Hospital-Based Directly Observed Therapy for HIV-Infected Children and Adolescents to Assess Adherence to Antiretroviral Medications

Abstract

BACKGROUND. The introduction of highly active antiretroviral therapy for HIV led to significant declines in HIV-associated morbidity and mortality in children. Nonadherence to antiretroviral therapy is the leading cause of treatment failure in HIV-infected patients. The ability to recognize nonadherence is suboptimal, and differentiating it from other causes of inadequate viral suppression may be difficult. OBJECTIVES. The purpose of this work was to examine the efficacy of hospital-based directly observed therapy in assessing adherence to antiretroviral medications in HIV-infected children and adolescents suspected of nonadherence and failing other interventions. METHODS. The medical charts of all HIV-infected patients admitted to the University of Chicago Comer Children's Hospital for directly observed therapy from July 2004 to June 2006 were reviewed. Patients were hospitalized for 7 days. Data collected included demographics, clinical and immune class category, previous and current antiretroviral medications, viral resistance tests, HIV-1 RNA viral load, and CD4+ T-cell number and percentage before and after directly observed therapy. RESULTS. There were 9 perinatally infected patients with a total of 13 admissions. The median age was 13 years, and 8 had been treated with multiple antiretroviral regimens. Three common patterns of changes in the viral load over time were observed. In the first, the viral load dropped at the end of the directly observed therapy period and stayed low thereafter. In the second, the drop in the viral load seen at the end of the period was not sustained. In the third, there was no change in the viral load during or after the directly observed therapy period. Compared with the viral load at admission, the viral load at the end of directly observed therapy was lower in 8 patients with a mean ± SD decrease of 0.8 ± 0.55 log10 copies per mL. CONCLUSIONS. Short, hospital-based directly observed therapy was helpful in confirming nonadherence to antiretroviral medications, therefore impacting future therapeutic decisions in HIV-infected children and adolescents. Short, hospital-based directly observed therapy should be considered in patients with poor virological control for whom outpatient interventions have failed.

Virologic Response Using Directly Observed Therapy in Adolescents With HIV: An Adherence Tool

“…Our data, Glikman et al (2007), and Parsons et al (2006) demonstrated that measuring viral loads with DOT can provide valuable information about a patient's response to ARV treatment. These results also demonstrate that heavily treatment-experienced patients can experience a virologic response with DOT and without a change in regimen.…”

“…Recent reports have demonstrated that using medical institution-based DOT can improve adherence and virologic and immunologic responses (Glikman, Walsh, Valkenburg, Mangat, & Marcinak, 2007;Parsons et al, 2006). In these studies, children and adolescents (mean age of 13 years [range, 7-17 years] and 12.6 years [range, 0.8-16 years], respectively) with perinatally-acquired HIV were admitted to the hospital for non-adherence concerns and received DOT for all ARV doses.…”

“…Christie and Viner (2005) note that physical and psychological changes interact with external and internal system demands (tasks) during adolescence. When these systems also include the healthcare organization, new challenges arise, especially with risk taking and adherence to medication or treatments.Recent reports have demonstrated that using medical institution-based DOT can improve adherence and virologic and immunologic responses (Glikman, Walsh, Valkenburg, Mangat, & Marcinak, 2007;Parsons et al, 2006). In these studies, children and adolescents (mean age of 13 years [range, 7-17 years] and 12.6 years [range, 0.8-16 years], respectively) with perinatally-acquired HIV were admitted to the hospital for non-adherence concerns and received DOT for all ARV doses.…”

Directly Observed Therapy (DOT) for Nonadherent HIV-Infected Youth: Lessons Learned, Challenges Ahead

“…9,10 Published DOT experience in youth is limited but promising and is primarily from inpatient and clinic-based settings. [13][14][15] DOT is resource intensive and before designing large-scale studies to assess DOT efficacy and associated behavior change among nonadherent youth, the feasibility and acceptability of this potentially intrusive intervention were assessed. Here, we describe the results of a pilot study to examine DOT feasibility in nonadherent youth with HIV.…”

Adolescents and HIV: Prevention and clinical care

“…Short-term hospitalizations in the era of cART have been successfully utilized to assess cART adherence and work on strategies to improve motivation and self-effi cacy of antiretroviral medication adherence. Hospital-based directly observed therapy can be considered for patients with severe immune-compromise and poor virologic control in whom all outpatient interventions have been unsuccessful [42].…”