1. Adherence Works In 1998, knew missed doses led to resistant virus. Since 1998, studies have demonstrated that adherence leads to lower viral loads, decreased AIDS progression, and increased survival. For example, clients followed for 7 months demonstrated virologic failure: –22% with 95% adherence –61% with 80-95% adherence –80% with 80% adherence

2. Major Changes in Treatment Since 1998 More understanding of long term side effects and toxicity. New guidelines start treatment later. Resistance testing (genotype and phenotype) may inform prescribing Some evidence on: –Structured treatment interruptions –Intermittent treatment –Rotating regimens

3. Associations of Characteristics and Adherence: Consistent Active psychiatric illness Depression Heavy drinking Adherence at baseline

4. Associations of Characteristics and Adherence: Inconsistent Race Age Sex Mood Drug use Homelessness Health beliefs Coping skills Rapport with providers Poor communication with provider Pill burden Away from home Side effects Mistrust of system Pre-existing conditions Self efficacy Frequency of stressful life events No recent clinic visit Health literacy Economic barriers

5. Associations of Characteristics and Adherence: Ever Income (MACS) Education Meaningful life Comfortable and well cared for Using time wisely Taking time for important things Joy Fear

6. Reasons for Differences in Findings Very different populations Different measures of adherence Different things are measured/asked

7. Reasons for Non-Adherence and Barriers Forgetting Side effects Complexity Knowledge Reminds of HIV status Don’t want others to know Don’t like the way I feel No one to help

8. Reasons for Adherence and Supports Mechanical devices Commitment Belief in medications Social support Professional support Regular meals Use bedtime, other routine to remind Store in a bag to take everywhere Store where others won’t see

9. Patterns of Reasons that Vary for Different Groups IDU history (JHU) –IDU history: stress; heroin use –No IDU history: less than 2 meals per day; less belief in efficacy of drug Health Literacy (WI) –12+ years of education and low health literacy: more confused, side effects, depressed, overslept, cleansing body –Below 12 years education: forgot, no pills, busy

10. Patterns of Reasons that Vary for Different Groups Adherence Level (WI)

11. Patterns of Reasons that Vary for Different Groups Confidential vs. Anonymous Disclosure (CDC- in Bronx) –Confidentially: forgot, medication inaccessible, perceived toxicity –Anonymously: perceived lack of drug efficacy

12. Interventions with Demonstrated Effectiveness: Directly Observed Therapy (DOT) Florida retrospective study comparing 50 treatment naïve prison inmates to 50 similar controls. –Found 100% in DOT group with less than 400VL at 24 weeks and at 90 weeks. –80% in controls with less than 400VL at 24 weeks and at 90 weeks. 10 person pilot (Mitty et. al) showed 1.2 log drop in VL with DOT.

13. Interventions with Demonstrated Effectiveness: DOT (cont.) Miriam Hospital (Providence, RI) pilot shows “drastic” improvements in adherence with peer outreach workers delivering drugs. Caveat: DOT cannot reverse resistance, treatment failure. –Analysis of very experienced patients in NYS LTC facilities showed 1/3 never got to VL<400 copies; 1/2 virologic failure.

14. Interventions with Demonstrated Effectiveness: Mechanical Devices Small study randomizing patients with under 90% adherence into: –Online paging reminder (“medimom”) and MEMS: 16% improvement from baseline level of 52% adherence. –MEMS alone: no change Small trial (N=36 at start; 10 at 24 weeks) of people with cognitive dysfunction: –Mechanical verbal reminder: 99% adherence at 24 weeks. –Control: 69% adherence at 24 weeks.

15. Interventions with Demonstrated Effectiveness: Multifaceted Educational, “Psychoeducational” Support SUNY Buffalo/Erie Medical Center show big effect from 16 week multifaceted intervention (intensive, multifaceted, education, readiness, tools, support). 16 weeks -93% intervention patients had VL <400 copies. -37% SOC patients had VL <400 copies. 32 weeks -100% of those in (16/23) had VL <400 copies. -20% of those in (14/37) had VL <400 copies.

16. Interventions with Demonstrated Effectiveness Spain: 116 patients followed for 48 weeks in randomized groups: –Psychoeducative intervention: 94% had 95% adherence. 89% VL<400. –SOC intervention: 68% had 95% adherence. 60% VL <400. Bandura self efficacy includes education on handling medications; “solving” doubts; input on dosage schedule; tackling problems like forgetting, delays, changes, side effects; given phone number to call for questions; follow up reinforcement and problem solving. Note: Effect not evident until week 48.

17. Interventions with Demonstrated Effectiveness San Fransisco Action Point: pilot intervention with 68 homeless urban poor. –No appointments, open six days per week, $10 cash incentive weekly, pager, prescriptions delivered and held at center, acupuncture, referrals to mental health, substance abuse treatment, housing. –62% retained at 5months: 25/44 knew VL; of these 16 had VL below 500.

18. San Diego: 168 patients randomized and followed for 6 months. Intervention focused on self management, education, and support through group patient education. Interventions with Demonstrated Effectiveness

19. Themes about Effectiveness Flexibility/problem solving/different approaches for different clients. Little evidence on long term effects: some suggestion that interventions maintain initial high level Very different results if analyzed as treated or intend to treat. Need interventions that help keep people connected.

20. Conclusions/Implications Adherence predicts adherence People are different. Their issues are different. Different issues require different solutions. This kind of intervention very difficult to evaluate. Short term and long terms effects not the same.

21. For more HIV-related resources, please visit www.hivguidelines.org