Transcript Slide 1

ADHERENCE
Patrick Desmet
HIV / Therapycounselor
D V D - Testimonies
• 1. What is adherence and why is it important?
• 2. The factors that influence adherence?
• 3. How can we improve adherence?
• “ …Stick to the times, having the right amount of
drugs at all times in the system. Otherwise the virus
will breakthrough and starts multiplying again…”
• “…Never missed a dose during my pregnancy…”
• “…Taking your medication as directed, to have a
sufficient dose that will have the desired effect…”
• “…The ability to take your drugs to an extent that
they will work…”
What is Adherence ?
The medication adherence is the ability of the patient
to be involved in:
choosing , starting, managing and maintaining
a given therapeutic combination regimen
to control viral replication and improve the immune
function.
Jane M.Simoni Ph D
• “ …Stick to the times, having the right
amount of drugs at all times in the system.
Otherwise the virus will breakthrough
and starts multiplying again….”
• “ …Taking your medication as directed, to
have a sufficient dose that will have the
desired effect…..”
Electronic Event Monitoring (MEMS®)
24:00
Time
20:00
16:00
12:00
08:00
04:00
6
10
14 18 22 26 30
September
4
8
12 16 20 24 28
October
Fabienne Dobbels
UZ Leuven
“….Otherwise the virus will breakthrough and starts
multiplying again”
Patients Reaching Undetectable
HIV RNA LOQ 400 (%)
Relationship of adherence (measured by
MEMS® 81 patients / 45397 doses /
6 months of FU ) to virologic success
100
Mean adherence rate
78
P = <0.001
75
45
50
33
29
25
18
0
>95%
90%-95% 80%-90% 70%-80%
<70%
Greatest danger zone for developing resistance
Adapted from: Paterson DL et al. Ann Intern Med 2000;133: 21-30
•“ …Taking your medication as directed, to have a
sufficient dose that will have the desired effect….”
Log concentration (ng/mL)
10000
1000
Half life: >12 hours
100
Even 48 hours post-dose, plasma levels remain above EC50
10
1
day 1
dose
day 2
dose
day 3
dose
day 4
miss
Examples: EFV, TDF, ddI, Atazanavir
day 5
dose
EC50
ADHERENCE vs. PHARMACY REFILLS
Objective : HIV-disease progression / AIDS vs. Adherence
Methods :
• 950 patients ARV naive
• (85% PI and 15%NNRTI) + 2NRTI
• Median follow-up 13 months
• Pharmacy based records, refills
Conclusion
For each 10% decline in adherence
16% increase in mortality
Hogg et al.7th CROI 2000/abs73.
• “ …It’s difficult when I need to go to an
event, wedding, party, …. Anytime where
you are exposed taking your drugs…”
Disclosure
“… Absolutely terrible, it was worse going to
therapy than having my AIDS diagnosis. For me
it was the slippery slope downhill…”
Anxiety
• “…I forgot my medication for days, because I
was living a very hard life. My mind was thinking
of many other things than medication….”
• “….It was the most difficult thing I had to do in
my life…”
• “… I was never been sick since my diagnosis it
was very difficult to convince myself to start up
therapy…”
Motivation
MOTIVATION
ESTABLISH : READINESS
COMMITMENT
ASYMPTOMATIC
MOTIVATION
vs.
LONG-TERM
TREATMENT
SYMPTOMATIC
• Preventive Measures
MOTIVATION
• Reinforce the Necessity
• ART-SE Distress
ART Stop = SE Relief
• OI-status, Pill Burden,
Drug-drug Interactions
• “…Somethimes I rush to work, because
there is an important meeting I need to go
to and I forgot to take my medication…”
• “…Yes sometimes I forgot them because I
was not at home and I was in a rush…”
Anticipation
Why do Patients Miss Doses?
%
0
10
20
30
40
50
52
Too busy/simply forgot
46
Away from home
27
Felt depressed/overwhelmed
Took drug holiday/medication break
20
Ran out of medication
20
Too many pills
19
Worried about becoming 'immune'
19
Reasons given for missing
antiretroviral doses
(structured questionnaire)
18
Felt drug was too toxic
Wanted to avoid side effects
17
Didn't want others to notice
17
16
Reminder of HIV infection
14
Confused about dosage direction
13
Didn't think it was improving health
Were told the medicine is no good
n=133
45
Change in daily routine
To make it last longer
60
10
9
Adapted from: Gifford AL et al. JAIDS 2000; 23: 386-395
possible interventions
simplify dosing schedule
decrease pill burden
other
ADHERENCE
PATIENT FACTORS
•Denial HIV- status
•Negative beliefs (negative arv history partner)
•Fear of Short or Longterm - Side Effects
•Lack off trust towards Health-Care team
•ARV = ongoing reminder of HIV status
HEALTHCARE FACTORS
• STAFF TRAINING
• INSUFFICIENT STAFF & SPACE for COUNSELLING
• CONFLICTING PATIENT-INFORMATION (EDUCATION)
• CONFIDENTIALITY (reception, waiting rooms,
personalised interviews vs. Multidisciplinary team)
• POOR ORGANIZATION OF DAILY CARE
•AUTHORITARIAN AND JUDGEMENTAL ATTITUDE
Cultural and Socio-economic
Status
•Welfare status: housing, financial support…
•Fear of Disclosure : ARV > trigger HIV-Status
•Stigmatisation : cultural / religious beliefs
•Drug (speed, ecstasy…) and Alcohol use
TREATMENT FACTORS
• DRUG TOXICITIES: SHORT AND LONGTERM SE
• COMPLEX REGIMEN / PILL BURDEN
• DOSING FREQUENCY / DRUG INTERACTIONS
• DIETARY RESTRICTIONS
• LOGISTICAL : APPROVALS / AVAILABILITY OF DRUGS
• CONCOMITANT /ALTERNATIVE MEDICINE
• ACCUMULATIVE TREATMENT CHANGES
“…It’s incredible important to get the right
regimen for the right person, it’s really about
looking at the individual patient….”
“…As a patient I need much more information…”
“…You need to prepare the patient properly…”
Fit the ARV’s into the lifestyle
BASIC KNOWLEDGE
PATIENT
HEALTH
BELIEFS
&
CULTURAL /
SOCIO-ECONOMIC
STATUS
EMPOWERMENT
SKILLS
&
MOTIVATION
Flow Chart Counseling New HIV+
3 STEP APPROACH = a stepwise informationflow
OPTIMISING HAART
TRUST
KNOWLEDGE
LIFESTYLE
Potential ADHERENCE
and ARV-BARRIERS
DYNAMIC MONITORING
PEOPLES LIVES
= VARIABLE BEHAVIOR
IMPACT from ENVIRONMENT
 SOCIAL FACTORS
 NEW DIAGNOSES
2 visits
Counseltopics
Evaluation 2 ARV proposals
• Sec.Prevention: Safe sex,…
Lifestyle:Diet, work, co-medication…
•HIV basics
Potential Adherence and Therapy
barriers
•AIDS vs. HIV
•Disclosure
•CD4 & VL-interpretation before
and during therapy
•Life expectansy
Social status check cf. social nurses!
Drug specific Side effects: short &
longterm
• Initiate Dummy Run
• ARV support : community (sensoa)
• Adherence: timing, dosing, food,
anticipation
• Adherence vs. Resistance
Initiation Haart and follow- up
READINESS
COMMITMENT
Counseltopics
Counseltopics
•Drugplanning: optimizing
drugintake, identify ARVreminders, ARV-storage, food
recommendations….
•Telephone call patient / counselor
•Patient rehearses
drugplanning and potential SE
= Timing , dosing, diet,anticipation,
ARV_storage.
•Drug specific SEffects
•Reasons for non-adherence
• Supportive Tools
•Anticipate SEffects cf Dr.
•Adherence check:
Pillbox and reminder system
UZ Leuven
Vibrating alarms, watches,
cell-phone alarm, SMS
ADHERENCE COUNSELING
MULTIDISCIPLINARY TEAM EFFORT
INFORMATION
EDUCATION
NEGOTIATION
BEFORE, DURING and AFTER START of ART