Aging, neurocognition, and medication adherence in HIV infection.

Department of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA.
The American journal of geriatric psychiatry: official journal of the American Association for Geriatric Psychiatry (Impact Factor: 3.52). 05/2009; 17(4):281-90. DOI: 10.1097/JGP.0b013e31819431bd
Source: PubMed

ABSTRACT To evaluate the hypothesis that poor adherence to highly active antiretroviral treatment (HAART) would be more strongly related to cognitive impairment among older than among younger HIV-seropositive adults.
A volunteer sample of 431 HIV-infected adult patients prescribed self-administered HAART was recruited from community agencies and university-affiliated infectious disease clinics in the Los Angeles area.
Neurocognitive measures included tests of attention, information processing speed, learning/memory, verbal fluency, motor functioning, and executive functioning. Medication adherence was measured using microchip-embedded pill bottle caps (Medication Event Monitoring System) and self-report. Latent/structural analysis techniques were used to evaluate factor models of cognition and adherence.
Mean adherence rates were higher among older (>or=50 years) than younger (<50 years) HIV-positive adults. However, latent/structural modeling demonstrated that neurocognitive impairment was associated with poorer medication adherence among older participants only. When cognitive subdomains were examined individually, executive functioning, motor functioning, and processing speed were most strongly related to adherence in this age group. CD4 count and drug problems were also more strongly associated with adherence among older than younger adults.
Older HIV-positive individuals with neurocognitive impairment or drug problems are at increased risk of suboptimal adherence to medication. Likewise, older adults may be especially vulnerable to immunological and neurocognitive dysfunction under conditions of suboptimal HAART adherence. These findings highlight the importance of optimizing medication adherence rates and evaluating neurocognition in the growing population of older HIV-infected patients.

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    ABSTRACT: Thanks to highly active antiretroviral therapy, many people infected with HIV will likely live into old age. Although this is a welcome prognosis, new issues are emerging that may complicate the ability to successfully age in this clinical population. HIV and aging independently are related to cognitive impairments, so there are concerns that those aging with HIV may be more at risk of such cognitive impairments. Moreover, highly active antiretroviral therapy itself can create metabolic disorders, such as prediabetes and/or frank type 2 diabetes, which have also been linked to poorer cognitive functioning. Thus, concerns increase that, as people age with HIV and develop comorbid metabolic disorders that may lead to type 2 diabetes, they will be at triple risk of developing cognitive impairments that can impair everyday functioning and reduce quality of life. This article explores these issues and provides implications for practice and research.
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    ABSTRACT: Background Adherence to combination antiretroviral therapy (ART) is a key predictor of the success of human immunodeficiency virus (HIV) treatment, and is potentially amenable to intervention. Insight into predictors or correlates of non-adherence to ART may help guide targets for the development of adherence-enhancing interventions. Our objective was to review evidence on predictors/correlates of adherence to ART, and to aggregate findings into quantitative estimates of their impact on adherence.Methods We searched PubMed for original English-language papers, published between 1996 and June 2014, and the reference lists of all relevant articles found. Studies reporting on predictors/correlates of adherence of adults prescribed ART for chronic HIV infection were included without restriction to adherence assessment method, study design or geographical location. Two researchers independently extracted the data from the same papers. Random effects models with inverse variance weights were used to aggregate findings into pooled effects estimates with 95% confidence intervals. The standardized mean difference (SMD) was used as the common effect size. The impact of study design features (adherence assessment method, study design, and the United Nations Human Development Index (HDI) of the country in which the study was set) was investigated using categorical mixed effects meta-regression.ResultsIn total, 207 studies were included. The following predictors/correlates were most strongly associated with adherence: adherence self-efficacy (SMD¿=¿0.603, P¿=¿0.001), current substance use (SMD¿=¿¿0.395, P¿=¿0.001), concerns about ART (SMD¿=¿¿0.388, P¿=¿0.001), beliefs about the necessity/utility of ART (SMD¿=¿0.357, P¿=¿0.001), trust/satisfaction with the HIV care provider (SMD¿=¿0.377, P¿=¿0.001), depressive symptoms (SMD¿=¿¿0.305, P¿=¿0.001), stigma about HIV (SMD¿=¿¿0.282, P¿=¿0.001), and social support (SMD¿=¿0.237, P¿=¿0.001). Smaller but significant associations were observed for the following being prescribed a protease inhibitor-containing regimen (SMD¿=¿¿0.196, P¿=¿0.001), daily dosing frequency (SMD¿=¿¿0.193, P¿=¿0.001), financial constraints (SMD ¿0.187, P¿=¿0.001) and pill burden (SMD¿=¿¿0.124, P¿=¿0.001). Higher trust/satisfaction with the HIV care provider, a lower daily dosing frequency, and fewer depressive symptoms were more strongly related with higher adherence in low and medium HDI countries than in high HDI countries.Conclusions These findings suggest that adherence-enhancing interventions should particularly target psychological factors such as self-efficacy and concerns/beliefs about the efficacy and safety of ART. Moreover, these findings suggest that simplification of regimens might have smaller but significant effects.
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