Sex with partners met online: risky sexual behavior among bachelors in rural China.

In the context of gender imbalance and marriage squeeze in China, this study identifies socio-demographic characteristics of bachelors who reported having sex with partners whom they met online and examines associations between having sex with such partners and other risky sexual behaviors. Data are from a cross-sectional survey conducted in 2017. 735 men who have rural household registration (hukou, in Chinese), and who were at least 28 years old and unmarried were interviewed. 16.5% of the sample had experienced sexual intercourse with a partner met online. After adjustment for socio-demographic characteristics, having sex with such partners was associated with a range of risky sexual behaviors: unsafe sexual intercourse (such as anal sex, group sex, not using a condom) (adjusted OR (aOR) = 5.11, 3.14-8.33, p < 0.001); commercial sex (aOR = 4.42, 2.78-7.02, p < 0.001); having sex in public places (aOR = 3.11, 1.97-4.91, p < 0.001); and multiple sexual partners (> = 6 partners) (aOR = 12.57, 6.55-24.12, p < 0.001). This suggests that bachelors who had sexual intercourse with partners whom they met online are at higher risk for HIV or other STD infections. Future interventions targeted at this population will improve the efficiency of China's HIV/STD prevention.

Cultural Adaptation of a Medication Adherence Intervention With Prisoners Living With HIV in Indonesia: A Pragmatic Approach to Intervention Development.

Cultural adaptation is a research strategy used to tailor evidence-informed interventions for new populations and settings. We describe a pragmatic approach used to culturally adapt a nurse-led medication adherence intervention, Adherence Through Home Education and Nursing Assessment (ATHENA), for prisoners living with HIV in Indonesia. Researchers reviewed data from completed studies in Indonesia and identified core components of the ATHENA intervention considered essential for effectiveness. Adaptations likely to render ATHENA acceptable and feasible in the Indonesian prison setting were proposed. An intervention led by nurses and peer educators was feasible and congruent with existing models in Indonesian prisons. Involving prisoners with HIV in successive developmental phases helped to ensure a good cultural fit. In the context of prisons and other freedom-limiting environments, a pragmatic approach that integrates members of the target population within an anti-oppressive Freirian pedagogical framework is highly appropriate for adapting evidence-informed interventions.

Group music interventions for dementia-associated anxiety: A systematic review.

OBJECTIVE: This systematic review examines the few published studies using group music interventions to reduce dementia-associated anxiety, the delivery of such interventions, and proposes changes to nursing curriculum for the future. DESIGN: Literature review. METHODS: All quantitative studies from 1989 to 2014 were searched in CINAHL and PubMed databases. Only published articles written in English were included. Studies excluded were reviews, non-human subjects, reports, expert opinions, subject age less than 65, papers that were theoretical or philosophical in nature, individual music interventions, case studies, studies without quantification of changes to anxiety, and those consisting of less than three subjects. Components of each study are analyzed and compared to examine the risk for bias. RESULTS: Eight articles met the inclusion criteria for review. Subject dementia severity ranged from mild to severe among studies reviewed. Intervention delivery and group sizes varied among studies. Seven reported decreases to anxiety after a group music intervention. CONCLUSIONS: Group music interventions to treat dementia-associated anxiety is a promising treatment. However, the small number of studies and the large variety in methods and definitions limit our ability to draw conclusions. It appears that group size, age of persons with dementia and standardization of the best times for treatment to effect anxiety decreases all deserve further investigation. In addition, few studies have been conducted in the United States. In sum, while credit is due to the nurses and music therapists who pioneered the idea in nursing care, consideration of patient safety and improvements in music intervention delivery training from a healthcare perspective are needed. Finally, more research investigating resident safety and the growth of nursing roles within various types of facilities where anxiety is highest, is necessary.

Efficacy of an evidence-based ARV adherence intervention in China.

We designed a randomized controlled trial of a home based intervention to improve antiretroviral adherence and to assess the impact of depressive symptoms among people living with HIV in Hunan, China. At baseline, 110 subjects reported taking 90% or less of prescribed medication. At 6 months, when the intervention ended, 56% of subjects in the control and 87% of subjects in the experimental group were adherent. This difference was maintained at 12 months. In multivariate analyses, controlling for baseline visual analogue adherence scale, stigma, social support, and Center for Epidemiological Studies Depression scale, the experimental group had a significantly higher proportion of people who were adherent (p=0.009). The high prevalence of significant depressive symptoms (67%) at baseline is of concern. It is of particular importance that future studies look at the types of depression likely to be seen in these patients and differentiate early between those likely to benefit from HIV-related support and those who will require additional depression-targeted interventions.

Prevalence of WHO transmitted drug resistance mutations by deep sequencing in antiretroviral-naïve subjects in Hunan Province, China.

BACKGROUND: There are few data on the prevalence of WHO transmitted drug resistance mutations (TDRs) that could affect treatment responses to first line antiretroviral therapy (ART) in Hunan Province, China. OBJECTIVE: Determine the prevalence of WHO NRTI/NNRTI/PI TDRs in ART-naïve subjects in Hunan Province by deep sequencing. METHODS: ART-naïve subjects diagnosed in Hunan between 2010-2011 were evaluated by deep sequencing for low-frequency HIV variants possessing WHO TDRs to 1% levels. Mutations were scored using the HIVdb.stanford.edu algorithm to infer drug susceptibility. RESULTS: Deep sequencing was performed on samples from 90 ART-naïve subjects; 83.3% were AE subtype. All subjects had advanced disease (average CD4 count 134 cells/mm3). Overall 25.6%(23/90) of subjects had HIV with major WHO NRTI/NNRTI TDRs by deep sequencing at a variant frequency level ≥ 1%; 16.7%(15/90) had NRTI TDR and 12.2%(11/90) had a major NNRTI TDR. The majority of NRTI/NNRTI mutations were identified at variant levels <5%. Mutations were analyzed by HIVdb.stanford.edu and 7.8% of subjects had variants with high-level nevirapine resistance; 4.4% had high-level NRTI resistance. Deep sequencing identified 24(27.6%) subjects with variants possessing either a PI TDR or hivdb.stanford.edu PI mutation (algorithm value ≥ 15). 17(19.5%) had PI TDRs at levels >1%. CONCLUSIONS: ART-naïve subjects from Hunan Province China infected predominantly with subtype AE frequently possessed HIV variants with WHO NRTI/NNRTI TDRs by deep sequencing that would affect the first line ART used in the region. Specific mutations conferring nevirapine high-level resistance were identified in 7.8% of subjects. The majority of TDRs detected were at variant levels <5% likely due to subjects having advanced chronic disease at the time of testing. PI TDRs were identified frequently, but were found in isolation and at low variant frequency. As PI/r use is infrequent in Hunan, the existence of PI mutations likely represent AE subtype natural polymorphism at low variant level frequency.

Depressive symptoms and social support among people living with HIV in Hunan, China.

Depressive symptoms are common among people living with HIV (PLWH) and are associated with poor adherence to antiretroviral treatment and poor treatment outcomes. Our study investigated the prevalence of and factors associated with depressive symptoms in PLWH in one Chinese province. Data were collected from 496 PLWH between July 2009 and July 2010 at two HIV treatment sites in Hunan Province, China. Sixty-two percent (n = 309) of participants scored 16 or more on the Center for Epidemiological Studies of Depression scale, indicating moderate to high levels of depressive symptoms. Independent predictors of depressive symptoms included active heroin use, lack of a stable job, female gender, and limited social support. These data suggest that interventions addressing depressive symptoms should be included in HIV care programs provided by the Chinese government, with a special focus on PLWH who are heroin users, female, unemployed, or socially isolated.

Cultural adaptation of an evidence-based nursing intervention to improve medication adherence among people living with HIV/AIDS (PLWHA) in China.

BACKGROUND: Adapting nursing interventions to suit the needs and culture of a new population (cultural adaptation) is an important early step in the process of implementation and dissemination. While the need for cultural adaptation is widely accepted, research-based strategies for doing so are not well articulated. Non-adherence to medications for chronic disease is a global problem and cultural adaptation of existing evidence-based interventions could be useful. OBJECTIVES: This paper aims to describe the cultural adaptation of an evidence-based nursing intervention to improve medication adherence among people living with HIV/AIDS and to offer recommendations for adaptation of interventions across cultures and borders. SITE: The intervention, which demonstrated efficacy in a randomized controlled trial in North America, was adapted for the cultural and social context of Hunan Province, in south central China. SOURCES OF DATA: The adaptation process was undertaken by intervention stakeholders including the original intervention study team, the proposed adaptation team, and members of a Community Advisory Board, including people living with HIV/AIDS, family members, and health care workers at the target clinical sites. PROCEDURES: The adaptation process was driven by quantitative and qualitative data describing the new population and context and was guided by principles for cultural adaptation drawn from prevention science research. RESULTS: The primary adaptation to the intervention was the inclusion of family members in intervention activities, in response to the cultural and social importance of the family in rural China. In a pilot test of the adapted intervention, self-reported medication adherence improved significantly in the group receiving the intervention compared to the control group (p=0.01). Recommendations for cultural adaptation of nursing interventions include (1) involve stakeholders from the beginning; (2) assess the population, need, and context; (3) evaluate the intervention to be adapted with attention to details of the original studies that demonstrated efficacy; (4) compare important elements of the original intervention with those of the proposed new population and context to identify primary points for adaptation; (5) explicitly identify sources of tension between intervention fidelity and cultural adaptive needs; (6) document the process of adaptation, pilot the adapted intervention, and evaluate its effectiveness before moving to dissemination and implementation on a large scale.

Stigma mediates the relationship between self-efficacy, medication adherence, and quality of life among people living with HIV/AIDS in China.

Although the relationship between self-efficacy and health-related behaviors is well known, limited data are available describing the association between self-efficacy and HIV stigma. Specifically, it is not known if the relationship between self-efficacy and health outcomes is mediated by HIV stigma. This study aimed to test these relationships. Data were collected from 202 HIV/AIDS patients in China using questionnaires measuring self-efficacy for disease management, self-reported 7 day medication adherence, perceived HIV/AIDS stigma and quality of life. The total mean score for self-efficacy was 6.73 (range, 2.78-10.0), and the total mean score for HIV stigma was 102.24 (range, 57.0-148.0). Seventy-four percent (150/202) of subjects reported missing no medication doses during past 7 days, and 73% (148/202) subjects reported a quality of life score over 60. There was a moderate level of association between self-efficacy and HIV stigma (Pearson r=-0.43, p=0.000). High self-efficacy predicted better medication adherence (odds ratio [OR]=1.82, 95% confidence interval [CI]=1.40-2.36) and better quality of life (OR=1.28, 95% CI=1.03-1.60) after controlling for demographic and HIV related characteristics. HIV stigma partially mediated the relationship between self-efficacy and medication adherence (OR=1.64, 95% CI=1.26-2.15; Sobel test result Z=1.975, p=0.048). HIV stigma totally mediated the relationship between self-efficacy and quality of life (OR=1.15, 95% CI=0.91-1.46; Sobel test result Z=2.362, p=0.018). The results suggest that, although self-efficacy is an important predictor for medication adherence and quality of life, HIV stigma as a mediator should not be neglected. Health care providers should also evaluate HIV stigma conditions when seeking to improve self-efficacy through interventions.

Effects of nurse-delivered home visits combined with telephone calls on medication adherence and quality of life in HIV-infected heroin users in Hunan of China.

AIMS AND OBJECTIVES: This study aimed to examine the effects of nurse-delivered home visits combined with telephone intervention on medication adherence, and quality of life in HIV-infected heroin users. BACKGROUND: Drug use is consistently reported as a risk factor for medication non-adherence in HIV-infected people. DESIGN: An experimental, pretests and post-tests, design was used: baseline and at eight months. METHODS: A sample of 116 participants was recruited from three antiretroviral treatment sites, and 98 participants completed the study. They were randomly assigned to two groups: 58 in the experimental group and 58 in the control group. The experimental group received nurse-delivered home visits combined with telephone intervention over eight months, while the control group only received routine care. The questionnaire of Community Programs for Clinical Research on AIDS (CPCRA) Antiretroviral Medication Self-Report was used to assess levels of adherence, while quality of life and depression were evaluated using Chinese versions of World Health Organization Quality of Life Instrument-Abbreviated version (WHOQOL-BREF) and Self-rating Depression Scale, respectively. Data were obtained at baseline and eight months. RESULTS: At the end of eight months, participants in the experimental group were more likely to report taking 100% of pills (Fisher's exact = 14.3, p = 0.0001) and taking pills on time (Fisher's exact = 18.64, p = 0.0001) than those in the control group. There were significant effects of intervention in physical (F = 10.47, p = 0.002), psychological (F = 9.41, p = 0.003), social (F = 4.09, p = 0.046) and environmental (F = 4.80, p = 0.031) domains of WHOQOL and depression (F = 5.58, p = 0.02). CONCLUSIONS: Home visits and telephone calls are effective in promoting adherence to antiretroviral treatment and in improving the participants' quality of life and depressive symptoms in HIV-infected heroin users. RELEVANCE TO CLINICAL PRACTICE: It is important for nurses to recognise the issues of non-adherence to antiretroviral treatment in heroin users. Besides standard care, nurses should consider conducting home visits and telephone calls to ensure better health outcome of antiretroviral treatment in this population.

An analysis of electronically monitored adherence to antiretroviral medications.

Medication adherence studies increasingly collect data electronically, often using Medication Event Monitoring System (MEMS) caps. Analyses typically focus on summary adherence measures, although more complete analyses are possible using adaptive statistical methods. These methods were used to describe individual-subject adherence patterns for MEMS data from a clinical trial. Subjects were adaptively clustered into groups with similar adherence patterns and clusters were compared on a variety of subject characteristics. There were seven different adherence clusters: consistently high, consistently moderately high, consistently moderate, consistently moderately low, consistently low, deteriorating starting early, and deteriorating late. Compared to other subjects, subjects with consistently high and consistently moderately high adherence were more likely to be male, White, and older and to maintain during study participation a CD4 cell count over 500 and an HIV viral load of at most 400 copies/ml. These results demonstrate the effectiveness of adaptive methods for comprehensive analysis of MEMS data.

Hormonal contraception and metabolic outcomes in women with or at risk for HIV infection.

OBJECTIVE: The use of hormonal contraception (HC) is increasing in HIV-infected women. Both HC and HIV infection have been associated with adverse metabolic outcomes. We investigated the association of progestin-only and combined (estrogen/progestin) HC with disorders of glucose and lipid metabolism in HIV-infected and uninfected women. METHODS: Linear mixed models evaluated the association of HC type with fasting high density lipoprotein, low density lipoprotein, triglycerides, the homeostasis model assessment estimate of insulin resistance (HOMA-IR), and glucose in 885 HIV-infected and 408 HIV-uninfected women from the Women's Interagency HIV Study seen between October 2000 and September 2005. RESULTS: Compared with non-HC users, progestin-only HC was independently associated with lower HDL [-3 mg/dL; 95% confidence interval (CI) -5, -1 in HIV-infected and -6 mg/dL; 95% CI: -9, -3 in HIV-uninfected women] and greater HOMA-IR (+0.86; 95% CI: 0.51-1.22 and +0.56; 95% CI: 0.12-1.01). Combined HC was associated with higher HDL (+5 mg/dL; 95% CI: 2-7 and +5 mg/dL; 95% CI: 3-7). CONCLUSIONS: HIV-infected women using progestin-only HC have lower HDL and greater HOMA-IR than HIV-infected non-HC users. Combined HC may be preferred in HIV-infected women of reproductive age at risk for cardiovascular disease, but interactions with antiretroviral therapy that may impair contraceptive efficacy have been reported. Alternative HC methods that minimize adverse outcomes but maintain efficacy require further study.

Consistent ART adherence is associated with improved quality of Life, CD4 counts, and reduced hospital costs in central China.

This study aimed to assess levels of ART adherence and to examine the relationship between adherence and treatment outcomes. A longitudinal study in Hunan and Hubei provinces used the CPCRA Antiretroviral Medication Self-Report and a 7-day Visual Analogue Scale to assess levels of adherence, while quality of life was evaluated using SF-36. CD4 cell count and the number, duration, and cost of hospitalizations were collected from participant medical records. Measurements were obtained at baseline, month 3, and month 6. A total of 113 participants enrolled and 98 completed the study. The mean level of adherence was 91%, 89%, and 88% at baseline and at 3 and 6 months, respectively. Of participants, 54/98 (58%) reported taking all doses at all three interviews and were classified as consistent adherers (CA). CAs had better physical function (p = 0.001), general health (p = 0.009), vitality (p = 0.016), social functioning (p = 0.001), and mental health (p = 0.023), and presented a higher CD4 cell count (p = 0.028). CAs also had fewer hospital admissions and readmissions (p = 0.005), shorter hospital stays (p = 0.005), and lower hospital expenses (p = 0.006). Consistent adherence is associated with better outcomes including improved quality of life, higher CD4 counts, and lower health care costs.

Adherence to antiretroviral medication among HIV-positive patients in Thailand.

BACKGROUND: The use of antiretroviral (ARV) medications is expanding rapidly in Thailand. The determinants of optimal adherence for HIV-positive patients in Thailand are unknown. METHODS: A sample of 149 Thai patients receiving ARV therapy at Bhumrasnaradura Infectious Disease Institute located near Bangkok completed a structured questionnaire and reported medication adherence on a 30 day visual analog scale. HIV RNA test results were abstracted from the medical record. RESULTS: Adherence ranged from 25% to 100%. The median was 100% and the mean was 96%. The majority of subjects (114, 77%) had an HIV RNA /=95% (odds ratio [OR] = 3.0; 95% confidence interval [CI] 1.3 to 7.1; P = 0.02) and with a lower mean number of months on ARV therapy (22 versus 32 months; P = 0.03). Gender, educational level, method of payment, use of GPO-VIR, and whether or not the patient was on his or her initial ARV regimen were not associated with an undetectable viral load. In the multivariate analysis, only length of time in months was associated with an undetectable viral load. For each additional month, the odds of being undetectable were 0.975. (OR = 0.975; 95% CI 0.954 to .996; P = 0.02). CONCLUSIONS: Adherence was high in this cohort and was associated with HIV-RNA levels. However, these data confirm that adherence is only 1 factor that determines the effectiveness of ARV treatment. Duration of treatment was associated with virologic failure, controlling for adherence.

Adjusting and censoring electronic monitoring device data. Implications for study outcomes.

Electronic monitoring device (EMD) data are widely used to measure adherence in HIV medication adherence research. EMD data represent an objective measure of adherence and arguably provide more valid data than other methods such as self-reported measures, pill counts, and drug level concentration. Moreover, EMD data are longitudinal, include many measurements, and yield a rich data set. This article illustrates potential pitfalls associated with this measurement technique, including lack of clarity associated with EMD data, and the extent to which adherence outcomes are affected by data management decisions. Recommendations are given regarding what information should be included in publications that report results based on EMD data so as to facilitate comparisons between studies.

The health care relationship (HCR) trust scale: development and psychometric evaluation.

A sequential multi-method approach using focus groups, individual interviews, and quantitative instrument development procedures was used to develop and evaluate a scale to measure patient trust in health care providers (HCPs). The resulting 15-item Health Care Relationship (HCR) Trust Scale was tested for internal consistency, test-retest reliability, and construct validity. The Cronbach alphas were .92 (time 1) and .95 (time 2), respectively. Test-retest reliability was .59 (p < .01). The HCR Trust Scale did not correlate with the Marlowe-Crowne Social Desirability Scale (r = .20, p = .07) or the Rapid Estimate of Adult Literacy in Medicine scale (r = -.21, p = .13). Principal component factor analysis with varimax rotation revealed a three-factor solution that explained 69% of the estimated common variance in the HCR trust scale. Cronbach alphas for the 3 factors ranged from .81 to .89. Findings of this study support the use of the HCR Trust Scale for measuring trust in various HCPs by diverse patient populations. More work is needed to test the usefulness of the scale with a greater number of patients and in other chronic illness populations.

Home visits to improve adherence to highly active antiretroviral therapy: a randomized controlled trial.

BACKGROUND: Few rigorously designed studies have documented the efficacy of interventions to improve medication adherence among patients prescribed highly active antiretroviral. Data are needed to justify the use of limited resources for these programs. METHODS: A 2-arm, randomized, controlled trial evaluated the efficacy of a community-based, home-visit intervention to improve medication adherence. Participants were 171 HIV-infected adults prescribed a minimum of 3 antiretroviral agents. The majority had a past or current history of substance abuse. Subjects were randomly assigned to receive home visits for 1 year or usual care. Medication adherence was assessed with Medication Event Monitoring stem caps at 3-month intervals from randomization through 3 months after the conclusion of the intervention. RESULTS: A larger proportion of subjects in the intervention group demonstrated adherence greater than 90% compared with the control group at each time point after baseline. The difference over time was statistically significant (Extended Mantel-Haenszel test: 5.80, P = 0.02). A statistically significant intervention effect on HIV-RNA level or CD4 cell count was not seen, but there was a statistically significant association between greater than 90% adherence and an undetectable HIV-RNA over time (P < 0.03). CONCLUSION: Home visits from a nurse and a community worker were associated with medication adherence greater than 90% among a cohort of socially vulnerable people living with HIV/AIDS in northeastern United States.

Effectiveness of an HIV/AIDS educational programme for Chinese nurses.

AIM: This paper reports a study examining the effect of a multifaceted HIV/AIDS educational intervention on the knowledge, attitudes and willingness of Chinese nurses in caring for patients with human immunodeficiency virus. BACKGROUND: The expanding HIV/AIDS epidemic challenges nurses to increase their knowledge about this devastating illness to provide effective HIV/AIDS prevention and care to their patients. HIV/AIDS educational interventions, which were developed for North American and European nurses, have not been studied among nurses in other societies. METHODS: The study employed a pretest, post-test experimental design with 208 nurses from seven Chinese provinces. The intervention consisted of a 5-day workshop comprising didactic lectures interspersed with activities designed to elicit discussion of participants' values and personal feelings about HIV/AIDS. Bloom's Taxonomy and principles of good HIV/AIDS educational practice guided the educational intervention. Outcome variables were HIV/AIDS knowledge, attitude toward patients with HIV/AIDS (including empathy for and desire to avoid these patients) and willingness to provide nursing care to these patients. The data were collected in 2003. FINDINGS: At baseline, HIV/AIDS knowledge was not high and attitudes and willingness to care were neutral. Knowledge, attitudes toward patients with HIV/AIDS and willingness to provide nursing care to these patients were each improved at the conclusion of the workshop (P<0.001). CONCLUSIONS: As the HIV/AIDS epidemic expands, nurses will be called upon to deliver competent, compassionate and comprehensive care to patients and their significant others. Intensive, interactive HIV/AIDS professional workshops can contribute to the national effort by increasing knowledge and improving attitudes towards and willingness to provide nursing care for patients with HIV/AIDS.

Knowledge, attitudes, behaviors, and perceptions of risk related to HIV/AIDS among Chinese university students in Hunan, China.

The purpose of this paper is to describe HIV/AIDS knowledge, attitudes, and perceptions and identify personal risk behaviors among undergraduate students in China. A descriptive, cross-sectional survey of 1326 students between ages 17 through 28 was conducted in 2002. Results indicated that students held considerable misconceptions about HIV transmission by casual contact and needle sharing as well as stigmatizing attitudes about injection drug use, homosexuality and HIV-positive women who bear children. Results indicated that 14% of Chinese university students are sexually active and risk behaviors tended to increase with age. Additionally, 24% of the students considered themselves to be at moderate to very high risk of contracting HIV and 40% of sexually active students never used condoms. Therefore, it is important to design HIV prevention strategies that target university students in China.

Kitchen table wisdom: a Freirian approach to medication adherence.

Most interventions to promote medication adherence are based on psychological theories of individual behavior. In contrast, this article describes the theory and practice of a socially based adherence intervention that is guided by the educational principles of Paolo Freire. This approach asserts that adherence is influenced by the patient's social context and attempts to improve adherence through identifying social constraints on adherence behavior. The program builds on the traditions of patient education through home nursing visits. Using a dialectic process of dialogue and problem solving and working with a team that includes a nurse and a peer-educator, patients are encouraged to act to change their social environment to support their desire to achieve high levels of medication adherence. This strategy does not replace, but rather supplements, traditional methods of understanding individual patient behavior and allows the patient and the nurse to consider potential solutions to adherence challenges in the larger social context.

Use of electronic monitoring devices to measure antiretroviral adherence: practical considerations.

The purpose of this paper is to describe electronic monitoring device (EMD) (e.g., MEMS caps) use among HIV-infected adults enrolled in a randomized clinical trial and to make explicit some of the benefits and caveats of using electronic monitoring device technology. This is a descriptive, exploratory study of EMD use among 128 HIV-infected adults treated with at least three antiretroviral agents. Thirty-six percent of the sample admitted that they did not use the EMD consistently. Forty-one percent of the subjects reported taking out more than one dose at a time and 26% reported opening the EMD but not taking the medication. Special subject-related issues accounted for only a small percentage of all reported problems with EMD use (e.g., transient housing, incarceration, substance abuse relapse and drug treatment). Results of this study suggest that EMDs may underestimate antiretroviral adherence among HIV-infected adults. Recommendations for improving EMD data quality are presented.