Administering Adherence:

1. A reflective analysis examining the implementation and evaluation of HIV medication adherence programs Administering Adherence: Rachel L. Rees, MPA Kate Cooke, MSEd. Virginia Department of Health Washington D.C. – ADAP Technical Assistance Meeting July 16, 2009

2. PresentationObjectives • Define the role of adherence in the treatment of HIV, both clinically and programmatically • Illustrate Virginia’s ADAP medication dispensing structure • Examine service delivery systems and communities of practice as tools to establish medication adherence programs • Discuss Virginia’s adherence initiative

3. Defining Adherence & The Impact of (Poor) Adherence • Adherence is.. the degree to which an individual is able to follow a recommended course of treatment • Optimum treatment of HIV requires near-perfect adherence to dosing schedules* • The impact of poor adherence can result in… • Clinically • Opens the door to resistance, limiting treatment options • More complex regimens • Programmatically • Ineffective use of dollars • More expensive • Transmission of drug resistant virus (!) *Source: Bangsberg et al 2000

4. What Degree of Adherence Is Needed? Adherence to a PI-containing regimen correlates with HIV RNA response at 3 months Patients with HIV RNA<400 copies/mL, % PI adherence, % (MEMScaps) Source: Peterson, et al. 6th Conference on Retroviruses and Opportunistic Infections; 1999; Chicago, IL. Abstract 92. AETC NRC Training Slide

5. Virginia's ADAP Structure (Direct Purchase) • Drugs dispensed by Central Pharmacy (state office) • Available at any of the 135 health departments statewide, plus the Medical College of Virginia • Formulary includes over 100 medications • LHDs provide ADAP services in-kind • Eligibility and medication coordination! Active Clients by Region – September 2008 (n=2798)

6. VA ADAP’s Service DeliveryNetwork Drops off prescription to be filled ADAP Client Local health department Picks up medications (1 – 3 days later) Submits prescriptions to be filled, ships orders back Ships order to local health department Service Delivery Networks* -------- Economic/low cost Flexible Broad geographic coverage High quality Central Pharmacy (Richmond, VA) *Source: Dawes et al, 2009

7. From a Service Delivery System to aCommunity of Practice Communities of practice share a concern, a set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting. Source: Dawes et al, 2009

8. VA ADAP’s Adherence Initiative Establishing Communities of Practice…. • In 2008, six individual local health departments (LHD) were selected to participate • Each LHD has varying backgrounds/experience within their ADAP staff– regionally & structurally diverse • Funded for 18 months during pilot phase • $50,000 available per funding cycle, subject to renewal

9. Scope of Work – Program Development • Implementation of selected strategies to support treatment adherence to a designated number of ADAP clients • Participate in evaluation activities to develop best practices for ADAP clients • Submit monthly reports identifying: • Successes/Challenges • Interventions used • Clients served/units provided • Technical Assistance needed.

10. Implemented Adherence Interventions • Client Interventions • Pill boxes • Chronic disease self management course • Referral of new ADAP clients to case manager for one-one counseling • Calendars, timers, etc… • Pre-paid cell phones with limited minutes • Reminder calls, letters, pharmacy cards, etc. • Home delivery of meds • Have clients verbalize how & when to take meds • Bus tickets System Interventions • Analyzing internal health department ADAP processing system • Medication ordering processes • Client accessibility-hours, medication refill requests • ADAP dedicated phone lines • Hiring dedicated ADAP staff member • Client satisfaction surveys • Community Partners Networking opportunities • Routine meetings with large medical partners Stakeholders are connecting to solve problems, build tools, share ideas, and set standards*… building an adherence community of practice. *Dawes et al 2009

11. Measuring Adherence – Evaluating Success • For this project, adherence has been measured in a variety of ways (pill counting, pick-up schedule, etc.), depends on the intervention utilized • The project’s service units are reported on a monthly basis (number of interventions delivered) • Dispense logs are monitored to determine if the client is still actively participating in ADAP • Measures are evolving (!) as the program grows

12. Opportunities for ContinuedImprovement • Each LHD ADAP functions differently—must tailor technical assistance provided • Providing on-going encouragement to highly qualified staff • Assisting the HDs to streamline 3 interventions (can be very simple, small things that are currently being done---just need to be identified) • Working with various levels of HIV/AIDS knowledge and/or ADAP understanding in the field and providing effective feedback • Reducing anxiety over submitting monthly progress reports • Reporting client listings and interventions utilized to identify service units

13. Future Plans – Expanding the Community of Practice • Adherence Summit with Minority AIDS Initiative sites (some are dual-funded) • Discuss successes • Address challenges • Collaborate with other community partners • Identify what did not work as well in each area • Implement proven strategies in other health departments • Best practices to be compiled in a compendium to be shared statewide

14. Thank you for your time Questions?