Transcript AIDS 2008 PowerPoint Template

Intervening to Improve
Adherence – What do we Know?
Conall O’Cleirigh, Ph.D.
Associate Director
Behavioral Medicine, Department of Psychiatry
Massachusetts General Hospital
Harvard Medical School
Behavioral Scientist
The Fenway Institute
Boston
www.ias2011.org
Intervening to Improve
Adherence – What do we Know?
• Qualitative Reviews of the Intervention
Literature
– Simoni et al., Cur HIV/AIDS Rep, 2010
– Reisner et al., Topics in HIV Medicine, 2008
• Recent and current meta analyses
– Simoni et al., JAIDS 2006
– De Bruin et al Arch Intern Med 2010
– Hart et al., JAIDS, 2010
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Intervening to Improve
Adherence – What do we Know?
• Recently Reported RCTs
- Ingersoll, et al., Drug Alcohol Dep, 2011
- Johnson et al., Ann Behav Med, 2011
- Fisher et al., AIDS Behav, 2011
- Kalichman et al., Am J Public Health, 2011
- Safren et al., Health Psychology, 2010
- De Bruin et al., Health Psychology, 2010
- Webel et al., AIDS Care, 2010
- Simoni et al., JAIDS, 2009
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Intervening to Improve
Adherence – What do we Know?
• Technology Based Studies
- Pager/Electronic Reminder
- Simoni et al., JAIDS, 2009
- Hardy et al., AIDS Patient Care, 2011
- Text Messages
- Lester et al., Lancet, 2010
- Pop-Eleches., et al., AIDS, 2011
- Other Preliminary Acceptability Studies
- Skrajner, Et al., HIV AIDS Auckl, 2009
- Harris, et al., Telemed J E Health, 2010
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Interventions are heterogeneous with
respect to
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Intervention content
Interventionist
Dose (length, # of sessions)
Assessment/Follow-up period
Patient characteristics
Range of target behaviors
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Interventions are heterogeneous with
respect to….
…..Intervention Content
- Video based motivational interviewing
- Social Problem Solving/Coping Effectiveness Training
- Peer Based
Social Support/Pager Messaging
Peer based symptom management/self monitoring
- Integrated Interventions
w/sexual risk reduction
substance use treatment
CBT for depression
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Interventions are heterogeneous with
respect to….
…..Intervention Content
-Technology Based Intervention
Personalized Text Messaging
Interactive Text Messaging
Informational Content
Motivational Content
Short/Long Messages
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Interventions are heterogeneous with
respect to….
.….Interventionist/ Dose (length, # of sessions)
-
Nurses (2 sessions)
Video delivered (6 sessions)
Computer administered (mean 6 brief sessions – variable dose)
Doctorate Level Psychologists (10 sessions)
Masters Level Clinicians (5 sessions)
Community-based facilitator (5 2-hour groups & 2 1-hour indiv)
HIV Peer Interventionists (6 1-hour groups)
Pharmacists (mean = .9 sessions per month (18 min session)
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Interventions are heterogeneous with
respect to….
.…. Assessment/Follow-up period
- MEMS Cap
9 month f/u
-
Self-Report Time Line Follow Back
Self-Report Dichotomized @ 100%
Unannounced Monthly Pill Counts
MEMS Cap and Self –Report
Self-Report (% missed doses)
Self Report (analogue and % missed)
MEMS Cap and Self –Report
Self-Report (% missed past 30 days)
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6 month f/u
15 month f/u
9 month f/u
9 month f/u
6 month f/u
up to 18 months f/u
6 month f/u
12 month f/u
Interventions are heterogeneous with
respect to….
.…. Patient Characteristics
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MSM 18 + (no substance abuse)
MSM 18 + substance users (predominantly African American)
Men and women with high levels of ART s/e distress
Depressive symptoms and history of opiate dependence
Predominantly African American men
Predominantly men
Women
Men and women with no cognitive impairments
Less than 85% adherence
Kenyan, 18+, ART naïve (less than 3 months), with mobile phone
Kenyan, 18+, less than 3 months on ART
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Interventions are heterogeneous with
respect to…. .…. Results
Ingersoll, et al., Drug Alcohol Dep, 2011
No significant difference between MI and Video MI conditions
Johnson et al., Ann Behav Med, 2011
Treatment effect for non adherence maintained at 15 months
Fisher et al., AIDS Behav, 2011
ITT non-significant: Intervention related changes in adherence for those
with minimum dose and no ART interruptions.
Kalichman et al., Am J Public Health, 2011
Treatment effect for adherence (pill count) maintained at follow up
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Interventions are heterogeneous with
respect to…Results
Safren et al., Health Psychology, 2010
Treatment effect on MEMS adherence, depression (mediator) and CD4
count (6 month). Adherence did not maintain at follow up
De Bruin et al., Health Psychology, 2010
Effects significant for adherence and undetectable viral load at 4 months
Treatment related changes in VL were mediated by adherence.
Webel et al., AIDS Care, 2010
No significant intervention effects
Simoni et al., JAIDS, 2009
Peer support alone yielded a 2 fold increase in adherence – did not
maintain post treatment. Pager alone was not significant for adherence
but was for CD4 at 6 and 9 months
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Interventions are heterogeneous with
respect to…. .…. Results
• Technology Based Studies
Electronic Reminders
Hardy et al., AIDS Patient Care, 2011
Significant effect for cell phone intervention over beeper at 6 weeks on
MEMS adherence .
Text Messages
Lester et al., Lancet, 2010
Intervention associated with significantly more reports of 95%+ adherence
and higher proportion with undetectable viral load at follow up.
Pop-Eleches., et al., AIDS, 2011
Significant treatment effect for MEMS adherence for those receiving
weekly reminders across 48 weeks of follow up.
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Some tentative conclusions
It appears that various methodologies are associated with the acquisition
of significantly improved adherence including
Project Balance (social problem solving/ coping effectiveness tx)
IMB based intervention
Peer Support delivered MI based intervention
Integrated Interventions
Life Steps (MI, Problem Solving) and CBT
Combination Secondary Prevention
Cell Phone Based Interventions (x 3)
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Some tentative conclusions
It appears that various methodologies are associated with the
maintenance of improved adherence post treatment discontinuation.
IMB based intervention
Life Windows (computer based) for On Protocol only
Integrated Interventions
Combination Secondary Prevention (Kalichman)
Cell Phone Based text messages
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Some tentative conclusions
Interventions associated with the significant impact on Viral Load or CD4
Cell count
Peer Support delivered MI based intervention - VL
Pager only - CD4
Integrated Interventions
Combination Secondary Prevention
Life Steps with CBT – CD4
Cell Phone Based text messages - VL
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Some tentative conclusions
Programs the provide additional components may have additional impact
(e.g., side effect management, sexual health counseling, depression or
substance use treatment).
Flexible programs that can be individualized address particular profiles
Treating adherence with in the functional context (substance use, mental
health issues, limited resources) to keep programatic problem solving
realistic.
Utilize data based feedback to identify ongoing barriers and targeted
problem solving
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Some tentative conclusions
Address multiple treatment adherence targets to support effectiveness
(e.g., retention in care, communication with health care providers,
access to….,)
Train adherence in the context of adherence lapse/relapse and program
for maintenance (e.g., relapse prevention, booster sessions)
Develop triage model to tailor a menu of programs to individual need and
anticipated outcome (brief versus integrated).
Describe in detail “standard of care” comparison connditions. Intervening
to Improve Adherence – What do we Know? Intervening to Improve
Adherence – What do we Know?
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