A high level of adherence to antiretroviral therapy is required for complete suppression of HIV replication, immunological and clinical effectiveness. We investigated whether cognitive behaviour therapy can improve medication adherence.
Design
Prospective randomized 1-year trial.
Setting
Collaboration of HIV university outpatient clinic and psychotherapists in private practice.
Participants
60 HIV-infected persons on stable anti-retroviral combination therapy and viral load below 50 copies/ml.
Intervention
Cognitive behaviour intervention in individual patients, in addition to standard of care.
Main outcome measures
Feasibility and acceptance of intervention; adherence to therapy assessed using medication event monitoring system (MEMS) and self-report questionnaire; virological failure; psychosocial measures.
Results
The median number of sessions for cognitive behaviour intervention per patient during the 1-year trial was 11 (range 2–25). At months 10–12, mean adherence to therapy as assessed using MEMS was 92.8% in the intervention and 88.9% in the control group (P=0.2); the proportion of patients with adherence ≥95% was 70 and 50.0% (P=0.014), respectively. While there was no significant deterioration of adherence during the study in the intervention arm, adherence decreased by 8.7% per year (P=0.006) in the control arm. No differences between the intervention group and standard of care group were found regarding virological outcome. Compared with the control group, participants in the intervention group perceived a significant improvement of their mental health during the study period.
Conclusions
Cognitive behavioural support in addition to standard of care of HIV-infected persons is feasible in routine practice, and can improve medication adherence and mental health.
References
1.
AndrewsL., & FriedlandG.Progress in HIV therapeutics and the challenges of adherence to antiretroviral therapy.Infectious Disease Clinics of North America2000; 14: 901–928.
2.
ArnstenJ.H., DemasP.A., FarzadeganH., GrantR.W., GourevitchM.N., ChangC.J., BuonoD., EckholdtH., HowardA.A., & SchoenbaumE.E.Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring.Clinical Infectious Diseases2001; 33: 1417–1423.
BanduraA.Self-efficacy: toward a unifying theory of behavioral change.Psychological Review1977; 84: 191–215.
5.
BerginA.E., & GarfieldS.L.Handbook of Psychotherapy and Behavioral Change.1994; New York: Wiley.
6.
BurneyK.D., KrishnanK., RuffinM.T., ZhangD., & BrennerD.E.Adherence to single daily dose of aspirin in a chemoprevention trial. An evaluation of self-report and microelectronic monitoring.Archives of Family Medicine1996; 5: 297–300.
7.
ButlerJ.U., & HaighG.V.Changes in the relation between self-concepts and ideal concepts consequent upon client entered counseling. In Psychotherapy and Personality Change, 1954; Edited by CR Rogers & RF Dymond.
8.
ChaissonR.E., BarnesG.L., HackmanJ., WatkinsonL., KimbroughL., MethaS., CavalcanteS., & MooreR.D.A randomized, controlled trial of interventions to improve adherence to isoniazid therapy to prevent tuberculosis in injection drug users.American Journal of Medicine2001; 110: 610–615.
9.
ChunT. W., StuyverL., MizellS.B., EhlerL.A., MicanJ.A., BaselerM., LloydA.L., NowakM.A., & FauciA.S.Presence of an inducible HIV-1 latent reservoir during highly active antiretroviral therapy.Proceedings of the National Academy of Sciences, USA1997; 94: 13193–13197.
10.
CramerJ.A., MattsonR.H., PreveyM.L., ScheyerR.D., & OuelletteV.L.How often is medication taken as prescribed? A novel assessment technique.Journal of the American Medical Association1989; 261: 3273–3277.
DerogatisL.R., RickelsK., & RockA. F.The SCL-90 and the MMPI: a step in the validation of a new self-report scale.British Journal of Psychiatry1976; 128: 280–289.
13.
DobsonK.S., & ShawB. F.The use of treatment manuals in cognitive therapy: experience and issues.Journal of Consulting & Clinical Psychology1988; 56: 673–680.
14.
EggerM., HirschelB., FrancioliP., SudreP., WirzM., FleppM., RickenbachM., MalinverniR., VernazzaP., & BattegayM.Impact of new antiretroviral combination therapies in HIV infected patients in Switzerland: prospective multi-centre study. Swiss HIV Cohort Study.British Medical Journal1997; 315: 1194–1199.
15.
FeltonB.J., RevensonT.A., & HinrichsenG.A.Stress and coping in the explanation of psychological adjustment among chronically ill adults.Social Science & Medicine1984; 18: 889–898.
16.
FilippS.H., FerringD., FreudenbergE., & KlauerT.[Affective motivational correlates of strategies of coping with illness – initial results of a longitudinal study on cancer patients].Psychotherapie, Psychosomatik, Medizinische Psychologie1988; 38: 37–42.
17.
FinziD., HermankovaM., PiersonT., CarruthL.M., BuckC., ChaissonR.E., QuinnT.C., ChadwickK., MargolickJ., BrookmeyerR., GallantJ., MarkowitzM., HoD.D., RichmanD.D., & SilicianoR. F.Identification of a reservoir for HIV-1 in patients on highly active antiretroviral therapy.Science1997; 278: 1295–1300.
18.
FlandreP., PeytavinG., MeiffredyV., SaidiY., DescampsD., DelagnesM., Brun-VezinetF., & RaffiF.Adherence to anti-retroviral therapy and outcomes in HIV-infected patients enrolled in an induction/maintenance randomized trial.Antiviral Therapy2002; 7: 113–121.
19.
FogartyL., RoterD., LarsonS., BurkeJ., GillespieJ., & LevyR.Patient adherence to HIV medication regimens: a review of published and abstract reports.Patient Education & Counseling2002; 46: 93–108.
20.
FrankeG.H.SCL-90-R. Die Symptom-Checkliste von Derogatis – Deutsche Version – Manual.1995; Göttingen, Germany: Beltz.
21.
FrankeG.H., JägerH., & StäckerK-H. Die Symptom-Check-Liste – SCL-90-R – im Einsatz bei HIV-infizierten Patienten.Zeitschrift für Differentielle und Diagnostische Psychologie1995; 16: 195–208.
22.
GraweK., & BraunU.[Quality control in psychotherapy].Zeitschrift für klinische Psychologie1994; 23: 242–267.
23.
GreubG., Cozzi-LepriA., LedergerberB., StaszewskiS., PerrinL., MillerV., FrancioliP., FurrerH., BattegayM., VernazzaP., BernasconiE., GunthardH.F., HirschelB., PhillipsA.N., & TelentiA.Intermittent and sustained low-level HIV viral rebound in patients receiving potent antiretroviral therapy.AIDS2002; 16: 1967–1969.
24.
HaddadM., InchC., GlazierR.H., WilkinsA.L., UrbshottG., BayoumiA., & RourkeS.Patient support and education for promoting adherence to highly active antiretroviral therapy for HIV/AIDS.Cochrane Database of Systematic Reviews2000; CD001442.
25.
HavlirD.V., BassettR., LevitanD., GilbertP., TebasP., CollierA.C., HirschM.S., IgnacioC., CondraJ., GunthardH.F., RichmanD.D., & WongJ.K.Prevalence and predictive value of intermittent viremia with combination HIV therapy.Journal of the American Medical Association2001; 286: 171–179.
26.
HaynesR.B., McDonaldH., GargA.X., & MontagueP.Interventions for helping patients to follow prescriptions for medications.Cochrane Database of Systematic Reviews2002; CD000011.
27.
HaynesR.B., McKibbonK.A., & KananiR.Systematic review of randomised trials of interventions to assist patients to follow prescriptions for medications.Lancet1996; 348: 383–386.
28.
HollonS.D., & BeckA.T.Cognitive and cognitive-behavioral therapies. In Handbook of Psychotherapy and Behavior Change, 1994; pp 428–466. Edited by AE Bergin & SL Garfield.
29.
HowardA.A., ArnstenJ.H., LoY., VlahovD., RichJ.D., SchumanP., StoneV.E., SmithD.K., & SchoenbaumE.E.A prospective study of adherence and viral load in a large multi-center cohort of HIV-infected women.AIDS2002; 16: 2175–2182.
30.
KastrissiosH., SuarezJ.R., HammerS., KatzensteinD., & BlaschkeT. F.The extent of non-adherence in a large AIDS clinical trial using plasma dideoxynucleoside concentrations as a marker.AIDS1998; 12: 2305–2311.
31.
KastrissiosH., SuarezJ.R., KatzensteinD., GirardP., SheinerL.B., & BlaschkeT.F.Characterizing patterns of drug-taking behavior with a multiple drug regimen in an AIDS clinical trial.AIDS1998; 12: 2295–2303.
32.
KiresukT.J., LundS.H., & LarsenN.E.Measurement of goal attainment in clinical and health care programs.Drug Intelligence & Clinical Pharmacy1982; 16: 145–153.
33.
KirklandL.R., FischlM.A., TashimaK.T., PaarD., GenslerT., GrahamN.M., GaoH., RosenzweigJ.R., McClernonD.R., PittmanG., HessenthalerS.M., & HernandezJ.E.Response to lamivudine-zidovudine plus abacavir twice daily in anti-retroviral-naive, incarcerated patients with HIV infection taking directly observed treatment.Clinical Infectious Diseases2002; 34: 511–518.
34.
KlauerT., & FilippS.Trier Skalen zur Krankheitsbewältigung.1993; Göttingen, Germany.
35.
KnobelH., CarmonaA., GrauS., AballsP., ImenoJ.L., & Opez ColomesJ.L.Strategies to optimise adherence to highly active antiretroviral therapy.12th World AIDS Conference. Geneva, Switzerland, 1998. Abstract No 32322.
36.
LedergerberB., EggerM., OpravilM., TelentiA., HirschelB., BattegayM., VernazzaP., SudreP., FleppM., FurrerH., FrancioliP., & WeberR.Clinical progression and virological failure on highly active antiretroviral therapy in HIV-1 patients: a prospective cohort study. Swiss HIV Cohort Study.Lancet1999; 353: 863–868.
37.
LittleS.J., HolteS., RoutyJ. P., DaarE.S., MarkowitzM., CollierA.C., KoupR.A., MellorsJ.W., ConnickE., ConwayB., KilbyM., WangL., WhitcombJ.M., HellmannN.S., & RichmanD.D.Antiretroviral-drug resistance among patients recently infected with HIV.New England Journal of Medicine2002; 347: 385–394.
38.
LiuH., GolinC.E., MillerL.G., HaysR.D., BeckC.K., SanandajiS., ChristianJ., MaldonadoT., DuranD., KaplanA.H., & WengerN.S.A comparison study of multiple measures of adherence to HIV protease inhibitors.Annals of Internal Medicine2001; 134: 968–977.
39.
LohausA., & SchmidtG.M.Fragebogen zur Erhebung von Kontrollüberzeugungen zu Krankheit und Gesundheit (KKG).1989; Göttingen, Germany: Hofgrefe.
40.
MannheimerS., FriedlandG., MattsJ., ChildC., & ChesneyM.The consistency of adherence to antiretroviral therapy predicts biologic outcomes for human immunodeficiency virus-infected persons in clinical trials.Clinical Infectious Diseases2002; 34: 1115–1121.
41.
McDonaldH.P., GargA.X., & HaynesR.B.Interventions to enhance patient adherence to medication prescriptions: scientific review.Journal of the American Medical Association2002; 288: 2868–2879.
42.
PatersonD.L., PotoskiB., & CapitanoB.Measurement of adherence to antiretroviral medications.Journal of Acquired Immune Deficiency Syndromes2002; 31(Suppl. 3): S103–S106.
43.
PatersonD.L., SwindellsS., MohrJ., BresterM., VergisE.N., SquierC., WagenerM.M., & SinghN.Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.Annals of Internal Medicine2000; 133: 21–30.
44.
PradierC., BentzL., SpireB., Tourette-TurgisC., MorinM., SouvilleM., RebillonM., FuzibetJ.G., PesceA., DellamonicaP., & MoattiJ.P.Efficacy of an educational and counseling intervention on adherence to highly active antiretroviral therapy: French prospective controlled study.HIV Clinical Trials2003; 4: 121–131.
45.
ProchaskaJ.O., & DiclementeC.C.Stages of change in the modification of problem behaviors.Progress in Behavior Modification1992; 28: 183–218.
46.
ProchaskaJ.O., DiclementeC.C., & NorcrossJ.C.In search of how people change. Applications to addictive behaviors.American Psychologist1992; 47: 1102–1114.
47.
RobertsK.J.Physician-patient relationships, patient satisfaction, and antiretroviral medication adherence among HIV-infected adults attending a public health clinic.AIDS Patient Care & STDS2002; 16: 43–50.
48.
RobertsK.J., & VolberdingP.Adherence communication: a qualitative analysis of physician–patient dialogue.AIDS1999; 13: 1771–1778.
49.
SchmittG.M., LohausA., & SalewskiC.[Control beliefs and patient compliance: an empirical study exemplified by adolescents with diabetes mellitus, bronchial asthma and alopecia areata].Psychotherapie, Psychosomatik, Medizinische Psychologie1989; 39: 33–40.
50.
SchockmelG.A., YerlyS., & PerrinL.Detection of low HIV-1 RNA levels in plasma.Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology1997; 14: 179–183.
51.
StrainM.C., GunthardH.F., HavlirD.V., IgnacioC.C., SmithD.M., Leigh-BrownA.J., MacaranasT.R., LamR.Y., DalyO.A., FischerM., OpravilM., LevineH., BachelerL., SpinaC.A., RichmanD.D., & WongJ.K.Heterogeneous clearance rates of long-lived lymphocytes infected with HIV: intrinsic stability predicts lifelong persistence.Proceeding of the National Academy of Sciences, USA2003; 100: 4819–4824.
52.
TuldraA., FumazC.R., FerrerM.J., BayesR., ArnoA., BalagueM., BonjochA., JouA., NegredoE., ParedesR., RuizL., RomeuJ., SireraG., TuralC., BurgerD., & ClotetB.Prospective randomized two-arm controlled study to determine the efficacy of a specific intervention to improve long-term adherence to highly active antiretroviral therapy.Journal of Acquired Immune Deficiency Syndromes2000; 25: 221–228.
53.
TurnerB.J.Adherence to antiretroviral therapy by human immunodeficiency virus-infected patients.Journal of Infectious Diseases2002; 185(Suppl. 2): S143–S151.
54.
WallstonK.A., WallstonB.S., & DeVellisR.Development of the Multidimensional Health Locus of Control (MHLC) Scales.Health Education Monographs1978; 6: 160–170.
55.
WillutzkiU.VEV-WW. Neue Version des Veränderungsfragebogens des Erlebens und Verhaltens von Zielke.1999; Bochum, Germany: (unpublished) Institut für Psychologie der Ruhr-Universität.
56.
WongJ.K., HezarehM., GunthardH.F., HavlirD.V., IgnacioC.C., SpinaC.A., & RichmanD.D.Recovery of replication-competent HIV despite prolonged suppression of plasma viremia.Science1997; 278: 1291–1295.
57.
YerlyS., VoraS., RizzardiP., ChaveJ.P., VernazzaP.L., FleppM., TelentiA., BattegayM., VeutheyA.L., BruJ.P., RickenbachM., HirschelB., & PerrinL.Acute HIV infection: impact on the spread of HIV and transmission of drug resistance.AIDS2001; 15: 2287–2292.
58.
ZielkeM., & Kopf-MehnertC.Veränderungsfragebogen des Erlebens und Verhaltens (VEV).1978; Weinheim, Germany: Beltz.
