Transcript Powerpoint - AIDS 2014

Promoting Adherence and
Retention in ARV-based
Prevention
Dr. Seema Sahay, Ph.D
Division of Social and Behavioral Research
National AIDS Research Institute
Indian Council of Medical Research, Pune (India)
www.aids2014.org
Overview
• Defining and measuring adherence
• Issues around adherence
• The adherence framework
– Individual, Product, Provider and Community
• Lessons learnt from treatment adherence
• Adherence in HIV prevention trials
• Known drivers of adherence
• Meeting the adherence challenges
• Addressing retention
• The CLUB message
www.aids2014.org
What is adherence?
• WHO defines adherence:
• ‘The extent to which a person’s behavior – taking
medication, following a diet, and/or executing lifestyle
changes – corresponds with agreed recommendations from
a health care provider’ .
• Multidimensional: Interplay of participant behavior,
adverse effect profiles, patient fatigue, and
integration of therapy into the routine of daily living.
Adherence in HIV prevention – To take / use the drug as
prescribed in order to achieve optimal drug levels at the
time of exposure to virus.
www.aids2014.org
Measuring adherence
• Self-report use / recall
• Direct measures
• Smart applicators
• Wise Pill/Bags
• Unannounced product count
• Biomarkers – drug levels
• Triangulation of measures – combination of different
measures
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Issues around ARV based
prevention
• How do we ensure that the drug/ product is available
at the time of potential HIV exposure (when it relies
on self-directed use)?
• Who would be the potential users? Key populations?
• In real life scenarios, how should PrEP products be
positioned?
• How do we promote adherence to drugs/
interventions in non-therapeutic situations?
www.aids2014.org
Adherence Framework
Product
Provider
Individual
Community
Adherence
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Environmental
Economic
Individual
• Motivations for using the product –
perception of self risk
• Time when product use might be most
desirable: Example: desire to conceive
• Convenient to incorporate into lifestyle
• Is the product empowering?
• Relationship dynamics
• Attitudes and beliefs towards the product
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Product
• Delivery vehicle
• Oral – tablets
• Vaginal - gels, rings, films
• Regimen
• Dosing and timing
• Daily vs coitally
• Product characteristics
• Sticky, drippy, dry, smell, color, taste, too large to
swallow
• Potential side effects
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Provider
• Is the provider equipped with necessary
information? – Training / Skills
• Is the provider community literate?
• Are appropriate educational aids available?
• Support of strengthened health care system
• How would linkages between ARV delivery and
prevention programs be established?
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Community
• Disclosure to partner and families
• For TasP: partner’s support would be useful
• Stigma / discrimination
• Example: ARVs and TB drugs
• Community understanding of product
• Buy-in at all levels of government / DoH is
critical
• Country, province, states, district, municipality
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Lessons learnt from treatment
adherence
• Buddy system – providing support
• Treatment clubs – delivery of drugs to patient’s homes
and discussing experiences
• Prescription and drug dispensing for longer period
• Partner support
• Peer involvement and community education
• Empowered health educators, nurses or community
health workers
• Cell phone reminders
• Unannounced pill counts
www.aids2014.org
Effectiveness in PrEP trials is strongly
correlated with adherence levels
80
PartnersPreP (FTC)
PartnersPrep (TDF)
TDF2
Effectiveness (%)
60
iPrEX
40
CAPRISA 004
VOICE (TFV gel)
20
FemPrEP
0
VOICE (Truvada)
-20
-40
VOICE (TDF)
Pearson correlation = 0.86, p=0.003
-60
0
20
40
60
Adherence by drug levels
www.aids2014.org
Source: Prof Salim Abdool Karim, CAPRISA
80
100
Lessons learnt from ARV
prevention trials
• * Respect the individual *
• Identify barriers to adherence and help the
individual come up with solutions
• Product must suit the individual's lifestyle,
i.e. if sex is infrequent then a daily dose may
not suit the need
• Encourage honesty – providers should not
be judgemental
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Known drivers of adherence
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Risk perception: a key indicator
of adherence
• Short message surveys for PrEP [K. Curran et al, 2013]
• Missed doses were correlated with sexual
abstinence
• Unprotected sex was not associated with
decreased PrEP adherence
• Low perception of HIV risk could explain low
PrEP adherence [Van Damme et al, 2012]
• Self-perception of risk might increase PrEP
use [Grant et al, 2010]
Perceived self risk would be an indicator of adherence
www.aids2014.org
Promoting adherence: challenges ahead
• Individual:
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•
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Self-perceived HIV risk: generally healthy!
Personal needs, priorities, motivations, and behavior
How do we promote adherence to drug in non-therapeutic condition?
• Products:
•
•
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Unknown efficacy and incomplete safety profile
Frequency and timing of drug/product delivery
Do we have options available?
• Provider:
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Are providers empowered to educate their patients?
Are providers working within a strengthened health care system?
Are there linkages between ARV delivery and prevention program?
• Community:
•
•
Addressing stigma and discrimination
Do we have buy-in at all levels of government?
www.aids2014.org
Adherence: Meet the challenge
• Social science research:
• For understanding stigma
• Learn about the social process that sustains stigma
• Impact of stigma on health-related behavior.
• Develop and systematically test enhanced adherence
counseling interventions
• Identify drivers of adherence to ARV based prevention
to provide reliable explanation of variable adherence
• There is a need to leverage upon existing routines and
establish client-centered relationships/ environments to
support promote adherence and accurate reporting
[Vitamin pills…]
• Development of products that do not depend on human
behaviors: Injectable PrEP.
•www.aids2014.org
Strategies to identify target population
Retention
• Retention and adherence should go beyond
individual boundaries
• Lessons from Link ART centre [LAC]
program for retention might be useful
• At program level, linkages between ARV for
prevention and ARV for treatment needs to
be planned
• Identify individual, individual’s behavioral,
family, societal and environment factors that
can prevent retention in prevention program.
www.aids2014.org
RETENTION
Program (INDIA)
Retention committee
HCP, Social Scientist, Community Liaison
CLUB Message
•
•
•
•
Commitment to remain HIV free
Live and prevent
Understand personal challenges
Believe in yourself to adhere
www.aids2014.org
Acknowledgements
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Indian Council of Medical Research (ICMR)
AIDS 2014
Dr. S. M. Mehendale
Prof. S. Abdool Karim
Dr. L. Mansoor
Dr. S. Chariyalertsak
Dr. J. de Wit
Ms. M. Francois
Dr. R. Paranjape
www.aids2014.org