Can Short-Term Use of Electronic Patient Adherence Monitoring Devices Improve Adherence in Patients Failing Second-Line Antiretroviral Therapy? Evidence from a Pilot Study in Johannesburg, South Africa

Abstract

High levels of adherence are required to achieve the full benefit of ART. We assess the effectiveness of electronic adherence monitoring devices among patients failing second-line ART, as measured by viral load suppression. Cohort study of Wisepill™ real-time adherence monitoring in addition to intensified adherence counselling over 3 months in adults with a viral load ≥400 copies/ml on second-line ART in Johannesburg, South Africa between August 2013 and January 2014. Patients were sent SMS reminders upon missing a scheduled dose. We compared outcomes to earlier historical cohorts receiving either intensified adherence counselling or adherence counselling alone. Overall, 63 % of the participants (31/49) took >80 % of their prescribed medication; this dropped from 76 to 53 and 49 % at 1, 2 and 3 months post-enrolment respectively. Compared to those with good adherence (>80 %), participants with poor adherence (≤80 %) had a higher risk for a subsequently elevated viral load ≥400 copies/ml (relative risk (RR) 1.47 95 % CI 0.97–2.23). Participants found the intervention “acceptable and useful” but by 6 months after eligibility they were only slightly more likely to be alive, in care and virally suppressed compared to those who received intensified adherence counselling (44.9 vs. 38.5 %; RR 1.19; 95 % CI 0.85–1.67) or adherence counselling alone (44.9 vs. 40.9 %; RR 1.12; 95 % CI 0.81–1.56). In patients with an elevated viral load on second-line ART electronic adherence monitoring was associated with a modest, but not significant, improvement in viral suppression.

A Systematic Review on Promoting Adherence to Antiretroviral Therapy in HIV-infected Patients Using Mobile Phone Technology

“…8, Of these 26 studies, 23 studies used SMS alone for reminders, and 3 used SMS plus counseling as noted in ►Table 1. Six reports were from the United States; [35][36][37][42][43][44] three each from Kenya 8,31,40 and South Africa; 28,39,48 two each from Uganda, 38,45 China, 34,47 and Cameroon; 30,41 and one each from Italy, 26 Brazil, 29 Nigeria, 32 New Zealand, 27 India, 33 Argentina, 46 Canada, 49 and Malaysia. 50 The types of studies included 19 RCTs, 8,27,[29][30][31][32][34][35][36]38,39,[41][42][43][44][45]47,50 three prospective cohort studies, 26,37,46 two ambidirectional studies (retrospective/prospective cohort study...…”

“…The primary outcomes addressed in the studies included one ART usage among study participants, 40 one adherence measured through prescription refills, 48 two viral load adherences, 37,46 six adherences over time, 31,33,34,38,39,43 and 16 self-reported adherences (►Table 2). 8,[26][27][28][29][30]32,35,36,41,42,44,45,47,49,50 Adherence interventions were measured as self-report, ART usage, adherence over time using a medication event monitoring system (MEMS) or an electronic adherence monitoring device, such as Wisepill, pharmacy refills, pill count, and clinical outcomes (viral load, HIV-ribonucleic acid [RNA] suppression, and cluster of differentiation 4 [CD4] count). Additionally, a summary of the outcome data, adherence assessment, metrics, relative effect (risk and odds ratios [OR]), and a measure of precision (95% confidence interval [CI]) for each study are shown in ►Table 2.…”

“…All the studies were deemed to be at low risk for attrition bias, with two exceptions. Two studies-one by Evans et al 28 and another by Lewis et al 37 -had a high risk of reporting bias because of missing data, but in the Evans et al study, the authors noted the missing data and addressed the issue by including a sensitivity analysis. A major factor in determining the risk of bias was the inadequate reasoning for missing data with low attrition rates.…”

“…[39][40][41][42]45,46 One study observed that in patients with an elevated viral load on a second-line ART, electronic adherence monitoring was associated with a modest, but not significant, improvement in viral suppression. 28 Those authors concluded that adherence strategies increase the durability of second-line ART, decrease the need for costly third-line regimens, and prevent unnecessary genotyping tests.…”

“…Several studies showed that wireless devices could provide real-time behavior data 28,34,38 that allow messages to be tailored to the patient and promote faster behavior correction. Four studies monitored the patients' ART adherence electronically in real time by providing them with a medication dispenser device.…”