Self-Report Measures of Antiretroviral Therapy Adherence: A Review with Recommendations for HIV Research and Clinical Management

Abstract

A review of 77 studies employing self-report measures of antiretroviral adherence published 1/1996 through 8/2004 revealed great variety in adherence assessment item content, format, and response options. Recall periods ranged from 2 to 365 days (mode = 7 days). The most common cutoff for optimal adherence was 100% (21/48 studies, or 44%). In 27 of 34 recall periods (79%), self-reported adherence was associated with adherence as assessed with other indirect measures. Data from 57 of 67 recall periods (84%) indicated self-reported adherence was significantly associated with HIV-1 RNA viral load; in 16 of 26 (62%), it was associated with CD4 count. Clearly, the field would benefit from item standardization and a priori definitions and operationalizations of adherence. We conclude that even brief self-report measures of antiretroviral adherence can be robust, and recommend items and strategies for HIV research and clinical management.

Self-report measures of medication adherence behavior: recommendations on optimal use

“…Among comparisons that were not highly concordant, self-reports produced higher estimates of adherence than other assessment methods 92 % of the time (45 out of 49 comparisons). A meta-analysis showed the estimated degree of regimen execution is approximately 15 % higher by self-report when compared with EDM devices [56], which is consonant with estimates in other reviews and syntheses [5,35,56,58].Sensitivity and specificity-Because of potential overreporting, self-report adherence measures are considered to have good specificity (i.e., positive predictive value) and weak sensitivity (i.e., negative predictive value) for detecting poor adherence [5,32,46]. Stated simply, self-reports of nonadherence can be trusted; self-reports of adherence less so.…”

“…Two syntheses of research conducted with adult HIV/AIDS patients offer strong evidence that self-report medication adherence measures can significantly and meaningfully predict clinical outcomes [5,47]. Across pooled studies containing over 15,000 HIV patients, Nieuwkerk and Oort [47] determined that those who self-report nonadherence (at any cutoff level) were 2.31 times more likely to have clinically detectable HIV viral load than those who selfreport high adherence.…”

“…In the context of clinical research, proper interpretation of proof-of-concept trials testing new pharmacologic regimens requires valid adherence data, because any null findings may stem from poor adherence rather than a lack of drug efficacy. Research designed to understand and promote medication adherence also requires precise methods of adherence assessment.Among many approaches to assessing medication adherence, patient self-report measures remain the most common method [1][2][3][4][5][6]. These measures are defined by asking respondents to characterize their medication adherence behavior.…”

“…Similar findings have emerged in hypertension studies, although Gonzales and colleagues [53] found the best performance when asking for an estimate of the percentage of doses taken, rather than rating adherence on a Likert-type scale. This evidence suggests that self-report measures that ask for global estimates of adherence may be preferable.Self-report adherence measures which specify a time frame for recall of adherence behavior are helpful when conducting longitudinal assessments that examine adherence trends over time [1,5,12]. Determining the optimal recall period requires balancing shorter intervals (to improve recall/estimation) with longer intervals (to increase the representativeness of the sampled time period and capture cases of infrequent nonadherence).…”

“…Studies comparing self-report measures with different recall time frames have determined that 30-day recall intervals reduce ceiling effects relative to shorter intervals [44,68,69,71] Although these findings suggest that estimated adherence over 30-day periods may be optimal, this approach could present concerns when working with populations characterized by significant cognitive impairment or memory problems, such as persons with severe mental illness or dementia. Basic approaches to assist recall include use of medication lists and pill diagrams, as well as anchoring recall to salient events through a timeline follow-back method [5,9]. Assessment of self-reported medication adherence among cognitively compromised populations may additionally benefit from more specialized techniques such as the conduct of daily or periodic ecologic assessments via text message or interactive voice response surveys regarding medication adherence over the last 24 h [72].…”