Computerised counselling for patients taking HIV therapy can reduce viral load, improve treatment adherence and reduce rates of risky sex

Computerised counselling can achieve reductions in viral load and HIV transmission risk behaviour, investigators from the United States report in the online edition of the Journal of Acquired Immune Deficiency Syndromes. The counselling programme was associated with significant reductions in viral load, improvements in adherence to HIV therapy and reductions in risky sexual behaviour.

“The adherence effect was most pronounced among those whose plasma HIV-1 load was not suppressed at baseline,” comment the investigators. “This reduced viral load and fewer sexual transmission risk behaviors seen among those undergoing the intervention both may contribute to decreasing HIV transmission to sexual partners.”

Thanks to antiretroviral therapy, many people with HIV now have a normal life expectancy. The best outcomes are seen in individuals who adhere to their treatment. Good adherence also has a secondary benefit, as suppression of viral load is associated with a reduced risk of HIV transmission to sexual partners.

However, some people living with HIV have difficulty achieving and sustaining the levels of adherence associated with the best treatment outcomes, and a significant proportion of patients with HIV have sexual behaviour that involves a risk of HIV transmission.

Investigators in Seattle wanted to see if a computer-delivered intervention called Computer Assessment and Rx Education for HIV-positive people (CARE+) improved treatment adherence and reduced transmission risk behaviours.

They therefore designed a nine-month randomised-controlled trial involving 240 adult patients taking antiretroviral therapy.

The study had two arms.

Participants in the intervention arm had access to a computerised programme that provided counselling about treatment adherence, HIV disclosure, safer sex, condom use, substance abuse and the impact of adherence on viral load. Individuals in the control arm completed computerised questionnaires, answering questions about their treatment adherence, substance use and sexual risk behaviour.

The primary outcomes were changes from baseline in viral load, 30-day adherence to HIV therapy and the likelihood of reporting unprotected anal/vaginal sex or problems with condom use.

The participants had an average age of 45 years and approximately 90% were male. Participants reported taking a median of 76% of their treatment doses at baseline. Sex without condoms or condom problems were reported by approximately 30% of people on entry to the study, and viral load was detectable in a similar proportion of individuals.

The study was completed by 87% of the participants.

There were marginally significant differences in viral load changes from baseline to the end of the study between the study arms (p = 0.053). People in the intervention arm had an average decrease in viral load of 0.17 log₁₀ copies/ml, compared to an average increase of 0.13 log₁₀ copies/ml among people in the control arm. Compared to baseline, the chances of having an undetectable viral load at the end of the study increased significantly for people in the CARE+ arm (p = 0.037) but fell non-significantly for people in the assessment-only arm.

Among the study participants who had a detectable viral load at baseline, the people receiving computerised counselling had an average decrease in viral load of 0.60 log₁₀ copies/ml (p = 0.004), while the control group participants had an average non-significant increase in viral load of 0.15 log₁₀ copies/ml. At the end of the study, viral load was a significant 0.73 log₁₀ copies/ml lower among people in the intervention arm (p = 0.041).

The intervention also had a significant impact on adherence. This increased by approximately 5% (p = 0.014) among people receiving computerised counselling, but fell by a non-significant 1.4% among people in the control arm.

Focusing on participants with a detectable baseline viral load showed CARE+ intervention participants had an average increase in adherence of 8% (p = 0.04), whereas the control patients had a non-significant decrease of approximately 1.5%. At the end of the study, adherence was a significant 13% higher (p = 0.038) in people in the intervention arm compared to people in the control arm.

CARE+ was associated with changes in HIV transmission risk behaviour. The odds of behaviour involving a risk of transmission were reduced by 55% among people in the intervention arm (p = 0.02), but increased modestly for individuals in the control arm. At the end of follow-up, CARE+ intervention participants had reduced odds of transmission risks compared with the controls (OR = 0.46; 95% CI, 0.25-0.84, p = 0.12).

The intervention was highly acceptable, with 97% of participants reporting it was easy to use, and 93% felt CARE+ sessions helped them as much, if not more, than face-to-face counselling sessions.

“As far as we know this is the first ART adherence and secondary transmission risk intervention to find biological effect (viral load) and behavioral impact among persons living with HIV,” conclude the authors. “The computer format was highly acceptable and facilitated delivery in busy settings. Such an approach warrants further evaluation to determine utility in improving HIV treatment outcomes and reducing secondary HIV transmission among persons living with HIV.”

Kurth AE et al. Computerized counseling reduces HIV-1 viral load and sexual transmission risk: findings from a randomized controlled trial. J Acquir Immune Defic Syndr, online edition. DOI: 10.1097/QAI.0000000000000100, 2013.

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