Adherence and ART

1. Adherence and ART HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. Learning Objectives By the end of this session, participants should be able to: • Describe the importance of adherence and consequences of non-adherence • Explain the link between adherence and resistance • Identify potential barriers to adherence • Assess patient’s readiness to start ART • Discuss strategies to promote adherence success

3. Overview of Adherence • Adherence to most drug regimens is poor across all populations and all diseases • e.g. diabetes, TB, heart disease • 20% to 100% (average: 50%) fail to take medication as prescribed • For most chronic diseases, greater than 80% adherence is considered successful For ART, more than 95% adherence is essential!

4. Importance of Near-Perfect Adherence Relationship between adherence and virological success Ann Intern Med 2000;133:21 Courtesy of Paterson, 6th CROI

5. Why is Adherence so Important in the Case of HIV? • Adherence is extremely important in the case of HIV because: • The virus rapidly multiplies in the absence of the drugs • With increasing viral load, more mutations occur that cause resistance to the drugs • Once resistance develops, drugs stop working • This, in turn, creates more mutations making future treatment difficult

6. How Quickly Does Resistance Develop? • Imperfect adherence can result in resistance to certain ARVs within a few weeks • Resistance to NNRTIs and 3TC each require only a single mutation • Resistance to either nevirapine or efavirenz can occur rapidly • Resistance to one means resistance to both • Resistance to 3TC can occur rapidly

7. Adherence Dimensions • At the right time* • Every 12 hours • 2 times a day • Sufficient period of time (lifelong) • All the time • >95% • Right drugs and dose • Rifampicin/NVP • PIs/Rifampicin • The right way • With food • Without food • Avoiding alcohol • Avoiding traditional herbs • Right number of pills Maintaining adherence is the most important factor for success in ARV therapy!

8. Small Group Activity

9. Factors Affecting Adherence: Medication Factors • Adherence is affected by factors related to medications, including: • Dose frequency • Pill burden, number of pills (all medicines) • Complexity of treatment • Food requirements • Side effects (real or anticipated)

10. Factors Affecting Adherence: Patient-Provider Relationship (1) • A poor patient-provider relationship will decrease a patient’s adherence success • Factors that might contribute to a poor relationship include: • ‘Superiority’ attitude of doctors and nurses • Contradicting information from doctor, nurse, pharmacist • Lack of trust and confidence of PLHIV in their care providers • Poor support by care providers

11. Factors Affecting Adherence: Patient-Provider Relationship (2) • Adherence is affected by whether a provider: • Has adequate knowledge of HIV, ARV, side effects and drug-drug interactions • Understands the relationship between adherence and resistance • Can detect the early stages of non-adherence and support patient to adhere • Has effective communication skills and can create trusting relationships with patients • Has adequate skills in patient education

12. Factors Affecting Adherence: Patient Factors (1) • Patient adherence is also influenced by whether they have: • An understanding of how HIV multiplies, how ARVs work • Belief in the benefit of treatment • Belief system – “self-efficacy” • Trust in providers and health care system • Competing cultural/religious beliefs and practices, i.e., traditional medicine • Illness, pain, other morbidities

13. Factors Affecting Adherence: Patient Factors (2) • Adherence may be more challenging for specific groups such as: • Children/adolescents • Substance users • Prisoners • Persons with mental illness • What specific adherence-related challenges or issues might each of these groups face?

14. Factors Affecting Adherence: Psychosocial Factors Psychosocial or lifestyle issues may also impact adherence and ability to adapt to ARV therapy: • Financial issues • Multiple competing priorities • Homelessness, unstable living • Hunger, not enough food • Alcohol and other substance abuse • Depression, other mental health issues • Stigma • Lack of family support • Fear of disclosure, rejection, isolation • Sharing medicine with family, sexual partner

15. Factors Affecting Adherence: Health Services • Highly functional health services will increase patient’s adherence success through: • Maintaining an accessible clinic, pharmacy • Having flexible working hours • Weekend coverage • Employing experienced, well-trained staff • Providing good patient follow-up • Linkage to community support & home care services • Adequate ART pills till next appt with “buffer pills” • Avoiding stock-outs

16. Group Discussion

17. Assessing Patient Readiness (1) • To assess whether a patient is ready to start ART, determine his or her level of understanding of: • HIV pathogenesis and its implications • Purpose and effect of ARV therapy • Treatment options and limitations • Also, determine: • Cultural beliefs, practices regarding disease and treatment • Previous experiences with illness and treatment such as adherence to cotrimoxazole

18. Assessing Patient Readiness (2) To assess whether a patient is ready to start ART, look at: • Stability of environment • Income, shelter, access to clean water and refrigeration • Lifestyle • Single, married, children • Potential for other positive or sick family members • Family, friends, community • potential supports and/or barriers

19. Assessing Patient Readiness (3) • Patient readiness to start ART is also influenced by: • Transportation – can they return to clinic for follow up? • Routines • Work/job – time off to attend clinic • Migration/travel – for business, holidays • Use of alcohol, intravenous drugs • Willingness to disclose to family member, sexual partner

20. Assessing Patient Readiness (4) • Current state of physical health • Can they manage treatment on their own or will they need caregivers? • Mental health and understanding of illness • Depression related to HIV status • Stigma, discrimination • HIV-related neurological effects, e.g. dementia

21. Activity

22. Strategies for Successful Adherence (1) Strategies for successful adherence include: • Starting ART only when patient is ready • Tailoring ART schedule to individual • Combining interventions for maximum effectiveness • Multidisciplinary team approach • Systems for adequate documentation • ART and adherence training for all health-care team members

23. Strategies for Successful Adherence (2) Strategies for successful adherence also include: • Creating a trusting relationship between patient and health-care team members • Supportive and non-judgmental attitudes • Revising assessment regularly to meet changing patient needs • Identifying treatment assistant at beginning • Intensifying adherence support as problems arise

24. Starting Treatment Before starting treatment: • Reaffirm patient’s choice to begin and commit to lifelong therapy • Set goals such as > 95% adherence • Explain medications, timing and any restrictions • Discuss use of other medications • Drug-drug interactions • Traditional medicines

25. Side Effects • Prepare for potential side effects and offer practical coping strategies • Make sure that patient understands exactly what to expect from each drug • Reassure the patient that side effects can be managed medically

26. Practical Support (1) • Adherence success is enhanced if the regimen fits into the person’s daily routine, so it is important to: • Ask the patient to decide on the best times within the dosing guidelines • Provide a picture schedule for the drugs

27. Practical Support (2) • Success also depends upon patient’s understanding of regimen, so: • Ask patient to repeat explanation of schedule back to provider • Show samples of medications • Have patient explain how to take each drug • For children: • Have family give child first doses in clinic, which allows for immediate problem solving

28. Practical Support (3) • Assist patient to plan ahead for changes in routine such as travel • Problem solve different situations • Advise on appropriate adherence helpers • Adherence assistant • Pill boxes • Alarm clocks • Cell phone alarms • Patient ARV-dose schedule cards

29. Treatment/Adherence Assistants • Patient should involve a family member or friend to assist with medication regimen • Explain how patient can access support from clinic: • Know doctor’s and treatment nurse facility phone numbers • Health care providers MUST be accessible • Can also utilize community health workers and other local individuals to provide patient support

30. How to Assess Adherence (1) In order to assess adherence: • Be non-judgmental • Encourage patients to report adherence problems • Assess patients at every visit • Develop measures appropriate to settings • Have you had difficulty with your pills? • How many pills did you miss in the last 3, 7 or 30 days? • What are the most important barriers to taking your medicine regularly?

31. How to Assess Adherence (2) • The following methods can be used to assess adherence: • Pharmacy patient refill patterns • Self report • Pill counts (at clinic visits or announced home visits) • Others (used for research purposes) • MEMS (Microchip Electronic Monitoring) • Drug levels

32. What Do You Do When Adherence is Poor? • Assess why adherence is incomplete • Review current regimen • Inquire about problems administering medications – obtain a descriptive assessment • Review WHO, WHAT, WHEN, HOW • Observe administration • Address the barriers to adherence

33. Addressing Adherence Barriers: What to Do Next • Identify and address specific barriers to adherence • Consider stopping current regimen • Alter current regimen or change to new regimen • Formulation or single drug substitution • New regimen in the case of treatment failure • Begin again • Adherence education • Adherence preparation • Adherence monitoring • Adherence support

34. Ask About Adherence Regularly • Reasons for missing doses change over time: • Lifestyle changes • Pill fatigue • Improved health • Intermittent hospital admissions for non-HIV-related issues • Therefore providers need to ask about adherence continually and regularly

35. Key Points • Adherence is the most important determinant of treatment success • Never start treatment without assessing patient readiness • Educate patient on all aspects of HIV, treatment options and outcomes • Offer support to promote the goal of up to 100% adherence • Monitor and counsel for adherence at every visit, even after months or years

36. Thank you! Questions?