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Studies of persons living with HIV (PLWH) have compared current non-drinkers to at-risk drinkers without differentiating whether current non-drinkers had a prior alcohol use disorder (AUD). The purpose of this study was to compare current non-drinkers with and without a prior AUD on demographic and clinical characteristics to understand the impact of combining them. We included data from six sites across the US from 1/2013 to 3/2015. Patients completed tablet-based clinical assessments at routine clinic appointments using the most recent assessment. Current non-drinkers were identified by AUDIT-C scores of 0. We identified a prior probable AUD by a prior AUD diagnosis in the electronic medical record (EMR) or a report of attendance at alcohol treatment in the clinical assessment. We used multivariate logistic regression to examine factors associated with prior AUD. Among 2235 PLWH who were current non-drinkers, 36% had a prior AUD with more patients with an AUD identified by the clinical assessment than the EMR. Higher proportions with a prior AUD were male, depressed, and reported current drug use compared to non-drinkers without a prior AUD. Former cocaine/crack (70% vs. 25%), methamphetamine/crystal (49% vs. 16%), and opioid/heroin use (35% vs. 7%) were more commonly reported by those with a prior AUD. In adjusted analyses, male sex, past methamphetamine/crystal use, past marijuana use, past opioid/heroin use, past and current cocaine/crack use, and cigarette use were associated with a prior AUD. In conclusion, this study found that among non-drinking PLWH in routine clinical care, 36% had a prior AUD. We found key differences between those with and without prior AUD in demographic and clinical characteristics, including drug use and depression. These results suggest that non-drinkers are heterogeneous and need further differentiation in studies and that prior alcohol misuse (including alcohol treatment) should be included in behavioural health assessments as part of clinical care.

ObjectiveRegular HIV RNA testing for all HIV-positive patients on antiretroviral therapy (ART) is expensive and has low yield since most tests are undetectable. Selective testing of those at higher risk of failure may improve efficiency. We investigated whether a novel analysis of adherence data could correctly classify virological failure and potentially inform a selective testing strategy.DesignMultisite prospective cohort consortium.MethodsWe evaluated longitudinal data on 1478 adult patients treated with ART and monitored using the Medication Event Monitoring System (MEMS) in 16 US cohorts contributing to the MACH14 consortium. Because the relationship between adherence and virological failure is complex and heterogeneous, we applied a machine-learning algorithm (Super Learner) to build a model for classifying failure and evaluated its performance using cross-validation.ResultsApplication of the Super Learner algorithm to MEMS data, combined with data on CD4 T-cell counts and ART regimen, significantly improved classification of virological failure over a single MEMS adherence measure. Area under the receiver operating characteristic curve, evaluated on data not used in model fitting, was 0.78 (95% confidence interval: 0.75 to 0.80) and 0.79 (95% confidence interval: 0.76 to 0.81) for failure defined as single HIV RNA level >1000 copies per milliliter or >400 copies per milliliter, respectively. Our results suggest that 25%-31% of viral load tests could be avoided while maintaining sensitivity for failure detection at or above 95%, for a cost savings of $16-$29 per person-month.ConclusionsOur findings provide initial proof of concept for the potential use of electronic medication adherence data to reduce costs through behavior-driven HIV RNA testing.

We examined the secondary effects of an antiretroviral therapy (ART) adherence intervention on information, motivation, and behavioral skills (IMB) and patient-provider communication (PPC). Data were from a sample of 116 patients enrolled in a quasi-experimental mixed-methods study at two large ART clinics in Haiti. We examined changes in IMB and PPC scores after the intervention and the association between baseline PPC and endline IMB. The intervention was associated with increased scores in information (ß = 0.89, 95% CI [0.07, 1.70]) and motivation (ß = 2.55, 95% CI [0.38, 4.72]) but a decreased score in behavioral skills (ß = –2.39, 95% CI [–4.29, –0.49]), after controlling for demographic and clinical variables. Baseline PPC was associated with higher endline IMB total scores (ß = 0.17, 95% CI [0.02, 0.31]), controlling for demographic variables, clinical variables, and baseline IMB score. At the subscale level, baseline PPC was associated with higher endline motivation score (ß = 0.09, 95% CI [0.01, 0.17]), marginally associated with higher endline information score (ß = 0.04, 95% CI [0.00, 0.08]), after controlling for demographic and clinical variables. The intervention was beneficial to patients' adherence related motivation. Favorable patient-provider communication is associated with more motivation to adhere to ART. [ABSTRACT FROM AUTHOR]

To inform a clinic-based adherence-promotion intervention, this qualitative study applied the Situated Information, Motivation, and Behavioral Skills Model of Care Initiation and Maintenance to elucidate cultural and contextual factors affecting antiretroviral therapy adherence in Haiti. From the 23 focus group discussions with patients (n = 58) and health care workers (n = 57), culturally specific themes emerged relating to Information (e.g., conflicts with allopathic medicine and heuristics about how treatment failure occurs), Motivation (e.g., protecting family members, health and physical appearance, material advantages, and relationships with health workers), and Behavioral Skills (e.g., managing food intake and side effects, navigating health services utilization, accessing medication, and advocating for care needs). Recommendations include: provide therapeutic education on HIV drug resistance; promote the concept of "undetectable = untransmittable"; develop treatment buddy relationships; invest in training and enforcement of patient privacy, transparency, and fairness in access to services and resources; and provide patient-centered behavioral skills counseling. [ABSTRACT FROM AUTHOR]

Nurses have an integral role to play in achieving the 95-95-95 goals to stem the HIV epidemic. We used the Information- Motivation-Behavioral Skills (IMB) theoretical model to develop a nurse-delivered, mHealth intervention to support antiretroviral therapy adherence among female sex workers living with HIV in Mombasa, Kenya. Twenty-three purposively sampled female sex workers living with HIV participated in 5 focus group discussions to iteratively develop the message content as well as the format and structure of the nurse-delivered, text-based intervention. Focus group discussion interview guides were developed in accordance with the IMB model. Transcripts were analyzed according to IMB themes, and findings were used to develop the intervention. Information-oriented texts addressed concerns and misconceptions; motivation-oriented texts reinforced women's desires to feel healthy enough to engage in activities; and behavioral skills-oriented texts included strategies to remember medication doses. The nurse-delivered, theory-based, culturally tailored intervention to support medication adherence was evaluated. [ABSTRACT FROM AUTHOR]

We examined adherence, medication-taking practices, and preferences to inform development of a wrist-worn adherence system. Two convenience samples of persons taking antiretroviral therapy and HIV pre-exposure prophylaxis completed a survey. Additional online questions asked about willingness to use a wrist-worn device and reminder and feedback preferences. Among 225 participants, 13% reported adherence < 90%; this was associated with younger age and clinic sample. Compared to pill bottle–using participants, mediset users less commonly reported adherence < 90% (aOR = 0.16, p =.02), and blister pack users (aOR = 6.3, p =.02) and pill roll users (aOR = 3.3, p =.04) more commonly reported adherence < 90%. Sixty-two percent of the online participants reporting adherence (< 100%) had some interest in receiving adherence reminders, including 42% with interest in receiving reminders by smartwatch notifications. Although confounders are likely, formative work identified potential users and interest in using a wrist-worn adherence system. Future work will determine its acceptability and efficacy. [ABSTRACT FROM AUTHOR]

HIV-positive Kenyan men who have sex with men (MSM) are a highly stigmatized group facing barriers to care engagement and antiretroviral therapy (ART) adherence. Because care providers' views are important in improving outcomes, we sought the perspective of those serving MSM patients on how to optimize ART adherence in a setting where same-sex behavior is criminalized. We conducted 4 focus group discussions with a total of 29 healthcare workers (HCWs) experienced in providing HIV care to MSM. The semistructured, open-ended topic guide used was based on an access-information-motivation-proximal cues model of adherence, with added focus on trust in providers, stigma, and discrimination. Detailed facilitator notes and transcripts were translated into English and reviewed for common themes. The HCW identified adherence challenges of MSM patients that are similar to those of the general population, including HIV-related stigma and lack of disclosure. In addition, HCWs noted challenges specific to MSM, such as lack of access to MSM-friendly health services, economic and social challenges due to stigma, difficult relationships with care providers, and discrimination at the clinic and in the community. HCWs recommended clinic staff sensitivity training, use of trained MSM peer navigators, and stigma reduction in the community as interventions that might improve adherence and health outcomes for MSM. Despite noting MSM-specific barriers, HCWs recommended strategies for improving HIV care for MSM in rights-constrained settings that merit future research attention. Most likely, multilevel interventions incorporating both individual and structural factors will be necessary. [ABSTRACT FROM AUTHOR]

This study tested depression as a mediator between childhood sexual abuse and adherence to antiretroviral therapy, an effect moderated by resilience. In total, 149 HIV+ Latino men who have sex with men were recruited for this study. Using a regression-based bootstrap approach, depression mediated the relationship between childhood sexual abuse and antiretroviral therapy adherence, with worse adherence for participants at lowest percentiles of the resilience index. The prevalence of childhood sexual abuse and depression in HIV+ men who have sex with men is high and must be addressed to better prevent disease progression and reduce transmission, especially in expanding Latino populations. [ABSTRACT FROM AUTHOR]

The article presents a randomized controlled trial on the relative efficacy of pager messaging and peer support in the promotion of antiretroviral modifying therapy among HIV-positive outpatients in Seattle, Washington. It notes on the association of peer intervention in self-reported adherence and of pager intervention in biological outcomes. It reveals the possible efficacy of peer support and pager messaging in improving antiretroviral adherence and biological outcomes of the outpatients.

Objective: To determine the efficacy of a peer-led social support intervention involving support groups and telephone contacts compared with standard clinical care to enhance antiretroviral medication adherence. Design: Randomized controlled trial with follow-up. Participants were 136 HIV-positive indigent mainly African American and Puerto Rican men and women recruited from an outpatient clinic in the Bronx, New York. The 3-month intervention was delivered by other HIV-positive clinic patients trained in addressing barriers to adherence and sensitively providing appraisal, spiritual, emotional, and informational adherence-related social support. Main outcome measures: Medical chart-abstracted HIV-1 RNA viral load, antiretroviral adherence according to electronic drug monitoring and participant self-report, and social support and depressive symptomatology. All assessments conducted at baseline, 3 months, and 6 months. Results: Intent-to-treat and as-treated analyses indicated no between-conditions intervention effects on the primary outcome of HIV-1 RNA viral load or any of the secondary outcomes at immediate postintervention or follow-up. Post hoc analyses within the intervention condition indicated greater intervention exposure was associated with higher self-reported adherence, higher social support, and lower depressive symptomatology at follow-up, even after controlling for baseline adherence. Conclusion: Null findings, consistent with the limited literature on efficacious highly active antiretroviral therapy (HAART) adherence interventions, may be due to insufficient exposure to the intervention, its low intensity, or the nature of the sample--a heterogeneous HAART-experienced group of patients with high levels of substance use and multiple other competing stressors. Overall, findings highlight the need for more comprehensive and intensive efforts to battle nonadherence. [ABSTRACT FROM AUTHOR]

The article presents a meta-analytic review of randomized controlled trials on the usefulness of interventions in improving highly active antiretroviral therapy (HAART) adherence and HIV-1 viral load. It examines whether the behavioral interventions dealing with HAART adherence are successful in enhancing the likelihood of patient adherence to 95 percent. Some HAART intervention strategies appear to be successful but added research is needed to know the most effective intervention method.

Nonadherence in the management of chronic illness is a pervasive clinical challenge. Although researchers have identified multiple correlates of adherence, the field remains relatively atheoretical. The authors propose a cognitive-affective model of medication adherence based on social support theory and research. Structural equation modeling of longitudinal survey data from 136 mainly African American and Puerto Rican men and women with HIV/AIDS provided preliminary support for a modified model. Specifically, baseline data indicated social support was associated with less negative affect and greater spirituality, which, in turn, were associated with self-efficacy to adhere. Sail-efficacy to adhere at baseline predicted self-reported adherence at 3 months, which predicted chart-extracted viral load at 6 months. The findings have relevance for theory building, intervention development, and clinical practice. [ABSTRACT FROM AUTHOR]

Background: Intimate partner violence (IPV) is associated with increased risk of HIV acquisition and reduced engagement in HIV care. There is limited understanding of the ways in which IPV exposure and other maladaptive relationship dynamics may influence adherence to antiretroviral treatment (ART) and pre-exposure prophylaxis (PrEP) for individuals in committed, HIV serodifferent partnerships. Methods: We used binomial generalized linear mixed-effect regression models to evaluate the association between IPV exposure and ART/PrEP adherence among members of serodifferent couples in Uganda. Secondarily, we assessed the association between relationship powerlessness and ART/PrEP adherence. Results: We enrolled and followed both partners in 149 heterosexual serodifferent couples. The partner living with HIV was female in 64% of couples. IPV exposure was associated with low ART adherence (15% vs. 5% in quarters with no IPV, odds ratio: 4.78, 95% confidence interval: 1.48 to 15.42), but not low PrEP adherence (33% vs. 36%, P = 0.69). Among HIV-negative individuals, those reporting moderate relationship powerlessness were less likely to have poor PrEP adherence compared with those with low relationship powerlessness (20% vs. 30%, odds ratio: 0.57, 95% confidence interval: 0.36 to 0.90). We observed no association between relationship powerlessness and ART adherence. Conclusions: We found that IPV exposure was associated with low adherence to ART and that relationship powerlessness was associated with good adherence to PrEP. These findings contribute to the evidence base outlining the influence of IPV and relationship power on ART/PrEP adherence for individuals in HIV serodifferent unions. [ABSTRACT FROM AUTHOR]

For pre-exposure prophylaxis (PrEP) and microbicides to effectively prevent HIV, optimal treatment adherence is required. Adherence to these strategies, however, has not been sufficiently studied. This investigation systematically reviews oral PrEP and microbicide trials across 4 domains of adherence: (1) definition and measures used, (2) risks for nonadherence, (3) promotion strategies, and (4) effects on outcomes. Nineteen (n = 19) trials, with 47,157 participants, published between 1987 and 2012 were identified. Reported mean adherence to microbicides was 79% and to oral PrEP 87%. Common risks for microbicide nonadherence were decreased motivation over time, sex with primary (noncommercial/casual) partners, and insufficient supply. Oral PrEP nonadherence risks were older age and medication side effects. Psychoeducation and outreach to participants and communities were frequently used promotion strategies. Most trials failed to systematically identify barriers and monitor and promote adherence, although adherence moderated outcomes. Recommendations for attending to adherence in future trials are provided. [ABSTRACT FROM AUTHOR]

The article assesses the efficacy of a peer-delivered intervention to promote short-term and long-term adherence to HAART in a Mozambican clinic population. It shows that a peer-delivered modified directly observed therapy program may be an effective strategy to promote long-term adherence among persons initiating HAART in resource-poor settings.

The article reports on the development and implementation of a modified directly observed therapy (mDOT) to assist highly active antiretroviral therapy (HAART) adherence in Beira, Mozambique. The study utilized a varied-methods approach to describe the process of executing mDOT for a randomized control trial in Beira, Mozambique. It also identifies the facets of mDOT that are efficient and can be adopted by clinics nursing HIV patients.

The article reports on how qualitative methods contribute to the understanding of combination antiretroviral therapy (ART) adherence. Qualitative research is a scientific method that uses observation and communications as tools to gather coherent information about a specific topic in research. It also provides powerful instruments to understand adherence. An overview of the qualitative research on ART nonadherence and a discussion of the rationales for using qualitative methods are presented.