Patient Comprehension of Antiretroviral Drug Resistance
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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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