1. Adetunji Adejumo, MD; Cynthia Lee MA; Sharon Mannheimer, MD
PATIENT CENTERED PEER BASED PROGRAM TO IMPROVE ADHERENCE TO HIV THERAPY: THE HATS-PC INITIATIVE
Adetunji Adejumo, MD; Cynthia Lee MA; Sharon Mannheimer, MD
Department of Medicine, Division of Infectious Disease,
Harlem Hospital Center/Columbia University, New York, New York. 
Issue
Method
Conclusion
We matched clients to peers with similar backgrounds.
Peers met with assigned client at least weekly in person or by telephone. They facilitated communication with providers and referred clients to case worker or health educators. Adherence specific case management is then employed by case workers. The goal is >95% adherence to prescribed doses. Adherence is measured by a 7-day self report assessment, evaluation of laboratory data at baseline, then quarterly and stage of behavioral change. We also conducted analysis of change in HIV viral load and CD4 T-cell count at 0, 3, 6, 9, and 12 months of participation Data are used to assess changes in adherence. Clients exited the program when they are consistently adherent to HAART for 6 months.
The success of HIV treatment depends on high adherence rate (>95%) to antiretroviral therapy (ART). Adherence is affected by several complex barriers most of which are modifiable. Peer educators can provide individualized adherence support to address poor social support as well as issues of mistrust in a minority community such as Harlem where the HIV prevalence rate is more than twice that of New York City as a whole.
In a minority population with high HIV prevalence like ours where stigma and stereotyping prevent access, utility and retention of healthcare, a HATS-PC program using peer based workers will improve treatment outcomes of HIV infected adults and reduce the risk of HIV resistance while impacting positively on the overall quality of life for HIV infected patients. Challenges remain in matching the ever increasing number of HATS-PC eligible clients with increasingly difficult to find qualified peer workers.
Setting
The Harlem Adherence to Treatment Support in Primary Care (HATS-PC) program, funded by NYS AIDS Institute, was initiated to improve ART adherence at an outpatient HIV clinic at Harlem Hospital which provides primary care to over 750 HIV-Infected individuals (population >80% African American, 47% women). With over one-third of patients reporting active substance use, we estimated that over half may be non adherent or at risk of non adherence (i.e. taking <80% of prescribed doses).
Baseline Demographics and Outcome
Lessons Learned
Variable Patients (n = 21)
Age, mean years (range) y ( 28-59)
Gender
Male % (n = 7)
Female % (n = 14)
Ethnicity
Black %
Hispanic %
White %
Entry
CD4, mean cells/uL
Viral Load, mean >100,000cpcs/ml
Exit
CD4, mean cells/uL
Viral Load, mean N/A
Reasons For Non-Adherence
Substance Abuse %
Depression %
Language Barrier %
HAART side effect %
Program Exit
Graduated % (n = 13)
Retained % (n = 7)
Lost % (n = 1)
Peer based adherence support can improve adherence to treatment in our population of inner city, predominantly African American HIV-infected adults.
Additionally, there is need for specific interventions to address substance use in this population.
Bibliography
1. Mannheimer, Sharon B MD; Morse, Edward PhD; Matts, John P PhD; et al. Sustained Benefit From a Long-Term Antiretroviral Adherence Intervention: Results of a Large Randomized Clinical Trial. J of Acquired Immune Deficiency Syndromes. 2006; 43(11): 41-47
2. Stone, VE: Strategies for optimizing adherence to highly active antiretroviral therapy: lessons from research and clinical practice. Clin Infect Dis. 2001; 33(6):
.3. Fielden SJ, Rusch ML, Yip B, et al: Nonadherence increases the risk of hospitalization among HIV-infected antiretroviral naive patients started on HAART. J Int Assoc Physicians AIDS Care (Chic Ill). 2008; 7(5):
4. Marino P, Simoni JM, Silverstein LB: Peer support to promote medication adherence among people living with HIV/AIDS: the benefits to peers. Soc Work Health Care. 2007; 45(1): 67-80
5. Broadhead RS, Heckathorn DD, Altice FL, et al. Increasing drug users' adherence to HIV treatment: results of a peer-driven intervention feasibility study. Soc Sci Med. 2002; 55(2):
Project
HATS-PC program is a patient-centered,
multidisciplinary team that includes peer worker, case
worker, HIV primary care providers and a program
coordinator/health educator. Peer workers are HIV
infected individuals from the same community,
adherent to HAART, with good communication skills
and commitment to helping others. Peers respect client
confidentiality, are nonjudgmental and in stable
recovery from substance use. Program peer workers
received a 6-week training focused on HIV/ART, and
counseling techniques.
Patients eligibility criteria include:
HIV-infected,
receiving HIV care at Harlem hospital,
currently receiving or eligible to receive HAART,
having current or prior difficulty with adherence or initiating HAART and,
willingness to work with a peer-worker.
Results
21 HIV-infected patients were enrolled in 2008, assigned to 2 peer workers. 66% (n =14) were females and 33% (n = 7) males, mean age 43.2y (range 28-59). 76% were African-American while 23% identified as Hispanic and 1% Caucasian.
Main reason for non-adherence was substance use (43%). Other reasons were depression (23%), communication barrier (14%) and medication side effect (9%).
At entry only 19% (n = 4) had HIV RNA undetectable (i.e. viral load <50copies; 50% men, mean age 49, CD4 range /uL).
In the majority 81% (n = 17) HIV RNA ranged between 480 copies/ml and ≥100,000 copies/ml (71% women, mean age 37, mean CD4 258 cells/uL
62% (n = 13) graduated from the program having achieved a target of >95% adherence for 6 months (mean CD4 490) while 33% (n = 7) continue to be non-adherent and remain in the program. One patient was lost to follow up.
Acknowledgments
1.Wafaar El-Sadr, MD. Division of Infectious Disease, Harlem Hospital Center, New York, NY10037
2.HATS-PC Peers Infectious Disease Clinic, Hospital Center, New York, NY 10037
3.Vel Sivapalan. Attending, Fellowship Program Director, Division of Infectious Disease, Harlem Hospital Center, New York, NY 10037
4. Zion Oshikanlu, MD. Chief Resident
Harlem Hospital Center, New York, NY 10037
Contact Information
Adetunji Adejumo, MD.
ID Clinical Fellow
Department of Medicine,Division of Infectious Diseases
Harlem Hospital Center/Columbia University
506 Lenox Avenue ,New York, NY