Using a Self-Administered Electronic Adherence Questionnaire to Identify Poor Adherence Amongst Adolescents and Young Adults on First-Line Antiretroviral Therapy in Johannesburg, South Africa

Kamban Hirasen; Denise Evans; Nelly Jinga; Rita Grabe; Julia Turner; Sello Mashamaite; Lawrence C Long; Matthew P Fox

doi:10.2147/PPA.S210404

Using a Self-Administered Electronic Adherence Questionnaire to Identify Poor Adherence Amongst Adolescents and Young Adults on First-Line Antiretroviral Therapy in Johannesburg, South Africa

Patient Prefer Adherence. 2020 Jan 22:14:133-151. doi: 10.2147/PPA.S210404. eCollection 2020.

Authors

Kamban Hirasen^#¹, Denise Evans^#¹, Nelly Jinga¹, Rita Grabe², Julia Turner², Sello Mashamaite², Lawrence C Long^{1

3}, Matthew P Fox^{1

3

4}

Affiliations

¹ Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
² Right to Care, Johannesburg, South Africa.
³ Department of Global Health, Boston University School of Public Health, Boston, MA, USA.
⁴ Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA.

^# Contributed equally.

Abstract

Introduction: The best method to measure adherence to antiretroviral therapy (ART) in resource-limited settings has not yet been established, particularly among adolescents and young adults (AYAs). The use of mobile technology may address the need for standardized tools in measuring adherence in this often marginalized population.

Methods: We conducted a cross-sectional validation study among AYAs (18-35 years) attending a South African HIV clinic between 07/2015-09/2017. We determine the diagnostic accuracy of two modes of delivering an adherence questionnaire (self-administered electronic vs interviewer-administered paper-adherence questionnaire) comprising two self-reported adherence tools (South African National Department of Health (NDoH) adherence questionnaire and the Simplified Medication Adherence Questionnaire (SMAQ)) to identify poor adherence compared to; 1) a detectable viral load (≥1000 copies/mL) and 2) a sub-optimal concentration of efavirenz (EFV) (EFV ≤1.00 µg/mL) measured by therapeutic drug monitoring (TDM).

Results: Of 278 included participants, 7.1% and 7.3% completing the electronic- and paper-questionnaires had a detectable viral load, while 14.7% and 16.5% had a sub-optimal concentration of EFV, respectively. According to viral load monitoring, the electronic-adherence questionnaire had a higher sensitivity (Se) in detecting poor adherence than the paper-based version across the NDoH adherence questionnaire (Se: 63.6% vs 33.3%) and SMAQ (Se: 90.9% vs 66.7%). In contrast, when using blood drug concentration (EFV ≤1.00 µg/mL), the paper-adherence questionnaire produced a higher sensitivity across both adherence tools; namely the NDoH adherence questionnaire (Se: 50.0% vs 38.1%) and SMAQ (Se: 75.0% vs 57.1%).

Conclusion: When using more accurate real-time measures of poor adherence such as TDM in this young adult population, we observe a higher sensitivity of an interviewer-administered paper-adherence questionnaire than an identical set of self-administered adherence questions on an electronic tablet. An interviewer-administered questionnaire may elicit more accurate responses from participants through a sense of increased accountability when engaging with health care workers.

Keywords: South Africa; adherence; adolescents; antiretroviral therapy; therapeutic drug monitoring; virologic suppression.

Grants and funding

This study has been made possible by the generous support of the American People and the President’s Emergency Plan for AIDS Relief (PEPFAR) through USAID under the terms of Cooperative Agreements AID-674-A-12-00029 and 72067419CA00004 to the Health Economics and Epidemiology Research Office and 674-A-12-00020 to Right to Care. The contents are the responsibility of the authors and do not necessarily reflect the views of PEPFAR, USAID or the United States Government. The funders had no role in the study design, collection, analysis and interpretation of the data, in manuscript preparation or the decision to publish.