The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission. AIDS CLINICAL ROUNDS
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Update on Individualized Texting for Adherence Building (iTAB): Lessons for Implementation
David J. Moore, PhD of the UC San Diego Department of Psychiatry presents "Update on Individualized Texting for Adherence Building (iTAB): Lessons for Implementation"
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The UC San Diego AntiViral Research Center sponsors weekly presentations by infectious disease clinicians, physicians and researchers. The goal of these presentations is to provide the most current research, clinical practices and trends in HIV, HBV, HCV, TB and other infectious diseases of global significance. The slides from the AIDS Clinical Rounds presentation that you are about to view are intended for the educational purposes of our audience. They may not be used for other purposes without the presenter’s express permission.
AIDS CLINICAL ROUNDS
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Update on Individualized Texting for
Adherence Building (iTAB): Lessons for
Implementation
David J. Moore, Ph.D.
University of California, San Diego
Department of Psychiatry
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Brief Outline
Texting and adherence in HIV
iTAB System
Results from completed/ongoing studies
» iTAB-B: HIV+ with bipolar disorder
» iTAB-M: HIV+ with active meth use
» CCTG 595: HIV- taking PrEP
Conclusions
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Texting Improves ART Adherence
SMS (texting) interventions for improving ART adherence
show promise
In a 2012 Cochrane report, two RCTs shown to be
efficacious for ART improvement:
» 1X week text over a 12-month interval decreased non-adherence
and virologic failure (Lester et al., 2010)
» 1X week versus 1X day text messages; at 48-weeks, weekly
messages were more likely to reduce non-adherence and
treatment interruptions (Pop-Eleches et al., 2011)
Optimal texting systems for adherence improvement in
difficult-to-treat populations in US still evolving
Horvath et al., Cochran Report, 2012; Lester et al., 2010; Pop-Eleches et al. 2011
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Personalized iTAB intervention
iTAB -- Pts create personalized med reminder texts:
• Description of medications
• Personalized reminder stems (e.g., “remember
to take your meds, they make you healthy”)
• Preferred name
• Ideal time for reminders each day by med
Both iTAB and CTRL received:
• Adherence psychoeducation (~30 min)
• A daily text message asking about mood
• Process of medication reminder creation
• Sentinel med for MEMS: ARV: Mostly combo
medication; PSY: Primary mood stabilizer
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Example of Customizable iTAB System
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Example of Customizable iTAB System
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB Decision Tree
Other iTAB components:
• 3 consecutive days of non-
responses get a
“noncompliance” text
• 5 consecutive days of non-
responses, call from RA
• Adherence Targets:“Ur
current adherence: xx%.
Adhr when u take ur next
dose: xx% (x/x doses)”
• Personalized Reinforcer
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB Studies
iTAB-B iTAB-M CCTG 595
Group HIV+ Bipolar HIV+ Meth HIV-
Design RCT (n=50) RCT (n=75) RCT (n=400)
Status Enrolled Enrolling (n=23) Start 12/1
Duration 4 weeks 6 weeks 48 weeks
Referrals N/A Please!619-543-
5000
619-543-5011
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB in HIV+ with Bipolar Disorder
(iTAB-B)
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB-B Study Flow
Assessed for eligibility (n=62)
Allocated to iTab intervention
(n=30)
Lost to follow up
(n=2)
Analyzed (n=25)
• Lost MEMS (n=3)
Allocated to CTRL intervention
(n=28)
Lost to follow up
(n=2)
Analyzed (n=25)
• Lost MEMS (n=1))
Excluded (n=4)
• Not meeting inclusion criteria (n=2)
• Declined to participate (n=1)
• Withdrawn (n=1)
Enrollment
Randomized (n=58)
Allocation
Follow-up
Analysis
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Example iTAB-B Intervention Stems
» Celebrate Health
• Stay healthy! It’s time 2
take ur meds, pls take ur…
» Time and Focus
• It’s pill time! Take ur…
» Control Disease
• Taking ur meds helps
control ur disease. Rmber
2 take ur…
» Empowering
• It’s med time, only u can
control this. Rmber 2
take ur…
» Importance of Adherence
• Adherence is impt. Pls
take ur…
Stems of personal reminder messages reflect different themes:
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Demographics
CTRL (n=25) ITAB (n=25) P-value
Age 45.9 (10.2) 48.4 (9.2) 0.36
Education 13.0 (3.1) 13.3 (2.2) 0.67
Ethnicity (% White) 44.0 64.0 0.26
Sex (% Male) 84.0 92.0 0.67
Global Deficit Score 0.7 (0.7) 0.6 (0.6) 0.68
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Psychiatric Characteristics
CTRL (n=25) ITAB (n=25) P-value
Lifetime Substance
Diagnosis,% 87.5 68.0 0.10
Current Substance
Diagnosis, % 4.2 4.0 0.98
Euthymic during the
prior month, % 64.0 64.0 0.62
Beck Depression
Inventory–II 18.0 (10.6) 17.0 (12.6) 0.77
Young Mania Rating
Scale 5.2 (4.5) 6.4 (7.6) 0.49
GAF 67.3 (10.9) 68.0 (10.0) 0.82
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Medical Characteristics
CTRL (n=25) ITAB (n=25) P-value
Current CD4 Count 655.8 (324.2) 603.4 (392.8) 0.67
Nadir CD4 Count 225.7 (153.1) 281.2 (258.2) 0.44
HIV RNA Detectable, % 8.0 24.0 0.12
AIDS Status, % 60.9 70.0 0.75
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Medication Characteristics
CTRL (n=25) ITAB (n=25) P-value
Self report % ARV doses
taken (past month) 87.9 (16.8) 96.0 (7.2) 0.10
Self report % PSY doses
taken (past month) 89.0 (19.2) 94.1 (9.9) 0.41
Total No. of ARVs 6.9 (4.5) 7.1 (4.5) 0.75
Total No. of rx doses, ARV 42.7 (13.8) 41.5 (14.2) 0.61
Total No. of rx doses, PSY 47.7 (24.1) 44.7 (19.0) 0.57
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Overall MEMS Adherence by Group
0
10
20
30
40
50
60
70
80
90
100
ARV PSY
ME
MS
% o
f P
rescri
bed
Do
eses
Taken
CTRL
iTAB
N=2
5
N=25
p = 0.28 p = 0.94
N=25 N=25
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Overall MEMS % On Schedule by Group
p = 0.25 p = 0.89
0
10
20
30
40
50
60
70
80
90
ARV PSY
CTRL
iTAB
N=25 N=25 N=25 N=25
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Time from Target Dose by Group
p = 0.03 p = 0.34
Cohen’s d = -0.33 Cohen’s d = 0.04
N=25 N=25 N=25 N=25
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Adherence & Mania Ratings
YMRS total
F (1, 49) = 6.774
p = 0.012
YMRS total
F (1, 46) = 2.705
p = 0.107
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Frequency of Stems Selected
# Stem # Stem
1 Ur health is impt, rmber 2 take ur meds. Take ur [med] now. 10 Adherence is impt. Pls take ur [med] now.
2 Stay healthy! It's time 2 take ur meds, pls take ur [med] now. 11 2 help keep u feeling good, rmber 2 take ur [med] now.
3 No matter what else is going on, it's impt 2 take ur [med] now. 12 Ur meds are important. It's time for ur next dose of ur [med] now.
4 It's med time! Pls take ur [med] now. 13 Ready, set, get healthy! It's meds time. Time for ur [med] now.
5 It's med time, only u can control this. Rmber 2 take ur [med] now. 14 Protect ur health. It's that time again 2 take ur [med] now.
6 Taking ur meds helps control ur disease. Rmber 2 take ur [med] now. 15 It's pill time! Take ur [med] now.
7 Yay, health! Don't frgt 2 take ur [med] now. 16 2 control ur health u need 2 take ur [med] now.
8 Taking ur meds helps 2 keep ur body healthy! Take ur [med] now. 17 Other/Custom
9 U've been doing gr8 w/ ur adherence. It's time 2 take ur [med] now.
0%
10%
20%
30%
40%
50%
60%
70%
80%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Frequency Selected (N=25)
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Adherence Rates by Stem
# Stem # Stem
1 Ur health is impt, rmber 2 take ur meds. Take ur [med] now. 10 Adherence is impt. Pls take ur [med] now.
2 Stay healthy! It's time 2 take ur meds, pls take ur [med] now. 11 2 help keep u feeling good, rmber 2 take ur [med] now.
3 No matter what else is going on, it's impt 2 take ur [med] now. 12 Ur meds are important. It's time for ur next dose of ur [med] now.
4 It's med time! Pls take ur [med] now. 13 Ready, set, get healthy! It's meds time. Time for ur [med] now.
5 It's med time, only u can control this. Rmber 2 take ur [med] now. 14 Protect ur health. It's that time again 2 take ur [med] now.
6 Taking ur meds helps control ur disease. Rmber 2 take ur [med] now. 15 It's pill time! Take ur [med] now.
7 Yay, health! Don't frgt 2 take ur [med] now. 16 2 control ur health u need 2 take ur [med] now.
8 Taking ur meds helps 2 keep ur body healthy! Take ur [med] now. 17 Other/Custom
9 U've been doing gr8 w/ ur adherence. It's time 2 take ur [med] now.
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Adherence Rate ARV Adherence Rate PSY
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB in HIV+ METH Users: iTAB-M
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
METH is Risk Factor for HIV
In 2008, 850,000 Americans
≥12 y.o. abused METH in
previous year (National Survey
on Drug Use and Health, 2008)
CDC estimates 12% of incident
US HIV cases attributable to
IVDU (HIV/AIDS Surveillance
Report, 2007)
Strong association between
METH use among MSMs and
continued high incidence of
HIV/AIDS in the US (CDC
HIV/AIDS Fact Sheet, 2007)
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB-M Focus Groups
AIM:
To identify barriers and strategies for ART adherence specific
to HIV+/MA+ persons and to integrate feedback on the content
of the text-message reminders for iTAB-M
METHOD:
Two focus groups, each with ten HIV+/MA+ individuals, were
conducted
Participants were middle aged (43.6 years, SD=7.7),
predominantly male (90%), Caucasian (60%), and high school
educated (12.3 years; SD=2.8).
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB-M Focus Group Data Analysis
Audio recordings transcribed
Independently coded by two investigators using QSR NVivo
software
Codes identified emergent themes related to barriers and
strategies of adherence and feedback on the content of
proposed text messages
Disagreements in coding resolved through consensus
Kappa calculated for final assigned codes
High Interrater reliability: kappa = 98.7
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Adherence Barriers in Meth HIV+
Mental Health
Lack of Social Support
Meth-related
Lack of Education
Pill Burden
Accessibility
Apathy
Cognitive Problems
Medicine Side Effects
Stigma
Nodes clustered by Word similarity
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Example: Adherence Barriers
My biggest problem was losing track of time,
you know, and so I would have them but I may
take it, you know, 12 hours and then 36 hours
and that kind of deal, but I always adhered. It
was just very sloppy, you know, while I was
using that weekend. So, that was my
biggest issue.
”
“
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Strategies for Adherence
Planning
Spirituality
Self Efficacy
Increase Accessibility
Utilize Reminders
Engagement of Health Care System
Efficient Medication Regimen
Health Promotion
Pharmacy Assistance
Self-Esteem
Nodes clustered by Word similarity
Education
Social Support
Token Economy
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Strategies for Adherence
I was thinking about taking meds and
things like that, if we have something
called the buddy system. Or just maybe
have one of the nurses giving you a call
everyday saying are you taking your
meds?
”
“
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Meth and Adherence
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Control ITAB
% of Days Reporting Meth Use
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Meth+ days Meth- days
Adherence by Meth Status
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
Example iTAB-M Intervention Stems
» Celebrate Health
• Stay healthy! It’s time 2 take ur
meds, pls take ur…
» Time and Focus
• It only takes a second! Take ur…
» Social Support
• People care about u. Pls take
ur…
» Control Disease
• It’s impt to take care of urself.
Pls take ur…
» Self-Esteem
• U are special. Pls take ur…
» Meth Focus
• Take ur meds so u can keep
having fun. Time 4 ur…
» Dangers of Non-adherence
• Not taking ur meds could
make u resistant. Take ur…
» Spiritual
• God grant me the serenity to
do this. It’s time 4 ur…
Stems of personal reminder messages reflect different themes:
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB-M Intervention Stems
# Reminder Stem
1 Stay healthy! It’s time to take your meds, please take your medications.
2 To help keep you feeling good, remember to take your medications.
3 Ready, set, get healthy! It’s med time. Time for your medications.
4 Live longer! Take your medications.
5 Yay, health! Don’t forget to take your medications.
6 It only takes a second! Take your medications.
7 It's med time! Please take your medications.
8 It’s pill time! Take your medications.
9 No matter what else is going on, it’s important to take your medications.
10 Stop everything and take your meds! Take your medications.
11 People care about you. Please take your medications.
12 Think about the people who love you. Take your medications.
13 We care about u and your health. Please take your medications.
14 [name] needs you. Take your medications.
15 You are not alone. It’s time to take your medications.
16 It’s important to take care of yourself. Please take your medications.
17 Your health is important, remember to take your meds. Take your medications.
18 To control your health you need to take your medications.
19 Adherence is important. Please take your medications.
20 Protect your health. It’s that time again to take your medications.
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO
iTAB-M Intervention Stems
# Reminder Stem
21 You are special. Please take your medications.
22 Stay strong. It’s time for your medications.
23 You’ve been doing great with your adherence. It’s time to take your medications.
24 You can do it! Take your medications.
25 It’s a great accomplishment to be adherent! Take your medications.
26 Take your meds so you can keep having fun. Time for your medications.
27 Ignore Tina and take your medications.
28 It’s not party time; it’s med time! Please take your medications.
29 You can have fun and take your meds. Time for your medications.
30 Stop screwing around and take your medications.
31 Not taking your meds has severe consequences. Take your medications.
32 Not taking your meds could make u resistant. Take your medications.
33 You need your meds to live longer. Time for your medications.
34 You will only get sicker if you don’t take your meds. Time for your medications.
35 Not taking your meds puts others at risk. Please take your medications.
36 God loves you. It’s time for your medications.
37 WWJD? Take his meds! Time for your medications.
38 Trust in the Lord. Take your medications.
39 The Lord believes in you; believe in yourself. Take your medications.
40 God grant me the serenity to do this. It’s time for your medications.
HIV NEUROBEHAVIORAL RESEARCH PROGRAM | UNIVERSITY OF CALIFORNIA, SAN DIEGO