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Decreases in Self-Reported ART Adherence Predict HIV Viremia Among Pregnant and Postpartum South African Women

Phillips, Tamsin K. MPH*; Wilson, Ira B. MD, MSc; Brittain, Kirsty MPH*; Zerbe, Allison MPH; Mellins, Claude A. PhD§; Remien, Robert H. PhD§; Orrell, Catherine MD, PhD; Abrams, Elaine J. MD‡,¶; Myer, Landon MD, PhD*

JAIDS Journal of Acquired Immune Deficiency Syndromes: March 1, 2019 - Volume 80 - Issue 3 - p 247–254
doi: 10.1097/QAI.0000000000001909

Introduction: Routine HIV viral load (VL) monitoring is recommended for patients on antiretroviral therapy, but frequent VL testing, required in pregnant and postpartum women, is often not feasible. Self-reported adherence can be valuable, but little is known about its longitudinal characteristics.

Methods: We followed women living with HIV from antiretroviral therapy initiation in pregnancy through 18-month postpartum in Cape Town, South Africa, with repeated measurement of VL and self-reported adherence using a 3-item scale. We used generalized estimating equations [with results presented as odds ratios (ORs) with 95% confidence intervals (CIs)] to investigate the association between viremia and change in adherence over pairs of consecutive visits.

Results: Among 2085 visit pairs from 433 women, a decrease in self-reported adherence relative to the previous visit on any of the 3 self-report items, or the combined scale, was associated with VL >50 and >1000 copies per milliliter. The best-performing thresholds to predict VL >50 copies per milliliter were a single-level decrease on the Likert response item “how good a job did you do at taking your HIV medicines in the way that you were supposed to?” (OR 2.08, 95% CI: 1.48 to 2.91), and a decrease equivalent to ≥5 missed doses or a one-level decrease in score on either of 2 Likert items (OR 1.34, 95% CI: 1.06 to 1.69).

Conclusions: Longitudinal changes in self-reported adherence can help identify patients with viremia. This approach warrants consideration in settings where frequent VL monitoring or other objective adherence measures are not possible.

*Division of Epidemiology and Biostatistics, Centre for Infectious Disease Epidemiology and Research, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa;

Department of Health Services, Policy and Practice, Brown University School of Public Health, Providence, RI;

ICAP at Columbia University, Mailman School of Public Health, Columbia University, New York, NY;

§HIV Center for Clinical and Behavioral Studies, New York State Psychiatric Institute, Columbia University, New York, NY;

Desmond Tutu HIV Centre, Institute of Infectious Disease and Molecular Medicine and Department of Medicine, University of Cape Town, Cape Town, South Africa; and

Vagelos College of Physicians & Surgeons, Columbia University, New York, NY.

Correspondence to: Tamsin K. Phillips, MPH, Level 5 Falmouth Building, School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa (e-mail:

Supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the National Institute of Child Health and Human Development (NICHD), Grant number 1R01HD074558. Additional funding comes from the Elizabeth Glaser Pediatric AIDS Foundation.

T.K.P. is partially supported by The South African Department of Science and Technology/National Research Foundation (DST-NRF), Centre of Excellence in Epidemiological Modeling and Analysis (SACEMA), Stellenbosch University, South Africa. I.B.W. is partially supported by the Providence/Boston Center for AIDS Research (P30AI042853) and by Institutional Development Award Number U54GM115677 from the National Institute of General Medical Sciences of the National Institutes of Health, which funds Advance Clinical and Translational Research (Advance-CTR) from the Rhode Island IDeA-CTR award (U54GM115677). C.O. is partially supported through DAIDS grants (1R01AI122300-01, 1R34MH108393-01, and 2UM1AI0695-08). C.A.M. and R.H.R. are partially supported by NIMH Center Grant (P30-MH43520). The remaining authors have no conflicts of interest to disclose.

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Received August 06, 2018

Accepted October 15, 2018

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