Having financial worries are a “strong and independent predictor” of poor adherence to antiretroviral therapy, US investigators report in the online edition of the Journal of Acquired Immunodeficiency Syndromes. Patients who used drugs and alcohol were also found to have poorer adherence.
Although it remains to be seen if the investigators’ findings can be generalised to other settings, it is worth noting that poverty is a feature of the HIV pandemic around the world, the US and some other industrialised countries included. Paying for medication or access to medical care has been associated with poor adherence and loss-to-follow-up in several African studies of antiretroviral therapy.
Adherence is the single most important factor affecting the success of anti-HIV therapy that is under a patient’s control. Finding out the factors that can predict adherence to treatment has long been a research priority. But few studies have examined the role of quality of life in adherence, and none has assessed the relationship between adherence and HIV-related quality of life.
Investigators from Pennsylvania therefore designed a prospective study involving 116 adults taking antiretroviral therapy. The patients were taking an efavirenz - (Sustiva) based regimen and all had a viral load below 75 copies/ml on entry to the study.
At baseline, the patients were asked to complete a questionnaire designed to determine their HIV-related quality of life in the previous four weeks. The questionnaire enquired about overall functioning, sexual function, health worries, medication worries, disclosure worries, financial concerns, ‘HIV mastery’, life satisfaction, and trust in their HIV care provider.
Adherence was assessed prospectively using electronic medication bottles which record when the bottle is opened using an electronic counter in the lid. The study endpoint was virological breakthrough (a viral load above 1000 copies/ml) or one year of follow-up.
The median age of study participants was 44 years, 81% were men, 66% were African American, 44% had received a post-high school education, 43% were gay, 21% had a history of injecting drug use, only 32% were employed and 71% had an income below $20,000 per year – the official US poverty line.
Most patients, 60% were taking their first antiretroviral regimen and 85% had a prior AIDS diagnosis.
Patients who took 95% or more of their medication were assessed as having good adherence, and patients with adherence below this level were said to have poor adherence. Only 52% of the cohort was assessed as having “good” adherence.
Alcohol (p = 0.01) and drug use (p = 0.02) in the previous year were significantly associated with poor adherence.
But the only HIV-related quality of life measures associated with below 95% adherence to antiretroviral therapy were financial worries (p = 0.01). These measures included “having to live on a fixed income”, concerns about “how to pay the bills”, and having too little money “to take care of myself the way I think I should.”
In further analysis, the investigators found that the odds of future good adherence increased by 2.65 for patients who did not drink alcohol (odds ratio, 2.65; 95% confidence interval, 1.20 – 5.87). A lack of financial worries was also associated with increased odds of better adherence, with each ten-fold improvement in the financial worries scores improving the odds of future adherence by 1.15 (odds ratio, 1.15; 95% confidence interval,1.03 – 1.31).
“Financial worries should be assessed in behavioral interventions designed to improve adherence”, conclude the investigators.
Holmes WC et al. HIV/AIDS-specific quality of life and adherence to antiretroviral therapy over time. J Acquir Immune Defic Syndr (online edition), 2007.