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Intervening to Improve Adherence – What do we Know?

Intervening to Improve Adherence – What do we Know? . Conall O’Cleirigh, Ph.D. Associate Director Behavioral Medicine, Department of Psychiatry Massachusetts General Hospital Harvard Medical School Behavioral Scientist The Fenway Institute Boston.

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Intervening to Improve Adherence – What do we Know?

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  1. Intervening to Improve Adherence – What do we Know? Conall O’Cleirigh, Ph.D. Associate Director Behavioral Medicine, Department of Psychiatry Massachusetts General Hospital Harvard Medical School Behavioral Scientist The Fenway Institute Boston

  2. Intervening to Improve Adherence – What do we Know? • Qualitative Reviews of the Intervention Literature • Simoni et al., Cur HIV/AIDS Rep, 2010 • Reisner et al., Topics in HIV Medicine, 2008 • Recent and current meta analyses • Simoni et al., JAIDS 2006 • De Bruin et al Arch Intern Med 2010 • Hart et al., JAIDS, 2010

  3. Intervening to Improve Adherence – What do we Know? • Recently Reported RCTs - Ingersoll, et al., Drug Alcohol Dep, 2011 - Johnson et al., Ann Behav Med, 2011 - Fisher et al., AIDS Behav, 2011 - Kalichman et al., Am J Public Health, 2011 - Safren et al., Health Psychology, 2010 - De Bruin et al., Health Psychology, 2010 - Webel et al., AIDS Care, 2010 - Simoni et al., JAIDS, 2009

  4. Intervening to Improve Adherence – What do we Know? • Technology Based Studies - Pager/Electronic Reminder - Simoni et al., JAIDS, 2009 - Hardy et al., AIDS Patient Care, 2011 - Text Messages • Lester et al., Lancet, 2010 • Pop-Eleches., et al., AIDS, 2011 • Other Preliminary Acceptability Studies • Skrajner, Et al., HIV AIDS Auckl, 2009 • Harris, et al., Telemed J E Health, 2010

  5. Interventions are heterogeneous with respect to • Intervention content • Interventionist • Dose (length, # of sessions) • Assessment/Follow-up period • Patient characteristics • Range of target behaviors

  6. Interventions are heterogeneous with respect to…. …..Intervention Content - Video based motivational interviewing - Social Problem Solving/Coping Effectiveness Training - Peer Based Social Support/Pager Messaging Peer based symptom management/self monitoring - Integrated Interventions w/sexual risk reduction substance use treatment CBT for depression

  7. Interventions are heterogeneous with respect to…. …..Intervention Content -Technology Based Intervention Personalized Text Messaging Interactive Text Messaging Informational Content Motivational Content Short/Long Messages

  8. Interventions are heterogeneous with respect to…. .….Interventionist/ Dose (length, # of sessions) • Nurses (2 sessions) • Video delivered (6 sessions) • Computer administered (mean 6 brief sessions – variable dose) • Doctorate Level Psychologists (10 sessions) • Masters Level Clinicians (5 sessions) • Community-based facilitator (5 2-hour groups & 2 1-hour indiv) • HIV Peer Interventionists (6 1-hour groups) • Pharmacists (mean = .9 sessions per month (18 min session)

  9. Interventions are heterogeneous with respect to…. .…. Assessment/Follow-up period - MEMS Cap 9 month f/u • Self-Report Time Line Follow Back 6 month f/u • Self-Report Dichotomized @ 100% 15 month f/u • Unannounced Monthly Pill Counts 9 month f/u • MEMS Cap and Self –Report 9 month f/u • Self-Report (% missed doses) 6 month f/u • Self Report (analogue and % missed) up to 18 months f/u • MEMS Cap and Self –Report 6 month f/u • Self-Report (% missed past 30 days) 12 month f/u • past 30 dayssdha

  10. Interventions are heterogeneous with respect to…. .…. Patient Characteristics • MSM 18 + (no substance abuse) • MSM 18 + substance users (predominantly African American) • Men and women with high levels of ART s/e distress • Depressive symptoms and history of opiate dependence • Predominantly African American men • Predominantly men • Women • Men and women with no cognitive impairments • Less than 85% adherence • Kenyan, 18+, ART naïve (less than 3 months), with mobile phone • Kenyan, 18+, less than 3 months on ART • past 30 dayssdha

  11. Interventions are heterogeneous with respect to…. .…. Results Ingersoll, et al., Drug Alcohol Dep, 2011 No significant difference between MI and Video MI conditions Johnson et al., Ann Behav Med, 2011 Treatment effect for non adherence maintained at 15 months Fisher et al., AIDS Behav, 2011 ITT non-significant: Intervention related changes in adherence for those with minimum dose and no ART interruptions. Kalichman et al., Am J Public Health, 2011 Treatment effect for adherence (pill count) maintained at follow up • past 30 dayssdha

  12. Interventions are heterogeneous with respect to…Results Safren et al., Health Psychology, 2010 Treatment effect on MEMS adherence, depression (mediator) and CD4 count (6 month). Adherence did not maintain at follow up De Bruin et al., Health Psychology, 2010 Effects significant for adherence and undetectable viral load at 4 months Treatment related changes in VL were mediated by adherence. Webel et al., AIDS Care, 2010 No significant intervention effects Simoni et al., JAIDS, 2009 Peer support alone yielded a 2 fold increase in adherence – did not maintain post treatment. Pager alone was not significant for adherence but was for CD4 at 6 and 9 months • past 30 dayssdha

  13. Interventions are heterogeneous with respect to…. .…. Results • Technology Based Studies Electronic Reminders Hardy et al., AIDS Patient Care, 2011 Significant effect for cell phone intervention over beeper at 6 weeks on MEMS adherence . Text Messages Lester et al., Lancet, 2010 Intervention associated with significantly more reports of 95%+ adherence and higher proportion with undetectable viral load at follow up. Pop-Eleches., et al., AIDS, 2011 Significant treatment effect for MEMS adherence for those receiving weekly reminders across 48 weeks of follow up.

  14. Some tentative conclusions It appears that various methodologies are associated with the acquisition of significantly improved adherence including Project Balance (social problem solving/ coping effectiveness tx) IMB based intervention Peer Support delivered MI based intervention Integrated Interventions Life Steps (MI, Problem Solving) and CBT Combination Secondary Prevention Cell Phone Based Interventions (x 3)

  15. Some tentative conclusions It appears that various methodologies are associated with the maintenance of improved adherence post treatment discontinuation. IMB based intervention Life Windows (computer based) for On Protocol only Integrated Interventions Combination Secondary Prevention (Kalichman) Cell Phone Based text messages

  16. Some tentative conclusions Interventions associated with the significant impact on Viral Load or CD4 Cell count Peer Support delivered MI based intervention - VL Pager only - CD4 Integrated Interventions Combination Secondary Prevention Life Steps with CBT – CD4 Cell Phone Based text messages - VL

  17. Some tentative conclusions Programs the provide additional components may have additional impact (e.g., side effect management, sexual health counseling, depression or substance use treatment). Flexible programs that can be individualized address particular profiles Treating adherence with in the functional context (substance use, mental health issues, limited resources) to keep programatic problem solving realistic. Utilize data based feedback to identify ongoing barriers and targeted problem solving

  18. Some tentative conclusions Address multiple treatment adherence targets to support effectiveness (e.g., retention in care, communication with health care providers, access to….,) Train adherence in the context of adherence lapse/relapse and program for maintenance (e.g., relapse prevention, booster sessions) Develop triage model to tailor a menu of programs to individual need and anticipated outcome (brief versus integrated). Describe in detail “standard of care” comparison connditions. Intervening to Improve Adherence – What do we Know? Intervening to Improve Adherence – What do we Know?

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