Keynote – Framing Sustainable Adherence to HIV Prevention, Care & Treatment: The ICAP Approach


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Keynote – Framing Sustainable Adherence to HIV Prevention, Care & Treatment: The ICAP Approach

  1. 1. Supporting Sustainable Adherence to HIV Care and Treatment<br />Robin Flam MD DrPH<br />Director, ICAP Clinical Unit<br />Kigali, 2009<br />
  2. 2. Burning question<br />If we deliver high quality care, will we always achieve great outcomes?<br />
  3. 3. Delivering high quality care is a necessary, but not sufficient, factor in achieving optimal outcomes<br />
  4. 4. What does it mean to receive care?<br />Patients must use and internalize the care in their daily lives<br />Most care happens at home<br />Patients are at clinic once per month or less<br />There is an “adherence continuum”<br />It is complex, multidimensional, and needs to be enduring over a lifetime<br />
  5. 5. Why would poor adherence be a problem?<br />Poor outcomes on the individual level<br />Treatment failure<br />Resistance and fewer treatment options<br />Viral rebound<br />Illness<br />Death<br />Poor outcomes on the population level<br />Resistant virus emergence and fewer treatment options<br />Increased transmission<br />Higher morbidity and mortality burdens<br />
  6. 6. The Back Story: 1990s - early 2000<br />“Adherence seen as potential barrier to ART in RLS”<br />
  7. 7. <ul><li> Self report mean Adherence = 90%
  8. 8. UDVL = 71%</li></ul>Compared to Avg US Adherence<br />~70-80%<br />AIDS 2003<br />
  9. 9. The Response<br />
  10. 10. We know it can be achieved<br />But there are complexities<br />
  11. 11. Adherence declines over time <br />
  12. 12. Most recent meta-analysisReview of Adherence at 2 years<br />Rosen et al. PLoS 2007<br />32 studies in SSA 1996-2007<br />~75,000 patients in non-research ART programs<br />Average follow-up time reported<br /> 9.9 mo, 77% retention<br />6 mo = 80% pts retained<br />12 mo = 60% pts retained<br />At 2 Years*:<br />BEST CASE = 84% <br />WORST CASE = 46%<br />AVERAGE = 61%<br />61% at 24 months<br />
  13. 13. 2. Resistance patterns are different with similar adherence to different regimens<br />NNRTI <br />Resistance develops quickly and nearly linearly<br />Boosted PI<br />Resistance develops more slowly and in a bell shaped curve<br />Bangsberg NY PRN 2009<br />
  14. 14. 3. There are external reasons for treatment interruption<br />Unstable drug supply<br />Access issues<br />Life circumstances change<br />
  15. 15. 4. Adherence is complex<br />
  16. 16. A Social Model of Adherence for sub-Saharan Africa<br />Ware and Bangsberg PLoS Medicine (in press)<br />Adherence<br />fulfills responsibility to <br />helpers and<br />preserve<br />relationships<br />as a resource<br />Relationships<br />as resources to overcome economic obstacles to adherence<br />Social Capital<br />Improving Health<br />Social Structural:<br />Patterns of Inequality,<br />e.g., stigma,<br />gender inequality<br />Individual:<br />HIV knowledge<br />Med side effects<br />Cognitive function<br />Mental health<br />Alcohol Use<br />Resource<br />Scarcity<br />Resource<br />Scarcity<br />Infrastructural:<br />Few treatment sites<br />Distance to care<br />Cost/Availability of <br />Transportation<br />Cultural:<br />Religious Beliefs<br />Respect for Authority<br />Importance of<br />having children<br />
  17. 17. What can we do to support sustainable adherence?<br />Understand the importance of adherence<br />Prioritize it as a PSYCHSOCIAL AND A CLINICAL issue and a main determinant of outcome<br />It requires a TEAM approach<br />Build program components that are sensitive and specific to supporting and enhancing sustainable adherence<br />Only a certain amount can be accomplished in the facility setting<br />Linkages are critical<br />Patient involvement and self-efficacy are critical<br />
  18. 18. This is why we are here<br />To explore on a deep level HOW to build and implement these components<br />Focus on five interventions, two of which have been designated as priority<br />Assessment of adherence within a counseling framework<br />Appointment systems<br />A structured approach<br />CSM<br />Conceptualize, operationalize, implement, assess<br />Model, derive goals and objectives, measure, monitor, intervene, assess<br />
  19. 19. For example<br />Operationalizing appointment systems<br />What are the components of a functional appointment system?<br />Using these criteria, every site should have one within one year of this meeting<br />
  20. 20. Keep our eyes on the prize<br />The sequence<br />Measuring—allows you to monitor<br />Monitoring—allows you to intervene<br />Intervening– allows you to achieve a good outcome<br />Assessing-- allows you to know if your intervention is working<br />The plan<br />Who?<br />What?<br />How?<br />
  21. 21. Special Recognition<br />Pharmacists<br />Part of patient care system<br />Part of multidisciplinary team<br />Key in adherence<br />Last or only person to see patients<br />Encourage the formation of a recommendation for two adherence or patient care-related things each pharmacist should do <br />
  22. 22. How it will go<br />“Warm-up”<br /><ul><li>Frame
  23. 23. Define the problem specific to ICAP programs</li></ul>“Starting Gate”: <br /><ul><li>Discuss in detail the goals, objectives, and organization of the workshop
  24. 24. Explore CSM as a methodology for doing adherence related work
  25. 25. Dive into issues and realities: Pharmacy work; country programs and interventions; involving people with HIV in care programs, and more</li></ul>“And you’re off….”<br /><ul><li>Do the work
  26. 26. Begin here
  27. 27. Continue at home</li>