Practical and Conceptual Challenges in Measuring Antiretroviral Adherence

Berg, Karina M.; Arnsten, Julia H.

doi:10.1097/01.qai.0000248337.97814.66

Cited by 262 publications

(283 citation statements)

References 89 publications

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“…Among comparisons that were not highly concordant, self-reports produced higher estimates of adherence than other assessment methods 92 % of the time (45 out of 49 comparisons). A meta-analysis showed the estimated degree of regimen execution is approximately 15 % higher by self-report when compared with EDM devices [56], which is consonant with estimates in other reviews and syntheses [5,35,56,58].Sensitivity and specificity-Because of potential overreporting, self-report adherence measures are considered to have good specificity (i.e., positive predictive value) and weak sensitivity (i.e., negative predictive value) for detecting poor adherence [5,32,46]. Stated simply, self-reports of nonadherence can be trusted; self-reports of adherence less so.…”

supporting

confidence: 59%

“…Research on the convergent validity of self-report adherence measures shows clear evidence that they tend to overestimate the extent of regimen execution relative to other adherence assessments [32,46]. In an examination of 57 studies across many chronic illnesses, Garber and colleagues [8] found high concordance between selfreport and other adherence assessments in 43 % of comparisons.…”

Section: Validity Of Medication Adherence Self-reportsmentioning

confidence: 99%

“…In a review of 41 medication adherence studies, Shi and colleagues [55] determined that a majority of studies (68 %) report correlations between self-report and EDM adherence measures that are either high (27 %), moderate (29 %), or low yet statistically significant (12 %). A related metaanalysis estimated that the pooled correlation coefficient between self-report and electronically monitored adherence was 0.45 (95 % CI, 0.34-0.56) [56].Moderate correlations between self-report and electronic monitoring reflect the performance of both adherence measures, and as such, may reflect limitations in self-reports as well as logistic challenges in EDM [57].Research on the convergent validity of self-report adherence measures shows clear evidence that they tend to overestimate the extent of regimen execution relative to other adherence assessments [32,46]. In an examination of 57 studies across many chronic illnesses, Garber and colleagues [8] found high concordance between selfreport and other adherence assessments in 43 % of comparisons.…”

mentioning

confidence: 98%

“…In addition to providing estimates of medication dose-taking behavior, self-reports can uniquely provide information about adherence determinants such as understanding of the medication regimen, reasons for nonadherence, attitudes and beliefs toward medicines, and other psychosocial factors. In clinical research settings, self-reports are frequently one component of triangulation strategies that combine multiple forms of adherence measurement [40], such as using self-report adherence measures to refine adherence data from electronic drug monitors (EDM) [32].Self-report measures of adherence have several potential disadvantages as well. These include the contestable assumptions that medication adherence behavior can be accurately recalled or reported without deference to social desirability concerns that encourage overreporting (for a review, see [9]).…”

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confidence: 99%

“…The criterion validity of adherence measures is established through comparison with clinical outcomes and biological endpoints likely affected by adherence [32]. Convergent validity has been tested through comparison of self-report measures to other medication adherence measures, such as EDM and pharmacy refill measures [32].Criterion validity-Research generally shows low-tomoderate correspondence between self-report adherence measures and clinical outcomes, and estimates are highly variable by chronic disease area and measure [46]. Two syntheses of research conducted with adult HIV/AIDS patients offer strong evidence that self-report medication adherence measures can significantly and meaningfully predict clinical outcomes [5,47].…”

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confidence: 99%

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Self-report measures of medication adherence behavior: recommendations on optimal use

Stirratt

Dunbar‐Jacob

Crane

et al. 2015

Behav. Med. Pract. Policy Res.

605

528

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Medication adherence plays an important role in optimizing the outcomes of many treatment and preventive regimens in chronic illness. Self-report is the most common method for assessing adherence behavior in research and clinical care, but there are questions about its validity and precision. The NIH Adherence Network assembled a panel of adherence research experts working across various chronic illnesses to review selfreport medication adherence measures and research on their validity. Self-report medication adherence measures vary substantially in their question phrasing, recall periods, and response items. Self-reports tend to overestimate adherence behavior compared with other assessment methods and generally have high specificity but low sensitivity. Most evidence indicates that self-report adherence measures show moderate correspondence to other adherence measures and can significantly predict clinical outcomes. The quality of self-report adherence measures may be enhanced through efforts to use validated scales, assess the proper construct, improve estimation, facilitate recall, reduce social desirability bias, and employ technologic delivery. Self-report medication adherence measures can provide actionable information despite their limitations. They are preferred when speed, efficiency, and low-cost measures are required, as is often the case in clinical care. KeywordsAdherence, Compliance, Self-management, Medication, Self-report Valid measurement of medication adherence plays a crucial role in healthcare and health research. When a patient is not benefiting from a medication regimen, clinicians need sound adherence information to determine whether the medication is ineffective or not being taken as prescribed. Assessing medication adherence during routine clinical care can further ensure that individuals in need of adherence support interventions receive them, ideally before deleterious outcomes occur. In the context of clinical research, proper interpretation of proof-of-concept trials testing new pharmacologic regimens requires valid adherence data, because any null findings may stem from poor adherence rather than a lack of drug efficacy. Research designed to understand and promote medication adherence also requires precise methods of adherence assessment.Among many approaches to assessing medication adherence, patient self-report measures remain the most common method [1][2][3][4][5][6]. These measures are defined by asking respondents to characterize their medication adherence behavior. Self-report measures of medication adherence range from simple singleitem questions regarding missed doses to complex multi-item assessments that incorporate reasons for nonadherence [7]. The widespread use of self-report adherence measures in clinical care and research reflects their low cost and ease of implementation across a large variety of medication regimens.There are two primary challenges related to selfreport measures of medication adherence. ImplicationsPractice: Routine assessment of medication...

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supporting

confidence: 59%

Section: Validity Of Medication Adherence Self-reportsmentioning

confidence: 99%

mentioning

confidence: 98%

mentioning

confidence: 99%

mentioning

confidence: 99%

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Self-report measures of medication adherence behavior: recommendations on optimal use

Stirratt

Dunbar‐Jacob

Crane

et al. 2015

Behav. Med. Pract. Policy Res.

605

528

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The accuracy of self‐reported drug ingestion histories in emergency department patients

Monte

Heard

Hoppe

et al. 2014

The Journal of Clinical Pharma

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Inaccuracies in self-reports may lead to duplication of therapy, failure to appreciate non-compliance leading to exacerbation of chronic medical conditions, or inaccurate research conclusions. Our objective is to determine the accuracy of self-reported drug ingestion histories in patients presenting to an urban academic emergency department (ED). We conducted a prospective cohort study in ED patients presenting for pain or nausea. We obtained a structured drug ingestion history including all prescription drugs, OTC drugs, and illicit drugs for the 48 hours prior to ED presentation. We obtained urine comprehensive drug screens (CDS) and determined self-report/CDS concordance. Fifty-five patients were enrolled. Self-reported drug ingestion histories were poor in these patients; only 17 (30.9%) of histories were concordant with the CDS. For the individual drug classes, prescription drug-CDS was concordant in 32 (58.2%), OTC-CDS was concordant in 33 (60%), and illicit drug-CDS was concordant in 45 (81.8%) of subjects. No demographic factors predicted an accurate self-reported drug history. Sixteen patients had drugs detected by CDS that were unreported by history. Nine of these 16 included an unreported opioid. In conclusion, self-reported drug ingestion histories are often inaccurate and resources are needed to confirm compliance and ensure unreported drugs are not overlooked.

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Universal test and treat is not associated with sub‐optimal antiretroviral therapy adherence in rural South Africa: the ANRS 12249 TasP trial

Iwuji

McGrath

Calmy³

et al. 2018

J Intern AIDS Soc

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Introduction HIV treatment guidelines now recommend antiretroviral therapy (ART) initiation regardless of CD4 count to maximize benefit both for the individual and society. It is unknown whether the initiation of ART at higher CD4 counts would affect adherence levels. We investigated whether initiating ART at higher CD4 counts was associated with sub‐optimal adherence (<95%) during the first 12 months of ART.MethodsA prospective cohort study nested within a two‐arm cluster‐randomized trial of universal test and treat was implemented from March 2012 to June 2016 to measure the impact of ART on HIV incidence in rural KwaZulu‐Natal. ART was initiated regardless of CD4 count in the intervention arm and according to national guidelines in the control arm. ART adherence was measured monthly using a visual analogue scale (VAS) and pill counts (PC). HIV viral load was measured at ART initiation, three and six months, and six‐monthly thereafter. We pooled data from participants in both arms and used random‐effects logistic regression models to examine the association between CD4 count at ART initiation and sub‐optimal adherence, and assessed if adherence levels were associated with virological suppression.ResultsAmong 900 individuals who initiated ART ≥12 months before study end, median (IQR) CD4 at ART initiation was 350 cells/mm3 (234, 503); median age was 34.6 years (IQR 27.4 to 46.4) and 71.7% were female. Adherence was sub‐optimal in 14.7% of visits as measured by VAS and 20.7% by PC. In both the crude analyses and after adjusting for potential confounders, adherence was not significantly associated with CD4 count at ART initiation (adjusted OR for linear trend in sub‐optimal adherence with every 100 cells/mm3 increase in CD4 count: 1.00, 95% CI 0.95 to 1.05, for VAS, and 1.03, 95% CI 0.99 to 1.07, for PC). Virological suppression at 12 months was 97%. Optimal adherence by both measures was significantly associated with virological suppression (p < 0.001 for VAS; p = 0.006 for PC).ConclusionsWe found no evidence that higher CD4 counts at ART initiation were associated with sub‐optimal ART adherence in the first 12 months. Our findings should alleviate concerns about adherence in individuals initiating ART at higher CD4 counts, however long‐term outcomes are needed. ClinicalTrials.gov NCT01509508.

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Practical and Conceptual Challenges in Measuring Antiretroviral Adherence

Cited by 262 publications

References 89 publications

Self-report measures of medication adherence behavior: recommendations on optimal use

Self-report measures of medication adherence behavior: recommendations on optimal use

The accuracy of self‐reported drug ingestion histories in emergency department patients

Universal test and treat is not associated with sub‐optimal antiretroviral therapy adherence in rural South Africa: the ANRS 12249 TasP trial

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