Factors Influencing Adherence to Antiretroviral Treatment in Nepal: A Mixed-Methods Study

Background Antiretroviral therapy (ART) is a lifesaver for individual patients treated for Human Immunodeficiency Virus (HIV) and Acquired Immune Deficiency Syndrome (AIDS). Maintaining optimal adherence to antiretroviral drugs is essential for HIV infection management. This study aimed to understand the factors influencing adherence amongst ART-prescribed patients and care providers in Nepal. Methods A cross-sectional mixed-methods study surveying 330 ART-prescribed patients and 34 in-depth interviews with three different types of stakeholders: patients, care providers, and key people at policy level. Adherence was assessed through survey self-reporting and during the interviews. A multivariate logistic regression model was used to identify factors associated with adherence, supplemented with a thematic analysis of the interview transcripts. Results A total of 282 (85.5%) respondents reported complete adherence, i.e. no missed doses in the four-weeks prior to interview. Major factors influencing adherence were: non-disclosure of HIV status (OR = 17.99, p = 0.014); alcohol use (OR = 12.89, p = 1 hour (OR = 2.84, p = 0.035). Similarly, lack of knowledge and negative perception towards ART medications also significantly affected non-adherence. Transport costs (for repeat prescription), followed by pills running out, not wanting others to notice, side-effects, and being busy were the most common reasons for non-adherence. The interviews also revealed religious or ritual obstacles, stigma and discrimination, ART-associated costs, transport problems, lack of support, and side-effects as contributing to non-adherence. Conclusion Improving adherence requires a supportive environment; accessible treatment; clear instructions about regimens; and regimens tailored to individual patients’ lifestyles. Healthcare workers should address some of the practical and cultural issues around ART medicine whilst policy-makers should develop appropriate social policy to promote adherence among ART-prescribed patients

Using Adherence-Contingent Rebates on Chronic Disease Treatment Costs to Promote Medication Adherence: Results from a Randomized Controlled Trial

Background: Poor adherence to medications is a global public health concern with substantial health and cost implications, especially for chronic conditions. In the USA, poor adherence is estimated to cause 125,000 deaths and cost $US100 Billion annually. The most successful adherence-promoting strategies that have been identified so far have moderate effect, are relatively costly, and raise availability, feasibility, and/or scalability issues. Objective: The main objective of SIGMA (Study on Incentives for Glaucoma Medication Adherence) was to measure the effectiveness on medication adherence of a novel incentive strategy based on behavioral economics that we refer to as adherence-contingent rebates. These rebates offered patients a near-term benefit while leveraging loss aversion and regret nd increasing the salience of adherence. Methods: IGMA is a 6-month randomized, controlled, open-label, single-center superiority trial with two parallel arms. total of 100 non-adherent glaucoma patients from the Singapore National Eye Centre were randomized into intervention (adherence-contingent rebates) and usual care (no rebates) arms in a 1:1 ratio. The primary outcome was the mean change from baseline in percentage of adherent days at Month 6. The trial registration number is NCT02271269 and a detailed study protocol has been published elsewhere. Findings: We found that participants who were offered adherence-contingent rebates were adherent to all their edications on 73.1$US5.94 as of 2 November 2017) per month during the intervention period. Conclusion: This study shows that simultaneously leveraging several insights from behavioral economics can significantly improve medication adherence rates. The relatively low cost of the rebates and significant health and cost implications of medication non-adherence suggest that this strategy has the potential to cost-effectively improve health outcomes for many conditions

Evaluation of medication adherence methods in the treatment of malaria in Rwandan infants

Objectives: To compare three methods for evaluating treatment adherence in a 7-day controlled treatment period for malaria in children in Rwanda. Methods: Fifty-six children (< 5 years) with malaria were recruited at the University Hospital of Butare, Rwanda. Patients were treated with quinine sulfate, taste-masked, pellets during seven days: three days in hospital (in-patient) followed by a four-day out-patient period. Three methods to evaluate medication adherence among patients were compared: manual pill count of returned tablets, patient self-report and electronic pill-box monitoring. These pill-boxes were equipped with a microchip registering date and time of every opening. Medication adherence was defined as the proportion of prescribed doses taken. The inter-dose intervals were analysed as well. Results: Medication adherence data were available for 54 of the 56 patients. Manual pill count and patient self-report yielded a medication adherence of 100% for the in-and out-patient treatment periods. Based on electronic pill-box monitoring, medication adherence during the seven-day treatment period was 90.5 +/- 8.3%. Based on electronic pillbox monitoring inpatient medication adherence (99.3 +/- 2.7%) was markedly higher (p < 0.03) than out-patient adherence (82.7 +/- 14.7%), showing a clear difference between health workers' and consumers' medication adherence. Conclusion: Health workers' medication adherence was good. However, a significant lower medication adherence was observed for consumers' adherence in the outpatient setting. This was only detected by electronic pill-box monitoring. Therefore, this latter method is more accurate than the two other methods used in this study

Managing the symptoms of neuropathic pain: An exploration of patients' experiences

The debilitating effects of chronic neuropathic pain on everyday life are considerable but little is known about how individual sufferers manage these effects. Virtually nothing is known about what patients prefer, what measures they take themselves, when, or in what combinations. The aim of this study was to explore patients’ reports of how they managed their neuropathic pain symptoms. Three focus groups including 10 participants were used to generate qualitative data on both individual and shared experiences of managing their symptoms of neuropathic pain. Discussions were recorded and transcribed verbatim. Data were analysed using thematic analysis, identifying categories and broader themes of importance to patients. The most common management strategy was the use of conventional medications, often associated with poor effectiveness and unpleasant side-effects. Complementary and alternative medicine was ineffective but many found resting or retreating helpful. They exhibited a repeated cycle of seeking help to manage the pain, with each unsuccessful attempt followed by new attempts. Some had tried to accept their pain, but there was insufficient psychological, social, emotional and practical support to allow them to do this successfully. This exploratory study provides a basis from which to develop a larger study to validate and extend the findings. Other issues meriting research are the effectiveness of cognitive behavioural therapies for those with neuropathic pain; and an exploration and subsequent evaluation of different types of social, practical and emotional support needed to help live with neuropathic pain

Stimulant drug effects on attention deficit/hyperactivity disorder: a review of the effects of age and sex of patients

Objective: As dopamine functioning varies by sex and age it might be expected that the effects of methylphenidate or amfetamine, the psychostimulants used for the treatment of Attention Deficit /Hyperactivity Disorder (ADHD), will also be moderated by these factors. Here we review the published literature on whether stimulant effects in ADHD symptoms vary by age and sex. Method: We searched for studies published from 1989 until October 2009. Databases searched included U. S. National Library of Medicine (PubMed), Medline, EMBASE, PsycINFO and ISI Web of Knowledge. Firstly, we reviewed the effects of stimulant drugs on male and female patients and also patients of pre-school, middle childhood, adolescence and adulthood. Secondly, we reviewed studies that directly tested the moderating effect of age and sex on stimulant treatment outcome. Results: Randomised controlled trials confirm that stimulant medication is efficacious for, and well tolerated by, males and females and patients across the age range; although preschoolers appear to have a less beneficial response and more side effects. Few studies that specifically examined the moderating effect of age and/or sex were identified. For sex, no effects on overall response were found, although one study reported that sex moderated methylphenidate pharmacodynamics. The few effects found for age were small and inconsistent. Conclusions: The available evidence suggests that stimulant medication, when appropriately administered, has efficacy as an ADHD treatment for both sexes and across all ages. There are currently too few published papers examining the effects of sex and age to draw strong conclusions about moderation. Further studies of the pharmacodynamics of stimulants on symptoms measured using objective tests in the laboratory or classroom setting need to be undertaken

IT-based Patient Interventions for Opioid Abuse: Evaluation using Analytical Model

The number of people in the US with opioid abuse exceeds 2 million and the total cost is approximately $100B per year. In this study, we focus on patient-level interventions and present three IT-based interventions: (a) mobile reminders, (b) electronic monitoring, and (c) composite intervention. We have developed an analytical model for evaluating interventions using Return-on-Investment (ROI). The interventions are cost-effective for higher values of intervention effectiveness, hospital, and emergency room cost. However, with QoL improvement, cost-effectiveness improves significantly. We also explored the use of financial incentives for increasing the adoption of interventions. These results will help patients, healthcare professionals, decision-makers, and family members to choose the most suitable intervention to address opioid abuse

The Effect of Olanzapine on Craving and Alcohol Consumption

Previous studies have indicated that olanzapine decreases craving after a priming dose of alcohol, that craving after a priming dose of alcohol is greater among individuals with the seven-repeat allele of the DRD4 variable number of tandem repeats (VNTR) polymorphism, and that the effect of olanzapine (a D2/D4 antagonist) is more pronounced among individuals with this allele. The present study tested the hypothesis that olanzapine may be differentially effective at reducing cue-elicited craving and differentially effective as a treatment for alcohol dependence over the course of a 12-week, randomized, placebo-controlled trial among individuals with and without the seven-repeat allele. Participants who met DSM IV criteria for alcohol dependence were randomly assigned to receive olanzapine (5 mg) or a placebo over the course of the trial. After 2 weeks of treatment, participants completed a cue reactivity assessment. The results suggested that participants who were homozygous or heterozygous for the seven (or longer)-repeat allele of the DRD4 VNTR responded to olanzapine with reductions in cue-elicited craving as well as reductions in alcohol consumption over the course of the 12-week trial, whereas individuals with the shorter alleles did not respond favorably to olanzapine

Applying hierarchical task analysis to medication administration errors

Medication use in hospitals is a complex process and is dependent on the successful interaction of health professionals functioning within different disciplines. Errors can occur at any one of the five main stages of prescribing, documenting, dispensing or preparation, administering and monitoring. The responsibility for the error is often placed on the nurse, as she or he is the last person in the drug administration chain whilst more pressing underlying causal factors remain unresolved. This paper demonstrates how hierarchical task analysis can be used to model drug administration and then uses the systematic human error reduction and prediction approach to predict which errors are likely to occur. The paper also puts forward design solutions to mitigate these errors