Improvement in adherence to HAART: Best practices in adherence education by three model programs
Improvement in adherence to HAART:Best practices in adherence education bythree model programsMyriam Hamdallah, MS, MPHCenter on AIDS & Community HealthFHI 360
Session Objectives – Provide a background/context of the study – Describe the three agencies and their adherence education interventions – Describe the study methodology – Share findings – Discuss implications and recommendations
Study Context – the ConnectHIV initiative• ConnectHIV was a national initiative supported by the Pfizer Foundation through $7.5million in grants, technical assistance and networking resources over three years (2007-2010) to 20 mid-sized AIDS Service Organizations (ASOs) in the10 states with highest AIDS prevalence in the United States.
ConnectHIV Funding CategoriesThe 20 organizations differed in populations served & interventions implemented – from prevention of infections among high-risk, HIV- negative persons, to promotion of adherence and delay of disease progression among persons living with HIV
Agency CharacteristicsCharacteristics ASO A ASO B ASO CAgency funds for HIV $2.17M $3.96M $2.80Mservices FTE staff in agency 47 36 24FTE staff dedicated to 2 1 4programPT staff dedicated to 5 2 3programVolunteers dedicated to 12 0 20program
Agency CharacteristicsCharacteristics ASO A ASO B ASO CStaff to client ratio for 1:26 1:26 1:21AE interventionHIV/AIDS services 13 5 6delivered in-house% Clients substanceabuse/addiction co- 30 66 75morbidity% Clients - psychiatric 65 30 70co-morbidity
Characteristics of populations served100% ASO A90% ASO B80% ASO C70%60%50%40%30%20%10% 0% Female Male Sex w persons of Sex w persons of the opposite sex the same sex
Age of the populations served50% ASO A45% ASO B40% ASO C35%30%25%20%15%10% 5% 0% <= 19 20 - 29 30 - 39 40 - 49 50+
Intervention Characteristics ASO A ASO B ASO C To mobilize family, peer To help clients needing To equip clients w. knowledge, & social support as key additional assistance for skills to understand scienceObjectives elements in successful stability in both housing behind HIV, care & treatment; adherence. and medical adherence. prevent 2˚ infection; focus on compliance and adherence; become advocates ● Individual counseling ● Individual level ● 18-hour peer-led training ● 8-session women’s intervention. (offered as a 3-day or a 6-day wellness HIV support ● Peers met with course) that includes 8 contentStructure groups clients once a week for specific education modules ● Peers met 1X week, & 12 weeks or about 3 face to face at intervals months. for one year ● MEMS cap –2 weeks
Intervention Characteristics ASO A ASO B ASO C Individual health Individual meeting with Counseling is provided in counseling with HIV Peers; review medication house as needed but is notCounseling medication adherence regimen; create I-MAPs; part of the intervention. specialist problem solve barriers to adherence; provide HIV med education & adherence counseling. Adherence education - Personalized medication Fundamentals of HIV biology Help clients understand education; Review of med development, resistance,Education illness; provide medication regimen; doc/patient relation, advocacy, information on meds & Individual Medication nutrition, compliance & regimen. Adherence Plans (I-MAPs), adherence to HIV in special are completed. popn, clin trials, co-infections
Intervention Characteristics ASO A ASO B ASO C Clients are assigned a Peers conduct the Peers lead the Peer Piece treatment adherence intervention with training. buddy; they can attend supervisory support. support groups. One-hour training session, Peers received 2 month 18-hour peer-led paid $40 to attend. training serve as Peer training (offered as a Training Coordinator or Peer 3-day or a 6-day Interns. course). $20 for treatment $200/week $20 at conclusion of Incentive adherence buddy; $10 for training; bus passes, joint coffee meeting. meals.
Study Methods• survey/interview designed in collaboration with the grantees and an Evaluation Advisory Committee• IRB approval obtained• 30 min individual interview with client• baseline and two follow-up measures – 2-6 months from baseline for the second measure – 6-12 months from baseline for the third measure
Variables• HIV disease management knowledge• Overall experience taking HIV medications• Viral load• CD4 count• Perceived health score
Variables and Measures• HIV disease management knowledge score 1. What happens when someone with HIV infection has a high CD4 count? 2. What indicates that HIV infection has progressed to AIDS? 3. Typically, how often should a person with HIV have their viral load and CD4+ counts assessed? 4. In order for HIV medications to be effective, they should be taken… 5. If someone with HIV misses or skips taking some of their anti- HIV medications… 6. Anti-HIV medications can cause some health issues called "side-effects."
Variables and Measures• Overall experience taking HIV medication• Over the last 30 days, which of the following best describes your general experience taking your HIV medications? – 1. I never take my pills – 2. I take my pills less than 50% of the time – 3. I take my pills between 50 and 90% of the time – 4. I take my pills at least 90% of the time – 5. I take them exactly as prescribed, never missing a dose.
Variables and Measures• Viral load• Categorical variable developed from actual viral load data or self-reported viral load data (if clinical data was not available) with the following Likert-style categories: – 1. Undetectable (<400 or <40 depending on test) – 2. Detectable, but less than 1,000 – 3. Between 1,000 and 9,999 – 4. Between 10,000 and 55,000 – 5. More than 55,000
Variables and Measures• CD4 count – What was your most recent CD-4 or T-cell count?’ A continuous variable was developed from the actual CD4 data or self-reported CD4 data (if clinical data was not available).• Perceived health score – On a scale from 1 to 100, how would you rate your overall health? – Worst Health = 1; Perfect Health = 100
Data Analysis• Generalized Estimated Equations (GEE) models were created to determine change over time (taking into account repeated measures over individuals – measures at baseline, post and follow-up)• N=386• The models controlled for client level confounders - age and gender• Significance was reported at a < 0.05 level.
FindingsChange Across Mean Scores of Client Outcomes from Baseline to 1stto 2nd Follow-up Mean Scores Level of SignificanceOutcome Baseline Baseline 1st FU vs. Baseline 1st FU 2nd FU vs. 1st FU vs. 2nd FU 2nd FUKnowledge of HIV 11.36 11.98 12.14 <.001 <.001 NSdisease management(1-14) (N=386)Overall experience 4.36 4.52 4.58 <.001 <.001 NStaking HIV medication(1-5) (N=356)Viral load (1-5) (N=374) 1.82 1.54 1.48 <.001 <.001 NSCD4 count (N=367) 517 543 554 <.05 <.01 NSPerceived health score 76 81 83 <.001 <.001 NS(1-100) (N=384)
Findings Overall Health Score by Period 100 "How would you rate your health (1-100)?" ASO A 95 ASO BAverage Health Score (1-100) ASO C 90 88 85 84 80 77 80 79 79 75 75 77 73 70 Baseline Post Followup
Interactions• Gender was significantly (p<.01) associated with knowledge of HIV disease management; males tended to score higher than females• Gender was significantly (p<0.01) associated with HIV medication experience; men took their medications more consistently than women• Age was significantly associated with viral load; clients 50 years and older had significantly lower viral load compared to those younger than 30 (p <0.05)
Interactions• Gender significantly associated with overall health score, with males scoring higher than females (P<0.001)• Age significantly associated with overall health score, with persons under 30 years of age scoring significantly higher than older persons (p<.001)
Discussion• Significant positive change from baseline to post, & baseline to follow-up across all client outcomes• All 3 interventions accomplished goal of improving adherence to HIV medications• Two ASOs (A and B) reviewed individual regimens; B developed IMAPs (Individual Medication Adherence Plans); C’s intense training focused on adherence
Discussion• Peers were key element in ASO B’s & C’s and a component of ASO A’s intervention – Rationale for peer support/peer-led interventions • Social support theory (positive relations; emotional & other support) • Experiential knowledge (practical experience) • Social learning theory (learning in social context & role modeling) – CDC’s compendium/adherence chapter includes two interventions with peer components
Discussion• Knowledge of disease mgmt – Men scored higher than women; & Adherence – Men had higher adherence than women (stigma; child care; adverse drug effects reported)• Viral load – older had lower VL than younger (increased virologic suppression in older adults reported in literature)• Health score – Men scored higher than women
Implications & Recommendations• Patient education, imparting knowledge on HIV management & importance of adherence; review of regimens; problem solving to reduce barriers• Strong, well supported peer components with structured training and incentives• Consider competing priorities for women, in addition to managing potential adverse drug effects and stigma
Unpublished Manuscript and AcknowledgementsAuthors:• Myriam Hamdallah• Stacey Little • Derek Worley• Dave Nimmons • Caitlin Corcoran• Lisa Rizzano • Susan J. Rogers• Acknowledgements:The authors would like to thank Evany Turk and Warren Reich as well asother staff from the ConnectHIV grantee agencies and their clients fortheir contribution to the manuscript and to Atiya Ali Weiss at the PfizerFoundation, David Holtgrave at Johns Hopkins University and to SallyMunemitsu and Janice Brown at TCC.