that influence the QOL and treatment adherence has to be counseled among the parents so that their adherence can be sustained throughout the disease process to maintain good QOL.

Epidemiological trends and treatment abandonment of paediatric solid tumours in a nigerian tertiary hospital: a seven-year review (2016–2022)

BackgroundPaediatric solid tumours, both benign and malignant, present significant health challenges, particularly in Sub-Saharan Africa where comprehensive data is limited. This study aims to elucidate the prevalence, distribution, and treatment outcomes of paediatric solid neoplasms in a tertiary hospital in South-East Nigeria over a seven-year period.MethodsA retrospective cohort study was conducted at Nnamdi Azikiwe University Teaching Hospital (NAUTH), Nnewi, Nigeria. Clinical details and histological slides of confirmed cases from January 2016 to December 2022 were reviewed. Data extraction focused on socio-demographic variables and treatment outcomes, analysed using statistical methods.ResultsThe study included 293 children diagnosed with solid tumours (58.1% malignant, 41.9% benign), with a female predominance (61.8%). The median age at diagnosis was 12 years. Fibroadenoma was the most common benign tumour (61.8% of benign cases), while non-Hodgkin lymphoma was the predominant malignant tumour (18.2% of malignant cases). Treatment abandonment rates differed significantly between benign (13.8%) and malignant (51.2%) tumours. Significant associations were found between treatment outcomes and factors such as gender (p = 0.0001 for benign tumours), age category (p = 0.0001 for benign tumours), and specific diagnoses (p = 0.0001 for both benign and malignant tumours).ConclusionThis study underscores the substantial burden of paediatric solid tumours in South-East Nigeria and highlights the critical need for improved treatment adherence strategies, particularly for malignant cases. The findings emphasize the importance of tailored interventions based on tumour type, age, and gender. These insights can inform future research, policy formulation, and healthcare strategies aimed at enhancing the management and outcomes of paediatric solid neoplasms in resource-limited settings.

Neurocognitive, Sociocultural, and Psychological Factors Impacting Medication Beliefs Among HIV-Seropositive Latinx Adults.

Among Latinx people living with HIV (PLWH), neurocognitive (NC) function, culture, and mental health impact medication adherence. Similarly, health beliefs and attitudes play a role in health care barriers and health behaviors. Research has not examined the effect that compromised neurocognition, sociocultural factors, and mental health have on health beliefs and attitudes. This is especially relevant for Latinx PLWH who are disproportionately impacted by HIV, given that sociocultural factors may uniquely impact HIV-related NC and psychological sequelae. This study investigated the associations between neurocognition, sociocultural factors, mental health, health beliefs, and health attitudes among Latinx HIV-seropositive adults. Within a sample of 100 Latinx PLWH, better verbal learning and executive functioning abilities were associated with more positive attitudes about the benefits of medications and memory for medications. In terms of sociocultural factors, higher English language competence was related to better self-reported memory for medications, and overall, higher US acculturation was associated with more positive attitudes toward health professionals. Depressive symptomatology was negatively associated with attitudes toward medications and health professionals, as well as with self-reported memory for medications. These findings highlight the important interplay between NC, sociocultural, psychological factors, and health beliefs among Latinx PLWH. Adherence intervention strategies and suggestions for dispensing medical information are presented for clinicians and health care practitioners.

Adherence, barriers, and facilitators for the treatment of systemic arterial hypertension: rapid review of evidenceAdhesión, obstáculos y elementos facilitadores en relación con el tratamiento de la hipertensión: revisión rápida de la evidencia

To identify strategies to increase adherence to systemic arterial hypertension (SAH) treatment and describe the barriers and facilitators for implementing these strategies in primary health care (PHC). A rapid evidence review was performed. We included systematic reviews with or without meta-analyses, published in English, Spanish or Portuguese, covering adults (age 18 to ≤ 60 years) with SAH followed in the PHC. Searches were performed in nine databases in December 2020 and updated in April 2022. The systematic reviews were assessed for methodological quality using the AMSTAR 2 tool. Fourteen systematic reviews on treatment adherence strategies and three on barriers and facilitators for implementation were included. Regarding methodological quality, one systematic review was classified as moderate, four as low, and the others as critically low. Four strategies were identified as options for health policies: actions performed by pharmacists; actions performed by non-pharmaceutical health professionals; self-monitoring, use of mobile apps, and text messages; and subsidies for the purchase of medicines. Low digital literacy, limited access to the internet, work process and incipient training were barriers for professionals. The users' educational and health literacy levels, accessibility to health services and good relationships with professionals were facilitators. Positive effects of strategies related to pharmaceutical care, self-monitoring, and the use of cell phone applications and text messages were identified to increase adherence to the treatment of SAH in the context of PHC. However, for implementation purposes, it is necessary to consider barriers and facilitators, in addition to the methodological limitations of the analyzed systematic reviews.

Physiotherapy exercise rehabilitation with tailored exercise adherence support for people with osteoporosis and vertebral fractures: protocol for a randomised controlled trial – the OsteoPorosis Tailored exercise adherence INtervention (OPTIN) study

IntroductionVertebral fragility fractures affect at least 20% of the older population in the UK. Best practice guidelines recommend the use of exercise to slow the rate of bone loss, to...

Antecedents of willingness to provide pharmaceutical services for mental illness individuals

Pharmacists play a role in providing health care for mental illness patients such as medication management, providing drug information, medication counseling, and facilitating treatment adherence strategies. This study aimed to determine the effect of stigma, attitude and belief on the willingness to provide pharmaceutival services for mental illness individuals. This study design is a quantitative correlational study with a cross sectional approach. The sampling technique in this study used a purposive sampling approach. The sample used was 376 respondents with the inclusion criteria of undergraduate and diploma pharmacy students in Central Java, Indonesia. Data analysis were conducted in structural equation modeling - partial least square (SEM-PLS). The statistical results showed that attitudes had a positive effect on the willingness of pharmacy students to provide pharmaceutical services for mental illness individuals (p<0.05). However, stigma and belief do not affect the willingness of pharmacy students to provide pharmaceutical services for mental illness individuals (p>0.05). This study suggested conducting learning evaluations such as improving mental health literacy and interdisciplinary collaboration.

HIV Treatment Adherence Strategies Among Virally Suppressed Black Sexual Minority Men in Baltimore, Maryland, and Los Angeles, California: A Theory-Based Qualitative Study.

The goals and strategies of Black sexual minority men living with HIV (BSMMLWH) who achieve viral suppression require further investigation. This study explored treatment adherence strategies among BSMMLWH with sustained viral suppression. We conducted 27 in-depth qualitative interviews with BSMMLWH in Baltimore, Maryland, and Los Angeles, California, between December 2018 and May 2019. Interviews included questions guided by Positive Deviance and Life Course theoretical frameworks regarding multilevel factors and explicit strategies for antiretroviral therapy adherence. Themes regarding intentional, age group-specific strategies such as using technology (among younger men) and taking HIV medications with other daily pills (among older men) were identified. Participants also reported symbiotic goals and values that encouraged adherence, such as having a desire to live, strong familial relationships with clinicians, and support networks. Identifying personal goals and having supportive clinical and social relationships could be key to improving treatment adherence and viral suppression among BSMMLWH.

Treatment outcomes of Gene Xpert positive tuberculosis patients in KwaMashu Community Health Centre, KwaZulu-Natal, South Africa: A retrospective review

BackgroundWe sought to investigate the relationship between tuberculosis (TB) treatment outcomes and its predictors in the KwaMashu region in KwaZulu-Natal (KZN). This area is currently a hotbed for TB and human immunodeficiency virus (HIV) co-infection.MethodA retrospective study design was adopted to characterise adult patients diagnosed with Gene Expert (GXP) positive pulmonary TB from 01 January 2016 to 31 December 2017. Tuberculosis treatment outcomes were assessed after two months and five months according to the standard World Health Organization (WHO) criteria. Multiple logistic regression analysis was used to calculate the odds ratio (OR) of the possible determinants associated with unsuccessful treatment outcomes.ResultsAmongst the 596 patients diagnosed, 57.4% (95% confidence interval [CI]: 53.3–61.4; 342 of 596) had successful treatment outcomes. Of these reported cases, 88.89% (85.1–92.0; 304 of 342) were cured. For the unsuccessful treatment outcomes, 52.4% (46.0–58.6; 133 of 254) patients were lost to follow-up, 20.9% (16.0–26.4; 53 of 254) failed treatment, 1.2% (0.2–3.4; 3 of 254) died and 25.6% (20.3–31.4; 65 of 254) of the patients could not be accounted for. Patients with unknown HIV status were more likely to have unsuccessful treatment outcomes (adjusted OR [aOR] = 4.94 [1.83–13.36]). Patients who had sputum conversion at 2 months (aOR = 1.94 [1.27–2.96]) were significantly more likely to exhibit unsuccessful treatment outcomes.ConclusionTreatment success rate was 57.4% which was below the target set by the WHO. This underscores the urgent need to strengthen treatment adherence strategies to improve outcomes, especially in high HIV burden settings.

Sw\u0101sthya, an integrated chronic condition management programme for families of patients with hypertension and diabetes mellitus: a study protocol for a randomised controlled trial

BackgroundKerala is known as the diabetes mellitus (DM) and hypertension (HTN) capital of the world, thus compelling health professionals to model strategies, addressing their social, behavioural, and cognitive risk factors and eliminating various barriers to management. This paper describes the protocol of our study that aims to examine the effectiveness and sustainability of an integrated care model for the management of chronic conditions and their risk factors through a family-based intervention. The proposed care model targets to modify systems and processes that predispose to chronic conditions by enhancing social cohesion and social networks, preventing lifestyle risks, developing iterative cognitive interventions, and engaging the family into customised treatment adherence strategies navigated by community health social workers (CHSWs).MethodsA cluster randomised controlled trial (RCT) in selected participants will be conducted involving additional assessments prior to the baseline assessment. The assessment will identify and categorise patients into four risk groups, namely behavioural, social, cognitive, and multiple, based on dominant risks identified. Eligible participants will be randomly allocated (at a ratio of 1:1) into the intervention or control arm. The intervention arm will receive social, behavioural, and cognitive or multiple interventions corresponding to the identified risk groups, whereas the control arm will receive general intervention. Both the groups will be followed up at 6 months and 12 months post baseline to measure outcomes. The primary outcome will be the control of HTN and DM, and secondary outcomes include decreased depression and anxiety and improved functioning, social cohesion, and social network linkages. The sustainability and scalability of this intervention will be assessed through cost effectiveness, acceptability, and user friendliness of the integrated approach by performing a qualitative evaluation.DiscussionThis RCT will inform the potential paradigm shift from a medical model of chronic condition management to a multidimensional, multisystem, and multidisciplinary convergence model navigated by CHSWs. Such a model is not currently considered in the management of chronic conditions in Kerala.Trial registrationTrial has been prospectively registered on Clinical Trial Registry of India- CTRI/2020/12/029474 on 1st December 2020.

HIV drug resistance profile in South Africa: Findings and implications from the 2017 national HIV household survey.

BackgroundHIV drug resistance (HIVDR) testing was included in the 2017 South African national HIV household survey. We describe the prevalence of HIVDR by drug class, age, sex and antiretroviral drugs (ARV) status.MethodsDried blood were spots tested for HIV, with Viral load (VL), exposure to ARVs and HIVDR testing among those HIV positive. HIVDR testing was conducted on samples with VL ≥1000 copies/ml using Next Generation Sequencing. Weighted percentages of HIVDR are reported.Results697/1,105 (63%) of HIV positive samples were sequenced. HIVDR was detected in samples from 200 respondents (27.4% (95% confidence interval (CI) 22.8–32.6)). Among these 130 (18.9% (95% CI 14.8–23.8)), had resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs) only, 63 (7.8% (95% CI 5.6–10.9)) resistance to NNRTIs and nucleoside reverse transcriptase inhibitors, and 3 (0.5% (95% CI 0.1–2.1)) resistance to protease inhibitors. Sixty-five (55.7% (95% CI 42.6–67.9) of ARV-positive samples had HIVDR compared to 112 (22.8% (95% CI 17.7–28.7)), in ARV-negative samples. HIVDR was found in 75.6% (95% CI 59.2–87.3), n = 27, samples from respondents who reported ARV use but tested ARV-negative, and in 15.3% (95% CI 6.3–32.8), n = 7, respondents who reported no ARV use and tested ARV-negative. There were no significant age and sex differences in HIVDR.Conclusion27% of virally unsuppressed respondents had HIVDR, increasing to 75% among those who had discontinued ARV. Our findings support strengthening first-line ARV regimens by including drugs with a higher resistance barrier and treatment adherence strategies, and close monitoring of HIVDR.

Protocol for a systematic review of treatment adherence for HIV, hepatitis C and tuberculosis among homeless populations

BackgroundHomelessness is a global issue and HIV, hepatitis C and tuberculosis are known to be prevalent in this group. Homeless populations face significant barriers to care. We aim to summarise evidence of treatment initiation and completion for homeless populations with these infections, and their associated factors, through a systematic review and meta-analysis.MethodsWe will search MEDLINE, Embase and CINAHL for all study types and conference abstracts looking at either (1) treatment initiation in a cohort experiencing homelessness with at least one of HIV, hepatitis C, active tuberculosis and/or latent tuberculosis infection (LTBI); (2) treatment completion for those who initiated treatment. We will perform a meta-analysis of the proportion of those with each infection who initiate and complete treatment, as well as analysis of individual and health system factors that may affect adherence levels. We will evaluate the quality of research papers using the Newcastle-Ottawa scale.DiscussionGiven the political emphasis on global elimination of these diseases, and the current lack of understanding of effective and equitable treatment adherence strategies in homeless populations, this review will provide insight to policy-makers and service providers aiming to improve homeless healthcare.Systematic review registrationPROSPERO CRD42019153150

Effect of a Daily Text Messaging and Directly Supervised Therapy Intervention on Oral Mercaptopurine Adherence in Children With Acute Lymphoblastic Leukemia

Suboptimal adherence to oral mercaptopurine treatment in children with acute lymphoblastic leukemia (ALL) increases the risk of relapse. A frequently expressed barrier to adherence is forgetfulness, which is often overcome by parental vigilance. To determine whether a multicomponent intervention, compared with education alone, will result in a higher proportion of patients with ALL who have mercaptopurine adherence rates 95% or higher, for all study participants and among patients younger than 12 years and vs those aged 12 years and older. The adherence intervention trial was an investigator-initiated, multi-institutional, parallel-group, unblinded, randomized clinical trial conducted between July 16, 2012, and August 8, 2018, at 59 Children's Oncology Group institutions in the US, enrolling patients with ALL diagnosed through age 21 years and receiving mercaptopurine for maintenance. The date of final follow-up was January 2, 2019. Data analysis was performed from February to October 2019. Patients were randomized 1:1 to education alone or the intervention package, which consisted of education and personalized text message reminders daily to prompt directly supervised therapy. Four weeks of baseline adherence monitoring were followed with a 16-week intervention. The primary end point was the proportion of patients with adherence rates 95% or higher over the duration of the intervention for all study participants, and for those younger than 12 years vs those aged 12 years and older. There were 444 evaluable patients (median age, 8.1 years; interquartile range, 5.3-14.3 years), including 230 in the intervention group and 214 in the education group. Three hundred two patients (68.0%) were boys, 180 (40.5%) were non-Hispanic White, 170 (38.3%) were Hispanic, 43 (9.7%) were African American, and 51 (11.5%) were Asian or of mixed race/ethnicity. The proportion of patients with adherence rates 95% or higher did not differ between the intervention vs education groups (65% vs 59%; odds ratio, 1.33; 95% CI, 1.0-2.0; P = .08). Exploratory analyses showed that among patients aged 12 years and older, those in the intervention group had higher mean (SE) adherence rates than those in the education group (93.1% [1.1%] vs 90.0% [1.3%]; difference, 3.1%; 95% CI, 0.1%-6.0%; P = .04). In particular, among patients aged 12 years and older with baseline adherence less than 90%, those in the intervention group had higher mean (SE) adherence rates than those in the education group (83.4% [2.5%] vs 74.6% [3.4%]; difference, 8.8%; 95% CI, 2.2%-15.4%; P = .008). No safety concerns were identified. Although this multicomponent intervention did not result in an increase in the proportion of patients with ALL who had mercaptopurine adherence rates 95% or higher, it did identify a high-risk subpopulation to target for future adherence intervention strategies: adolescents with low baseline adherence. ClinicalTrials.gov Identifier: NCT01503632.

Experiences and training needs of healthcare providers involved in the care of Ghanaian adolescents living with HIV: an interventional study

BackgroundCaring for adolescents living with HIV/AIDS (ALHIV) can be overwhelming due to their unique needs. Ghana is currently among nine countries in West and Central Africa contributing to 90% of new paediatric infections in the sub-region with a growing population of ALHIV. Regardless, gaps in paediatric related care including healthcare providers (HCPs) capacity issues have been identified. This study sought to assess the competencies of adolescent-oriented healthcare providers before, and after interventionist training to inform recommendation that would guide the psychosocial care they give to ALHIV.MethodsThe study adopted a mixed methods approach with a non-randomized interventional study involving three-phase multi-methods. The sample consisted of 28 adolescent-oriented and multi-disciplinary healthcare providers at the Cape Coast Teaching Hospital (CCTH) in Ghana. Data were obtained in three phases, namely, a baseline survey, interventionist training, and post-training in-depth interviews. Quantitative data were analyzed using Stata version 13 for descriptive analysis while the qualitative data were analyzed thematically using NVivo version 11.ResultsAlthough the majority of the HCPs claim to be knowledgeable about adolescent health issues (n = 21, 75.0%), only about a third (n = 10, 35.7%) could correctly define who an adolescent is. The majority (n = 18, 64.3%) had not received any training on how to work with the adolescent client. The main areas identified for improvement in the ALHIV care in phase 1 included issues with psychosocial assessment, communication and treatment adherence strategies, creating an adolescent-friendly work environment, and availability of job aids/protocols. During the post-training interviews, participants reported an improved understanding of the characteristics of an adolescent-friendly site and basic principles for ALHIV care. They were also able to correctly describe the widely used adolescent health assessment tool; the HEEADSSS. Post intervention interviews also revealed HCPs perception on increased practice related confidence levels and readiness to implement new knowledge and skills gained.ConclusionThis study has shown that targeted training on routine ALHIV care is effective in increasing HCPs knowledge, skills and confidence. Addressing the healthcare system/facility related gaps serves as an impetus for improved ALHIV care among HCPs.

Pharmaceutical recommendations in a university hospital transplant unit

Introduction: The transplanted patient has a complex pharmacotherapy, with the pharmacist having an important role in the multidisciplinary team. Objective: To analyze the pharmaceutical recommendations made during the hospitalization of the patients in kidney and liver transplant units. Methods: This was a cross-sectional study in which pharmaceutical recommendations from May 2017 to April 2018 were collected from the records contained in the database of the Clinical Pharmacy Unit of a University Hospital in Fortaleza, Brazil. The recommendations were categorized and analyzed based on the classification used in the institution. Results: There were 1241 pharmaceutical recommendations involving 325 patients and 1466 medications. The recommendations were more frequent during liver transplantation (54.2%, n = 672), with dose adjustments (18.2%, n = 122) and dilution / reconstitution (9.8%, n = 66) being the most predominant types. In kidney transplantation, recommendations for education about medication use (17.6%, n = 100) and treatment adherence strategies (17.6%, n = 100) were the most predominant. The most frequent therapeutic classes were systemic antibacterials (31.2%, n = 458) and immunosuppressants (25.1%, n = 368). The acceptance rate of recommendations for kidney and liver transplantation were 95.1% (n = 541) and 95.4% (n = 641), respectively. Conclusions: The present study showed a high frequency of pharmaceutical recommendations and these results demonstrate that the detection of drug-related problems generates pharmaceutical recommendations that can contribute to the reduction of negative drug-associated results and increase patient safety.

Integrating Financial Incentives for Viral Load Suppression into HIV Care Coordination Programs: Considerations for Development and Implementation

Interventions that support durable viral load suppression (VLS) among people living with HIV (PLWH) who face barriers to treatment adherence are needed to maintain optimal individual health, prevent new HIV infections, and advance health equity. Efficacy trials indicate that financial incentives (FIs) are a promising strategy for promoting VLS, although less is known about their implementation in "real-world" settings. This article describes considerations for the development and implementation of FI interventions identified in existing literature, and how they informed the scale-up of a multilevel treatment adherence support program designed to increase VLS among PLWH in New York City. The Undetectables VLS Program comprises a social marketing campaign and a "tool kit" of evidence-based HIV treatment adherence strategies, including quarterly FIs ($100) that patients receive for achieving or maintaining an undetectable viral load (<200 copies/mL; also referred to as VLS). The intervention was developed and pilot tested by Housing Works Community Healthcare and the University of Pennsylvania from 2014 to 2016. Initial findings from the pilot evaluation showed a statistically significant positive effect on VLS. The New York City Department of Health and Mental Hygiene contracted with 7 agencies across New York City to scale up The Undetectables Program over a 3-year period (2016-2019) by integrating the program into existing services for PLWH. Quality indicators (eg, percentage of clients who received an FI each quarter; percentage of clients who were virally suppressed at 90 days postenrollment) will be used to measure program performance and impact over time. Recommendations for implementing FIs for PLWH include packaging FIs with client-centered, evidence-based adherence strategies, incorporating FIs into existing service delivery systems, and obtaining organization-wide buy-in to facilitate their implementation. Implementation science research is needed to identify strategies to effectively implement and sustain evidence-based FI interventions.

A measure to assess HIV treatment readiness among adolescents and young adults

ABSTRACTHIV infections among adolescents and young adults continue to grow and clinical guidelines recommend the immediate start of life-saving antiretroviral therapy (ART). Unfortunately, suboptimal medication adherence among youth is common and can lead to poorer health outcomes as well as onward transmission of HIV to sexual partners. Clinical tools to assess treatment readiness are needed and can assist with adherence intervention strategies for youth. An assessment tool that we previously developed, the HIV Treatment Readiness Measure (HTRM), was administered to 595 HIV-positive youth ages 13–24 recruited from adolescent medicine clinics in the United States. Participants were followed for a minimum of 6 months and had to have at least one viral load test completed to be included in this analysis. The HTRM demonstrated high internal consistency (Chronbach’s alpha = 0.86). For participants currently on ART at study entry, higher overall treatment readiness scores predicted future viral suppression (OR 1.52). Individual scores on three of the measure’s factors (Psychosocial Issues, Connection with Care, and HIV Medication Beliefs) were also significant predictors of viral suppression. For those participants not on ART at study entry, the HIV Medication Beliefs factor significantly predicted who would eventually start ART (OR 2.26) but overall treatment readiness scores did not predict viral suppression in that group.

Early death by tuberculosis as the underlying cause in a state of Southern Brazil: Profile, comorbidities and associated vulnerabilities

AimTo know the profile of adults who died by tuberculosis as the main cause, the time interval between the diagnosis and death, associated comorbidities and vulnerabilities. MethodObservational study of secondary data regarding deaths by tuberculosis that occurred in the State of Paraná, Brazil, from 2008 to 2015. A linkage between the databases of mortality and tuberculosis notification system was conducted for data enrichment. Frequency tables, Exact Fisher test and Z test have identified statistical associations. ResultsLinkage points out 12.1% (115/944) of under-reporting in the 944 deaths identified. Early deaths accounted for 74.6% (705/944). The male sex (75.8%) was associated with the early death group. Almost half of the deaths reported in notification system (414/829) had one or more vulnerabilities. Early death were associated with respiratory system diseases and symptoms (p=0.0001) and mental and behavioral disorders (p=0.0001). ConclusionHigh number of early deaths due TB indicate the need to seek out the respiratory symptomatic and use faster diagnostic methods. Strategies for treatment adherence, adequate monitoring of comorbidities and multisectorial support may prevent early and late death. The presence of vulnerabilities indicates that efforts beyond the health sector are needed in order to eliminate tuberculosis as public health problem.

Effectiveness and cost-effectiveness of a nurse-delivered intervention to improve adherence to treatment for HIV: a pragmatic, multicentre, open-label, randomised clinical trial

No high-quality trials have provided evidence of effectiveness and cost-effectiveness of HIV treatment adherence intervention strategies. We therefore examined the effectiveness and cost-effectiveness of the Adherence Improving self-Management Strategy (AIMS) compared with treatment as usual. We did a pragmatic, multicentre, open-label, randomised controlled trial in seven HIV clinics at academic and non-academic hospitals in the Netherlands. Eligible participants were patients with HIV who were either treatment experienced (ie, with ≥9 months on combination antiretroviral therapy [ART] and at risk of viral rebound) or treatment-naive patients initiating their first combination ART regimen. We randomly assigned participants (1:1) to either AIMS or treatment as usual (ie, containing a range of common adherence intervention strategies) using a computer-generated randomisation table. Randomisation was stratified by treatment experience (experienced vs naive) and included block randomisation at nurse level with randomly ordered blocks of size four, six, and eight. 21 HIV nurses from the participating clinics received three training sessions of 6 h each (18 h in total) on AIMS and a 1·5 h booster training session at the clinic (two to three nurses per session) after each nurse had seen two to three patients. AIMS was delivered by nurses during routine clinic visits. We did mixed-effects, intent-to-treat analyses to examine treatment effects on the primary outcome of log10 viral load collected at months 5, 10, and 15. The viral load results were exponentiated (with base 10) for easier interpretation. Using cohort data from 7347 Dutch patients with HIV to calculate the natural course of illness, we developed a lifetime Markov model to estimate the primary economic outcome of lifetime societal costs per quality-adjusted life-years (QALYs) gained. This trial is registered at ClinicalTrials.gov (number NCT01429142). We recruited participants between Sept 1, 2011, and April 2, 2013; the last patient completed the study on June 16, 2014. The intent-to-treat sample comprised 221 patients; 109 assigned to AIMS and 112 to treatment as usual. Across the three timepoints (months 5, 10, and 15), log viral load was 1·26 times higher (95% CI 1·04-1·52) in the treatment-as-usual group (estimated marginal mean 44·5 copies per mL [95% CI 35·5-55·9]) than in the AIMS group (estimated marginal mean 35·4 copies per mL [29·9-42·0]). Additionally, AIMS was cost-effective (ie, dominant: cheaper and more effective) since it reduced lifetime societal costs by €592 per patient and increased QALYs by 0·034 per patient. Findings from preparatory studies have shown that AIMS is acceptable, feasible to deliver in routine care, and has reproducible effects on medication adherence. In this study, AIMS reduced viral load, increased QALYs, and saved resources. Implementation of AIMS in routine clinical HIV care is therefore recommended. Netherlands Organisation for Health Research and Development.