Objective. Measuring adherence levels and assessing the impact on adherence to ART (antiretroviral treatment) of the factors: disclosure to partner, partner support, other support and length of time between diagnosis and ART commencement, in a state-run ART clinic at Mitchells Plain Community Health centre. Design. A retrospective case control study was conducted and the information was obtained by means of a file audit. Methods. Every 5th file was selected for the study and 199 participants were chosen based on the inclusion and exclusion criteria. Adherence for each patient was measured using a formula documented in a published study. For the comparison group 82 cases (non-adherent patients) were matched for age and gender with 82 adherent controls. Results. The mean adherence for the initial group of 199 participants was 80.1%. Disclosure to a partner and partner support were not found to significantly affect adherence. The time between HIV diagnosis and ART commencement was also not found to make a statistically significant difference to adherence. There appeared to be an association, though not statistically significant, between other support (not from the partner) and >95% adherence (p= 0.0579). Conclusion. It can be concluded that adherence is probably influenced by a wide variety of factors. More qualitative studies or larger samples are recommended to better assess the impact of partner support and acceptance of HIV on adherence. Approaches to partner disclosure prior to commencing ART should be reviewed. The mean adherence level of 80.1% is an indication that more work is urgently needed to improve adherence levels in state-run clinics in South Africa.

Introduction: Rheumatoid arthritis (RA) is a multisystem disease associated with early mortality. Methotrexate (MTX) is the first-line therapy in RA but is associated with significant adverse events and response is not universal. There is, therefore, a need to identify early those patients with RA unlikely to respond or develop toxicity to MTX. One of the major influences on drug response is adherence and MTX can cause a range of side effects known to impact on adherence such as pneumonitis (MTX-P). The gold standard measurement of adherence would be direct detection of MTX or its metabolites in a biochemical assay. Currently, there are no reliable markers that predict response to MTX but some studies have suggested measurement of MTX levels may predict response. Previous studies have suggested that MTX-P may occur in individuals genetically predisposed to the disease. The aims of this research are to i) develop an assay to measure MTX levels; ii) test the ability of the assay to measure adherence; iii) investigate if MTX levels are associated with response; and iv) conduct a genome wide association study (GWAS) investigating MTX-P. Methods: An assay to measure MTX and 7-OH-MTX in urine and plasma was developed using HPLC-SRM-MS and the assay was used to measure levels in a cohort of RA patients to develop a pharmacokinetic model. Simulations of the model were used to determine the ability of the assay to monitor adherence and the model was validated in a separate cohort of patients with RA. An observational study of RA patients was used to measure MTX and 7-OH-MTX levels to investigate if levels are associated with response. Finally, a GWAS investigating MTX-P was conducted. Results: Results of the pharmacokinetic model demonstrated that MTX is the preferred analyte to monitor adherence. The model was validated in a separate cohort of patients with RA demonstrating the ability of the assay to measure adherence. MTX levels were not associated with disease response in this cohort. A GWAS of MTX-P demonstrated three SNPs associated with disease (p <5 x 10-5) with subsequent bioinformatics analysis showing a potential functional role for rs7514182.ConclusionAdherence to MTX may be a significant barrier to patients achieving full response to therapy. The development of a direct test to detect adherence based on measuring MTX levels using HPLC-SRM-MS has been developed in urine and blood. The assay was shown to be accurate in several domains from EMA guidelines and was validated in a separate cohort of patients. Finally, this program of work has investigated genetic markers associated with MTX-P. The results demonstrated a potential SNP associated with disease which demonstrates a functional role in the development of pulmonary fibrosis.

La survenue d’une infection sur prothèse articulaire demeure une complication redoutable conduisant le plus souvent au changement de l’implant avec des risques de séquelles fonctionnelles et un impact socio-économique important. La lutte contre l’adhérence bactérienne au moment de la mise en place de l’implant représente une des voies de recherche pour la prévention de ces infections.L’objectif principal de cette étude était la mise au point de ciments acryliques modifiés par l’ajout de polymères et l’analyse in vitro de leur efficacité sur l’inhibition de l’adhérence bactérienne à leur surface.Les analyses d’adhérence bactérienne ont été réalisées avec du ciment acrylique commercialisé (CERAFIX® et CERAFIXGENTA® - société CERAVER – Roissy – France)associé à du polymère (polyNaSS) puis à des copolymères (MMA/NaSS) à différents dosages. La souche bactérienne testée était du Staphylococcus aureus en système purifié(fibrinogène seul) et en milieu plasmatique. L’ajout de polyNaSS, même en faible pourcentage, apporte au ciment un effet inhibiteur très important (entre 20 et 40% d’inhibition selon les mélanges). Les mélanges des ciments avec des copolymères MMA/ NaSS ont des propriétés d’inhibition de l’adhérence bactérienne plus faibles (environ 11%), avec un effet inhibiteur qui suit un modèle linaire d’inhibition dépendant de la quantité de copolymère dans le mélange. Ces mélanges sont biocompatibles et ne conduisent pas à des modifications de la morphologie des ostéoblastes.Les résultats obtenus permettent de montrer que le ciment CERAFIXGENTA® n’a pas un effet bactéricide immédiat et ne conduit pas à une inhibition de l’adhérence de bactéries sur les ciments. L’évaluation chimique a permis de préciser l’importance du relargage des polymères surtout dans les 24 premières heures indiquant un effet maximal immédiat et limité dans le temps sur l’adhérence bactérienne ce qui est l’objectif de cette prophylaxie. Ce relargage semble cependant entraîner des modifications architecturales du ciment avec augmentation de la porosité. Les observations en microscopie électronique des mélanges montrent des hétérogénéités de surfaces avec la présence des zones de porosité augmentée dues à la présence de copolymères. Ces observations semblent indiquer que bien que cette stratégie de prévention de l'infection des arthroplasties semble être très attrayante et fiable, les modifications mécaniques sur les surfaces d’implants pourraient conduire à l'échec précoce de l’arthroplastie avec descellement. L’étude biomécanique sur les différents mélanges de ciment et de polymères est nécessaire afin de préciser l’influence de la présence aussi bien du polyNaSS que des copolymères MMA/NaSS sur les qualités mécaniques du ciment. Ces85études permettront aussi de trouver le dosage optimal à obtenir pour maintenir les caractéristiques mécaniques du ciment tout en conservant les propriétés antiadhésives. / Résumé e anglais non fourni

Class of 2017 Abstract / Objectives: Medication adherence tools and technologies can have a significant impact on the level of drug therapy continuation as well as improved outcomes. The RxTimerCap© is a device that aims to act as a medication adherence cap with an embedded timer to indicate the time since the medication was last taken. Our aim was to assess if this cap technology would aid in increased drug adherence and duration of therapy with abiraterone (Zytiga®). Methods: The study was a prospective, single-center, interventional study that included males 18 or older being treated with Zytiga for castration-resistant metastatic prostate cancer. Medication possession ratio (MPR) and duration on therapy were the primary measures used to assess if there would be improved adherence. Paired t- tests were used to analyze the data and assess the significance of the outcomes. Results: There was no significant difference between patients in MPR (p = 0.50) or in the duration of treatment (p = 0.20). Conclusions: The difference in adherence rates for patients using the RxTimerCap© and those using the standard vial cap were non-significant. The limited size of our study population and short study duration may have led to these undifferentiated outcomes. Future studies should examine this type of adherence technology in a larger sample of patients with a prolonged window of observation to better assess the benefits of using the RxTimerCap©.

Magister Public Health - MPH / Namibia is one of the countries in the world most affected by HIV/AIDS with the national prevalence of 18.8% in 2010. In 2010, it was reported that an estimated 180,000 Namibians were living with HIV/AIDS; of which 95,000 adult women, 69,000 adult men and 16,000 children. An estimated 6,700 deaths was recorded in 2009 with an estimated number of 70,000 orphans due to the disease. The introduction of anti-retroviral therapy (ART) in public health facilities in Namibia in 2003 has improved the quality of lives of patients with advanced HIV disease, prolonged their lives and enabled them to be economically productive. By 2010 about 90,000 patients were enrolled on ART program in all 34 district hospitals and 3 intermediate referrer hospitals. Adherence to antiretroviral therapy is a key attribute of clinical HIV care and the overall determining factor in gauging the effectiveness of treatment. Good adherence to ART is vital to sustain low viral loads and prevent the development of drug resistant HIV strains. Although the patient retention rate on ART at the Katima Mulilo Hospital was 98.3%, with increased patient uptake to the program in future, there is a need to be aware of factors that influence adherence to ART as such findings could inform the expanded ART program in Caprivi region. An explorative, qualitative study was conducted where in-depth interviews were conducted with 24 ART patients and key informants interviews with 2 health workers. Data were audiotape recorded and transcribed verbatim. Thematic and content analysis of transcribed data was performed.

Class of 2005 Abstract / Objectives: To determine compliance rate of patients enrolled in the AIDS Drug Assistance Program (ADAP) at El Rio Health Center. Methods: This study was a retrospective observational study design that utilized medication refill data obtained from computerized pharmacy records. Lists were created for each anti-retroviral drug that included the following data: medical record number, medication, quantity dispensed, days supply and refill date. Patient age, gender and ethnicity were also obtained. The data was compiled into a database using Microsoft Excel©. The medication possession ratio (MPR) was calculated for each drug as well as for each drug group. The subjects in this study were patients enrolled in the ADAP at El Rio Health Center who obtained prescription refills between December 1, 2003 and November 30, 2004. The mean age was 44.56 (range 25-78); 94.8% were male and 5.2% were female. Ethnic distribution included 52.6% Caucasian, 39.6% Hispanic, 3.2%African American, 1.3% Asian, and 3.2% other. Results: The MPR was calculated for each drug as well as for each drug group. MPRs for individual drugs ranged from 0.586-0.906; MPRs for drug groups ranged from 0.717-0.756. Implications: The results of the study indicated that ADAP patients did not have adequate (>95%) compliance rates. The implications of the results are that patients are not fully benefiting from their medication, while at the same time promoting the development of resistant strains of HIV.

Medication non-adherence, the extent to which a person's behavior does not coincide with medical or health advice, is a serious public health issue. Objectives: 1) Develop a new typology of medication non-adherence, 2) Develop models to predict different types of non-adherence based on Andersen Behavioral Model (ABM) and Leventhal's Common Sense Model (CSM), and 3) Test the models across two different medications used in treating disease conditions with varying symptomatology. Methodology: A new typology of medication non-adherence was developed through literature review of the frequently reported reasons for non-adherence based on the possibility of a cognitive process intervention directed towards patients and the mutability of interventions. The typology was analyzed qualitatively and quantitatively. A new self-reported scale to measure non-adherence was developed from the frequently reported reasons and compared to the Morisky scale. The conceptual models developed using ABM and CSM were tested using regression techniques to identify significant predictors of non-adherence. Results: Qualitative analysis supported the typology from the literature review, yet the quantitative exploratory factor analysis did not support it. Instead, four types of non-adherence each for cholesterol lowering (non-adherence due to managing issues, multiple medication issues, belief issues with medications, forgetfulness due to busy schedule) and asthma maintenance medications (non-adherence due to managing and availability issues, beliefs and convenience issues, cost issues, forgetfulness due to busy schedule) were identified. Predisposing factors such as concern beliefs in medications, enabling factors such as self efficacy, and need factors such as self health and illness perceptions, and severity of disease were significant predictors of medication non-adherence. The Reasons scale had moderate levels of agreement with the Morisky scale based on kappa coefficients. Conclusion: No one typology of medication non-adherence fit cholesterol lowering and asthma maintenance medications, and the typology was driven by type of disease condition and reasons for non-adherence. The Reasons scale measured and categorized non-adherence better than the Morisky scale. Adding CSM to ABM facilitated in identifying predictors of medication non-adherence.

Magister Scientiae (Physiotherapy) - MSc(Physio) / Reduced adherence levels have been demonstrated by some patients affected with Osteoarthritis. Therefore, this study aimed at exploring the barriers and facilitators regarding patient adherence towards physiotherapy rehabilitation programs in the management of osteoarthritis in Nairobi, Kenya. The objectives of the study were to determine the clinical profile of patients with osteoarthritis on physiotherapy rehabilitation programs, to explore the patient-reported barriers and facilitators towards physiotherapy rehabilitation programs and exploring physiotherapists’ perceptions of patient adherence towards physiotherapy rehabilitation programs. The study setting was at the Kenyatta National Hospital physiotherapy clinic in Nairobi, Kenya.

The cornerstone in the fight against HIV/AIDS is prevention followed by the access to and use of highly active antiretroviral treatment (HAART). Adherence is the greatest patient- enabled predictor of treatment outcome for the patients on HAART, as good adherence leads to a decrease in disease progression and death. There is no ‘gold standard’ in the measurement of adherence. Also, factors that influence adherence and hence the prevalence of adherence differ across different settings making it necessary to determine local adherence prevalence as well as factors that might impact on it. This was a cross sectional study which assessed the prevalence of one- week adherence to antiretroviral therapy at St Rita’s hospital through an abridged version of the questionnaire developed by the Adult Aids Clinical Trials Group in the United States. Results from the questionnaires were compared to the results from a decrease in plasma viral load to undetectable limits within six months. The study found out that the prevalence of one- week adherence by self-report was 96.8% (95% CI: 93.2 – 98.9%). Using a decrease in viral load to undetectable limits within six months of initiating treatment as a tool to assess adherence, the prevalence in this study was 96%. A combined prevalence of 94% was found for this study. These results were identical to a few results locally but it was much higher than most local studies. The explanation for this apparent higher adherence rate might be that the study site has not reached its maximum capacity for the delivery of service as it is still operating at just below the staff/patient ratio recommended by the Department of health. The study also found out that being a member of an AIDS support group was a facilitator to adherence while lack of adherence counselling and monitoring is a barrier. Based on these findings it is therefore recommended that measures should be put in place to ensure improving existing adherence counselling and monitoring, encouraging patients to belong to at least one AIDS support group, more decentralization of antiretroviral therapy roll out to the districts that are yet to roll out and providing financial assistance through improved access to disability grants for those who qualify and income generating activities for the unemployed that do not qualify for disability grant.

Problem: Asthma affects one out of every ten children in the United States. It is recommended that children with persistent asthma take long-term controller (LTC) medications to achieve control. However, adherence varies, and many children do not take their LTC medication at all. The average cost for hospitalization of a child with asthma is $8,406. Asthma in children also contributes to school absenteeism and a decrease in quality of life. Objective: A literature review was performed to examine factors that affect adherence to LTC medications used to control asthma in children. Method: A literature review was performed using the CINAHL, ERIC, Medline, Psych Info, and Academic Search Premier databases. Keywords included asthma AND child* OR pediatric* AND adherence OR compliance AND corticosteroid* OR “leukotriene modifier*” OR “mast cell stabilizer*” OR “monoclonal antibod*” OR “long-acting beta agonist.*” After applying exclusion criteria 35 articles were included in this review. Results: A variety of factors that affect adherence were identified. Internal factors included age, sex, and race/ethnicity. External factors included socioeconomic status, environment, health perception, lack of motivation, parental education, disease/medication beliefs, family dynamics and planning, responsibility, severity, and exacerbations. Interventional factors included caregiver-family communication, asthma knowledge, specialty care, white coat adherence, number of prescriptions, asthma action plans, medication regimens, and technology. Conclusion: It is recommended that healthcare providers use a four-step process during inpatient and outpatient asthma visits. The steps include assess and educate, collaborate, problem-solve, and follow-up. Collectively, this method can help healthcare providers overcome many of the barriers that were identified.