Medication Adherence: What Can We Do to Help Patients Stick to Therapy Lois Eldred, DrPH, MPH Special Projects of National Significance HIV/AIDS Bureau, HRSA

Viral Suppression in Clinical Practice Lucas, Annals Intern Med 1999

Adherence Critical to Care Nonadherent patients with: u Increased mortality from HIV – OR 1.16 ( ) / 10%  adh 1 u Lower CD4 count increase –+ 6 versus +83 cell/ml increase 2 u Increased hospital days – 12.9 versus 2.5 hosp. days / 1000 days F/U 2 1 Hogg, 7th CROI, Paterson, Ann Intern Med, 2000

How much adherence is enough? Paterson, Ann Intern Med, 2000

Viral Load by Adherence Arnsten, 7th CROI, 2000

Viral load and adherence (MEMS) Mostly women and minorities viral load <100,000 copies/ml, ARV naive Thompson M, et al. XIII IAC, Durban Abstract 1129

Measuring Adherence u No gold standard u Use what is practical –Patient report will overestimate % –Pharmacies can be your friend –Electronic monitoring in selected cases, especially if it will help the patient –Drug levels not practical for adherence monitoring

Factors in Adherence

Predictors of Adherence: Patient u Understanding of the regimen u Alcohol/drug use u Depression u Appointment keeping u Health beliefs and attitudes u Perception of control (self efficacy) u Social support

Adherence and Illicit Drug Use Adapted Cheever, ICAAC, 1999

Drug Abuse Treatment Works 1 OR 1.88 ( ) 2 OR 4.91 ( ) Moatti, AIDS, 2000

Health Beliefs and Attitudes u Associated with antiretroviral (ARVs) use –ARVs will help me have fewer symptoms of HIV –ARVs will help me live longer u Associated with adherence –Medications will often fit into daily routine –If don’t take right, resistance will develop Paterson, Abs 92; Kaplan, Abs 96; Wenger, Abs 98; 6th CROI, 1999; Cheever, Abs 591, 39th ICAAC, 1999

Interventions to Improve Adherence u Barriers to adherence –Differ among patients –Vary over time u Principles of interventions –Multifaceted –Repetitive –Initiated prior to resistance developing

Self Efficacy Counseling to Improve Adherence u Randomized, controlled trial u Intervention: –Counseling to increase self efficacy –Strategies to increase adherence –Association of adherence and resistance –Telephone number for questions Tuldra, JAIDS 2000

Self Efficacy Counseling to Improve Adherence Tuldra, JAIDS 2000

Factors in Adherence

Adherence: Treatment Regimen u Number of doses, medications, pills u Length of time on therapy u Dietary restrictions u Side effects

Side Effects Impact Adherence Arnsten, 7th CROI, 2000

Factors in Adherence

Medical System u Team support and interventions u Doctor- Patient relationship –Trust / satisfaction u Patient education –Appointment reminders –Multiple and varied reinforcers u Accessibility of appointments, medication –Child care / child friendly environment –Transportation

Engagement in Care u Convenience Sample of 707 outpatients u Engagement in care: Interaction with health care provider (13 item scale) –Listens to me –Cares about me –Respects me –Spends enough time with me –Includes me in decision making Bakken, AIDS Patient Care and STDs, 2000

Non-engaged Patients u More likely to be current/past injection drug users (p=0.002) u Nonadherent with –Medication taking –Medical appointments –Following medical advice u Not associated: type of provider, sex, race Bakken, AIDS Patient Care and STDs, 2000

Satisfaction with Information p=0.02 Tuldra, 7th Euro. Conf. Clin. Aspect. And Tx of HIV, 1999

Asking about Adherence: What works Steele, J Fam Pract 1990 “You’re gaining weight. You must be taking your medicine okay.” 0% “Any problems with your medicines?”63% “Almost everyone misses medicines some of the time. In the last (week/month) how many doses of medicine do you think you’ve missed?” “Tell me exactly how you take your medicines.” 80%

Asking About Adherence u Permission for missed dose: Almost everyone misses medicines some of the time. u Specific questioning: In the last (week/month) how many doses of medicine do you think you’ve missed? u Verify understanding of regimen: Tell me exactly how you take your medicines.

Interventions to Improve Adherence: Background u Clinicians play a specific role and significant role in initiating and monitoring adherence u Adherence research and other diseases focuses primarily on physicians u Most HIV adherence interventions involve a team of providers

Improving Access to Care u >1/3 of patients in U.S. sample (HCSUS) went without medical care due to:1 – Need for money for food/clothing/housing – Lack of transportation – Inability to get time off from job/work – Feeling too sick u Caring for others: Putting off care 2 – Women OR 1.6 ( ) – Having child in household OR 1.8 ( ) 1 Cunningham, Med Care 1999, 2 Stein Am J of Pub Health 2000

Support Services and Retention in Care Sherer R, AIDS Care, 2002 n= % increase in regular visits (>2/year) in an urban clinic with support services,

Directly Observed Therapy DOT = directly observed therapy (incarcerated cohort) SAT = self-administered therapy (free clinic cohort) 4 Fischl 7th CROI, SF, Abs 71

Interventions: Incentives Work Chaisson, JAIDS, 1996

Incentive to Improve Adherence u Randomized, controlled trial –MEMS device and AZT plasma levels u Intervention –Cue dose training –Feedback from MEMS device –Cash ($2/correct dose up to $10/day, $280 max.) Rigsby, J Gen Intern Med 2000

Incentive to Improve Adherence Rigsby, J Gen Intern Med 2000

SPNS/HRSA Initiative: Adherence u 14 Projects with varying adherence interventions ( ) u Common core data evaluated among the projects u Evaluation Center: New York Academy of Medicine; Center for Adherence Support and Education (CASE)

CASE Findings u “readiness” component helps client maintain high levels of adherence u Interventions based on Prochaska’s stages of change helpful over 6 months u No direct relationship between the intensity of encounters and improvement in adherence u Specific support and clinical services have positive impact over time

Medication Support Versus Standard of Care: Johns Hopkins HIV Clinic u Nurse Education u Case Management u Peer Advocacy u Group Education u Results: High users of readiness program more likely to achieve improved viral suppression (< 50)

Self Efficacy Counseling to Improve Adherence VariableOdds RatioCIp value Self efficacy – Intervention group – Effort Index – Multivariate Analysis: Adh. >95% at 48 wks Tuldra, JAIDS 2000

Adherence: Conclusions u Adherence is critical for long term success of HAART u Interventions must be maintained over time u Barriers differ among patients and over time interventions must be patient-tailored u Adherence interventions are now a standard part of quality HIV care

Adherence: Where do we go from here? u Needs assessment of readiness and active interventions to promote self-efficacy for taking medications u Collaborative approach in timing the initiation of medication u Group support and education is a powerful tool Self-management Programs

Adherence: Where do we go from here? u Use experiences with other chronic disease self-management programs u Cost effectiveness must be demonstrated as adherence interventions are integrated into practice

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