Ramani S. Durvasula

Medication adherence in HIV-infected adults: Effect of patient age, cognitive status, and substance abuse

Objective: To examine the predictors of antiretroviral adherence among HIV-infected adults, with a particular focus on advancing age, neuropsychological dysfunction, and substance abuse. Design: Prospective observational design. Methods: Participants were 148 HIV-infected adults between the ages of 25 and 69 years, all on a self-administered antiretroviral regimen. Medication adherence was tracked over a one-month period using an electronic monitoring device (medication event monitoring system caps). All participants completed a comprehensive battery of neuropsychological tests as well as a structured psychiatric interview. Results: The mean adherence rate for the entire cohort was 80.7%, with older patients (⩾ 50 years) demonstrating significantly better medication adherence than younger patients (87.5 versus 78.3%). Logistic regression analyses found that older patients were three times more likely to be classified as good adherers (defined as ⩾ 95% adherent). Neurocognitive impairment conferred a 2.5 times greater risk of poor adherence. Among the older patients, those who were classified as poor adherers performed significantly worse on neuropsychological testing, particularly on measures of executive function and psychomotor speed. Current drug abuse/dependence, but not current alcohol abuse/dependence, was also associated with sub-optimal medication adherence. Conclusion: Although older age is associated with higher rates of antiretroviral adherence, older participants who were cognitively impaired showed disproportionate difficulty in adequately adhering to their medication regimen. As such, efforts to detect neuropsychological dysfunction, particularly among older patients, and a thorough assessment of substance abuse, appear to be essential for the effective treatment of HIV-infected adults.

Medication adherence among HIV+ adults: Effects of cognitive dysfunction and regimen complexity

Background: Although the use of highly active antiretroviral therapy in the treatment of HIV infection has led to considerable improvement in morbidity and mortality, unless patients are adherent to their drug regimen (i.e., at least 90 to 95% of doses taken), viral replication may ensue and drug-resistant strains of the virus may emerge. Methods: The authors studied the extent to which neuropsychological compromise and medication regimen complexity are predictive of poor adherence in a convenience sample of 137 HIV-infected adults. Medication adherence was tracked through the use of electronic monitoring technology (MEMS caps). Results: Two-way analysis of variance revealed that neurocognitive compromise as well as complex medication regimens were associated with significantly lower adherence rates. Cognitively compromised participants on more complex regimens had the greatest difficulty with adherence. Deficits in executive function, memory, and attention were associated with poor adherence. Logistic regression analysis demonstrated that neuropsychological compromise was associated with a 2.3 times greater risk of adherence failure. Older age (>50 years) was also found to be associated with significantly better adherence. Conclusions: HIV-infected adults with significant neurocognitive compromise are at risk for poor medication adherence, particularly if they have been prescribed a complex dosing regimen. As such, simpler dosing schedules for more cognitively impaired patients might improve adherence.

Age-Associated Predictors of Medication Adherence in HIV-Positive Adults: Health Beliefs, Self-Efficacy, and Neurocognitive Status

OBJECTIVE Although most agree that poor adherence to antiretrovirals is a common problem, relatively few factors have been shown to consistently predict treatment failure. In this study, a theoretical framework encompassing demographic characteristics, health beliefs/attitudes, treatment self-efficacy, and neurocognitive status was examined in relationship to highly active antiretroviral therapy adherence. DESIGN Prospective, cross-sectional observational design. MAIN OUTCOME MEASURES Neuropsychological test performance, health beliefs and attitudes, and medication adherence tracked over a 1-month period using electronic monitoring technology (Medication Event Monitoring System caps). RESULTS The rate of poor adherence was twice as high among younger participants than with older participants (68% and 33%, respectively). Results of binary logistic regression revealed that low self-efficacy and lack of perceived treatment utility predicted poor adherence among younger individuals, whereas decreased levels of neurocognitive functioning remained the sole predictor of poor adherence among older participants. CONCLUSION These data support components of the health beliefs model in predicting medication adherence among younger HIV-positive individuals. However, risk of adherence failure in those ages 50 years and older appears most related to neurocognitive status.

Drug Use and Medication Adherence among HIV-1 Infected Individuals

This longitudinal study examined the impact of drug use and abuse on medication adherence among 150 HIV-infected individuals, 102 who tested urinalysis positive for recent illicit drug use. Medication adherence was tracked over a 6-month period using an electronic monitoring device (MEMS caps). Over the 6-month study drug-positive participants demonstrated significantly worse medication adherence than did drug-negative participants (63 vs. 79%, respectively). Logistic regression revealed that drug use was associated with over a fourfold greater risk of adherence failure. Stimulant users were at greatest risk for poor adherence. Based upon within-participants analyses comparing 3-day adherence rates when actively using versus not using drugs, this appears to be more a function of state rather than trait. These data suggest that it is the acute effects of intoxication, rather than stable features that may be characteristic of the drug-using populace, which leads to difficulties with medication adherence.

Impact of Breast Cancer on Asian American and Anglo American Women

This pilot study constitutes the first exploration ofthe impact of breast cancer on Asian American women.Three hypotheses guided this study: (1) Asian Americanwomen would choose breast conserving therapy andbreast reconstruction at a lower rate than the AngloAmerican women due to cultural differences in bodyimage, (2) Asian American women with breast cancerwould express psychological distress somatically andAnglo American women would express distress emotionally, and acculturation levels of the AsianAmerican women would modify the expressions ofdistress such that women with high acculturation willexpress distress more emotionally and lessacculturated women would express distress moresomatically, and (3) Asian American women would seekassistance for psychosocial problems at asignificantly lower rate than Anglo women. Ethnicity,age, and levels of acculturation were found to besignificant variables that had to be consideredsimultaneously. The three hypotheses were onlypartially supported: (1) Asian American women chosebreast conserving therapy and adjuvant therapy at asignificantly lower rate than the Anglo Americanwomen, (2) Contrary to the hypothesis, somatization didnot appear to be a dominant form of symptompresentation for Asian American women regardless oflevel of acculturation, and (3) Asian American womensought professional assistance for psychosocialproblems at a significantly lower rate than Anglowomen. Asian American women reported using differentmodes of help-seeking behavior for emotional concernsand receiving different sources of social support thanthe Anglo American women. Cultural interpretations ofthe findings are offered to explain the differences inthe physical, emotional, and social responses to thebreast cancer experience of Asian American womencompared with the Anglo Americans, and notably betweenthe Chinese- and Japanese Americans as well. Thefindings of this study warrant more refinedexploration in order to improve the medical,psychological and social outcomes for Asian Americanwomen with breast cancer.

Aging, Neurocognition, and Medication Adherence in HIV Infection

OBJECTIVE To evaluate the hypothesis that poor adherence to highly active antiretroviral treatment (HAART) would be more strongly related to cognitive impairment among older than among younger HIV-seropositive adults. SETTING AND PARTICIPANTS A volunteer sample of 431 HIV-infected adult patients prescribed self-administered HAART was recruited from community agencies and university-affiliated infectious disease clinics in the Los Angeles area. MEASUREMENTS Neurocognitive measures included tests of attention, information processing speed, learning/memory, verbal fluency, motor functioning, and executive functioning. Medication adherence was measured using microchip-embedded pill bottle caps (Medication Event Monitoring System) and self-report. Latent/structural analysis techniques were used to evaluate factor models of cognition and adherence. RESULTS Mean adherence rates were higher among older (>or=50 years) than younger (<50 years) HIV-positive adults. However, latent/structural modeling demonstrated that neurocognitive impairment was associated with poorer medication adherence among older participants only. When cognitive subdomains were examined individually, executive functioning, motor functioning, and processing speed were most strongly related to adherence in this age group. CD4 count and drug problems were also more strongly associated with adherence among older than younger adults. CONCLUSIONS Older HIV-positive individuals with neurocognitive impairment or drug problems are at increased risk of suboptimal adherence to medication. Likewise, older adults may be especially vulnerable to immunological and neurocognitive dysfunction under conditions of suboptimal HAART adherence. These findings highlight the importance of optimizing medication adherence rates and evaluating neurocognition in the growing population of older HIV-infected patients.

Variations in Patterns of Highly Active Antiretroviral Therapy (HAART) Adherence

Strict adherence to highly active antiretroviral therapy (HAART) is necessary for successful suppression of HIV replication. A large number of individuals are not adherent, however, and the reasons for non-adherence are varied and complex. We utilized cluster analyses to identify subgroups of adherers in a sample of 222 HIV positive individuals whose HAART use was electronically monitored. Five distinct subgroups were identified, with characteristic variations across the week and over the course of the 4-week study. Additional comparisons of demographic and behavioral variables found the worst adherers to have higher rates of substance use, and that a group with higher rates of cognitive impairment had a consistent drop in adherence during the weekends. In addition, the group with the best adherence had more individuals over the age of 50 years. The results of the current study indicate that distinct subgroups of adherers may exist, and suggest that interventions designed to improve adherence can be designed to accommodate this variability in behavior.

Adherence to antiretroviral medications in HIV: differences in data collected via self-report and electronic monitoring.

Controversy remains regarding the reliability of methods used to determine adherence to antiretroviral medication in HIV. In this study the authors compared adherence rates of 119 HIV-positive participants during a 6-month study, as estimated via electronic monitoring (EM) and self-report (SR). Adherence for both short (4-day) and long (4-week, or intervisit) periods was examined, as well as factors that underlie discrepancies between EM and SR. Results showed that intervisit EM estimates were consistently lower than those of SR. SR estimates based on shorter periods (4 days) were closer to those of EM. Higher discrepancies between EM and SR estimates were associated with lower cognitive functioning and externalized locus of control. These findings lend support for using both EM and SR methods; however, study design (e.g., length) and other factors (e.g., cognitive status, cost) should be considered.

Severity of disturbance among Asian American outpatients.

Although Asian Americans are low utilizers of mental health services, they may suffer from a greater degree of disturbance by the time they are accepted for services. In this study, thousands of Asian and White clients who utilized a large mental health system over a 5-year period were compared on three measures of severity of disturbance: severity of diagnosis, ratings of functioning, and presence of psychotic features. Results for all three indicators supported the hypothesis that Asian Americans show greater disturbance than do Whites. The findings provide convincing evidence of greater disturbance among Asian American clients. It is suggested that for cultural reasons, only the most severely disturbed Asian clients use mental health services.

Predictors of Neuropsychological Performance in HIV Positive Women

This study examines predictors of neuropsychological (NP) performance in a community sample of 237 HIV seropositive and seronegative women. Consistent with literature describing the NP sequelae of HIV infection in men, we expected that HIV status would predict poorer NP performance on tests assessing verbal memory, psychomotor speed and motor speed. Multiple regression analyses testing the association between HIV serostatus and NP performance and controlling for predictors including age, ethnicity, education, psychological distress, and drug and alcohol use indicated that HIV serostatus was associated with slowed psychomotor speed. Specifically, AIDS diagnosis and HIV seropositivity predicted poorer performance on tests of psychomotor speed relative to HIV seronegatives. Contrary to expectations, no relationship between HIV serostatus and either motor speed or verbal memory performance emerged. Education, ethnicity, depressive distress, recent exposure to drugs as indexed by toxicology, and alcohol use were also associated with NP performance. Given that the HIV seropositive and seronegative samples differed on a number of demographic and drug use variables, a second series of analyses examining a subset of participants (matched on all key demographic factors) and with no illicit drug use during the past year was also conducted. Results of these analyses were similar to those obtained for the full sample, with AIDS diagnosis and HIV seropositivity predicting psychomotor slowing. To date, little work describing the NP sequelae of HIV infection in women has been conducted. This study provides one of the first descriptions of the NP effects of HIV/AIDS in a largely non-injection drug using community sample of women.