The current study is the first to explore and characterize the nature of medication-taking routines of HIV-positive individuals in the home environment. Participants’ descriptions and recreations of their home-based medication-taking routines collectively demonstrated a wide array of pill-taking triggers in the home environment (e.g., meals/food, visual cues, going to bed, watching a specific TV program). The consistency with which participants referred to routines and the “automatic” nature of remembering to take their medication suggests that many clients who have been on ART for a lengthy period of time (as most participants in this study had been) may have highly routinized medication-taking behavior.
Certain characteristics of home-based medication-taking routines were observed to be more typical of individuals with high self-reported adherence relative to low self-reported adherence. As expected, participants with higher levels of self-reported adherence described more highly routinized pill-taking behavior than participants with lower levels of self-reported adherence. These findings converge with earlier findings suggesting the importance of routinization in promoting adherence10, 11, 15
. However, the nonexperimental design of the current study precludes inferences regarding the causal impact of routinization on adherence.
Participants with higher levels of self-reported adherence also more commonly reported triggers such as automaticity/time of day, visual cues, and meals/food and the use of a pillbox to keep track of medication than did participants with lower levels of self-reported adherence. It is not clear whether these characteristics may contribute causally to greater adherence. However, these findings suggest that a potentially fruitful direction for future research might be to experimentally manipulate and examine the causal contributions of these characteristics of medication-taking routines to adherence.
Medication was typically taken at home, though most participants did have occasional disruptions to their routine that necessitated taking medication elsewhere. It was also typical for participants to pocket doses in preparation for taking medication when they knew they were going to be away from home. The pattern of findings on pocketed doses highlights this medication-taking behavior as an important focus of future interventions to improve ART adherence. Specifically, the findings that pocketed doses were reported by most participants; that several participants reported sometimes forgetting to take pocketed doses or taking them later than intended; and that several participants don’t use any strategies to remember to take pocketed doses collectively suggest that this aspect of medication-taking behavior may leave clients vulnerable to adherence lapses and thus warrants additional attention in efforts to increase adherence.
Procurement of prescription refills in a timely manner (i.e., before running out of medication) was also explored. Most participants reported that they had run out of medication before getting a refill at least once since they began taking medication. Recent technological innovations in the systems for ordering prescription refills, which are increasingly common, would be expected to enhance timely procurement of prescription refills. Most participants reported that technology played a role in obtaining prescription refills. However, several participants reported that these systems were vulnerable to malfunction and unreliable, which interfered with timely procurement of prescription refills. These findings suggest the need for pharmacies to monitor the success of their automated systems in providing prescription refills in a timely manner and to identify and remedy problems soon after they emerge. If this is not possible, then, minimally, patients should be alerted to the problem so that they can keep track of the need for and order prescription refills through alternative means until the problem has been corrected.
Most patients in the current sample did not recall their providers having communicated with them about the importance of timing of doses, and many patients’ responses conveyed limited understanding of the importance of timing of doses. While dose timing is rarely measured in studies of adherence, a few studies have highlighted the importance of dose timing to achieving virologic suppression1, 16, 17
. In particular, patients need to know the ideal interval in between doses and the window of time around the ideal timing of doses during which doses can still be taken without increasing the risk for development of resistance or drug toxicity. As the current findings represent patients’ recall of provider communication, rather than actual provider communication, it is unclear whether the findings reflect providers’ deficits in communication or patients’ faulty recall of provider communication that did occur. Nonetheless, the poor understanding of the importance of dose-timing expressed by many participants underscores a critical gap in patient education. As the nature of deficits in patient education efforts cannot be inferred from this study, more research is needed to determine the nature of improvements that are best suited to close this gap.
In interpreting the findings of the current study, some caveats should be considered. First, given that the sample consisted exclusively of men, most of whom were unemployed, the generalizability of the current findings to other populations, such as HIV positive females and employed individuals, is unclear. In particular, barriers to and facilitators of adherence may differ for employed and unemployed individuals, as unemployed individuals typically lead more unstructured, unstable lives. Past research has indicated that individuals with more unstructured, unstable lives have greater difficulty establishing and adhering to medication-taking routines10, 11
. The current findings would need to be replicated in a more demographically diverse sample to determine how barriers to and facilitators of adherence may differ for women and employed individuals.
In sum, the current study expands our understanding of the nature of home-based medication-taking routines. Medication-taking behavior in the home environment was found to be highly routinized for the majority of participants, and several characteristics of home-based medication-taking routines were observed. Findings illuminate areas of inquiry for future research that may be propitious for identifying modifiable targets of home-based interventions to promote ART adherence.