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HIV TherapyAdherence: Strategies for Success

HIV TherapyAdherence: Strategies for Success. Kirsten B. Balano, PharmD National HIV/ AIDS Clinician’s Consultation Center. Case Presentation. 28 yo man with AIDS comes to triage nurse requesting refills D4T/3TC/Nevirapine CD4 count 76, VL 1,064

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HIV TherapyAdherence: Strategies for Success

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  1. HIV TherapyAdherence: Strategies for Success Kirsten B. Balano, PharmD National HIV/ AIDS Clinician’s Consultation Center

  2. Case Presentation • 28 yo man with AIDS comes to triage nurse requesting refills D4T/3TC/Nevirapine • CD4 count 76, VL 1,064 • Saw primary MD 3 months ago as first visit to SFGH clinic and was supposed to return in 1 month (2 months late for appt) • Has next primary appt 2 weeks from now. • Also taking Septra DS & Itraconazole (for disseminated histoplasmosis infection)

  3. Challenges associated with antiretroviral therapy: • When to start medications? • When to change medications? • What medications to start with? • What medications to change to when fail?

  4. The most effective regimen for HIV infected individuals is the one they will take.

  5. “The achilles heel of HAART” • G. Friedland • “Drugs don’t work if people don’t take them.” • C. Everett Koop

  6. Paterson et al. Ann Int Med 2000;133:21-30

  7. Adherence to antiretroviral medications using ACTG tools Skipped Taking Pills% (n=75) Within Last 2 Days 17 Yesterday 11 Day before yesterday 13 Last weekend 21 Within last 2 weeks 36 Chesney, et al, AIDS Care 2000, 12;(3): 255-266

  8. Factors Independently Associated with Nonadherence in 3 day history Variable Odds ratio p value Nausea 4.47 (1.66-12.1) 0.003 Anxiety 2.63 (1.32-5.23) 0.006 Younger age 2.28 (1.26-4.15) 0.007 Unemployment 2.92 (1.55-5.49) <0.001 Not recalling name, 2.18 (1.21-3.92) 0.009 color and timing Running out between 2.62 (1.42-4.86) 0.002 visits Being too busy 2.04 (1.07-3.89) 0.03 Ammassari etal, JAIDS Dec 2001;28(5)

  9. Patient factors affecting adherence • Understand purpose of therapy • Belief in treatment efficacy • Confidentiality/Disclosure • Social Support • Lifestyle fit with medication routine • Mental Health Issues • Substance Use/Abuse • Housing

  10. Medication factors affecting adherence • Identify medication (name, color, purpose) • Frequency of dosing • Number of pills taken with each dose • Size of pills • Taken with regard to meals? • Side-effects of medications and the ability to manage these side effects • Drug-drug interactions

  11. Reasons for Missed Doses using ACTG tools Reason% (n=51) Simply forgot 66 Away from home 57 Busy with other things 53 Change in daily routine 51 Fell asleep/slept through dose 40 Felt ill or sick 28 Wanted to avoid side effects 24 Felt depressed/overwhelmed 18 Too many pills 14 Did not want others to notice 14 Felt drug toxic/harmful 12

  12. Interventions Associated with Improved Adherence • Pharmacist-based adherence encounters/clinics • Adherence encounters at each visit, often multi-disciplinary • Reminders, alarms, pagers, timers on pillboxes • Patient education aids, including regimen pictures, calendars, stickers • Clinician education aids (e.g., medication guides, pictures, calendars)

  13. Center for HIV Prevention & Care Adherence Program • Multidisciplinary • Client-centered • Goals: • Provide support • Provide education • Develop trusting relationship • Manage side-effects • Assess Adherence

  14. Providers asked to estimate the % of pill pt miss in typical week Provider estimates explained 26% of variance in pill count. Bangsberg, et al. JAIDS April 2001;Vol 26, No 5

  15. Face-to-face interviews with patients reviewing missed doses over the last 3 days. Patient report explained 72% of variance in pill count Bangsberg, et al. JAIDS April 2001;Vol 26, No 5

  16. Sensitivity, specificity, PPV and NPV for detecting nonadherence Bangsberg, et al. JAIDS April 2001;Vol 26, No 5

  17. Adherence Challenges • >95% adherence desired • Regimens are complicated with many side effects • Difficult predicting non-adherent/adherent • Interventions multidisciplinary and time-intensive • Assessing adherence difficult

  18. Not-So-Helpful Questions • “You’re taking your medications aren’t you?” • “You haven’t missed any doses have you?” • “Everything is going great, right?” • “This looks really easy to me – what’s the problem here?”

  19. Helpful Questions • “What reminders do you use to help remember?” • “How do you manage/control side-effects?” • “How do you like working with your pharmacy?” • “What do you find most difficult about taking your medications?”

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