Abstract #228  -  Effective HAART adherence interventions need to address AIDS stigma
Authors:   Presenting Author:   Dr Maria Ekstrand - University of California, San Francisco
Additional Authors:  Dr Sara Chandy, Ms Elsa Heylen, Mr Sijuthomas Panicker, Dr  Wayne Steward, Mr Thomas Osmand, Dr Girija Singh,
Aim: Excellent long-term adherence is crucial to maintaining the effectiveness of first line HAART in resource-limited settings. This study was designed to examine patterns of adherence and treatment interruptions, their relationship with virologic failure, and barriers that interfere with optimal adherence.
Method / Issue: We recruited and interviewed a cohort of 229 HIV-infected patients on HAART in Bangalore, India every 3 months for a year, assessing adherence behaviors, treatment interruptions, and adherence barriers. Viral load and CD4 counts were assessed every 6 months.
Results / Comments: Self-reported adherence rates at each interview were high, with 77-83% of participants reporting >95% adherence during the past month at the different data waves. However, an examination of individual longitudinal adherence patterns showed that only 55% of the sample reported >95% adherence at all data waves, suggesting that maintenance of optimal adherence is a challenge. In addition, 50% of the sample reported a history of treatment interruptions lasting >48 hours. Suboptimal adherence was associated with viral load, with 20% of >95% adherent participants having detectable viral load vs 40% of non-adherent (<95%) participants (p<.002). Three adherence barrier subscales were developed to examine their role in adherence: 1) lack of a consistent daily routine, 2) their specific regimen (e.g. side effects), 3) their health status (e.g. felt too sick), and 4) refilling their prescription (e.g. transportation issues and availability of medication). High scores on all subscales were significantly associated with non-adherence in bivariate cross-sectional analyses. In addition, non-adherence was associated with high internalized stigma, using avoidant coping strategies, alcohol consumption, medication side effects and having less education. Multivariate models were developed to examine the role of adherence barriers in long term adherence. These showed that baseline health-related barriers and refill-related barriers predicted both treatment interruptions (OR=4.0 and OR=5.6, respectively) and failure to maintain stable adherence over time (OR=3.9 and OR=2.2, respectively).
Discussion: Maintaining long-term consistent adherence in this setting is challenging and treatment interruptions are common. This increases both the risk of virologic failure and the development of drug resistance. These results suggest that future adherence interventions need to address multiple levels of determinants in order to be successful. While more traditional adherence intervention components, such as tailoring medication intake to daily routines and minimizing medication side effects are still needed, future adherence interventions will also need to address AIDS-related stigma and discrimination in order to improve long term adherence and minimize the risk of treatment interruptions. These social determinants prevent people both from consistently taking their medications and from refilling their prescriptions in a timely manner, when these behaviors involves a risk of disclosure. This makes stigma reduction a crucial component of successful HIV treatment efforts in this setting.
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