Motivations, Attitudes Distinguish Consistent Versus Inconsistent ART Adherence

According to 2015 CDC data, current viral suppression rates from antiretroviral therapy (ART) leave room for improvement among both HIV-positive individuals who are aware of their disease status and those receiving care, at 40.0% and 81.5%, respectively. In addition, untreated HIV, not undiagnosed, leads to a majority of new HIV transmissions in the United States.

Study results published this month in SAGE Open Medicine may shed light on why not all HIV-positive individuals adhere to their medication regimen, as well as identify new ways to intervene and provide assistance for those encountering difficulties initiating or staying on ART.

The study patients, who came from a safety net hospital—based HIV clinic, were eligible for study inclusion if, among many factors, they were currently receiving care at the clinic, were at least 18 years old, could conduct an interview without physical or mental impairment (eg, dementia, deafness), and were receiving treatment for their HIV for at least 6 months. From October 10, 2017, through November 18, 2017, phone calls and in-person requests during clinic visits were used to recruit participants.

Patients were divided into 2 groups: consistent (n = 19) and inconsistent (n = 10). The median ages were 35 and 30 (range for both, 18-58) years, respectively. Medicaid was the primary insurance for 63% and 70%. A majority were male (72.4%), and there was 1 transgender female.

The consistent group was further defined as “no single break in medication adherence greater than 2 weeks and with medication being taken most days of each week other than this single gap,” while the inconsistent group “had not been taking medication regularly throughout the past year.” Confidential interviews were conducted with all members of both groups.

Overall, the authors discovered key differences affecting adherence in these 6 areas, while, the World Health Organization divides reasons for adherence/nonadherence into 3 categories: healthcare delivery system related, medication related, and individual related.

“We find that many traditional barriers to care have been addressed by existing programs, but there are still key differences between those consistent with ART and those inconsistent with ART. In particular, self-motivation, diagnosis acceptance, involvement in treatment for depression, spiritual beliefs, perceived value of the HIV care team, and prior experience with health care distinguish these 2 groups,” the authors note. “We hope that our findings can be used to target interventions to people living with HIV [PLWH] entering care who are at increased risk for inconsistent adherence.”

The results start off on a positive note: A majority of participants made connections to HIV care soon after their diagnosis, and they knew, and accepted, that ART was effective at achieving viral suppression. Differences were more apparent in such areas as prior healthcare experience, self-motivation, obstacles to receiving care, lack of initiative, and viewpoint of depression.

For example, overall, half of the study participants lacked consistent healthcare prior to their diagnosis. This breaks down to just 20% of the inconsistent ART group compared with half of the consistent group. And despite such common self-motivators are familial support and better health on ART, the consistent group reported their motivation to adhere to ART was more internal (ie, positive health habits such as working out), while the inconsistent group deferred to outside influences (ie, support from doctors and social workers).

In addition, there were start differences where lack of initiative as an obstacle to care came in to play. The consistent ART group was just that: self-motivated on a regular basis. In contrast, the inconsistent ART group was not as driven. One respondent noted, “I get ‘em filled, but then I would move away from wherever I was at, or leave ‘em at different places. I wasn’t very consistent with anything I was doing.…Myself is the only challenge.”

Regarding depression, this was an obstinate roadblock to care for the inconsistent ART group. Those patients attributed their lack of medication use and regular care appointments to being in a depressed state, whereas the consistent group recognized their depression but did not let it become part of their mindset. These patients recognized the dangers inherent in not dealing with their HIV.

“We saw a difference in attitudes toward having HIV. PLWH in the inconsistent group were more likely to struggle with denial; whereas PLWH in the consistent group talk about positive thinking, and the importance of accepting it, dealing with it, and moving on,” the authors concluded. “An important next step is to translate our findings into an assessment tool to better identify patients at risk for inconsistency and design effective interventions targeted to this group earlier in treatment.”

Reference

Fleischer L, Avery A. Adhering to antiretroviral therapy: a qualitative analysis of motivations for and obstacles to consistent use of antiretroviral therapy in people living with HIV. SAGE Open Med. 2020;8:1-10. doi: 10.1177/2050312120915405