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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

Authors Hirasen K, Evans D, Jinga N, Grabe R, Turner J, Mashamaite S, Long LC, Fox MP

Received 28 March 2019

Accepted for publication 18 September 2019

Published 22 January 2020 Volume 2020:14 Pages 133—151


Checked for plagiarism Yes

Review by Single anonymous peer review

Peer reviewer comments 2

Editor who approved publication: Dr Johnny Chen

Kamban Hirasen,1,* Denise Evans,1,* Nelly Jinga,1 Rita Grabe,2 Julia Turner,2 Sello Mashamaite,2 Lawrence C Long,1,3 Matthew P Fox1,3,4

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

*These authors contributed equally to this work

Correspondence: Denise Evans Tel +27 10 001 0637

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: antiretroviral therapy, adherence, adolescents, virologic suppression, therapeutic drug monitoring, South Africa

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