95% adherence for a regimen taken twice a day equal missing 2-3 doses a month. These studies were done with earlier Pis and ARV meds. Newer studies suggest that potency of boosted PIs and NNRTIs may make for more forgiving regimens even out to 70-80%. One very important thing that we do know about adherence is that providers assessment of adherence is often inaccurate. Patients self report of adherence predictably overestimates adherence by as much as 20%. Is also really important to realize that adherence as changed a lot meds have changed a lot, but there are still significant barriers.
Adherence correlates strongly to Viral Suppression is key, community viral load begins in the chair sitting across from you. It begins with patient and provider. You and the patient play a key role in the scope of public health.
Much of the focus of research has been on predicting non adherence. So we don’t have as much data about what contributes to good adherence, but we “assume” they would be the converse of those that negatively predict adherence.
Important to note that history of substance use does not predict negative adherence. IF A PATIENT HAS ALL OR SOME OF THESE IN THEIR LIVES IT DOESN’T MEAN THAT THEY WON’T BE ADHERENT. THIS COULD DESCRIBE ALMOST EVERY PATIENT THAT COMES THROUGH THE DOOR! RACE, AGE, SEX ARE NOT ASSOCIATED WITH RECENT POOR ADHERENCE.
What NOT to do!? ARE YOU TAKING YOUR MEDS? “You’re taking your meds right? “Well it looks like your not taking your meds” MAYBE THE PATIENT IS TAKING THEIR MEDS…..THEY JUST MAY NOT BE TAKING THEM EVERY DAY. Make sure the scope of time is finite and memorable. Don’t ask about the last 3 months. These types of real-time or electronic indicators of adherence, are not neccesarily feasible for every site. Sometimes I like to begin by asking a broad question like: so tell me how things are going with the medication. Make it relatable. “So it looks like you have been on the meds for about 6 months now. Sometimes patients find those first six months tough when it comes to remembering to take a pill everyday. What has your experience been like? “ Have you had any difficulties with taking the meds everyday?Biological markers would include surrogate markers like viral load, hyperbilirubinemia, plasma concentrations of arv’s
I included these for you so you have specific examples of questions. I encourage you to use these as a basic guide and ADAPT them for your particular practice. These are adaptable to all your patients who are taking meds, not just patients on ARV’s.
Assessment of factors that might negatively impact adherence. Think about the specific needs of your patients. Do they work at night, do have depression. Do they have a very busy life. What is the easiest regimen available for them. Do they have a history of GI intolerance. Some meds are better and more well tolerated by people. Its important to have an “action plan” around SE and Adverse drug reactions. Tell the patient when it is ok to self-dc. Advise the patient as to when its ok to keep taking meds, but contact your office first. Barriers they may not have considered ….WHAT ABOUT THE DATE THAT DOESN’T END? Early days, skipping breakfast, medical emergencies, travel emergencies. Use creative strategies (pill boxes, medi-sets, home med delivery, key chain pill boxes)
Don’t assume that medisets and pill boxes are only for people who have adherence difficulties. Teaching the patient to expect the unexpected! You also have to be realistic. Not every single person is going be a succcess story. We all have those one or two patients who drive us crazy. As my attending says, we’re not god!
You all know adherence techniques and we all have our favorite techniques to use.
What are some of the barriers to adherence in Ms. D? Does she have anything going for here? SHE’S IN YOUR CLINIC? SHE MUST BE HERE FOR SOME REASON? SHE HAS BEEN UNDETECTABLE IN THE PAST? SHE HAS A GOAL.So she is indifferent, but she is here! The question is to figure out why??
I made her a deal. IT WAS THANKSGIVING TIME, THAT IF SHE STAYED WITH US, BY NEXT CHRISTMAS SHE WOULD BE A WHOLE NEW PERSON WOMEN
This is obviously a success story. But it doesn’t always work out this way. Ultimately this was her choice to get sober (although she was prompted by other circumstances)
WHEW!!!!! OK! SO WE ARE DONE! Before we get to questions I just want to sincerely thank you again, I hope you were able to gain some knowledge from this. I am happy to answer any questions. If you would like to e-mail me as well that would be great. I have a packet of some of the slides here available (the charts) blown up for you. BUT Not the med (those you need to look up Also I can am happy to link you to any of the resources or references I have used here today.
1. “Stephen, I’m taking my meds, I swear”Adherence as a Path to Virologic Suppression Stephen Perez, RN, NP, AAHIV-S HealthHIV
2. Objectives• Define adherence as it relates to antiretroviral therapy• Discuss current positive and negative predictors of adherence• Describe methods for improving adherence• Identify effective strategies for increasing patient adherence in the clinical setting 2
3. Adherence• How do we define adherence? – Taking medications or treatments as prescribed or advised by a health care provider – Average ART adherence rate in the United States is approx. 70%.1 – Earlier studies of adherence showed resistance associated with <95% adherence.2 – Providers assessments are often inaccurate! 1,2 – There is no gold standard for assessment3 3
4. Why does adherence matter?• Reduced Rates of Resistance• Improved Quality of Life• Improved Virologic SuppressionU.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults andAdolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012. 4
5. Predicting Adherence• Positive Predictors – Ability to identify medications – Ability to describe the proper dosing – Lower pill burden – Ummmmmmm………… 1. Matchinger, E & Bangsberg, D. 2006. Adherence to Antiretroviral Therapy. UCSF HIV inSite. http://hivinsite.ucsf.edu/insite?page=kb-03-02-09 accessed April 3, 2012. 5
6. Predicting Aherence• Factors Associated with Non- Adherence – Younger age – Age-related changes – Mental health/Social issues – Non-disclosure of HIV status – Active substance abuse – Side Effects – Complex regimens – Non-adherence to clinic appointments 6 U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012.
7. Assessment of Adherence• No gold standard• Keep it simple and non-judgemental• Normalize less than perfect adherence• Try to minimize “socially desirable” responses• Survey about a finite time: “last 3 days”, “Last week”• Ask about missing other meds or treatments• Pill boxes, bottle cap counters, dispensing systems, biological markersU.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults andAdolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012. 7
8. Questions to Assess Adherence• Do you manage your own medications? If not, who manages them for you?• What HIV medications do you take and what is their dosage? When do you take these?• What is your average daily schedule like? How well does taking your HIV medications at this time fit into your daily schedule?• How do you remember to take your medications?• How many doses of your HIV medication have you missed in the past 72 hours, past week, past 2 weeks, and past month?• When are you most likely to miss doses?• Do you have any adverse effects from your HIV medications? If so, what are they?• Are you comfortable taking medications in front of others?• What is most difficult about taking your medications?• How do you like working with your pharmacy? 1. Health Resources and Services Administration, HIV/AIDS Bureau, 2011. Guide for HIV/AIDS Clinical Care. “Adherence”. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-406_adherence.html accessed April 3, 2012 8
9. Interventions to Improve Adherence • Assessment of the patients readiness for ARV’s • Use critical thinking when prescribing ARV therapy • Simplify a patients regimen • Educate around side effects and adverse drug reactions – Let the patient know they are supported • Talk about the risks/benefits of therapy • Identify barriers they may not have considered • Get creative! 9
10. Strategies for Improving Adherence • Patient-centered approach • Educate your patients • Assess for use/need for specific interventions (medisets, pill boxes, text reminders) • Multi-disciplinary approach if/where available • Expect the unexpected • Hang in there 10
11. Case Study in Adherence• Ms. D – 44 y.o. HIV positive African American female – HIV-positive for 9 years – Presenting for first HIV care visit in 3 years • No meds, can’t remember her last meds • Feels sick. CC: “Has sore on her stomach” • BP is 86/54, Pulse is 130, Temp: 101.4 • Intake labs, were CD4 32, VL 132,000 • Actively drinking 6-10 beers a day, using crack cocaine off and on weekly 11
12. Case Study in Adherence• Ms. D – Physical exam: • In addition to the vitals noted, she has a large open abscess and cellulitis on her abdomen, abscesses on her upper thigh/buttocks, palpable femoral nodes. • Height is 5’3”, wt. 86 lbs • ED referral, and admission for 4 days, discharged on TMP- SMX and azithromycin – She returns 4 months later • Wt. has remained the same, no meds, t 98/60, p110, afebrile. • Substance use pattern is the same • Is indifferent about meds, and indifferent about care in general • Hx: has been on meds before (can’t name them) records say Lopinavir/ritonavir and emtricitabine/tenofovir DF (She says they “tore up her stomach”) • Previous records say that she has M184v but was <75. • Sexually active, inconsistent condom use • Uninsured 12
13. Case Study in Adherence• Ms. D – Daughter won’t speak to her because of her substance use – Recently was arrested for “something”, Has court case pending – Wants to get sober before the hearing 13
14. Case Study in Adherence• Plan for Ms. D – Prescribe her darunavir/ritonavir and emtricitabine/tenofovir DF (once daily). – Recheck labs for baselines (CD4 75, VL 89,000) – Enroll her for one visit with SAC, RNCM, and SW – Bactrim daily for PCP prophylaxis until meds arrive – Preemptively give her OTC for diarrhea and RX for nausea meds – Work out a visit schedule and assist her with transportation arrangements – Agree to write a letter of support for her court case – I made her a deal 14
15. Case Study in Aherence• Plan for Ms. D (continued) – Adherence education and counseling session with RNCM and subsequent monthly meetings – Counseling about diet – Sees provider every 2-3 months – SAC and SW every 2 weeks – Took a year before she came back undetectable, misses about 1-2 doses a month 15
16. Adherence• Today Ms. D is still undetectable• She weighs 130lbs• Still struggling with ETOH sobriety, stopped crack altogether• Avoided jail time• Was maid-of-honor at her daughter’s wedding• Brought in pictures of her 4th grandchild the following Christmas 16
17. Adherence Take Home• Virologic suppression begins with adherence.• Ultimately its up to the patient, but providers play a crucial role• Be creative• Be determined• Be realistic 17
18. References1. Matchinger, E & Bangsberg, D. 2006. Adherence to Antiretroviral Therapy. UCSF HIV inSite. http://hivinsite.ucsf.edu/insite?page=kb-03-02-09 accessed April 3, 2012.2. Health Resources and Services Administration, HIV/AIDS Bureau, 2011. Guide for HIV/AIDS Clinical Care. “Adherence”. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-406_adherence.html accessed April 3, 20123. U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012. 18