Transcript document

Adherence Works
• In 1998, knew missed doses led to resistant virus.
• Since 1998, studies have demonstrated that
adherence leads to lower viral loads, decreased
AIDS progression, and increased survival.
• For example, clients followed for 7 months
demonstrated virologic failure:
– 22% with 95% adherence
– 61% with 80-95% adherence
– 80% with 80% adherence
Major Changes in Treatment
Since 1998
• More understanding of long term side effects
and toxicity.
• New guidelines start treatment later.
• Resistance testing (genotype and phenotype)
may inform prescribing
• Some evidence on:
– Structured treatment interruptions
– Intermittent treatment
– Rotating regimens
Associations of Characteristics
and Adherence: Consistent
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Active psychiatric illness
Depression
Heavy drinking
Adherence at baseline
Associations of Characteristics
and Adherence: Inconsistent
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Race
Age
Sex
Mood
Drug use
Homelessness
Health beliefs
Coping skills
Rapport with providers
Poor communication with
provider
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Pill burden
Away from home
Side effects
Mistrust of system
Pre-existing conditions
Self efficacy
Frequency of stressful life
events
• No recent clinic visit
• Health literacy
• Economic barriers
Associations of Characteristics
and Adherence: Ever
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Income (MACS)
Education
Meaningful life
Comfortable and well
cared for
• Using time wisely
• Taking time for
important things
• Joy
• Fear
Reasons for Differences in
Findings
• Very different populations
• Different measures of adherence
• Different things are measured/asked
Reasons for Non-Adherence and
Barriers
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Forgetting
Side effects
Complexity
Knowledge
Reminds of HIV status
• Don’t want others to
know
• Don’t like the way I
feel
• No one to help
Reasons for Adherence and
Supports
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Mechanical devices
Commitment
Belief in medications
Social support
Professional support
Regular meals
• Use bedtime, other
routine to remind
• Store in a bag to take
everywhere
• Store where others
won’t see
Patterns of Reasons that Vary for
Different Groups
• IDU history (JHU)
– IDU history: stress; heroin use
– No IDU history: less than 2 meals per day; less
belief in efficacy of drug
• Health Literacy (WI)
– 12+ years of education and low health literacy:
more confused, side effects, depressed,
overslept, cleansing body
– Below 12 years education: forgot, no pills, busy
Patterns of Reasons that Vary for
Different Groups
Adherence Level (WI)
Adherent
Non-Adherent
Confused/how many
5
31
Need more than Dr. says
0
39
Instructions too complex
to understand
Instructions too complex
to follow
Hard to travel to
appointments
Don’t think treatment
helps
25
69
3
23
12
39
0
23
Patterns of Reasons that Vary for
Different Groups
• Confidential vs. Anonymous Disclosure
(CDC- in Bronx)
– Confidentially: forgot, medication inaccessible,
perceived toxicity
– Anonymously: perceived lack of drug efficacy
Interventions with Demonstrated
Effectiveness: Directly Observed
Therapy (DOT)
• Florida retrospective study comparing 50
treatment naïve prison inmates to 50 similar
controls.
– Found 100% in DOT group with less than
400VL at 24 weeks and at 90 weeks.
– 80% in controls with less than 400VL at 24
weeks and at 90 weeks.
• 10 person pilot (Mitty et. al) showed 1.2 log
drop in VL with DOT.
Interventions with Demonstrated
Effectiveness: DOT (cont.)
• Miriam Hospital (Providence, RI) pilot shows
“drastic” improvements in adherence with
peer outreach workers delivering drugs.
• Caveat: DOT cannot reverse resistance,
treatment failure.
– Analysis of very experienced patients in NYS
LTC facilities showed 1/3 never got to VL<400
copies; 1/2 virologic failure.
Interventions with Demonstrated
Effectiveness: Mechanical Devices
• Small study randomizing patients with under 90%
adherence into:
– Online paging reminder (“medimom”) and MEMS:
16% improvement from baseline level of 52%
adherence.
– MEMS alone: no change
• Small trial (N=36 at start; 10 at 24 weeks) of
people with cognitive dysfunction:
– Mechanical verbal reminder: 99% adherence at 24
weeks.
– Control: 69% adherence at 24 weeks.
Interventions with Demonstrated
Effectiveness: Multifaceted Educational,
“Psychoeducational” Support
• SUNY Buffalo/Erie Medical Center show big
effect from 16 week multifaceted intervention
(intensive, multifaceted, education, readiness,
tools, support).
16 weeks
- 93% intervention patients had VL <400 copies.
- 37% SOC patients had VL <400 copies.
32 weeks
- 100% of those in (16/23) had VL <400 copies.
- 20% of those in (14/37) had VL <400 copies.
Interventions with Demonstrated
Effectiveness
• Spain: 116 patients followed for 48 weeks in
randomized groups:
– Psychoeducative intervention: 94% had 95% adherence.
89% VL<400.
– SOC intervention: 68% had 95% adherence. 60% VL <400.
• Bandura self efficacy includes education on handling
medications; “solving” doubts; input on dosage
schedule; tackling problems like forgetting, delays,
changes, side effects; given phone number to call for
questions; follow up reinforcement and problem
solving.
• Note: Effect not evident until week 48.
Interventions with Demonstrated
Effectiveness
• San Fransisco Action Point: pilot
intervention with 68 homeless urban poor.
– No appointments, open six days per week, $10
cash incentive weekly, pager, prescriptions
delivered and held at center, acupuncture,
referrals to mental health, substance abuse
treatment, housing.
– 62% retained at 5months: 25/44 knew VL; of
these 16 had VL below 500.
Interventions with Demonstrated
Effectiveness
• San Diego: 168 patients randomized and followed for 6
months. Intervention focused on self management,
education, and support through group patient education.
Post Intervention
Six Months
Intervention
85% (excellent)
47% (fair)
13% (poor)
72% (excellent)
41% (fair)
15% (poor)
SS Control
76% (excellent)
34% (fair)
8% (poor)
67% (excellent)
35% (fair)
12% (poor)
PM Control
64% (excellent)
22% (fair)
5% (poor)
78% (excellent)
48% (fair)
20% (poor)
Themes about Effectiveness
• Flexibility/problem solving/different
approaches for different clients.
• Little evidence on long term effects: some
suggestion that interventions maintain
initial high level
• Very different results if analyzed as treated
or intend to treat.
• Need interventions that help keep people
connected.
Conclusions/Implications
• Adherence predicts adherence
• People are different. Their issues are
different. Different issues require different
solutions.
• This kind of intervention very difficult to
evaluate.
• Short term and long terms effects not the
same.