CLINICAL ISSUESEffects of nurse-delivered home visits combined with telephone callson medication adherence and quality of life in HIV-infected heroin usersin Hunan of ChinaHonghong Wang, Jun Zhou, Ling Huang, Xianhong Li, Kristopher P Fennie and Ann B WilliamsAims and objectives. This study aimed to examine the effects of nurse-delivered home visits combined with telephone inter-vention 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 completedthe study. They were randomly assigned to two groups: 58 in the experimental group and 58 in the control group. Theexperimental group received nurse-delivered home visits combined with telephone intervention over eight months, while thecontrol 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 evaluatedusing Chinese versions of World Health Organization Quality of Life Instrument – Abbreviated version (WHOQOL-BREF) andSelf-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 = 14Æ3, p =0Æ0001) and taking pills on time (Fisher’s exact = 18Æ64, p =0Æ0001) than those in the controlgroup. There were significant effects of intervention in physical (F =10Æ47, p =0Æ002), psychological (F =9Æ41, p =0Æ003),social (F =4Æ09, p =0Æ046) and environmental (F =4Æ80, p =0Æ031) domains of WHOQOL and depression (F =5Æ58,p =0Æ02).Conclusions. Home visits and telephone calls are effective in promoting adherence to antiretroviral treatment and inimproving 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 inheroin users. Besides standard care, nurses should consider conducting home visits and telephone calls to ensure better healthoutcome of antiretroviral treatment in this population.Key words: acquired immunodeficiency syndrome, adherence, antiretroviral treatment, heroin addiction, home visit, quality oflife, telephone interventionAccepted for publication: 6 June 2009Authors: Honghong Wang, PhD, RN, Associate Professor, School ofNursing of Central South University; Jun Zhou, BSN, RN, AssistantProfessor, School of Nursing of Central South University; LingHuang, BSN, RN, Assistant Professor, School of Nursing of CentralSouth University; Xianhong Li, BSN, RN, Assistant Professor, Schoolof Nursing of Central South University, Changsha, Hunan, China;Kristopher P Fennie, MPH, PhD, Research Scientist and Lecturer,Yale School of Nursing; Ann B Williams, EdD, RNC, FAAN,Professor of Nursing and Medicine, Yale University, New Haven,CT, USACorrespondence: Honghong Wang, Associate Professor, School ofNursing of Central South University, 172 Tong Zi Po Road,Changsha 410013, Hunan, China. Telephone: 86 731 2650270.E-mail: [email protected]  2010 Blackwell Publishing Ltd, Journal of Clinical Nursing, 19, 380–388doi: 10.1111/j.1365-2702.2009.03048.xIntroductionThe application of antiretroviral treatment (ART) withcombination of drugs has significantly improved the qualityof life, delayed the disease progression and reduced the deathrate in patients with HIV/AIDS (Murphy et al. 2001, Lou-wagie et al. 2007). In China, the national free ARTprogramme began in 2003 and was scaled up in response tothe rapidly growing HIV epidemic (Zhang et al. 2007). Sincelate 2007, according to the Chinese Ministry of Health, acumulative total of 39 298 HIV-infected people had receivedfree ART (MOH/UNAIDS/WHO 2007). The success of ART,however, depends on the levels of patients’ adherence tomedication. As a lifetime treatment, ART requires thatpatients take HIV medication in strict adherence to thephysician’s prescription. Studies have shown that optimaladherence to ART was strongly linked to viral suppressionand improved immunity and quality of life. As adherencedecreases, HIV viral load and the risk of progression to AIDSincrease, as do risks of generating drug-resistant strains ofHIV and of infecting others (Chesney et al. 2000, Patersonet al. 2000, Bartlett 2002, Garder et al. 2008).However, non-adherence is common among HIV-positiveindividuals. Cheever and Wu 1999 reported that 40% ofpatients receiving ART have significant problems withadherence. Some reports from western countries showed thatclose to 20% of the patients had non-adherent behaviours toART medication (Chesney et al. 2000, Aloisi et al. 2002).Two recent studies in China showed similar results (Wang &Wu 2007, Wang et al. 2008). Adherence is a multifacetedissue, influenced by many factors. Studies consistentlyshowed that drug use was associated with high risk ofadherence failure (Aloisi et al. 2002, Golin et al. 2002, Geboet al. 2003, Wang et al. 2008). Drug addiction is a chronicrelapsing condition, which is often associated with periods oflifestyle instability, thereby affecting ART adherence insettings where ART is available. Furthermore, the majorityof drug users are unemployed and poor, experiencessubstantial social stigma and receives limited social support.A carefully designed intervention programme is needed tosupport and improve adherence to HIV medication for thispopulation.As a doubly stigmatised group, HIV-infected drug addictsare less likely to seek counselling and health care from theregular health care settings as others do. Therefore, improv-ing adherence to HIV medication in drug users is a complexprocess that needs to be a addressed at the individualbehavioural and social support levels. Toughette and Shapiro(2008) conclude that intervention programmes to improvemedication adherence should be tailored to meet individuals’need rather than be standardised. ART is a life-longtreatment, therefore, intervention to improve adherence toART should be implemented and addressed in home andcommunity settings. Nurses have more