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PubMed2005

Barriers to adherence of deferoxamine usage in sickle cell disease.

BACKGROUND: We hypothesized that child cognitive disability would be a significant risk factor for non-adherence with home deferoxamine (DFO) administration and that a factor that would contribute to improved adherence would be sharing of responsibilities for chelation between parents and patients. We explored the influences on adherence of behavioral and psychological adjustment; family stress; perceived convenience of and satisfaction with the DFO regimen; and parent and patient knowledge about DFO. PROCEDURE: Fifteen pediatric patients with sickle cell disease (SCD) who had evidence of excessive iron stores, and their parents, were interviewed about adherence and responsibility for chelation therapy. A neuropsychological assessment battery was administered to the patients. Family stress, the child's emotional and behavioral status, knowledge about chelation and iron overload were explored. Adherence was rated objectively using pharmacy refill patterns and observable signs of chelation. RESULTS: Sharing of responsibilities for chelation between parents and children was related to better adherence while neuropsychological status bore a complex relation to adherence. Of the exploratory variables, low family stress were related to better adherence while satisfaction with the home care regimen and convenience ratings were not useful in predicting adherence. No one element of adherence, even objective measures, was capable of classifying adherence, while a multifactorial scheme categorizing adherent, partially adherent and non-adherent groups demonstrated good face validity. CONCLUSIONS: Supporting developmentally appropriate sharing of responsibilities for self-care is critical, taking patient neurocognitive status into consideration. Clinicians should evaluate adherence using a multifactorial model that highlights the most salient targets for intervention.

Adolescent↗

PubMed2005

Pediatric adherence: perspectives of mothers of children with HIV.

This study approached pediatric adherence practices from the perspective of mothers of children with HIV in the USA. The study aimed to articulate what is involved in the daily life experience of giving or supervising a child's HIV medication (i.e., adherence practices) in order to clarify, in more dynamic terms than is often found in adherence research, what promotes or impedes adherence. A team-based qualitative analytic approach was used to analyze the narrative responses of 71 maternal caregivers of children with HIV to interview questions regarding the activities and stresses of caring for a child with HIV. Four themes of dealing with medication on a daily basis that impacted mothers' adherence practices emerged from the analysis: (1) Mothers' attitudes and feelings related to adherence practices. (2) The impact of the medications on adherence practices. (3) Interactions of mothers and children related to adherence practices. (4) Developmental issues and responsibility for medication adherence. These themes, taken together, demonstrate the contextual and longitudinal factors that impact adherence and illustrate the complexity of influences on adherence practices. We found that adherence practices were impacted in a positive way by mothers' commitment to adherence, and in a negative way by feelings of stigma and guilt, by the effects of bereavement on children and by children adopting their mothers' attitudes about medications. The interactive process of giving medication was shaped by children's behavior, mothers' developmental expectations for children, and, for mothers with HIV, their adherence for themselves. We found that pediatric adherence often came at a cost to the caregiving mother's well-being.

Adolescent↗

PubMed1995

The effects of quinolones on the adherence of type-1 fimbriated Escherichia coli to mannosylated agarose beads.

Bacterial adherence is reported to be antagonized by several classes of antibiotics including quinolones, beta-lactams and tetracyclines, based primarily on in-vitro studies in which bacterial cells are exposed to antimicrobials, incubated in the presence of uroepithelial cells (UECs) and assessed for adherence by light microscopy. Some problems associated with the use of this approach, include low sensitivity, high variability and, in the case of adherence of mannose-sensitive Escherichia coli interference by mannose-containing uromucoid. To avoid these problems, mannosylated agarose beads (MABs) were used as a model for UECs. Adherence of E. coli strain AAEC356, which is constitutive for type-1 fimbrial expression, was maximal with 3 x 10(4) beads/mL and 1 x 10(8) bacterial cells/mL co-incubated for 35 min at 37 degrees C. Those bacterial cultures showed 40-60% adherence to MABs but only 4-10% adherence to UECs. This study reports a novel method to detect mannose-sensitive bacterial adherence, using MABs, in order to determine the effects of quinolones, cefdinir and tetracycline on E. coli adherence. Cefdinir and the quinolones ciprofloxacin, enoxacin and PD131628 caused significant reductions in the adherence of AAEC356 to UECs at concentrations equivalent to 1/2 x MIC, while up to 1 x MIC of these antibiotics had no significant effect on adherence to MABs. A direct comparison of UEC to MAB-based techniques showed that PD131628, at concentrations equivalent to 1/16x, 1/4x, 1/2x and 1 x MIC, had no effect on bacterial adherence to MABs, while reductions of 34%, 38%, 87% and 85% respectively were seen in adherence to UECs. The anti-adherent effect mediated by quinolones may not therefore be related to the specific interaction between type-1 fimbriae and mannosylated receptors. While quinolones and cefdinir had no effect on overall bacterial adherence to MABs, there was a decrease in the ability of alpha-methyl-D-mannoside (alpha-MM) to inhibit competitively this adherence. Concurrent exposure of PD131628 or cefdinir with tetracycline prevented this, suggesting that protein synthesis is required for this effect.

4-Quinolones↗

PubMed2004

Changes in adherence to highly active antiretroviral therapy medications in the Multicenter AIDS Cohort Study.

OBJECTIVES: To characterize the determinants of changes in adherence to antiretroviral therapy and examine whether there are persistent lower adherers. DESIGN: A cohort study with repeated measurements. METHODS: Self-reported 100% adherence was defined as taking all doses and numbers of pills over a 4-day period as prescribed for current HIV medications. Independent predictors of changing adherence (< 100% to 100% and 100% to < 100%) were determined by logistic regression, correcting for correlated repeated measures for 597 HIV-positive men reporting the use of highly active antiretroviral therapy (HAART) between October 1998 and October 2000. RESULTS: Of the 942 visit-pairs with initial 100% adherence, 106 (11.3%) reduced adherence to less than 100%, and 836 (88.7%) remained 100% adherent at the next 6-month visit. No recent outpatient visits, younger age, depression, less than college educated, and later in calendar time predicted decreasing adherence. Among 186 visit-pairs starting with less than 100% adherence, 133 (71.5%) improved adherence to 100% and 53 (28.5%) remained less than 100% adherent at the next visit. The determinants of improving adherence included not being African-American, not using recreational drugs, and having had more than three HAART regimens. Lower adherence was not a random event; it was significantly correlated across visits within the individual. CONCLUSION: Characteristics associated with improving and lowering adherence differed and should be considered in developing interventions to enhance adherence and optimize effective therapies.

Adult↗

PubMed2000

Prospective randomized two-Arm controlled study to determine the efficacy of a specific intervention to improve long-term adherence to highly active antiretroviral therapy.

BACKGROUND: Nearly perfect compliance seems to be indispensable to obtain the maximum benefit from highly active antiretroviral therapy (HAART). Interventions to ensure a high level of adherence during a relatively long-term period of therapy are necessary. METHODS: This is a prospective, randomized, two-arm controlled study including patients starting their first-or second-line HAART who were randomized to receive psychoeducative intervention to implement adherence (experimental group [EG]) or a usual medical follow-up (control group [CG]). We aimed to study the efficacy of a psychoeducative intervention to ensure long-term adherence to HAART, its relation with the virologic efficacy of treatment, and to determine the variables related to long-term adherence. Visits were made at weeks 0, 4, 24, and 48 for data collection. Self-reported adherence was registered at each visit and its veracity was tested by randomized blood analyses performed without previous warning to 40% of patients. Appropriate adherence was defined as the consumption of >/=95% of medication prescribed. Statistical analyses were performed both by the as treated (AT) and the intention to treat missing = failure (ITT) methods. RESULTS: In all, 116 patients were included. At week 48, 94% of patients in the EG versus 69% controls achieved adherence >/=95% (p =.008); 89% of patients in the EG versus 66% controls had HIV-1 RNA levels <400 copies/ml (p =.026). Overall, 85% of patients with adherence >/=95% but only 45% of those with adherence <95% had viral load (VL) <400 copies/ml (p =. 008). In multivariate analysis, variables significantly related to adherence were having received a psychoeducative intervention (odds ratio [OR], 6.58; p =.04), poor effort to take medication (OR, 5.38; p =.03), and high self-perceived capacity to follow the regimen (OR, 13.76; p =.04). Self-reported adherence and drug plasma levels coincided in 93% of cases. However, differences in adherence did not reach statistical significance in the ITT analysis although a clear tendency toward benefit was observed in EG. CONCLUSIONS: Specific and maintained psychoeducative interventions based on excellence on clinical practice are useful to keep high levels of adherence as well as high levels of viral suppression. There is a clear relation between high adherence levels and virologic success. Assessment of certain specific variables related to adherence may be helpful to monitor patient's compliance in the clinical setting.

Adult↗

PubMed2001

Determinants of heterogeneous adherence to HIV-antiretroviral therapies in the Multicenter AIDS Cohort Study.

Assessment of adherence to HIV antiretroviral therapy (ART) is required for studying therapeutic effectiveness and identifying subgroups needing focused education. The study's goals were to describe the level of ART adherence using self-reported recall over a 4-day period and to characterize determinants of lower adherence. The interaction between adherence and drug holidays on level of HIV RNA also was investigated. Perfect self-reported adherence was defined as taking all doses and numbers of pills as prescribed for current HIV medications. Independent predictors of <100% adherence were determined using multivariate logistic regression. Among 539 men, 419 (77.7%) were 100% adherent by the algorithm using self-reported data. HIV-1 RNA was <50 copies/ml in 48.2% of the adherent group versus 33.7% in the less adherent group (p = .015). This proportion dropped to 28% if a drug holiday was reported in addition to lower adherence. A drug holiday was not virologically detrimental if the participant was otherwise adherent. Determinants of lower adherence included African American race (odds ratio [OR], 2.4; p = .008), income <U.S.$50,000 (OR, 2.2; p = .002), no outpatient visits (OR, 3.6; p = .003) and increasing numbers of ART medications (OR, 4.5; p = .001). These data support the validity of using a questionnaire to assess adherence in observational studies. Identification of individuals with characteristics associated with lower adherence provides the basis for interventions to enhance adherence and optimize effective therapies.

Adult↗

PubMed2005

Antidepressant treatment improves adherence to antiretroviral therapy among depressed HIV-infected patients.

BACKGROUND: Antiretroviral regimens for HIV-infected patients require strict adherence. Untreated depression has been associated with medication nonadherence. We proposed to evaluate the effect of antidepressant treatment (ADT) on antiretroviral adherence. METHODS: Data were retrieved for HIV-infected patients seen at an urban health care setting (1997-2001) from chart review and administrative and pharmacy files. Antiretroviral adherence was determined for depressed patients stratified by receipt of and adherence to ADT. Antiretroviral adherence was compared before and after initiation of ADT. RESULTS: Of 1713 HIV-infected patients, 57% were depressed; of those, 46% and 52% received ADT and antiretroviral treatment, respectively. Antiretroviral adherence was lower among depressed patients not on ADT (vs. those on ADT; P = 0.012). Adherence to antiretroviral treatment was higher among patients adherent to ADT (vs. those nonadherent to antidepressant treatment; P = 0.0014). Antiretroviral adherence improved over a 6-month period for adherent, nonadherent, and nonprescribed ADT groups; however, the mean pre- versus post-6-month change in antiretroviral adherence was significantly greater for those prescribed antidepressants. CONCLUSIONS: Depression was common, and antiretroviral adherence was higher for depressed patients prescribed and adherent to ADT compared with those neither prescribed nor adherent to ADT. Attention to diagnosis and treatment of depressive disorders in this population may improve antiretroviral adherence and ultimate survival.

Adult↗

PubMed1978

Adherence of group A streptococci to human epithelial cells.

The adherence of group A streptococci to epithelial cells was studied by using streptococcal strains labeled with [(3)H]uridine or fluorescein isothiocyanate. The ability of the labeled organisms to adhere to Detroit 562 epithelial cells, derived from a human pharyngeal carcinoma, as well as to epithelial cells scraped from the oral cavity was determined. Adherence to monolayer cultures or cell suspensions of Detroit cells compared favorably with adherence to suspensions of human oral epithelial cells. Initial experiments to determine the optimal conditions for adherence showed that adherence was temperature dependent and that the optimal incubation time was 15 min for adherence to epithelial cells in suspension and 30 to 60 min for monolayer cultures. Both streptococci and epithelial cells exhibited specificity in the adherence process. Different streptococcal strains varied in their ability to adhere. Adherence was also affected by the growth stage of the bacterial cultures. Trypsin treatment of the streptococci slightly decreased adherence, whereas hyaluronidase treatment increased the adherence of some strains. Streptococci were found to adhere to only about half of the epithelial cells. Those epithelial cells apparently have a limited number of receptor sites since they can be saturated by adding increasing concentrations of bacteria. Further support for limited receptor sites was provided by competition experiments. Adherence was inhibited by trypsin treatment of the epithelial cells, suggesting that proteins in the epithelial cell membrane may play a role in streptococcal adherence.

Binding Sites↗

PubMed1991

Adherence of Porphyromonas (Bacteroides) gingivalis to Streptococcus sanguis in vitro.

Intergeneric bacterial adherence is responsible for the complexity of the microbiota in human dental plaque and is believed to enable some extraneous bacteria to initially colonize the human oral cavity. Some current evidence indicates that Streptococcus sanguis, an early colonizer of teeth, enhances subsequent colonization by Porphyromonas (Bacteroides) gingivalis, a bacterium associated with advanced adult periodontitis. In this study, selected strains of P. gingivalis and S. sanguis were tested for their adherence activities in vitro. A differential filtration assay was devised in which one member of the test pair was radiolabeled. Heterogeneous aggregates that formed in mixed suspensions were collected on polycarbonate filters (8-microns pore size) and were washed free of individual bacteria and small homologous clumps. P. gingivalis 381, W50, JKG7, and 33277 adhered to S. sanguis G9B, M5, Challis 6, and 38. P. gingivalis A7A1-28 did not adhere well to S. sanguis under these conditions. More precise measurements of intergeneric adherence were obtained with an alternative assay with radiolabeled P. gingivalis and an artificial dental plaque composed of S. sanguis coupled to cyanogen bromide-activated agarose beads. CNBr-agarose was selected as the supporting matrix for the plaque because it was uniformly and permanently coated with S. sanguis and because P. gingivalis had negligible adherence activity for streptococcus-free beads. P. gingivalis W50 grown to the early stationary phase adhered to S. sanguis-coated beads in higher numbers than either midlogarithmic- or late-stationary-phase cells. Intergeneric adherence was not inhibited or reversed by the presence of lactose or other monosaccharides or disaccharides. Pretreatment of either bacterium with trypsin or proteinase K reduced subsequent adherence by 86 to 100%. Neuraminidase treatment of P. gingivalis caused 98% reduction of adherence, whereas similar treatment of S. sanguis caused only a 2% loss. Preincubation of P. gingivalis at 60 degrees C for 30 min decreased subsequent adherence to S. sanguis-coated beads by 94%. Adherence was reduced by 96% when bacteria were assayed while suspended in human whole saliva or when pretreated with saliva and subsequently assayed in buffer. The concentration of whole human saliva required to inhibit 50% adherence in this assay was 23 micrograms per ml (1:200 dilution). Suspension of the bacteria in normal rabbit serum resulted in 94% inhibition of adherence. These data indicate that saliva and serum may be important host defense factors for controlling Porphyromonas-Streptococcus adherence.

Adhesins, Bacterial↗

PubMed2005

Comparative adherence to human A549 cells, plant fibronectin-like protein, and polystyrene surfaces of four Pseudomonas fluorescens strains from different ecological origin.

The main objective of this study was to compare the adherence properties of four Pseudomonas fluorescens isolates from different ecological niches (human tissue, rhizosphere, drinking water, and cow milk). The substrates used to test P. fluorescens adherence were as follows: cultured human respiratory epithelial cells A549, immobilized plant fibronectin-like protein, and polystyrene. For all the experiments, bacteria were grown at 27 degrees C. The adherence assay to human cells was performed at 37 degrees C, whereas adherence to fibronectin and polystyrene was done at 27 degrees C. The four strains tested adhered to A549 cells but showed different adherence patterns. At 3 h, the milk isolate showed an aggregative adherence phenotype, whereas the three other isolates showed a diffuse adherence pattern. With a longer incubation time of 24 h, the aggregative pattern of the milk isolate disappeared, the adherence of the clinical strain increased, the adherence of the water isolate decreased, and morphological changes in A549 cells were observed with the clinical, water, and soil isolates. The four strains tested formed biofilms on polystyrene dishes. The clinical and milk isolates were the more efficient colonizers of polystyrene surfaces and also the more adherent to immobilized plant fibronectin-like protein. There was no relation between bacterial surface hydrophobicity and P. fluorescens adherence to the substrates tested. The main conclusions of these results are that P. fluorescens is an adherent bacterium, that no clear correlation exists between adherence and ecological habitat, and that P. fluorescens can adhere well to substrates not present in its natural environment.

Animals↗

PubMed1993

When tuberculosis treatment fails. A social behavioral account of patient adherence.

Several conclusions about measuring adherence can be drawn. Probably the best approach is to use multiple measures, including some combination of urine assays, pill counts, and detailed patient interviews. Careful monitoring of patient behavior early in the regimen will help predict whether adherence is likely to be a problem. Microelectronic devices in pill boxes or bottle caps have been used for measuring adherence among patients with tuberculosis, but their effectiveness has not been established. The use of these devices may be particularly troublesome for some groups such as the elderly, or precluded for those whose life styles might interfere with their use such as the homeless or migrant farm workers. Carefully designed patient interviews should be tested to determine whether they can be used to predict adherence. Probably the best predictor of adherence is the patient's previous history of adherence. However, adherence is not a personality trait, but a task-specific behavior. For example, someone who misses many doses of antituberculosis medication may successfully use prescribed eye drops or follow dietary recommendations. Providers need to monitor adherence to antituberculosis medications early in treatment in order to anticipate future problems and to ask patients about specific adherence tasks. Ongoing monitoring is essential for patients taking medicine for active tuberculosis. These patients typically feel well after a few weeks and either may believe that the drugs are no longer necessary or may forget to take medication because there are no longer physical cues of illness. Demographic factors, though easy to measure, do not predict adherence well. Tending to be surrogates for other causal factors, they are not amenable to interventions for behavior change. Placing emphasis on demographic characteristics may lead to discriminatory practices. Patients with social support networks have been more adherent in some studies, and patients who believe in the seriousness of their problems with tuberculosis are more likely to be adherent. Additional research on adherence predictors is needed, but it should reflect the complexity of the problem. This research requires a theory-based approach, which has been essentially missing from studies on adherence and tuberculosis. Research also needs to target predictors for specific groups of patients. There is clear evidence of the effect on adherence of culturally influenced beliefs and attitudes about tuberculosis and its treatment. Cultural factors are associated with misinformation about the medical aspects of the disease and the stigmatization of persons with tuberculosis. Culturally sensitive, targeted information is needed, and some has been developed by local tuberculosis programs.(ABSTRACT TRUNCATED AT 400 WORDS)

Humans↗

PubMed1978

Adherence of glucan-positive and glucan-negative streptococcal strains to normal and damaged heart valves.

The adherence of 18 strains of streptococci to sections of normal canine and human aortic, mitral, and tricuspid valves and to canine interatrial septum was compared in an in vitro system. Quantitative measurements of adherence ratios were performed by two independent methods. Adherence ratios for Streptococcus mutans, S. sanguis, S. bovis, and Group D streptococci were higher (0.0058-0.0101) than for the other streptococcal strains studied (0.0025-0.0041). With the exception of Group D streptococci, adherence ratios for each bacterial strain were similar with the aortic, mitral, and tricuspid valve sections. Adherence ratios with normal human and canine valve leaflets were similar, but adherence ratios with interatrial septum were lower than with normal valve sections. Adherence ratios for glucan-positive and glucan-negative strains of streptococci with normal and with damaged aortic valve leaflets were also compared. The adherence ratios of the glucan-positive streptococci (S. mutans, S. sanguis, and S. bovis) and one glucan-negative enterococcal strain (KG-3) were approximately five times higher with damaged aortic valves (0.039-0.051) than with normal aortic valves (0.009-0.010). For glucan-positive strains, adherence ratios with normal aortic leaflets were similar when bacteria were grown in media which contains or lacks sucrose. In striking contrast, growth of the glucan-positive strains in medium which lacks sucrose, with resultant deficiency of glucan production, decreased the adherence ratios with damaged aortic valve leaflets to those found with normal aortic leaflets. Treatment of glucan-positive strains with dextranase resulted in a decrease in their adherence ratios to levels seen with bacteria grown in medium lacking sucrose, but the higher adherence ratios could be restored in the presence of exogenous dextran.It is concluded that glucan production is one quantitatively important factor that contributes to the greater adherence of glucan-positive streptococci to damaged rather than to normal aortic heart valve leaflets. However, glucan production is not the only factor that determines preferential adherence of streptococci to damaged heart valves, because glucan-negative strains may also show some degree of increased adherence to damaged valves. Thus, bacterial glucan production is one of the factors that could contribute to the pathogenesis of bacterial endocarditis.

Animals↗

PubMed1981

Role of adherence in cytopathogenic mechanisms of Entamoeba histolytica. Study with mammalian tissue culture cells and human erythrocytes.

The enteric pathogen, Entamoeba histolytica, appears to cause disease by adhering to and then destroying mucosal barriers. Using an in vitro method of studying the interaction of E. histolytica with target cells (Chinese hamster ovary [CHO] and human erythrocytes [RBC]), we examined the mechanism of amebic adherence and its role in lysis of target cells. Killing and phagocytosis of target cells by amebas ceases at 4 degrees C, allowing observation of adherence. Amebas adhere to CHO cells at 4 degrees C, 78.9% formed rosettes (amebas with >/=3 adherent CHO cells each) at 2 h. At 37 degrees C, cytochalasins B and D inhibit adherence of amebas to CHO cells (P < 0.0005). Amebas adhere to and kill CHO cells in media with <0.1 muM calcium and magnesium plus 10 mM EDTA, indicating that divalent cations are not required in the medium. Adherence of amebas to human RBC was not ABO blood group specific and showed greater adherence to human than bovine or sheep RBC (P < 0.005). Neither Fc nor complement receptors were found on amebas by standard rosette studies. The amebic adherence receptor is not trypsin (0.125%) sensitive nor inhibited by trypan blue (1 mM). N-acetyl-d-galactosamine (GALNAc) inhibited the adherence of amebas to CHO cells and human RBC (0.1 g/100 ml or 4.5 mM GALNAc, P < 0.005) by binding to a receptor on the amebic surface. GALNAc abolishes amebic cytolysis of target CHO cells (determined by (111)Indium oxine release from CHO cells, P < 0.001) but not amebic phagocytosis of CHO cells. By suspending ameba-CHO cells rosettes in dextran, we found that GALNAc (1%) reversibly inhibits amebic adherence (P < 0.0005) and that cytochalasins decrease amebic killing of adherent CHO cells (P < 0.025). These findings indicate that the adherence of E. histolytica to target cells requires microfilament function, is via a specific amebic receptor that has affinity for GALNAc, and is required to lyse cells. Inhibition of the adherence of E. histolytica may alter the pathogenicity of this organism.

Acetylgalactosamine↗

PubMed2002

Consequences and determinants of adherence to antiretroviral medication: results from Adult AIDS Clinical Trials Group protocol 370.

OBJECTIVES: (1) To document rates and patterns of adherence from enrollment until week 24 of an AIDS clinical trial; (2) to examine the association of adherence to clinical end-points including plasma HIV-1 RNA level and CD4 cell count; and (3) to identify predictors of adherence from clinical, behavioural, psychosocial and demographic factors. DESIGN: Sub-study of a multicentre, randomised, open-label, comparison-controlled trial; 21 collaborating units of the Adult AIDS Clinical Trials Group. Observational, prospective analysis. METHODS: Ninety-three subjects with baseline plasma HIV-1 RNA levels >500 copies/ml, who completed clinical assessment, plasma HIV-1 RNA titres and CD4 cell counts at study entry, weeks 2, 4 and every 4 weeks thereafter until week 24. All patients were antiretroviral-experienced but were naive to non-nucleoside reverse transcriptase inhibitors and protease inhibitors. Self-reported adherence to antiretroviral therapies prescribed as part of the trial was assessed every 4 weeks from trial, week 4 until week 24. RESULTS: Average adherence was high, with 63% of subjects reporting >95% adherence across the trial. However, there was a significant decline in adherence over time on trial. After controlling for potential confounding variables, patients who were less than 95% adherent to medications were 3.5-times more likely to have treatment failure (HIV-1 RNA >50 copies/ml) than subjects with adherence rates of 95-100%. The strongest predictor of adherence was adverse clinical events (for example, dermatological, gastrointestinal symptoms): patients with adverse events were 12.8-times less likely to have 95-100% adherence. Other clinical, demographic, psychosocial and behavioural factors were also significant predictors of adherence. CONCLUSIONS: Adherence influences virological outcome even in AIDS clinical trials where overall adherence rates are high and should therefore be monitored in future trials. Intervention may be warranted to enhance adherence for subjects who have early toxicities, express concern about taking medications as directed, and for women and minorities.

Adult↗

PubMed2003

Impact of early versus late adherence to highly active antiretroviral therapy on immuno-virological response: a 3-year follow-up study.

OBJECTIVE: To assess the impact of different patterns of adherence to highly active antiretroviral therapy (HAART), in particular, the relative impact of early and late adherence, on long-term immuno-virological response in HIV-infected individuals started on a protease inhibitor-containing regimen. DESIGN: Clinical, immuno-virological and self-reported adherence data were collected at 4 (M4), 12 (M12), 20 (M20), 28 (M28) and 36 (M36) months after HAART initiation in the French APROCO cohort. METHODS: A standardized self-administered questionnaire classified patients as non-adherent, moderately or highly adherent at each visit. Stable viral suppression at both M28 to M36, and a CD4 cell increase > 200 between M0 and M36 were used as outcome measures. RESULTS: Of the 582 patients followed regularly through M36, 360 patients had complete adherence data. Although 59.2% were highly adherent at M4, only 25.8% maintained consistent high adherence throughout the follow-up. High adherence at M4 was independently associated with both stable viral suppression at M28-M36 [OR (95% CI): 2.8 (1.4-5.5)] and a CD4 cell increase > 200 during the same period [OR (95% CI): 3.9 (1.7-9.7)]. However, 'moderately adherent' patients between M12 and M36 had the same likelihood [OR (95% CI): 1.9 (1.1-3.2)] as patients who were always high adherent [OR (95% CI): 1.9 (1.1-3.2)] of achieving stable viral load suppression, relative to those who reported non-adherence episodes. CONCLUSION: Optimizing adherence in the early months of treatment is crucial to ensure long-term immuno-virological high adherence during follow-up have a less negative impact. Priority should be given to interventions aimed to improve adherence in the early months of HAART.

Acquired Immunodeficiency Syndrome↗

PubMed2006

Physicians' communication with patients about adherence to HIV medication in San Francisco and Copenhagen: a qualitative study using Grounded Theory.

BACKGROUND: Poor adherence is the main barrier to the effectiveness of HIV medication. The objective of this study was to explore and conceptualize patterns and difficulties in physicians' work with patients' adherence to HIV medication. No previous studies on this subject have directly observed physicians' behavior. METHODS: This is a qualitative, cross-sectional study. We used a Grounded Theory approach to let the main issues in physicians' work with patients' adherence emerge without preconceiving the focus of the study. We included physicians from HIV clinics in San Francisco, U.S.A. as well as from Copenhagen, Denmark. Physicians were observed during their clinical work and subsequently interviewed with a semi-structured interview guide. Notes on observations and transcribed interviews were analyzed with NVivo software. RESULTS: We enrolled 16 physicians from San Francisco and 18 from Copenhagen. When we discovered that physicians and patients seldom discussed adherence issues in depth, we made adherence communication and its barriers the focus of the study. The main patterns in physicians' communication with patients about adherence were similar in both settings. An important barrier to in-depth adherence communication was that some physicians felt it was awkward to explore the possibility of non-adherence if there were no objective signs of treatment failure, because patients could feel "accused." To overcome this awkwardness, some physicians consciously tried to "de-shame" patients regarding non-adherence. However, a recurring theme was that physicians often suspected non-adherence even when patients did not admit to have missed any doses, and physicians had difficulties handling this low believability of patient statements. We here develop a simple four-step, three-factor model of physicians' adherence communication. The four steps are: deciding whether to ask about adherence or not, pre-questioning preparations, phrasing the question, and responding to the patient's answer. The three factors/determinants are: physicians' perceptions of adherence, awkwardness, and believability. CONCLUSION: Communication difficulties were a main barrier in physicians' work with patients' adherence to HIV medication. The proposed model of physicians' communication with patients about adherence--and the identification of awkwardness and believability as key issues--may aid thinking on the subject for use in clinical practice and future research.

Adult↗

PubMedDate not supplied

Placebo practice trials: a tool to assess and improve adherence readiness.

PURPOSE: Antiretroviral therapy is being increasingly delayed until later stages of illness. Therefore, prior to prescribing HAART, providers are emphasizing the need for patients to be ready to adhere well to the treatment regimen. Unfortunately, providers are no better than chance at predicting a patient's adherence, and there are no established methods for accurately assessing a patient's adherence readiness. This pilot study assessed the utility of a series of up to five 1-week placebo practice trials accompanied by adherence counseling as a clinical tool to both assess and improve adherence readiness. METHOD: Participants were not prescribed treatment until they demonstrated readiness, which was defined as 90+% adherence during a single practice trial. Once HAART was initiated, adherence to one selected antiretroviral was monitored for 4 weeks. Electronic monitoring caps were used to measure adherence. RESULTS: Twenty men enrolled in the study at two HIV outpatient clinics in Southern California. Mean age was 33, 50% were non-White, 35% were employed, 30% had not completed high school, 15% were Spanish monolingual, and 30% had unstable housing. Nine participants achieved 90+% adherence in the first practice trial, with an additional 8 participants demonstrating readiness after two to four practice trials; two participants withdrew from the study because of intolerance of the restrictions related to the use of the caps; and one participant was removed from the study after no effort was given during two practice trials. Of the 17 participants who completed the program and demonstrated adherence readiness, 15 started on an antiretroviral regimen and 2 decided to defer treatment indefinitely. Of the 15 who started therapy, 13 (87%) achieved 90+% adherence during the first month of antiretroviral therapy. The sample's mean adherence during the first 4 weeks of treatment was 93% (SD = 13). CONCLUSION: These results suggest that once a patient is able to adhere well to a 1-week practice trial they are likely to adhere equally well to HAART. A larger controlled study is needed to further assess the effectiveness of practice trials as a clinical tool for both assessing and improving adherence readiness.

Adult↗

PubMed2005

Race and electronically measured adherence to immunosuppressive medications after deceased donor renal transplantation.

Nonadherence to immunosuppressive medications may partly explain the worse allograft outcomes among black recipients of renal transplants. In a prospective cohort study of recipients of deceased donor renal transplants, microelectronic cap monitors were placed on bottles of one immunosuppressive medication to (1) measure average daily percentage adherence during the first posttransplantation year and (2) determine the factors associated with adherence. A total of 278 transplant recipients who provided sufficient microelectronic adherence data were grouped into four categories of average daily percentage adherence: 95 to 100% adherence (41.0% of patients), 80 to 95% adherence (32.4%), 50 to 80% adherence (12.9%), and 0 to 50% adherence (13.7%). In the unadjusted ordinal logistic regression model, black race was associated with decreased adherence (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.26 to 0.72; P = 0.001). Cause of renal disease, Powerful Others health locus of control, transplant center, and dosing frequency were also associated with adherence. After adjustment for transplant center and dosing frequency, the association between black race and decreased adherence was substantially attenuated (OR, 0.65; 95% CI, 0.38 to 1.14, P = 0.13). Transplant center (P = 0.003) and increased dosing frequency (OR, 0.43; 95% CI, 0.22 to 0.86, for three or four times per day dosing; OR, 2.35; 95% CI, 1.01 to 5.45, for daily dosing; versus two times per day dosing; P = 0.003) remained independently associated with adherence. Other baseline demographic, socioeconomic, medical, surgical, and psychosocial characteristics were not associated with adherence. The transplant center and dosing frequencies of immunosuppressive medications are associated with adherence and explain a substantial proportion of the race-adherence relationship.

Adult↗