Transcript Patient Comprehension of Antiretroviral Drug Resistance

Patient Comprehension of
Antiretroviral Drug Resistance:
Implications for Treatment and
Clinical Practice
Catherine Sarai Racey
March 19th 2009
MPH Capstone Defense
BC Centre for Excellence in HIV/AIDS
 The B.C. Centre for Excellence in HIV/AIDS (CfE) is Canada’s
largest HIV/AIDS research and treatment facility.
 The Centre was founded by St. Paul’s Hospital and the
provincial Ministry of Health and is dedicated to improving
the health of British Columbians with HIV.
 In B.C., all anti-HIV medications are distributed at no cost to
eligible HIV-infected individuals through the Centre’s Drug
Treatment Program.
 As of the last update nearly 4,380 HIV-positive persons are
accessing therapy in the province.
 Approximately 54 new patients access therapy each month.
(www.cfenet.ubc.ca)
Health Literacy
 Vital component for chronic disease care
 Encompasses:
 the capacity to act on knowledge
 understand treatment and health risks
 ability to utilize the health care system
 A key element of self-management is health literacy
 Poor health literacy is associated with poor health
outcomes
 A component of high health literacy is understanding
treatment
HIV/AIDS Treatment
 Dramatic reduced morbidity and mortality
 High level of adherence in order to maximize benefits
 Incomplete adherence is a key determinant in the
development of drug resistance
 Antiretroviral drug resistance is:
 a significant reduction of drug efficacy due to mutations in the
viral genome. Drug resistant quasi-species can emerge and be
selected when the viral population is exposed to sub-optimal
drug levels13
 Antiviral drug resistance limits treatment options
 Differential adherence and drug resistance have been
associated with an increased risk of death
Importance of Health Care Providers
 The health care provider plays an important role
 The relationship is an important factor in treatment
success, including better adherence
 Positive relationships provide opportunities
 Physician experience associated with improved survival
and perception of care
 Pharmacists play an important role in adherence
counseling and daily treatment concerns
HIV/AIDS Health Literacy
 Self-management strategies minimize symptoms in HIV
patients
 Knowledgeable about HIV/AIDS, as well as overall
treatment plans
 Key focus in treatment is preventing and prolonging
development of HIV drug resistance
 Patients need to understand fully the nature of their
treatment, the implications of incomplete adherence
and the consequences of developing drug resistance
Objective
 To determine the current level of Knowledge of HIV drug
resistance in a cohort of HIV+ people on HAART
 Identify predictive factors for comprehension
 Identify areas of focus for improving comprehension
Methods
 The LISA project is conducted through the Drug Treatment
Program (DTP) at the CfE
 LISA is a 3 – year prospective cohort, which aims to examine
the effects of various supportive health services on the health
status of HIV+ persons on meds
 Eligibility: HIV+, 18+years and on medication after 1996
 Participants were recruited through physician letters and
advertisements at local HIV/AIDS service organizations
 A 45 minute comprehensive interviewer-administered survey
 On-going linkage with the DTP provided data on the clinical
variables
Instrument – Variables
 Physician – patient relationship

length of time with physician, if they choose or were referred, ever switched physicians and if they are satisfied
with care
 Pharmacist involvement

ever received one-to-one counseling by a pharmacist when beginning or switching medications
 Quality of life

using a 9-item HIV/AIDS – targeted quality of life scale18
 Housing stability

assessed with stable or non-stable housing
 Food security

13-item Radimer/Cornell measurement scale19
 Other socio-demographic variables

ever or current illicit drug use, current employment, provincial income assistance and level of education
 Adherence

refill adherence, measured as the number of days medication is dispensed divided by the number of days
medication is prescribed (<95% and ≥95% adherence)
Resistance knowledge variable
 Knowledge of HIV drug resistance was conducted through a 2 –
part question
 A complete definition had to identify:
 Importance of adherence
 Presence of a viral mutation (or change)
 Drugs ceasing to work
 Coding:




Identify 3 factors – complete
Identify 1 – 2 factors – partial
Identify 0 factors – incorrect
Responses of ‘unsure’, ‘don’t know’, or blank were coded as
no response
Statistical Analysis
 In the multivariable analysis ‘complete’ and ‘partial’
definitions were pooled and ‘no response’ and
‘incorrect’ were pooled.
 Three comparison groups
 Bivariable analysis investigated associations using
Fisher’s Exact test or the Chi-square test for categorical
variables and the Wilcoxon rank sum test for continuous
variables
 Logistic regression was used for unadjusted bivariable
and the adjusted multivariable analysis
Results
 As of July 2008 there were 457 participants
 90% are currently on HAART
 The median age is 46, with 75% being male
 At the time if interview 46% of participants had CD4 cell
counts of ≥350 cells/mm3 and 58% were virologically
suppressed
 45% of the cohort was ≥95% adherent
 23% reported gainful employment and 47% reported using
illicit drugs (heroin, cocaine, crack, speedball, crystal meth)
 94% reported being highly satisfied with their physician and
over 80% reported high provider trust
Results – Bivariable Analysis
 Based on Bivariable model participants who gave partial or
complete definitions more likely to:
Variable
Younger
High school education or greater
Be employed
Live in stable housing
Discuss medications with their
physician
Received a one-to-one counseling
session with a pharmacist
Have higher provider trust
Have CD4 cell count >350cells/mm3
(44.4 yrs vs. 45.9 yrs)
(65.7% vs. 47.6%)
(31.0% vs. 21.1%)
(73.1% vs. 12.1%)
(95.8% vs. 91.9%)
(66.8% vs. 53.2%)
(91.7% vs. 83.3%)
(55.1% vs. 38.3%)
Results – Resistance Knowledge
 Based on multivariable model participants who gave
partial or complete definitions more likely to:
OR (95% CI)
Variable
Younger
Unadjusted
0.98 (0.960.99)
High school education or greater 1.84 (1.292.62)
Discuss medications with their
4.49 (2.43physician
8.29)
Received a one-to-one counseling 2.46 (1.72session with a pharmacist
3.53)
Adjusted
0.98 (0.960.99)
1.64 (1.072.51)
5.15 (2.6010.18)
1.79 (1.192.69)
Results – Resistance Knowledge
 Based on multivariable model participants who gave
partial or complete definitions more likely to:
OR (95% CI)
Variable
Younger
Unadjusted
0.98 (0.960.99)
High school education or greater 1.84 (1.292.62)
Discuss medications with their
4.49 (2.43physician
8.29)
Received a one-to-one counseling 2.46 (1.72session with a pharmacist
3.53)
Adjusted
0.98 (0.960.99)
1.64 (1.072.51)
5.15 (2.6010.18)
1.79 (1.192.69)
Results – Resistance Knowledge
 Based on multivariable model participants who gave
partial or complete definitions more likely to:
OR (95% CI)
Variable
Younger
Unadjusted
0.98 (0.960.99)
High school education or greater 1.84 (1.292.62)
Discuss medications with their
4.49 (2.43physician
8.29)
Received a one-to-one counseling 2.46 (1.72session with a pharmacist
3.53)
Adjusted
0.98 (0.960.99)
1.64 (1.072.51)
5.15 (2.6010.18)
1.79 (1.192.69)
 The probability of a complete or partial definition
increased from 15.90% (without discussing medications
with a physician or receiving one-to-one counseling by a
pharmacist) to 63.90% (if a participant received both)
Limitations
 Use of participant reported definitions
 The working definition is stringent with complete
definitions having to identify all 3 factors
 Subsequently controlled for in the analysis by pooling.
Participants who were able to identify 1 to 3 of the factors
were pooled.
 Distribution of participants
 As of July 1st ½ the LISA cohort reported current illicit drug
use and over 45% of interviews were conducted at one site
 As the number of interview sites increases the make-up of
the cohort will become more representative of the HIV
population in BC
Conclusions
 HIV drug resistance knowledge is low
 Participants who were able to completely or partially define
resistance had: higher provider trust, higher education, were on
average younger, discussed medications with their physician and
had one-to-one counseling session with a pharmacist.
 Two areas of focus for interventions are: discussing medications
with physicians and one-to-one counseling with a pharmacist
 Health literacy has been demonstrated as an important factor in
treating chronic diseases
 Building health literacy capacity through increased knowledge of
HIV drug resistance may help close the gap between adherence
and improve clinical outcomes
 Clinically relevant universal guidelines for patient education may
help direct consistent discussions and information for patients
Future Directions
 There are no provincial guidelines for patient education
 Devising a standardized patient education package which
incorporates the major mechanisms for developing
resistance, the implications for treatment and quality of life
and the importance of adherence
 A clinically relevant example: The IDC
 The program will comprise of a series of workshops whose
objectives tackle different areas of patient education
 Including: access to special health care services and preventing and
prolonging drug resistance
 The workshops will be delivered over a period of time in
hopes of engaging patients
 Engaged patients, with better health literacy, will do better
in self-management
Dissemination
 Accepted Poster presentation at Ontario HIV Treatment
Network (OHTN) 2008 Conference – November 13-14th
2008
 Accepted Oral presentation at the Canadian Association
for HIV Research (CAHR) 2009 Conference – April 23-26th
2009
 To be submitted for peer review in the Journal - AIDS
Acknowledgements
 I would like to acknowledge all of the LISA participants.
 Forever grateful to Wendy Zhang, Kimberly Fernendes, Eirikka
Brandson, Despina Tzemis, Richard Harrigan, Julio Montaner,
Junine Toy, Rolando Barrios and Bob Hogg for their
contributions and guidance.
 Thank you to the LISA team:Alexis Palmer, Katie Duncan, Andy
Mtambo, Oghenowede Eyawo, Despina Tzemis, Alexandra
Borwein, Mark Philips and Elizabeth Pipes.
 Special thank you to Eirikka Brandson, for her mentorship and
encouragement, Rolando Barrios for his insight and support,
and Bob Hogg for the wonderful opportunity to be a part of
the LISA team and for providing excellent guidance and
support throughout.
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