Antiretroviral Medication Adherence

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Antiretroviral Medication Adherence

  1. 1. Antiretroviral Medication Adherence Cindy Lyles, PhD Prevention Research Branch, Division of HIV/AIDS Prevention, CDC National HIV Prevention Conference August 16, 2011 National Center for HIV/AIDS, Viral Hepatitis, STD , and TB Prevention Division of HIV/AIDS Prevention
  2. 2. Thanks to Adherence Writing GroupCDC: Linda Beer, Nicole Crepaz, Linda Koenig, Cindy Lyles, Khiya Marshall, Rebecca Morgan, David Purcell, Paul WeidleHRSA: Brian Feit, Anna Huang
  3. 3. Outline Rationale Methods Evidence Recommendations
  4. 4. Rationale for ART Adherence ART reduces viral burden, prolongs survival and quality of life ART is now key for treatment & prevention  health benefits for the PLWH  Preventing sexual transmission of HIV Adherence is critical for treatment success  Positively associated with longer survival, lower HIV viral load, greater viral suppression  Declines/slips associated with treatment failure  Suboptimal adherence can lead to viral resistance & limited future trt options
  5. 5. Rationale for ART Adherence Success of HPTN 052 trial  RCT: efficacy of early treatment (vs trt as usual)  Both arms received couples risk reduction counseling  Early initiation of ART led to a 96% reduction in risk of transmitting HIV to uninfected sexual partners  In combination w/ ART, regular, intense adherence counseling & support was provided • Regular monthly visits • Provided to both the index patient and the partner • Provided by both the physician and an adherence counselor
  6. 6. Context for Promoting ART Adherence Critical to help achieve NHAS goals Key activity in DHAPs strategic plan & in the new Enhanced Comprehensive HIV Prevention Plan (ECHPP) Project Expanded testing & early treatment  more critical to focus on adherence
  7. 7. Methods (page 1) Recommendations based on:  Reviewed existing published recommendations  Review of Reviews – Previously published literature reviews, systematic reviews, and meta- analyses Two types of reviews: • Efficacy of HIV medication adherence interventions • Correlates of HIV medication adherence  Published cost-effectiveness literature
  8. 8. Methods (page 2) Recommendations based on:  Results of CDC’s Prevention Research Synthesis (PRS) Efficacy Review • Systematic review of all U.S.-based intervention evaluation studies • Identify specific interventions shown to be efficacious in improving adherence or reducing viral load • Compendium of Evidence-based HIV Prevention Interventions (http://www.cdc.gov/hiv/topics/research/prs/)
  9. 9. Methods (page 3) Recommendations based on:  Other published literature, with emphasis on specific topics: • Measurement & monitoring • Current adherence levels & status of adherence interventions • Barriers to implementation • Special considerations & special populations
  10. 10. Evidence – What are Current Adherence Levels? Adherence levels tend to be sub-optimal; tend to decrease over time Estimates vary; 20% - 80% Data sources/methods vary greatly  Study design (e.g. drug trials, cohort studies, surveys)  Study sample (e.g. target, eligibility)  How to measure/calculate adherence • Method of measurement (e.g. EDM, S-R, pharmacy) • Recall or time periods • Calculation (mean #; mean %; cutoff >90%)
  11. 11. Evidence – What are Current Adherence Levels? Percent of individuals w/ >90% adherence to ART (n=84 studies) 62% Worldwide 59% North America 50 55 60 65 70 75 80Meta-analysis (Ortego, 2011)
  12. 12. Evidence – Correlates of Adherence Treatment regimen factors Individual-level factors Patient-Provider factors
  13. 13. Evidence – Correlates of Adherence Treatment regimen factors:  Complexity of regimen – Pill burden, dosing frequency, dietary restrictions  Frequency and severity of side effects
  14. 14. Evidence – Correlates of Adherence Individual-level factors:  Co-morbidity factors –substance abuse, alcohol abuse; mental health issues, including depression, anxiety, other psychological symptoms  Psycho-social factors – Attitudes, beliefs, fear, stigma, & denial related to HIV disease; quality of life/life satisfaction; social support
  15. 15. Evidence – Correlates of Adherence Individual-level factors:  Adherence cognitions/competencies – Understanding of ART regimen, ART benefits; Attitudes & beliefs about ART efficacy; Self-efficacy of adherence; poor self- management/adherence skills  Other – daily schedule issues; homelessness; income/financial issues
  16. 16. Evidence – Correlates of Adherence Patient-Provider factors:  Quality of relationship; provider support; shared decision-making
  17. 17. Evidence – Adherence Interventions Interventions are efficacious in improving adherence  Several rigorous meta-analyses  Moderate magnitude of effects  Slightly weaker findings, in general, for clinical outcomes (viral suppression; CD4 cell count)  Stronger effects during the intervention or short follow- up; weaker effects over time
  18. 18. Evidence – Adherence Interventions Interventions are cost-effective & beneficial to long-term survival of the individual  No systematic reviews; handful of studies  Varied by study design, type of intervention, etc.
  19. 19. Evidence – Adherence Interventions Key Intervention Elements  Improving knowledge about treatment  Discussing/addressing cognitive barriers  Providing patient-centered or individual-level approach  Targeting medication management skills  Providing support (provider, group, peer, family)  Longer intervention duration Robust findings with regards to:  Deliverer; Setting; Delivery unit; Risk group; ART naïve/exp
  20. 20. Adherence Recommendations – Patient IssuesAssess patient’s readinessEducate on importance of adherence to ARTAddress misconceptions or other concernsAddress barriers by linking patients to appropriateservices  Structural: homelessness, transportation, insurance  Co-morbidities: depression, mental health, drug/alcohol abuse
  21. 21. Adherence Recommendations – Regimen IssuesSimplify treatment regimen: reduce pill burden, dosingfrequency, and dietary restrictionsInvolve the patient in decision makingTailoring schedule to the patient’s lifestyle, linkingactivities to “cues” as reminders, clarify instructions usinga personal treatment planEncouraging pill sorting and storage devices to fit withdaily routinePrepare for, assess, and manage side effects at eachvisit
  22. 22. Recommendations – Maintaining AdherenceProvide adherence reminder devices or memory aides –alarms, diaries, pill boxes, beepersEmploy an adherence team to provide ongoing support -nurse practitioner, case manager, social worker,pharmacist, counselor, peer support person, familymemberAssess adherence at each visit, in a non-judgmental waywith open-ended questions to allow patient to discloseproblems or barriersInvolve patient in problem-solving activities
  23. 23. Summary We need to focus on every element in the care continuum, including adherence, in order to maximize TRT benefits Expanding Linking to testing care Initiating Adherence ART to ART
  24. 24. Thank You! Cindy Lyles clyles@cdc.govThe findings & conclusions in this report are those of the authors & do notnecessarily represent the official position of the Centers for DiseaseControl and Prevention

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