Evaluation of a brief low-cost intervention to improve antiretroviral treatment decisions

An earlier pilot study found that US DHHS guidelines for antiretroviral treatment were not being successfully implemented (Mann et al., 2000). A brief and inexpensive intervention (visual aid checklist) was developed with the assistance of HIV-expert physicians in order to aid HIV/AIDS health care providers' and their patients' decisions about antiretroviral therapy. The visual aid checklist consisted of a two-page coloured diagram and explanation of key concepts (T-cell, viral load and resistance) and a checklist of the benefits and risks of antiretroviral therapy. Twenty adult HIV-positive subjects and eight health care providers were studied. Ten subjects were observed with their providers without the intervention being used, and then ten subjects were observed with the intervention. A pre-/post-test format was used to assess the patients' antiretroviral knowledge, patient-provider discussion of the DHHS guidelines, and provider satisfaction with the intervention. No differences in baseline HIV knowledge were found between the two groups. Results showed that patients in the intervention condition had greater knowledge of the benefits and risks of antiretroviral therapy than patients in the control condition. Providers reported that the intervention was useful in aiding and encouraging communication as well as conveying knowledge.     

Paradoxical effects of clinician emphasis on adherence to combination antiretroviral therapy for HIV/AIDS

Constructive relationships between clinicians and patients being treated for HIV/AIDS are critical to treatment success. Trust, caring, and expertise have all been cited as important components of such relationships. As-yet unexamined, however, is the impact of the urgency patients sense in their clinicians concerning proper adherence to antiretroviral medications. Qualitative interviews (total, 214) from a study of adherence to highly active antiretroviral therapy (HAART) for active illegal drug users (n = 52) provided data for the analysis. Among other topics, interviews examined patients' perspectives on relationships with their providers. Study participants experienced their physicians as insisting on perfect adherence. Fearing disapproval if they disclosed missing doses, interviewees chose instead to conceal adherence information. Apprehensions about failing at perfect adherence led some to cease taking antiretrovirals over the course of the study. Well-intentioned efforts by clinicians to emphasize the importance of adherence can paradoxically undermine the very behavior they are intended to promote. Adherence can be approached in ways that inspire honesty and openness and build trust in the treatment relationship, laying the groundwork for a collaborative approach to solving problems in taking antiretroviral medications as prescribed.     

Supporting adherence to highly active antiretroviral therapy and protected sex among people living with HIV/AIDS: the role of patient-provider communication in Rio de Janeiro, Brazil

This exploratory study examined patient-provider communication dynamics regarding adherence to highly active antiretroviral therapy (HAART) and protective sexual behavior among people living with HIV/AIDS (PLWHA). We conducted 20 direct observations of routine consultations between PLWHA and care providers in two large public health clinics providing free HIV medications and clinical care to PLWHA in the greater Rio de Janeiro area of Brazil. Immediately after these observations, 20 semistructured in-depth interviews were conducted with observation participants regarding their communication with providers, overall clinic experience, and questions and concerns about adherence to HAART and safe sex. Findings from observations showed that patient-provider communication focused almost exclusively on biomedical aspects of HIV-related treatment such as symptom management. In most observations, adherence to HAART was addressed. However, questions posed by providers regarding adherence were generally close-ended and leading, discouraging an open exchange regarding potential difficulties related to adherence. HIV/sexually transmitted infection (STI)- related protective behaviors were seldom addressed except when the patient displayed STI symptoms or was thought to be pregnant. In qualitative interviews, patients generally reported satisfaction with their providers, but also reported a variety of concerns and challenges related to adherence to HAART and protective sexual behavior that were not expressed in patient-provider interactions. We conclude that one way in which adherence to HAART and protective sexual behavior among PLWHA could be facilitated is by improving patient- provider communication on these topics, including increasing the frequency of openended, nonjudgmental dialogue initiated by care providers.     

Three types of adherence to HIV antiretroviral therapy and their association with AIDS diagnosis, medication side-effects, beliefs about antiretroviral therapy, and beliefs about HIV disease

One hundred and ninety-three adults with HIV taking antiretroviral therapy completed a questionnaire on demographics, health beliefs, medication side-effects, and adherence to dose, schedule, and dietary instructions. Three health beliefs indices were identified: antiretroviral therapy (ART) benefits, ART adherence self-efficacy, and beliefs about future HIV-related health concerns. Patients who experienced medication side-effects reported strong beliefs that HIV infection would cause them future health problems or distrust in the benefits of ART. AIDS diagnosis obtained through medical records or medication side-effects were not related to any of the three types of adherence. Beliefs about future HIV-related health concerns were associated with suboptimal dose adherence. Beliefs about ART benefits were associated with suboptimal schedule and dietary instructions adherence. Older age and partner were protective factors of schedule adherence. Data suggest that health beliefs may vary across type of adherence and that adherence behaviours may be a coping strategy to adjust antiretroviral therapy to one's daily living.     

The Role of HIV Serostatus Disclosure in Antiretroviral Medication Adherence

This study examined the relationship between HIV serostatus disclosure and adherence to antiretroviral therapy (ART). The study was conducted with 215 HIV-seropositive patients who demonstrated poor adherence (<80%) and who were in serodiscordant relationships. Participants completed self-report measures regarding HIV serostatus disclosure and reasons for missing ART doses, as well as electronic monitoring of ART adherence (MEMS caps). Overall, 19% of the sample reported missing medication doses in the last two months due to concerns regarding serostatus disclosure. Participants who reported greater serostatus disclosure to others demonstrated higher rates of adherence, and this relationship remained after controlling for other explanatory variables. The relationship between disclosure and adherence was not mediated by practical support for adherence from others. Interventions to improve ART adherence should address the role of serostatus disclosure by providing patients with skills to maintain adherence in contexts of non-disclosure and to make informed choices regarding selective disclosure.     

Provider inaccuracy in assessing adherence and outcomes with newly initiated antiretroviral therapy

We studied the ability of providers to predict and estimate patient adherence to newly initiated highly active antiretroviral therapy (HAART). Nineteen providers referring 40 patients into an adherence study were surveyed. Widespread inaccuracy was found in providers' adherence predictions and estimates. Therefore, HAART should not be withheld solely on provider predictions of adherence. Providers should not rely on their own assessments when attempting to determine if patients are adhering to therapy.     

Adherence to combination antiretroviral therapies in HIV patients of low health literacy

OBJECTIVE: To test the significance of health literacy relative to other predictors of adherence to treatment for HIV and AIDS. PARTICIPANTS: Community sample of HIV-seropositive men (n = 138) and women (n = 44) currently taking a triple-drug combination of antiretroviral therapies for HIV infection; 60% were ethnic minorities, and 73% had been diagnosed with AIDS. MEASUREMENTS: An adapted form of the Test of Health Literacy in Adults (TOFHLA), a comprehensive health and treatment interview that included 2-day recall of treatment adherence and reasons for nonadherence, and measures of substance abuse, social support, emotional distress, and attitudes toward primary care providers. MAIN RESULTS: Multiple logistic regression showed that education and health literacy were significant and independent predictors of 2-day treatment adherence after controlling for age, ethnicity, income, HIV symptoms, substance abuse, social support, emotional distress, and attitudes toward primary care providers. Persons of low literacy were more likely to miss treatment doses because of confusion, depression, and desire to cleanse their body than were participants with higher health literacy. CONCLUSIONS: Interventions are needed to help persons of low literacy adhere to antiretroviral therapies.     

Clinical experience and choice of drug therapy for human immunodeficiency virus disease.

To determine if providers experienced in the management of human immunodeficiency virus (HIV) disease preferred different treatment regimens than providers with less experience, we analyzed data from a national survey of primary care providers' preferred regimens for the management of 30 HIV-related medical conditions. We mailed questionnaires to 999 correct addresses of providers in > 20 cities in the United States in May 1996. We received 524 responses (response rate, 52%). We found a statistically significant association between the number of HIV-infected patients cared for by the provider and the likelihood that the provider would report prescribing highly active antiretroviral therapy and multidrug combinations for treatment of opportunistic infections. Providers with few HIV-infected patients were substantially less likely to report using new therapeutic regimens or new diagnostic tools. We concluded that the preferred regimens of experienced providers are more likely to be consistent with the latest information on treatment for HIV disease than are those of less experienced providers.     

Improving HIV/AIDS care through treatment advocacy: going beyond client education to empowerment by facilitating client-provider relationships

Treatment advocacy (TA) programs have been implemented by AIDS service organizations (ASOs) and primary care clinics across the USA to help engage clients with HIV into care and support their adherence to antiretroviral therapy (ART). TA aims to empower people with HIV through education and client-centered counseling regarding HIV, ART, and other health issues; advocate on behalf of patients with providers; and make referrals to healthcare services and clinical trials. However, relatively little is known about the impact TA has on clients' healthcare experiences. The present study's objectives included exploring how TA services help clients engage in HIV care, initiate ART, and adhere to HIV medications. We conducted 25 semi-structured qualitative open-ended interviews with clients living with HIV/AIDS recruited from AIDS Project Los Angeles (APLA); four HIV medical providers; and two TA staff at APLA. Of the 25 clients interviewed, 92% were male and 8% were female. The average age was 43 years (SD=9). About 60% were African-American, 20% were White, 12% were other or multiracial, 4% were Latino, and 4% were Asian/Pacific Islander. Five interconnected themes consistently emerged across clients, TAs, and providers. TAs helped clients understand treatments and supported adherence within a holistic context. Further, TAs acted as a bridge to providers and helped clients build self-advocacy skills. Our data show that TA services go beyond traditional areas of education and treatment adherence. TA services within an ASO also provide a safe place to discuss initial HIV diagnoses and other health issues in a more comprehensive manner. TA services complemented medical and other social services by preparing clients with HIV to be better consumers of healthcare services. Future quantitative research examining the effectiveness of TA on improving clients' engagement in care and adherence is a critical next step.     

The implementation of the DHHS guidelines for the use of antiretroviral agents in HIV-infected adults: a pilot study

The objective of this study was to assess whether United States DHHS guidelines for treatment with antiretroviral therapies are being implemented by health care providers when discussing treatment options with newly diagnosed HIV patients. Health care providers were observed interacting with HIV patients while making decisions about treatment. Observers assessed whether providers and patients discussed the five benefits and six risks of initiating antiretroviral therapy, as recommended in the DHHS Guidelines. Preliminary results indicate that the DHHS Guidelines are not being implemented in the way they were intended. The risks and benefits of antiretroviral therapy were infrequently discussed. No more than four of the 11 risk/benefit items were discussed with any patient, and four of the six risk items were never mentioned to any patient. Potential reasons why the guidelines are not being implemented are discussed.     

Medical personnel knowledge and stigmatic attitude toward HIV patients in a high-income country

ABSTRACT

Negative attitudes of health care workers (HCW) toward people living with HIV (PLWH) impact patients’ care, quality-of-life, therapy adherence, and retention in care. Few publications address stigma and discrimination among HCWs in high income countries. This study aims to provide a better understanding of HCW knowledge and attitudes toward caring for PLWH, how this relates to discriminatory tendencies and professional contacts, and proposes effective strategies to reduce negative attitudes and stigmas among health care providers in a tertiary hospital in Israel. Of 321 health care personnel who responded to an electronic questionnaire, HCWs had a good level of general knowledge regarding HIV. A lack of knowledge was noted regarding antiretroviral therapy influences, HIV transmission from mother to child, and HIV risks and transmission. Cultural diversity was also noted. This study supports the need to implement a training program for HCWs on HIV-related stigma-reduction.     

Patient–provider perceptions on engagement in HIV care in Argentina

Approximately 30% of patients participating in the national antiretroviral therapy (ART) program in Argentina fail to achieve an undetectable viral load, and approximately 25% are not retained in care. This qualitative study was designed to explore and identify factors associated with engagement and retention in public and private health care in Buenos Aires, Argentina. Qualitative data from key informants (n = 12) and focus groups (n = 4 groups) of patients and providers from private and public HIV treatment facilities were recorded and transcribed. Predetermined and arising themes related to adherence, engagement, and retention in care were coded and analyzed using qualitative data analysis software. Reasons identified for patients' lack of adherence or engagement in care differed between patients and providers, and patients attributed limitations to low self-efficacy, fear and concerns about HIV, and lack of provider involvement in treatment. In contrast, providers viewed themselves as decision-makers in patient care and patients as responsible for their own nonadherence due to lack of commitment to their own health or due to medication side effects. Patients reported health care system limitations and HIV concerns contributed to a lack of engagement, and providers identified limited HIV literacy and stigma as additional problems. Both agreed that chronic illness and substance addiction impacted adherence and retention, and agreed on the importance of trust, honesty, and communication in the patient–provider relationship. Results support the incorporation of system-, provider-, and patient-focused components into interventions to facilitate patient engagement, adherence, and retention in public and private settings in Argentina.     

HIV and aging

Approximately one in five individuals living with HIV infection in the United States is 50 years of age or older. This proportion continues to increase as HIV incidence remains stable and potent antiretroviral therapy has reduced the morbidity and mortality associated with HIV infection. Newly identi.ed HIV-seropositive older individuals are proportionately more likely than younger persons to have AIDS at the time of diagnosis. Clinicians have to think about the possibility of HIV infection in older persons to avoid delays in diagnosis and treatment. Immunologic recovery in older individuals initiated on combination antiretroviral therapy is less robust in some studies compared with younger individuals. However, virologic suppression on treatment in young versus old antiretroviral naïve patients is comparable. Co-morbid conditions and their treatment pose a special challenge to health care providers with regard to drug metabolism and interactions with HIV medications. HIV prevention should be discussed with all at risk individuals. The HIV epidemic will only worsen if medical practitioners neglect to discuss sexual risk behavior with their older patients.     

Management of adults living with HIV/AIDS in low-income, high-burden settings, with special reference to persons with tuberculosis.

Because of the increasing availability of antiretroviral (ARV) agents for HIV in low-income countries, many clinicians now need training on their use. This is especially true for clinicians caring for individuals with tuberculosis (TB), given its close relationship with HIV/AIDS. This article summarizes the key decisions facing clinicians who manage HIV-infected persons, with particular reference to issues regarding those dually infected with TB. Health care provider-initiated diagnostic testing using rapid HIV tests should be offered to all individuals with symptoms and signs suggesting HIV infection, including all persons with TB. Issues to be included in pre- and post-test counseling sessions are discussed. HIV-infected patients should be evaluated to determine clinical staging of HIV; certain laboratory examinations should ideally be performed to assess the degree of immunosuppression and to aid decisions about when best to start ARV therapy and preventive therapies. The recommended ARV regimens and guidance on proposed patient follow-up are presented. Good adherence to ARVs is required and factors that induce and reinforce compliance are suggested. The treatment of TB is a high priority, and follows the same principles whether the patient is HIV-infected or not. Suggestions are made about ARV use in patients with TB. A standardized and complementary information system should be developed to monitor management of HIV-TB patients and performance of joint TB and HIV care efforts. By diagnosing and managing additional HIV cases detected through the portal of the TB control programme, clinicians will contribute to diminishing the burden of HIV, and thus, TB.     

Factors influencing the acceptance of changes in antiretroviral therapy among HIV-1-infected patients

Physicians routinely consider modifying antiretroviral therapy (ART) regimen for their patients with HIV. Little is known about the factors associated with patients' willingness to accept providers' recommended ART changes. This multicenter prospective observational study examined factors associated with willingness to accept ART changes recommended by their providers among HIV-infected adults from six urban outpatient HIV clinics. Patients were surveyed using the Patient Attitudes about Altering Antiretroviral Therapy Survey questionnaire (PAAARTS). Factors associated with willingness to accept ART changes were assessed using a multivariate generalized estimating equation (GEE) model to account for correlated responses. The Classification and Regression Trees (CART) analysis was also performed to determine subgroups of patients with higher acceptance of change. 216 of 289 patients (75%) definitely accepted recommended changes. Odds for acceptance were 3.2, 2.3, and 2.8 times higher for patients with higher attitudes and beliefs about ART (p < 0.01; 95% confidence interval [CI] = 1.59, 6.52), patients who rated their provider's care as excellent (p < 0.05; 95% CI = 1.07, 4.78), and non-Hispanic patients (p < 0.05; 95% CI 1.03, 7.57), respectively. CART analysis showed similar results and identified that when patients had less positive attitude about ART, acceptance rates were higher for non-Hispanic patients with higher assessments of their patient-provider communication. While most patients accepted providers' recommendation for ART changes, this willingness was influenced by both patients' attitudes and beliefs about ART and their assessment of either the effectiveness of patient-provider communication or their rating of providers' care. ART acceptance rates among Hispanic patients were lower.     

Medication adherence among HIV-infected patients: Understanding the complex behavior of patients taking this complex therapy

Adherence to antiretroviral regimens by HIV-infected patients is necessary to prolong viral suppression and forestall viral resistance. This review covers the major advances made in research on adherence to HIV therapy in the past year. Currently, approximately 40% of patients receiving antiretroviral therapy have significant problems with adherence. Established predictors of poor adherence include depression, alcohol and illicit drug use, poor self-efficacy, and certain health beliefs. Medical providers are poor at predicting adherence. Interventions to improve adherence can have modest effects, and many types of interventions are effective. Multifaceted and repetitive interventions provide the most benefit. Medical providers, as part of the medical management of HIV-infected patients, should use interventions to achieve high levels of adherence to therapy.     

Providers' Awareness of HIV Testing Policies and Perceived Testing Practices

The objective of this study was to examine providers' awareness of state guidelines regarding HIV testing of pregnant women and their perceptions of access to care for HIV-positive pregnant women. State health departments, county health clinics, and other health care practitioners (private physicians, nurse practitioners, and health educators) were surveyed regarding awareness of state policies on HIV testing, particularly of pregnant women, as well as perceptions of current practices in the care of HIV-positive pregnant women. About two thirds of state offices of public health (70%), county public health providers (62.7%), and private providers (66.7%) were able accurately to describe the HIV reporting policy of their state, and providers across settings perceived that only about half of pregnant women were being provided with information regarding the prevention of vertical transmission during pregnancy. A mechanism is needed to routinely update public health departments and providers regarding state HIV reporting policies.     

Behavioral aspects of HIV care: adherence, depression, substance use, and HIV-transmission behaviors

A variety of psychosocial stressors are involved in living with HIV, maintaining a regimen of highly active antiretroviral therapy, and negotiating necessary self-care behaviors. Because health care providers are in regular contact with HIV-infected individuals in care, these contacts allow for the opportunity to assess and intervene on important variables related to quality of life and HIV outcomes. This article reviews information about four important behavioral aspects of HIV care: treatment adherence, depression, high-risk sex, and substance abuse. Efforts by health care providers to address these factors may result in better treatment outcomes, enhanced quality of life among HIV patients, and decreased HIV transmission.     

Strategies for optimizing adherence to highly active antiretroviral therapy: lessons from research and clinical practice.

Successful treatment of human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) with highly active antiretroviral therapy (HAART) requires that patients maintain nearly perfect adherence to the prescribed regimen. Suboptimal adherence to antiretroviral therapy is clearly the most common cause of virologic failure of HAART regimens. Given the critical role of adherence in successful antiretroviral therapy, it is essential that providers of care for patients with HIV infection have a strategy that proactively assists and supports their patients' efforts to adhere to medication regimens. This review endeavors to provide a clinically focused approach to optimizing adherence of patients to HAART.     

Predictors of incomplete adherence, virologic failure, and antiviral drug resistance among HIV-infected adults receiving antiretroviral therapy in Tanzania.

BACKGROUND: Access to antiretroviral therapy is rapidly expanding in sub-Saharan Africa. Identifying the predictors of incomplete adherence, virologic failure, and antiviral drug resistance is essential to achieving long-term success. METHODS: A total of 150 subjects who had received antiretroviral therapy for at least 6 months completed a structured questionnaire and adherence assessment, and plasma human immunodeficiency virus (HIV) RNA levels were measured. Virologic failure was defined as an HIV RNA level >400 copies/mL; for patients with an HIV RNA level >1000 copies/mL, genotypic antiviral drug resistance testing was performed. Predictors were analyzed using bivariable and multivariable logistic regression models. RESULTS: A total of 23 (16%) of 150 subjects reported incomplete adherence. Sacrificing health care for other necessities (adjusted odds ratio [AOR], 19.8; P<.01) and the proportion of months receiving self-funded treatment (AOR, 23.5; P=.04) were associated with incomplete adherence. Virologic failure was identified in 48 (32%) of 150 subjects and was associated with incomplete adherence (AOR, 3.6; P=.03) and the proportion of months receiving self-funded antiretroviral therapy (AOR, 13.0; P=.02). Disclosure of HIV infection status to family members or others was protective against virologic failure (AOR, 0.10; P=.04). CONCLUSIONS: Self-funded treatment was associated with incomplete adherence and virologic failure, and disclosure of HIV infection status was protective against virologic failure. Efforts to provide free antiretroviral therapy and to promote social coping may enhance adherence and reduce rates of virologic failure.