The Feasibility of Modified Directly Observed Therapy for HIV-Seropositive African American Substance Users

ArticleinAIDS patient care and STDs 22(2):139-46 · March 2008with6 Reads
DOI: 10.1089/apc.2007.0063 · Source: PubMed
Recently, modified directly observed therapy (MDOT) has emerged as a promising intervention to address nonadherence for hard-to-reach populations infected with HIV. To date, there are no existing data on MDOT focusing exclusively on African Americans. The present study sought to determine the feasibility of MDOT among 31 HIV-seropositive African American substance users in the South. An outreach worker observed the participants' medication intake 5 days per week (once per day) for a period of 3 months (intensive phase). This phase was followed by a transition phase of 3 months during which the frequency of MDOT was gradually tapered from 5 days to once weekly. Assessments to gather demographic information, HIV risk behaviors, substance use, depression, and medication adherence were conducted at baseline, 3 months, and 6 months. Results indicated that more participants adhered to their medication regimen and had viral loads of less than 400 copies per milliliter at 3 and 6 months compared to baseline. Participants reported significantly less depressive symptoms at the 6-month assessment compared to baseline and 3 months. With regard to acceptability, 95% of participants indicated they liked having the outreach visits, 100% reported MDOT helped them take their medications, and only 5% felt MDOT was a violation of privacy. These results suggest MDOT is feasible among African American substance users in the South and a larger controlled study of MDOT with this population is warranted.
    • "No significant association between cumulative adherence counseling hours and post-counseling and VL, however, was found. Second tier data also suggest promising outcomes for DAART in improving virologic outcomes among heterogeneous populations, including African American HIVinfected PWUDs [55], treatment-naïve HIV-infected IDUs in Italian prisons [56], and HIV-infected cART experienced PWUDs [57]. Second and third tier data for interventions that incorporated both DAART and MMT were somewhat consistent with data from the Berg et al. [51] trial, although suggested persistence of virologic and immunologic improvements at longer-term follow-up points. "
    [Show abstract] [Hide abstract] ABSTRACT: HIV-infected persons who use drugs (PWUDs) are particularly vulnerable for suboptimal combination antiretroviral therapy (cART) adherence. A systematic review of interventions to improve cART adherence and virologic outcomes among HIV-infected PWUDs was conducted. Among the 45 eligible studies, randomized controlled trials suggested directly administered antiretroviral therapy, medication-assisted therapy (MAT), contingency management, and multi-component, nurse-delivered interventions provided significant improved short-term adherence and virologic outcomes, but these effects were not sustained after intervention cessation. Cohort and prospective studies suggested short-term increased cART adherence with MAT. More conclusive data regarding the efficacy on cART adherence and HIV treatment outcomes using cognitive behavioral therapy, motivational interviewing, peer-driven interventions and the integration of MAT into HIV clinical care are warranted. Of great concern was the virtual lack of interventions with sustained post-intervention adherence and virologic benefits. Future research directions, including the development of interventions that promote long-term improvements in adherence and virologic outcomes, are discussed.
    Full-text · Article · Aug 2012
    • "Several issues are likely to impact the sustainability of DOT. In particular, many programs require dedicated staff (eg, outreach workers) or space (eg, a community van), which can increase program complexity and cost123456 . For these reasons, feasibility and sustainability of DOT are likely to be maximized in settings with infrastructures that leverage existing staff and space and allow frequent contact, such as prisons [7], housing facilities [8], or methadone clinics91011 17]. "
    [Show abstract] [Hide abstract] ABSTRACT: Methadone clinic-based directly observed antiretroviral therapy (DOT) has been shown to be more efficacious for improving adherence and suppressing human immunodeficiency virus (HIV) load than antiretroviral self-administration. We sought to determine whether the beneficial effects of DOT remain after DOT is discontinued. We conducted a post-trial cohort study of 65 HIV-infected opioid-dependent adults who had completed a 24-week randomized controlled trial of methadone clinic-based DOT versus treatment as usual (TAU). For 12 months after DOT discontinuation, we assessed antiretroviral adherence using monthly pill counts and electronic monitors. We also assessed viral load at 3, 6, and 12 months after DOT ended. We examined differences between DOT and TAU in (1) adherence, (2) viral load, and (3) proportion of participants with viral load of <75 copies/mL. At trial end, adherence was higher among DOT participants than among TAU participants (86% and 54%, respectively; P < .001), and more DOT participants than TAU participants had viral loads of <75 copies/mL (71% and 44%, respectively; P = .03). However, after DOT ended, differences in adherence diminished by 1 month (55% for DOT vs 48% for TAU; P = .33) and extinguished completely by 3 months (49% for DOT vs 50% for TAU; P = .94). Differences in viral load between DOT and TAU disappeared by 3 months after the intervention, and the proportion of DOT participants with undetectable viral load decreased steadily after DOT was stopped until there was no difference (36% for DOT and 34% for TAU; P = .92). Because the benefits of DOT for adherence and viral load among HIV-infected methadone patients cease after DOT is stopped, methadone-based DOT should be considered a long-term intervention.
    Full-text · Article · Sep 2011
    • "In fact, among TAU participants with undetectable baseline VL, 21% experienced viral rebound. While several DOT studies have reported decreases in VL (Altice et al., 2007; Conway et al., 2004; Lucas et al., 2006; Macalino et al., 2007) and modest improvements in self-reported adherence (Altice et al., 2007; MA et al., 2008; Pearson et al., 2007), ours is one of the few DOT trials to report improvements in objectively measured adherence at multiple time points. "
    [Show abstract] [Hide abstract] ABSTRACT: To determine if directly observed antiretroviral therapy (DOT) is more efficacious than self-administered therapy for improving adherence and reducing HIV viral load (VL) among methadone-maintained opioid users. Two-group randomized trial. Twelve methadone maintenance clinics with on-site HIV care in the Bronx, New York. HIV-infected adults prescribed combination antiretroviral therapy. Between group differences at four assessment points from baseline to week 24 in: (1) antiretroviral adherence measured by pill count, (2) VL, and (3) proportion with undetectable VL (< 75 copies/ml). Between June 2004 and August 2007, we enrolled 77 participants. Adherence in the DOT group was higher than in the control group at all post-baseline assessment points; by week 24 mean DOT adherence was 86% compared to 56% in the control group (p < 0.0001). Group differences in mean adherence remained significant after stratifying by baseline VL (detectable versus undetectable). In addition, during the 24-week intervention, the proportion of DOT participants with undetectable VL increased from 51% to 71%. Among HIV-infected opioid users, antiretroviral DOT administered in methadone clinics was efficacious for improving adherence and decreasing VL, and these improvements were maintained over a 24-week period. DOT should be more widely available to methadone patients.
    Full-text · Article · Jan 2011
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