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Is Memory Really the Problem in ART Adherence?
Christopher J. Hoffmann, MD, MPH, Johns Hopkins University
An undetectable HIV viral load is the sine qua non of effective antiretroviral therapy (ART). Once the correct ART regimen is prescribed, achievement of an undetectable viral load then depends on sustained adherence. The authors of a recent study in AIDS Care ( Kalichman SC, et al.; PMID 27535297) sought to better understand and differentiate between factors associated with moderate and severe non-adherence. Moderate non-adherence was defined as 75% to 95% of medication doses taken as prescribed; severe non-adherence was defined as <75% of doses taken as prescribed.
The authors used computerized interviews to collect patient self-reported data on symptoms, side effects, use of common reminder strategies, depression, life stress, and alcohol consumption. The authors also used urine testing to assess for recent illicit drug use. Over a 1-month period, participants were contacted three times for telephone-based pill counts. Participants who had missed doses were then asked about cognitive, organizational, mental health, substance use, and structural barriers to adherence.
The team followed 214 severely non-adherent and 342 moderately non-adherent participants for 1 month. A large and equal proportion of patients in each group used memory aids to support adherence, including pill boxes, alarms, routine timing of pills, journals, reminders from family members, or posted reminder signs. Although a larger proportion of the severely non-adherent participants reported having forgotten or having been too busy to take medications, the number was not statistically significant. Of the severely non-adherent, 54% reported forgetting compared with 41% of the moderately non-adherent. A larger and statistically significant difference in adherence was related to side effects, running out of pills, and consumption of alcohol (see table below). Depression and stress were also higher among severely non-adherent participants.
Factors Affecting ART Adherence
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Participants Reporting this Effect,
by Level of Non-Adherence
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Severe
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Moderate
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Medication side-effects
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12%
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4%
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Running out of pills
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21%
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9%
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Consumption of alcohol
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21%
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13%
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The results of this study suggest that even when adherence reminder strategies are used, they are not effective in helping patients overcome factors related to both severe and moderate non-adherence, including, in this group, alcohol use, access to medications, and mental health challenges.
This study did have some limitations. The researchers followed participants for just 1 month, and the results were not strong: 68% of the severely non-adherent had undetectable viral loads, and less than 50% of non-adherence among participants was associated with the factors named above.
Nonetheless, the results highlight the roles that mental health, substance use, and structural barriers may play in reducing adherence to ART. The findings also suggest that other, yet-to-be identified factors are at play as well. Perhaps most importantly, the standard focus on memory, reminders, and memory aids may not be helpful in significantly improving adherence among those with demonstrated non-adherence, and we need to dig deeper to help our patients take the medications that will suppress their viral loads.
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Trends: How Do Users Find www.hivguidelines.org?
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Top Search Queries That Have Led Users to the HIV Clinical Resource in 2016
- HIV Window Period, HIV Window Period 2016, HIV Test Window Period, 4th Generation Test Window Period
- IRIS HIV, Immune Reconstitution Syndrome
- HIV Prophylaxis, Post Exposure Prophylaxis, HIV Post Exposure Prophylaxis, Post Exposure Prophylaxis Guidelines, PEP HIV
- Acute HIV Infection
- HIV-2
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UPCOMING EVENTS: NEW YORK
- HIV and Hepatitis C Symposium: Pharmacy Update (Rochester, NY, 10/9/2016)
- Understanding and Making Referrals for Substance Use Treatment in NYS(Multiple locations and dates, NYS)
- PrEP Implementation Workshop: Challenges and Solutions in Clinical Practice (Multiple locations and dates, NYS)
- Ending the HIV and STI Epidemics: Perspectives from ED and Urgent Care Practice(New York, NY, 10/28/2016)
- Two-Day STD Intensive Course(Rochester, NY, 11/1-11/2/2016)
- HIV Intensive Training Preceptorship Program (New York, NY, 11/7-11/8/2016)
UPCOMING EVENTS: BEYOND NEW YORK
- HIV Glasgow 2016 (Glasgow, UK, 10/23-10/26/2016)
- 11th National Harm Reduction Conference(San Diego, CA, 11/3-11/6/2016)
- Association of Nurses in AIDS Care (ANAC) 2016 Conference (Atlanta, GA, 11/10-11/12/2016)
- Healthy Teen Network 2016 Conference (Las Vegas, NV, 11/14-11/16/2016)
- 2016 National HIV PrEP Summit(San Francisco, CA, 12/3-12/4/2016)
- 28th Annual National Forum on Quality Improvement in Health Care (Orlando, FL, 12/4-12/7/2016)
- CROI 2017 (Seattle, WA, 2/13-2/17/2017)
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