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To the Editor: Adherence to antiretroviral (ARV) treatment among patients with HIV (human immunodeficiency virus) infection is a key issue in controlling viral replication1 and preventing progression to AIDS (acquired immunodeficiency syndrome) or death.2 Assessment of adherence by prescribers often results in overestimating the patient's level of adherence.3 Therefore, simple and reliable tools to independently assess adherence are needed.
During an ongoing multisite cross-sectional study of adherence to ARV therapy, we tested a pills identification test (PIT). Two hundred twenty-four HIV-infected patients attending outpatient clinics in Caen and Paris-Bichat University hospitals in France were asked to identify the ARV pills they had been prescribed on a board containing 23 ARV pills with 2 similar appearing pills (referred to as twin pills) for each ARV pill (Figure 1). All patients had received the same ARV therapy for at least 3 months. An independent investigator measured the patient's adherence prior to the prescriber's routine consultation using a 4-item adherence scale4 validated for other chronic diseases.
Example of an antiretroviral pill (center) and its 2 twin pills (right and left).
The PIT score was calculated as the sum of misidentifications weighted according to the degree of resemblance of the pills (0.5 for the twin, 1 for other or omission). The patient's knowledge of ARV treatment was considered satisfactory if the PIT score was lower than 1. The association between the 4-item adherence scale and PIT results was measured with the χ2 test and logit odd ratio (OR); the adjusted OR was calculated in a multivariate logistic regression model of the 4-item adherence test score including PIT results and adjusting for number of ARV drugs, age, CD4 cell count, income, and education (SAS, version 6.12; SAS Institute Inc, Cary, NC).
All but 1 patient completed the PIT, in an average time of 2 minutes. Based on the 4-item adherence scale, adherence to ARV therapy was good (4-item adherence scale score <2) for 150 patients (67%). The PIT score was satisfactory for 175 patients (78%). Among the patients who had good adherence according to self-report on the 4-item adherence scale, 21 patients (14%) had poor treatment knowledge based on PIT score and the remaining 129 (86%), satisfactory treatment knowledge. Forty-six patients (62%) with a 4-item adherence scale score showing nonadherence to treatment had a PIT score of less than 1, indicating satisfactory knowledge of ARV treatment, while 28 of these patients (38%) had a PIT score of 1 or greater. The bifurcated adherence scale scores and PIT scores were closely related (χ2 = 16.5, P<.001; OR, 3.7, 95% confidence interval [CI], 1.9-7.2). This association remained significant (OR, 6.5; 95% CI, 1.4-8.4) after adjusting for all covariates.
Our study shows that the PIT is easy to perform and well accepted by patients. The association between results of the 4-item adherence test and PIT shows that PIT could be used in addition to the 4-item adherence test to assess adherence to ARV treatment. The PIT is unaffected by the identity of person administering it. In clinical practice, the PIT may be useful to assess adherence a few weeks after starting or switching an ARV treatment regimen. It is also a simple way to ensure and improve patients' knowledge of their treatment regimen, and might be useful to assess adherence to treatment in conditions other than HIV infection.
Funding/Support: This study was supported by the Fondation pour la Recherche Médicale and Roche Pharma.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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