Transcript HIV Basics and The New HIV Story

Medication Adherence:
What Can We Do to Help
Patients Stick to Therapy
Lois Eldred, DrPH, MPH
Special Projects of National Significance
HIV/AIDS Bureau, HRSA
Viral Suppression in Clinical Practice
Johns Hopkins' Moore Clinic Experience
Proportion of Patients
with VL <500 copies/ml
100
80
60
42
44
40
37
20
0
1-90 days
3-7 months
7-14 months
Lucas, Annals Intern Med 1999
Adherence Critical to Care
Nonadherent patients with:
 Increased mortality from HIV
– OR 1.16 (1.06-1.26) / 10%  adh 1
 Lower
CD4 count increase
– + 6 versus +83 cell/ml increase 2
 Increased
hospital days
– 12.9 versus 2.5 hosp. days / 1000 days F/U 2
1
Hogg, 7th CROI, 2000
2 Paterson, Ann Intern Med, 2000
Viral load <400 (% patients)
How much adherence is enough?
100
90
80
70
60
50
40
30
20
10
0
78
45
29
33
18
<70
70-79.9
80-89.9
90-94.9
>95
Adherence with Protease Inhibitor Therapy
Paterson, Ann Intern Med, 2000
Viral Load by Adherence
Proportion of Patients with VL <400
c/ml
100
90
80
80
70
61
60
50
40
33
30
20
10
10
0
<50
50-70
70-95
Adherence with Antiretrovirals
>95
Arnsten, 7th CROI, 2000
Viral load and adherence (MEMS)
Proportion of pts with VL < 400
copies/ml
Thompson M, et al. XIII IAC, Durban 2000. Abstract 1129
100
80
88
74
87
85
85
90
81
60
40
20
0
<70 >70 >75 >80 >85 >90 >95
Adherence level (%)
Mostly women and minorities viral load <100,000 copies/ml, ARV naive
Measuring Adherence
 No
gold standard
 Use what is practical
– Patient report will overestimate 30- 50%
– Pharmacies can be your friend
– Electronic monitoring in selected cases,
especially if it will help the patient
– Drug levels not practical for adherence
monitoring
Factors in Adherence
Medical
System
Patient
Drug
Regimen
Predictors of Adherence: Patient
 Understanding
of the regimen
 Alcohol/drug use
 Depression
 Appointment keeping
 Health beliefs and attitudes
 Perception of control (self efficacy)
 Social support
Missed >1 dose in 3 days
Adherence and Illicit Drug Use
50
45
40
35
30
25
20
15
10
5
0
48
43
42
38
23
Heroin
21
Cocaine
24
Binging
26
Using
Not Using
Heavy Alcohol
Adapted Cheever, ICAAC, 1999
Drug Abuse Treatment Works
Adherence with Antiretrovirals Among Drug Users
Active IDU
42
Ex- IDU (1)
65
Bupenorphine
Maintence (2)
78
0
20
40
60
80
Proportion of Adherent Patients
100
1
OR 1.88 (0.69- 5.28)
2 OR 4.91 (1.22-20.76)
Moatti, AIDS, 2000
Health Beliefs and Attitudes
 Associated
with antiretroviral (ARVs) use
– ARVs will help me have fewer symptoms of
HIV
– ARVs will help me live longer
 Associated
with adherence
– Medications will often fit into daily routine
– If don’t take right, resistance will develop
Paterson, Abs 92; Kaplan, Abs 96; Wenger, Abs 98; 6th
CROI, 1999; Cheever, Abs 591, 39th ICAAC, 1999
Interventions to Improve
Adherence
 Barriers
to adherence
– Differ among patients
– Vary over time
 Principles
of interventions
– Multifaceted
– Repetitive
– Initiated prior to resistance developing
Self Efficacy Counseling to
Improve Adherence
 Randomized,
controlled trial
 Intervention:
–
–
–
–
Counseling to increase self efficacy
Strategies to increase adherence
Association of adherence and resistance
Telephone number for questions
Tuldra, JAIDS 2000
Proportion of Pts >95% Adh.
Self Efficacy Counseling to
Improve Adherence
100
90
80
70
60
50
40
30
20
10
0
Inter AT
Cntrl AT
Inter ITT
Cntrl ITT
Week 4
Week 24
Week 48
Tuldra, JAIDS 2000
Factors in Adherence
Medical
System
Patient
Drug
Regimen
Adherence: Treatment Regimen

Number of doses, medications, pills

Length of time on therapy

Dietary restrictions

Side effects
Proportion of Adherent Patients (%)
Side Effects Impact Adherence
100
90
80
70
60
50
40
30
20
10
0
66
47
<=2 Side Effects
>2 Side Effects
Arnsten, 7th CROI, 2000
Factors in Adherence
Medical
System
Patient
Drug
Regimen
Medical System

Team support and interventions

Doctor- Patient relationship
– Trust / satisfaction

Patient education
– Appointment reminders
– Multiple and varied reinforcers

Accessibility of appointments, medication
– Child care / child friendly environment
– Transportation
Engagement in Care
 Convenience
Sample of 707 outpatients
 Engagement in care: Interaction with
health care provider (13 item scale)
–
–
–
–
–
Listens to me
Cares about me
Respects me
Spends enough time with me
Includes me in decision making
Bakken, AIDS Patient Care and STDs, 2000
Non-engaged Patients
 More
likely to be current/past injection drug
users (p=0.002)
 Nonadherent with
– Medication taking
– Medical appointments
– Following medical advice
 Not
associated: type of provider, sex, race
Bakken, AIDS Patient Care and STDs, 2000
Satisfaction with Information
100
90
80
70
60
50
40
30
20
10
0
Proportion of Patients
with 95% Adherence
p=0.02
High Satisfaction
Low Satisfaction
Tuldra, 7th Euro. Conf. Clin. Aspect. And Tx of HIV, 1999
Asking about Adherence:
What works
“You’re gaining weight. You must be
taking your medicine okay.”
0%
“Any problems with your medicines?”
63%
“Almost everyone misses medicines
80%
some of the time. In the last (week/month) how
many doses of medicine do you think you’ve
missed?”
“Tell me exactly how you take your medicines.”
Steele , J Fam Pract 1990
Asking About Adherence
 Permission
for missed dose: Almost
everyone misses medicines some of the
time.
 Specific questioning: In the last
(week/month) how many doses of
medicine do you think you’ve missed?
 Verify understanding of regimen: Tell me
exactly how you take your medicines.
Interventions to Improve
Adherence: Background
 Clinicians
play a specific role and
significant role in initiating and monitoring
adherence
 Adherence
research and other diseases
focuses primarily on physicians
 Most
HIV adherence interventions involve
a team of providers
Improving Access to Care
 >1/3
of patients in U.S. sample (HCSUS)
went without medical care due to:1
–
–
–
–
Need for money for food/clothing/housing
Lack of transportation
Inability to get time off from job/work
Feeling too sick
 Caring for others: Putting off care 2
– Women
OR 1.6 (1.2 - 2.2)
– Having child in household OR 1.8 (1.4 - 2.3)
1Cunningham,
Med Care 1999, 2 Stein Am J of Pub Health 2000
Proportion of patients in
year 1 (%)
Support Services and Retention in Care
70
60
With regular service
50
40
30
Without support
services care
n=2647
20
10
de
pe
nd
ea
lth
Ch
em
lh
ta
M
en
sp
an
Tr
Ca
se
or
m
ta
ti o
gm
n
t
0
• 20% increase in regular
visits (>2/year) in an urban
clinic with support services,
1997-1998
Support service
Sherer R, AIDS Care, 2002
HIV viral<50 copies/ml (%)
Directly Observed Therapy
100
90
80
70
60
50
40
30
20
10
0
DOT
SAT
0
8
4
16
24
32
40
48
Time (weeks)
DOT = directly observed therapy (incarcerated cohort)
SAT = self-administered therapy (free clinic cohort)
Fischl 7th CROI, SF, 2000. Abs 71
Proportion Returning for
PPD Reading
Interventions: Incentives Work
100
90
80
70
60
50
40
30
20
10
0
61
48
35
Standard Care
Voucher
Voucher +
Education
Chaisson, JAIDS, 1996
Incentive to Improve Adherence
 Randomized,
controlled trial
– MEMS device and AZT plasma levels
 Intervention
– Cue dose training
– Feedback from MEMS device
– Cash ($2/correct dose up to $10/day, $280 max.)
Rigsby, J Gen Intern Med 2000
Incentive to Improve Adherence
100
+ + + + +
Adherence (%)
80
Cue dose + $
Cue Dose
Control
60
40
20
0
0
1
2
3
4
5
6
7
8
9 10 11 12
Weeks
Rigsby, J Gen Intern Med 2000
SPNS/HRSA Initiative: Adherence
 14
Projects with varying adherence
interventions (1999-2004)
 Common core data evaluated among the
projects
 Evaluation Center: New York Academy of
Medicine; Center for Adherence Support
and Education (CASE)
CASE Findings
 “readiness”
component helps client
maintain high levels of adherence
 Interventions based on Prochaska’s stages
of change helpful over 6 months
 No direct relationship between the intensity
of encounters and improvement in
adherence
 Specific support and clinical services have
positive impact over time
Medication Support Versus Standard
of Care: Johns Hopkins HIV Clinic
 Nurse
Education
 Case Management
 Peer Advocacy
 Group Education
 Results: High users of readiness program
more likely to achieve improved viral
suppression (< 50)
Self Efficacy Counseling to
Improve Adherence
Multivariate Analysis: Adh. >95% at 48 wks
Variable
Self
efficacy
Odds Ratio CI
13.76
Intervention
group
6.58
p value
1.2 – 188.1 0.04
1.1 – 39.5
0.03
1.1 – 25.4
0.03
Effort Index
5.38
Tuldra, JAIDS 2000
Adherence: Conclusions
 Adherence
is critical for long term success of
HAART
 Interventions must be maintained over time
 Barriers differ among patients and over time
interventions must be patient-tailored
 Adherence interventions are now a standard
part of quality HIV care
Adherence: Where do we go
from here?
Self-management Programs
 Needs
assessment of readiness and active
interventions to promote self-efficacy for
taking medications
 Collaborative approach in timing the
initiation of medication
 Group support and education is a powerful
tool
Adherence: Where do we go
from here?
 Use
experiences with other chronic disease
self-management programs
 Cost effectiveness must be demonstrated as
adherence interventions are integrated into
practice
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