Frequent antiretroviral therapy adherence monitoring could detect incomplete adherence before viral rebound develops and thus potentially prevent treatment failure. Mobile phone technologies make frequent, brief adherence interviews possible in resource-limited settings; however, feasibility and acceptability are unknown. Interactive voice response (IVR) and short message service (SMS) text messaging were used to collect adherence data from 19 caregivers of HIV-infected children in Uganda. IVR calls or SMS quantifying missed doses were sent in the local language once weekly for three to four weeks. Qualitative interviews were conducted to assess participant impressions of the technologies. Participant interest and participation rates were high; however, weekly completion rates for adherence queries were low (0-33%), most commonly due to misunderstanding of personal identification numbers. Despite near ubiquity of mobile phone technology in resource-limited settings, individual level collection of healthcare data presents challenges. Further research is needed for effective training and incentive methods.

BackgroundAdherence to HIV antiretroviral therapy (ART) among children in developing settings is poorly understood.Methodology/Principal FindingsTo understand the level, distribution, and correlates of ART adherence behavior, we prospectively determined monthly ART adherence through multiple measures and six-monthly HIV RNA levels among 121 Ugandan children aged 2–10 years for one year. Median adherence levels were 100% by three-day recall, 97.4% by 30-day visual analog scale, 97.3% by unannounced pill count/liquid formulation weights, and 96.3% by medication event monitors (MEMS). Interruptions in MEMS adherence of ≥48 hours were seen in 57.0% of children; 36.3% had detectable HIV RNA at one year. Only MEMS correlated significantly with HIV RNA levels (r = −0.25, p = 0.04). Multivariable regression found the following to be associated with <90% MEMS adherence: hospitalization of child (adjusted odds ratio [AOR] 3.0, 95% confidence interval [CI] 1.6–5.5; p = 0.001), liquid formulation use (AOR 1.4, 95%CI 1.0–2.0; p = 0.04), and caregiver’s alcohol use (AOR 3.1, 95%CI 1.8–5.2; p<0.0001). Child’s use of co-trimoxazole (AOR 0.5, 95%CI 0.4–0.9; p = 0.009), caregiver’s use of ART (AOR 0.6, 95%CI 0.4–0.9; p = 0.03), possible caregiver depression (AOR 0.6, 95%CI 0.4–0.8; p = 0.001), and caregiver feeling ashamed of child’s HIV status (AOR 0.5, 95%CI 0.3–0.6; p<0.0001) were protective against <90% MEMS adherence. Change in drug manufacturer (AOR 4.1, 95%CI 1.5–11.5; p = 0.009) and caregiver’s alcohol use (AOR 5.5, 95%CI 2.8–10.7; p<0.0001) were associated with ≥48-hour interruptions by MEMS, while second-line ART (AOR 0.3, 95%CI 0.1–0.99; p = 0.049) and increasing assets (AOR 0.7, 95%CI 0.6–0.9; p = 0.0007) were protective against these interruptions.Conclusions/SignificanceAdherence success depends on a well-established medication taking routine, including caregiver support and adequate education on medication changes. Caregiver-reported depression and shame may reflect fear of poor outcomes, functioning as motivation for the child to adhere. Further research is needed to better understand and build on these key influential factors for adherence intervention development.

To maximize scarce intervention dollars, pediatricians and other adolescent health professionals must position health promotion efforts in mediums that most effectively reach youth. This may be especially true in resource-limited settings where access to primary health care and medications is limited. To improve the efficiency and impact of disease prevention and health promotion efforts in resource-limited settings, we examine sources of health information cited by adolescents in Mbarara Uganda. Participants in the Uganda Media and You survey were students aged 12-18 (n = 500) randomly identified in five secondary schools in Mbarara municipality, Uganda. Ninety-three percent of eligible and invited youth completed the cross-sectional, pencil-and-paper survey. Four in five adolescents (81%) indicated they turned to parents, teachers, and other adults while around half read a book/went to the library (56%) or turned to siblings and friends (50%) for information about health and disease. More than one in three (38%) indicated that they used the computer and Internet to search for health information. Older versus younger respondents tended to rely upon siblings and friends for all types of health questions. On the other hand, younger versus older youth were significantly more likely to turn to parents, teachers, and other adults for their questions about sexual health. Adults may be an important component of effective disease prevention and health promotion campaigns. Multiple delivery methods may be especially effective for reaching older adolescents. Technology also may be an important health promotion tool in resource-limited settings.

A real-time wireless electronic adherence monitor(EAM) and weekly self-report of missed doses via interactive voice response (IVR) and short message service (SMS) queries were used to measure ART adherence in 49 adults and 46 children in rural Uganda. Median adherence was 89.5% among adults and 92.8% among children by EAM, and 99–100% for both adults and children by IVR/SMS self-report. Loss of viral suppression was significantly associated with adherence by EAM (OR 0.58 for each 10% increase), but not IVR/SMS. Wireless EAM creates an exciting opportunity to monitor and potentially intervene with adherence challenges as they are happening.

SUMMARY BACKGROUND Vitamin D increases cathelicidin production, and might alter mortality due to tuberculosis (TB) in human immunodeficiency virus (HIV) co-infection. However, due to abundant sun exposure, vitamin D levels might be excellent among Ugandans with HIV and TB. METHODS We measured 25(OH)D and calcium levels in 50 HIV-negative, 50 HIV-infected and 50 TB-HIV co-infected Ugandan adults. RESULTS Mean ± standard deviation 25(OH)D levels were 26 ± 7 ng/ml in HIV-negative, 28 ± 11 ng/ml in HIV-infected and 24 ± 11 ng/ml in TB-HIV co-infected adults (P > 0.05 all comparisons). Vitamin D deficiency (<12 ng/ml) was present in 10% of the HIV-infected subjects, 12% of the TB-HIV co-infected and none of the healthy controls (P = 0.03 for healthy vs. TB, P > 0.05 for other comparisons); 20% of the healthy controls, 22% of the HIV-positive and 38% of the TB-HIV co-infected subjects (P = 0.047 for healthy vs. TB, P > 0.05 for other comparisons) had suboptimal vitamin D levels (<20 ng/ml). No participant had hypercalcemia. Serum 25(OH)D levels correlated positively with body mass index (r = 0.22, P = 0.03) and serum calcium levels (r = 0.18, P = 0.03). CONCLUSIONS Ugandan HIV-infected adults with and without TB commonly had suboptimal vitamin D levels. Clinical trials are needed to evaluate the effect of vitamin D on health outcomes in HIV-infected patients with low vitamin D levels.