Efficacy of Interventions in Improving Highly Active Antiretroviral Therapy Adherence and HIV-1 RNA Viral Load

Department of Psychology, University of Washington, Seattle, Washington 98195-1525, USA.
JAIDS Journal of Acquired Immune Deficiency Syndromes (Impact Factor: 4.56). 01/2007; 43 Suppl 1(Suppl 1):S23-35. DOI: 10.1097/01.qai.0000248342.05438.52
Source: PubMed


Adherence to highly active antiretroviral therapy (HAART) is generally suboptimal, limiting the effectiveness of HAART. This meta-analytic review examined whether behavioral interventions addressing HAART adherence are successful in increasing the likelihood of a patient attaining 95% adherence or an undetectable HIV-1 RNA viral load (VL). We searched electronic databases from January 1996 to September 2005, consulted with experts in the field, and hand searched reference sections from relevant articles. Nineteen studies (with a total of 1839 participants) met the selection criteria of describing a randomized controlled trial among adults evaluating a behavioral intervention with HAART adherence or VL as an outcome. Random-effects models indicated that across studies, participants in the intervention arm were more likely than those in the control arm to achieve 95% adherence (odds ratio [OR] = 1.50, 95% confidence interval [CI]: 1.16 to 1.94); the effect was nearly significant for undetectable VL (OR = 1.25; 95% CI: 0.99 to 1.59). The intervention effect for 95% adherence was significantly stronger in studies that used recall periods of 2 weeks or 1 month (vs. </=7 days). No other stratification variables (ie, study, sample, measurement, methodologic quality, intervention characteristics) moderated the intervention effect, but some potentially important factors were observed. In sum, various HAART adherence intervention strategies were shown to be successful, but more research is needed to identify the most efficacious intervention components and the best methods for implementing them in real-world settings with limited resources.

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    • "Low adherence to HAART in the United States is common with approximately only 50%–70% of prescribed doses taken [3, 4]. One meta-analysis found that those who participated in HAART-related adherence-enhancing interventions were significantly more likely to achieve 95% adherence and viral load suppression compared to the control condition [5]. A recent systematic review analyzed findings from 31 projects assessing use of SMS (short message service) technology, most for patients with HIV/AIDS in developing countries [6]; the findings pointed towards SMS as a promising and mostly well-accepted intervention strategy for use in healthcare. "
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    ABSTRACT: Mobile phone technology is increasingly used to overcome traditional barriers limiting access to care. The goal of this study was to evaluate access and willingness to use smart and mobile phone technology for promoting adherence among people attending an urban HIV clinic. One hundred consecutive HIV-positive patients attending an urban HIV outpatient clinic were surveyed. The questionnaire evaluated access to and utilization of mobile phones and willingness to use them to enhance adherence to HIV medication. The survey also included the CASE adherence index as a measure of adherence. The average age was 46.4 (SD = 9.2). The majority of participants were males (63%), black (93%), and Hispanic (11.4%) and reported earning less than $10,000 per year (67.3%). Most identified themselves as being current smokers (57%). The vast majority reported currently taking HAART (83.5%). Approximately half of the participants reported some difficulty with adherence (CASE < 10). Ninety-six percent reported owning a mobile phone. Among owners of mobile phones 47.4% reported currently owning more than one device. Over a quarter reported owning a smartphone. About 60% used their phones for texting and 1/3 used their phone to search the Internet. Nearly 70% reported that they would use a mobile device to help with HIV adherence. Those who reported being very likely or likely to use a mobile device to improve adherence were significantly more likely to use their phone daily (P = 0.03) and use their phone for text messages (P = 0.002). The vast majority of patients in an urban HIV clinic own mobile phones and would use them to enhance adherence interventions to HIV medication.
    Full-text · Article · Aug 2013 · AIDS research and treatment
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    • "The pattern of results suggest that the MI-CBT/mDOT intervention may have had its greatest impact at 12 weeks coinciding with the most intensive portion of the intervention, and then declined more steeply than SC and MI-CBT as treatment was tapered and withdrawn. This is consistent with other studies of behavioral counseling that observe a decline at the conclusion of active treatment [6, 8, 16, 31]. Given the modest magnitude of the interaction effect and the lack of significant differences between groups at any time point, it is also possible that neither of the intervention arms had any true impact on adherence and the observed fluctuation is merely a function of being part of a study (i.e., Hawthorne Effect) followed by regression to the mean over time. "
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    ABSTRACT: This study determined whether motivational interviewing-based cognitive behavioral therapy (MI-CBT) adherence counseling combined with modified directly observed therapy (MI-CBT/mDOT) is more effective than MI-CBT counseling alone or standard care (SC) in increasing adherence over time. A three-armed randomized controlled 48-week trial with continuous electronic drug monitored adherence was conducted by randomly assigning 204 HIV-positive participants to either 10 sessions of MI-CBT counseling with mDOT for 24 weeks, 10 sessions of MI-CBT counseling alone, or SC. Poisson mixed effects regression models revealed significant interaction effects of intervention over time on non-adherence defined as percent of doses not-taken (IRR = 1.011, CI = 1.000-1.018) and percent of doses not-taken on time (IRR = 1.006, CI = 1.001-1.011) in the 30 days preceding each assessment. There were no significant differences between groups, but trends were observed for the MI-CBT/mDOT group to have greater 12 week on-time and worse 48 week adherence than the SC group. Findings of modest to null impact on adherence despite intensive interventions highlights the need for more effective interventions to maintain high adherence over time.
    Full-text · Article · Apr 2013 · AIDS and Behavior
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    • "These findings highlight the need for better data on the impact of adherence interventions on actual adherence over time. As noted in a review of adherence interventions for HIV [54], many studies of adherence interventions do not include follow-up data. Given the relation of cost-effectiveness to duration of intervention effect found in our current analyses, it is clear that more information is needed on how long an intervention may be effective and on strategies to promote adherence over time. "
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    ABSTRACT: High levels of adherence to medications for HIV infection are essential for optimal clinical outcomes and to reduce viral transmission, but many patients do not achieve required levels. Clinician-delivered interventions can improve patients’ adherence, but usually require substantial effort by trained individuals and may not be widely available. Computer-delivered interventions can address this problem by reducing required staff time for delivery and by making the interventions widely available via the Internet. We previously developed a computer-delivered intervention designed to improve patients’ level of health literacy as a strategy to improve their HIV medication adherence. The intervention was shown to increase patients’ adherence, but it was not clear that the benefits resulting from the increase in adherence could justify the costs of developing and deploying the intervention. The purpose of this study was to evaluate the relation of development and deployment costs to the effectiveness of the intervention. Costs of intervention development were drawn from accounting reports for the grant under which its development was supported, adjusted for costs primarily resulting from the project’s research purpose. Effectiveness of the intervention was drawn from results of the parent study. The relation of the intervention’s effects to changes in health status, expressed as utilities, was also evaluated in order to assess the net cost of the intervention in terms of quality adjusted life years (QALYs). Sensitivity analyses evaluated ranges of possible intervention effectiveness and durations of its effects, and costs were evaluated over several deployment scenarios. The intervention’s cost effectiveness depends largely on the number of persons using it and the duration of its effectiveness. Even with modest effects for a small number of patients the intervention was associated with net cost savings in some scenarios and for durations greater than three months and longer it was usually associated with a favorable cost per QALY. For intermediate and larger assumed effects and longer durations of intervention effectiveness, the intervention was associated with net cost savings. Computer-delivered adherence interventions may be a cost-effective strategy to improve adherence in persons treated for HIV. Trial registration identifier NCT01304186.
    Full-text · Article · Feb 2013 · BMC Medical Informatics and Decision Making
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