Antiretroviral adherence tools

NIMH supports research at universities, medical centers, and other institutions via grants, contracts, and cooperative agreements. Learn more about NIMH research areas, policies, resources, and initiatives.

Over 40 research groups conduct basic neuroscience research and clinical investigations of mental illnesses, brain function, and behavior at the NIH campus in Bethesda, Maryland. Learn more about research conducted at NIMH. Explore the NIMH grant application process, including how to write your grant, how to submit your grant, and how the review process works. Details about upcoming events — including meetings, conferences, workshops, lectures, webinars, and chats — sponsored by the NIMH.

NIMH videos and podcasts featuring science news, lecture series, meetings, seminars, and special events. Information about NIMH, research results, summaries of scientific meetings, and mental health resources. NIMH hosts an annual lecture series dedicated to innovation, invention, and scientific discovery.

Contribute to Mental Health Research. There remains no gold standard for behavioral assessments of ART adherence. Many assessment methods have been examined in the context of HIV treatment, including self-reports, pharmacy refill, announced and unannounced pill counts, and electronic drug monitoring.

The validity and precision of these tools vary, and each contains advantages and disadvantages. Any assessment approach for ART adherence would be made more useful if it could be configured to systematically provide prospective or real-time monitoring of adherence behavior. Routine monitoring of ART adherence could empower patients through timely feedback, and could offer healthcare providers actionable information for the delivery of targeted adherence support interventions.

Related studies may include:. Apart from drug concentrations, PrEP lacks a ready biomarker associated with behavioral adherence that is analogous to viral load in HIV treatment. Use cellphone-based technologies. Approaches include interactive voice response, text messaging, and mobile apps.

Strategies to Improve Adherence to Antiretroviral Medications Initial Intervention Strategies Establish trust and identify mutually acceptable goals for care. Obtain explicit agreement on the need for treatment and adherence. Evaluate and initiate treatment for mental health issues before starting ARV drugs, if possible. Determine whether the child is aware of their HIV status. Identify family, friends, health team members, and others who can support adherence.

Educate the patient and family about the critical role of adherence in therapy outcome, including the relationship between partial adherence and resistance and the potential impact on future drug regimen choices. Develop a treatment plan that the patient and family understand and to which they feel committed.

Work with the patient and family to make specific plans for taking medications as prescribed and for supporting adherence. Assist them in arranging administration during day care, school, and in other settings, when needed. Consider home delivery of medications. Schedule a home visit or telemedicine visit to review medications and determine how they will be administered in the home setting.

In certain circumstances, consider a brief period of hospitalization at the start of therapy for patient education and to assess the tolerability of the chosen medications.

Medication Strategies Choose the simplest regimen possible; reduce dosing frequency, pill size, and number of pills see Appendix A, Table 1 and Appendix A, Table 2. Choose the most palatable medicine possible pharmacists may be able to add syrups or flavoring agents to increase palatability. Choose drugs with the fewest AEs; provide anticipatory guidance for managing AEs. Simplify food requirements for medication administration. Prescribe drugs carefully to avoid adverse drug—drug interactions.

Assess pill-swallowing capacity and offer pill-swallowing training and aids e. Adjust pill size as needed. Follow-up Intervention Strategies Have more than one member of the multidisciplinary team monitor adherence at each visit and in between visits by telephone, email, text, and social media, as needed.

Provide ongoing support, encouragement, and understanding of the difficulties associated with maintaining adherence to daily medication regimens. Provide education and counseling that explain the meaning and significance of viral load results.

Use patient education aids, including pictures, calendars, and stickers. Encourage the use of pill boxes, reminders, mobile apps, alarms, and timers. Provide follow-up clinic visits, telephone calls, text messages, and telemedicine visits to support and assess adherence.

Provide access to support groups, peer groups, or one-on-one counseling for caregivers and patients, especially for those with known depression or drug use issues, which are known to decrease adherence. Provide pharmacist-based adherence support, such as medication education and counseling, blister packs, refill reminders, automatic refills, and home delivery of medications.

Consider DOT at home, in the clinic, or, in certain circumstances, during a brief period of inpatient hospitalization. Consider gastrostomy tube use in certain circumstances. Section Only PDF Full Guideline PDF 6. Recommendations Only PDF After adjusting for age, having received intervention and psychiatric history, significant risk factors for non-adherence to antiretroviral medication were mode of transmission, history of smoking and being symptomatic during the programme. Conclusion Significant psychological distress occurring early in HIV care predicts future non-adherence to antiretroviral treatment, highlighting the importance of early detection and intervention for psychological distress in people living with HIV.

Mental health interventions should be intercalated with treatment adherence interventions to improve HIV treatment outcomes. No data are available. Data are not available due to privacy and confidentiality issues.

Even as the number of new HIV infections has been and is projected to continue decreasing over the years, the number of people living with HIV who have access to treatment is increasing, whereby an estimated 26 million people living with HIV worldwide are on treatment as of June Multiple factors have been thought to contribute to psychological distress, including symptom burden, emotional distress from obtaining a positive test result and a heightened sense of HIV-related stigma. There is a complex interplay between HIV and mental health issues, with multiple contributory factors influencing each other.

Several studies on patients with HIV found that those who presented with symptoms of depression and anxiety tended to have poorer adherence to medication. Its use in helping to cope with psychological distress also contributes to negative health outcomes as increased substance use affects adherence. Despite the diminished quality of life patients with HIV may experience as a result of psychological distress, the stigma associated with mental illness and seeking treatment at mental health institutions often hinders them in seeking help, 11 resulting in untreated psychological distress.

A systematic review showed that the integration of both HIV and mental health services in a single facility can contribute to the alleviation of associated negative outcomes.

This highlights the importance of an integrated system of HIV and mental health services, the absence of which constitutes an additional significant barrier to HIV treatment. The Psychological Wellness Programme is a mental health screening service in an urban, tertiary healthcare setting that was introduced in to facilitate early identification of and appropriate intervention for anxiety and depressive symptoms as part of routine HIV care, with the goal of improving the health outcomes of patients with HIV.

This paper aims to identify the risk factors for the development of psychological distress and non-adherence to antiretroviral treatment ART , and to begin to understand the complex relationship between HIV and these factors. This may prove useful in the design and delivery of services, especially in identifying high-risk groups that may benefit from greater resources.

The HIV clinic, which is sited at an affiliated centre for infectious diseases, provides holistic care for more than people living with HIV and is the largest and most established HIV care centre in the country. Screening for psychological symptoms was done within the first 6 months of their access to HIV specialist care, with the objective of early detection and intervention to improve patient outcomes.

Patients exited from the programme after they had completed two standardised screenings that were between 6 and 12 months apart. Patients were considered dropouts if they did not have a repeat screen within 12 months after the entry screen and were not recontacted for follow-up.

Patients were also excluded from the programme if they did not undergo an entry screen within 6 months of their first HIV clinic consult or if they scored less than 7 on the Abbreviated Mental Test. The Hospital Anxiety and Depression Scale HADS is composed of an anxiety subscale and a depression subscale, each subscale comprising seven items that are scored on a scale of 0—3 maximum score 21 for each subscale.

This was a single question asked during exit repeat screening that asked patients how many days in the last 30 days they had missed taking their antiretroviral medications; this number was then subtracted from 30 and converted to a percentage.

A 1-month recall period has been shown to be more accurate with significantly less over-reporting than 3-day or 7-day recall periods.

Nevertheless, there is sufficient literature showing good correlation with objective measures 21 and ability to predict clinical outcomes in the HIV population despite their limitations. As part of the screening procedure, other variables were recorded.

These included demographics age, gender, educational level, employment status , mode of HIV transmission and disclosure of HIV diagnosis to family. Figure 1 presents the derivation of our study sample.

The study sample was divided into two groups for comparison. The first group comprises patients who screened positive on the HADS on at least one of the two screenings conducted according to programme protocol symptomatic during programme , and the second group consists of those who screened negative on the HADS on both screenings asymptomatic during programme. Flow chart of participants enrolled into the Psychological Wellness Programme August —December Created by the authors. Table 1 presents the comparison of demographic and clinical factors between patients who were symptomatic and asymptomatic during the programme.

In clinical practice, patients who screened positive once were no different from those who screened positive twice in terms of intervention workflows following case identification, in keeping with the main programme objective of early detection and intervention. National HIV statistics show that transmission was largely via sexual transmission, further subclassified as heterosexual, homosexual and bisexual contact, with few cases of transmission by intravenous drug use and none due to blood transfusion, transplant or perinatal routes.

A binomial logistic regression was performed to ascertain the effects of various demographic variables and clinical factors on the likelihood that patients were symptomatic during the programme table 2. After adjusting for age, significant risk factors found included psychiatric history and history of alcohol use.

Predictors of significant psychological distress during the period of surveillance dependent variable: symptomatic during the programme. A binomial regression was performed to determine whether non-adherence to antiretroviral medication could be predicted by demographic variables, clinical factors and being symptomatic during the programme table 3.

After adjusting for age, having received intervention and psychiatric history, significant risk factors found included mode of HIV transmission, history of smoking and presence of psychological distress during the programme.

Predictors of non-adherence to highly active antiretroviral therapy at exit screening dependent variable: non-adherence. A history of psychiatric illness was associated with the presence of symptoms of psychological distress in this study. Pre-existing psychiatric illness has been associated with a manifold increased risk of HIV acquisition, and it is unsurprising that a high proportion of people living with HIV newly linked to care would also present with concomitant psychological symptoms.

Nevertheless, the importance of services integrating general mental health and substance use for people living with HIV should not be undermined by our results. The association we found between younger age and an increased likelihood of reporting psychological symptoms is likely sociocultural and may include increased stressors from concealment of HIV status from parents and family members, as is typical in Asian sociocultural context.

Hence, further studies are required to fully elucidate the relationship between age and psychiatric morbidity in people living with HIV. It is interesting to note that the mode of sexual transmission was not significantly associated with the likelihood of having psychological symptoms.

Incomplete data from this group may have contributed to our negative finding. Adherence to ART is crucial in achieving durable virological suppression and immune reconstitution in people living with HIV and ensuring personal health and well-being, as well as preventing onward transmission of infection. Adherence to treatment is multifactorial and involves the interplay of health beliefs and health behaviour.

Our study found that the presence of significant psychological symptoms in the early phase of accessing care was associated with an increased likelihood of being non-adherent to treatment by self-report, which is consistent with findings in the published literature from different settings. Conversely, further research is required to verify whether effective intervention of psychiatric symptoms improves ART adherence.

We found that patients who reported disease transmission through heterosexual contact were more likely to be non-adherent to treatment. This was independent of symptoms of psychological distress, which were not significantly different between the heterosexual and MSM groups. Similar findings are reported elsewhere 29 and have been attributed to factors such as differences in educational level, knowledge about HIV, as well as perceived efficacy of treatment between the heterosexual and MSM groups.

Further research is needed, especially in the local context, to explore possible variations in HIV treatment-related knowledge and attitudes between heterosexual men and MSM. In our study, a history of smoking was found to be significantly associated with non-adherence to treatment, while substance use was not.

These findings are interesting and warrant further study, especially in view of published experience finding positive associations between use of recreational drugs and alcohol and antiretroviral adherence.

The relationship between smoking tobacco and medication adherence is more complex, with some authors describing no association between smoking status and non-adherence, and others observing poorer adherence to treatment in smokers compared with non-smokers, in concert with other behaviours suggesting lower engagement in health-seeking and health-protective attitudes.

There are several limitations to our study.