• Proportion of completed directly observed therapy (DOT) facilitator-participant interactions, among all scheduled interactions, for each participant during the second 4-week period on study
  
• number and proportion of participants who were able to complete the recommended duration of DOT
  

• Subject satisfaction with DOT, assessed by the Exit Survey Instrument
  
• cost of implementing DOT per participant
  
• effective ratio of DOT facilitators to participants, determined by the calculation of actual time spent by each DOT facilitator
  
• reproducibility of DOT implementation across sites and participants' adherence to DOT interactions and ability to complete the prescribed duration of DOT, compared across sites
  
• adherence for each participant in the 4-week period prior to a study visit, determined at Weeks 8 and 12 by participant self-report and adherence to DOT interactions and by pill count and participant 4-week recall at Week 24
  
• virologic outcomes, determined by the suppression of HIV-1 viral load at Weeks 8, 12, and 24
  
• immunologic outcome, defined by a change in absolute CD4 count from baseline to Week 24
  
• self-efficacy (confidence), assessed by Patient Assessment Tool - Part I and Beliefs About Medicine Scale
  
• beliefs about highly active antiretroviral therapy (HAART), assessed by Beliefs About Medicine Scale
  
• severity of depression experienced by each participant, assessed by Beck Depression Inventory (BDI)-II
  
• hopelessness, assessed by Beck Hopelessness Scale (BHS)
  
• emotional and behavioral problems, assessed by Youth Self Report (YSR)/Adult Self Report (ASR)
  
• coping of each participant, assessed by Coping Responses Inventory (CRI)-Youth and CRI-Adult
  
• perceived barriers to adherence, assessed at baseline and Weeks 12 and 24 by Patient Assessment Tool - Part I and Beliefs About Medication Scale
  
• substance abuse, assessed at baseline and Weeks 12 and 24 by Patient Assessment Tool - Part II
  
• sustainability of DOT benefits, assessed as the proportion of participants adherent at Week 24 among those who successfully complete the first 8 weeks of DOT and are taken off DOT at 12 weeks
  

For HIV infected people, control of HIV infection is best achieved by adhering to the highly active antiretroviral therapy (HAART) regimen prescribed by their doctors. Poor adherence to a HAART regimen leads to clinical failure and the development of resistance. Many HIV infected adolescents have difficulty adhering to their prescribed anti-HIV regimens or OI prophylaxis; often, they cite forgetting to take their medications as the reason for poor adherence. This is a pilot study of using DOT and assessing adherence during DOT in HIV infected adolescents who have had difficulty adhering to HAART regimens in the past. The purpose of this study is to evaluate the efficacy in increasing patient adherence and the feasibility of using DOT among HIV infected adolescents.

This study will last 24 weeks. For the first 2 weeks of the study, DOT will be provided 7 days a week at the study site; participants will visit the study site daily and will be observed taking their medication. For the next 6 weeks, the frequency of DOT will be reduced from 7 days a week to 5 days a week. Based on adherence from Weeks 4 to 8, each participant will be recommended to continue with a DOT strategy as follows:

• Adherence Level 1 (greater than 93%) - DOT 3 days a week
• Adherence Level 2 (86% to 93%) - DOT 5 days a week
• Adherence Level 3 (less than 86%) - DOT 7 days a week

Participants will decide whether to accept their DOT assignment and to continue in the study. At Week 12 and every 4 weeks thereafter, adherence will be assessed and DOT may be adjusted as follows:

• Adherence Level 1 - Reduce frequency of DOT. Those already receiving DOT 3 days a week stop DOT and start self-administered therapy.
• Adherence Level 2 - Keep same frequency of DOT as the past 4 weeks.
• Adherence Level 3 - Increase frequency of DOT by one level, as described in previous list.

HAART will not be provided by this study, so participants must have access to their HAART medications coordinated separately through the study site. Participants who are taking medication requiring twice-daily dosing will self-administer their second doses.

There will be 7 study visits; they will occur at study entry and every 4 weeks thereafter. Medical history will occur at study entry. At every visit, participants' adherence to their regimens will be assessed, and they will also be interviewed by a social worker about their use of support services. Participants will undergo several assessments at study entry and Weeks 12 and 24 to determine participant confidence, beliefs about medicine, severity of depression, feelings of hopelessness, coping responses, and emotional and behavioral problems. Blood collection will occur at study entry and Weeks 8, 12, and 24. When participants successfully complete their prescribed courses of DOT or elect to discontinue DOT, they will again be interviewed by study staff.