Might ART adherence estimates be improved by combining biomarker and self-report data?

Background As we endeavour to examine rates of viral suppression in PLHIV, reliable data on ART adherence are needed to distinguish between the respective contributions of poor adherence and treatment failure on high viral load. Self-reported data are susceptible to response bias and although biomarker data on drug presence and concentration can provide a superior, alternative method of measurement, complications due to drug-drug interactions and genetic variations can cause some inaccuracies. We investigate the feasibility of combining both biomarker and self-report data to produce a potentially more accurate measure of ART adherence. Methods Data were taken from a large general-population survey in the Manicaland province, Zimbabwe, conducted in 2009–2011. HIV-infected adults who had initiated ART (N = 560) provided self-report data on adherence and dried blood spot samples that were analysed for traces of ART medication. A new three-category measure of ART adherence was constructed, based on biomarker data but using self-report data to adjust for cases with abnormally low and high drug concentrations due to possible drug-drug interactions and genetic factors, and was assessed for plausibility using survey data on socio-demographic correlates. Results 94.3% (528/560) and 92.7% (519/560) of the sample reported faithful adherence to their medication and had traces of ART medication, respectively. The combined measure estimated good evidence of ART adherence at 69% and excellent evidence of adherence at 53%. The regression analysis results showed plausible patterns of ART adherence by socio-demographic status with men and younger participants being more likely to adhere poorly to medication, and higher socio-economic status individuals and those living in more urban locations being more likely to adhere well. Conclusion Biomarker and self-reported measures of adherence can be combined in a meaningful way to produce a potentially more accurate measure of ART adherence. Results indicate that ART adherence in Manicaland is at best 69%, which not only allows for considerable room for improvement but also suggests that the area may be falling short of the UNAIDS’ 90% target regarding viral suppression. Increased efforts are needed to improve ART adherence particularly amongst the young male population in rural areas of east Zimbabwe

New measure of adherence combining drug presence and NVP concentration while accounting for interaction with TB medication.

<p>New measure of adherence combining drug presence and NVP concentration while accounting for interaction with TB medication.</p

Distribution of concentrations of NVP in participants’ blood samples.

<p>Distribution of concentrations of NVP in participants’ blood samples.</p

Patterns of association between socio-demographic characteristics and a combined measure of ART adherence (bivariate analysis).

<p>Patterns of association between socio-demographic characteristics and a combined measure of ART adherence (bivariate analysis).</p

Patterns of association between socio-demographic characteristics and a combined measure of ART adherence (multinomial multivariate logistic regression).

<p>Patterns of association between socio-demographic characteristics and a combined measure of ART adherence (multinomial multivariate logistic regression).</p

Self-reported ART and ARV presence in DBS.

<p>Self-reported ART and ARV presence in DBS.</p

Mean (and 95%CI) socio-economic status scores by ART adherence group.

<p>Mean (and 95%CI) socio-economic status scores by ART adherence group.</p