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The challenge of longterm adherence

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Taking medication in the way prescribed by health provider ... (TRAC and Luxembourg development ) 70 patients on HAART. Women 62.3 % , Men 37.7 ... – PowerPoint PPT presentation

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Title: The challenge of longterm adherence


1
The challenge of long-term adherence
  • Joseph Vyankandondera
  • Gynecologist and Obstetrician /Kigali Teaching
    Hospital/ Belgian Technical Cooperation
  • Associate Professor/National University of Rwanda

2
Definition Adherence vs. Compliance
  • Adherence
  • Taking medication in the way prescribed by health
    provider
  • Active participation of a patient in a plan of
    care
  • Implies understanding, consent, and partnership
  • Includes adherence to care and adherence to
    treatment
  • Compliance
  • Adherence seen in the perspective of passive
    attitude

3
Non adherence and its implications
  • Individual level
  • Virus becomes resistant to available drug
  • Treatment not effective
  • Change of medication
  • Increased morbidity and mortality likely
  • Public Health level
  • Transmission of resistant virus
  • Increased treatment costs

4
Incidence and magnitude of non adherence
  • Lessons learnt
  • Individuals adherence at the start generally
    good
  • Long term adherence to treatment is 50 to 80
  • Cohort studies lt 10 observe drug adherence of
    more than 95
  • Challenges
  • Variation of adherence rates within individuals
  • Unreliable or non realistic/affordable tools for
    measurement
  • Multiple predictors/factors

HIV Inside Knowledge Base Chapter by Edward L. et
al
5
Reasons for non adherence
  • Patient factors
  • Some people just forget to take their pills
  • Change of habits (travel, special occasions)
  • Does not want to be reminded their HIV/AIDS
    status
  • Does not want to take pills in presence of others
  • Some people decide to skip pills to avoid side
    effects
  • Reluctance to take pills that day
  • Running out of pills

6
Risk factors for non adherence
  • Treatment regimen
  • Side effects
  • Complexity (multiple doses, elevated number of
    pills)
  • Food instructions (empty stomach versus fatty
    food)
  • Switching to a new regimen
  • Health provider related
  • Lack of convenience in scheduling appointments
  • Absence of confidentiality
  • Absence of integrated and comprehensive primary
    healthcare
  • Negative attitude of some healthcare workers

7
Conflicting facts
  • From Acute disease to Chronic disease
  • Lifelong care
  • Adherence deteriorating over time
  • More and more people under ARV
  • Shortage of qualified personnel
  • Better health
  • Tendency to hide the disease
  • Desire of child ?heterosexual transmission and
    MTCT

8
(No Transcript)
9
Methods measuring adherence
  • Self-report not accurate
  • MEM-CAPS
  • electronic device recording the removal of the
    cap
  • Used in research, but not suitable for most
    clinical settings
  • Pill counts Counting the remaining dose
  • Time-consuming
  • Rely on patients to bring their medication
  • Pills identification test (PIT)
  • Inviting patients to distinguish their pills from
    a display of antiretrovirals

10
Measuring adherence biological markers
  • Determining plasma drug levels
  • Good method
  • Many problems
  • Cost
  • NNRTI levels can be high while no close adherence
  • Measures recent adherence behaviour, not
    necessarily long term adherence
  • May be influenced by metabolism, malabsorption,
    etc.
  • Other surrogate markers
  • Elevated serum lactate levels correspond to good
    virologic response
  • Increased mean corpuscular volume (AZT)
  • Antiretroviral concentration in hair samples

11
TDM Study done in Rwanda (TRAC and Luxembourg
development )
  • 70 patients on HAART
  • Women 62.3 , Men 37.7
  • Most of them (80) indigents

12
TDM
  • Group 2
  • 27 dosages (EFV)
  • 100 with detectable levels of drug (EFV)
  • 85 in therapeutic range
  • 15 below therapeutic range
  • Group 1
  • 43 dosages (NVP)
  • 90.5 with detectable levels of drug
  • 88.5 in therapeutic range
  • 2 below therapeutic range

13
Compliance with appointment
  • 76.8 attended the appointment
  • 8.4 didnt attend the appointment
  • 14.8 no data in questionnaire

14
Social support Buddy
  • Spouse 15
  • Other family member 67
  • Friend 11
  • Association 1
  • None 6

15
Conclusions of the study
  • High level of treatment adherence despite
    advanced clinical stages and indigence of
    patients
  • Sub therapeutic levels could not be explained by
  • Lack of support through a  buddy 
  • Interaction of other medications

16
What is done in clinical practice ?
  • Self reporting
  • Overestimates adherence
  • Underestimates non adherence
  • Needs improvement (assessment of longer period)
  • Assessing the correct regimen
  • Visual analogue scale (VAS) patient indicates a
    point on a line to indicate how much of each drug
    has been taken in the past 4 weeks (0 to 100)

17
Preparing/monitoring for adherence
  • Have non judgmental attitude during discussion
  • Assess patients understanding of the importance
    of adherence
  • Identify potential obstacles
  • Understand reasons for missing doses
  • Assess side effects
  • Assess social support
  • Define long-term life plans

18
How to promote ART adherence
  • Continued support (family, community, HCP)
  • Target specific populations
  • Directly Observed Therapy (DOT)
  • potentially intrusive
  • time consuming
  • expensive
  • not easily sustainable in the long term

19
How to promote ART adherence (contd)
  • Simplified Treatment Regimens
  • Once or twice daily
  • Adherence devices
  • Medication organizers (pill box)
  • Reminder devices (Alarms, SMS.)
  • Visual medication schedules (VMS)

20
Conclusions
  • Assessing adherence is a very important component
    of long-term management
  • Accurate measurements tools of adherence
    sometimes require creativity
  • Challenges should be addressed as and when they
    occur
  • Social support and simplified regimen are
    important contributors to effective management
  • Reproductive health and desire to have children
    can be accommodated
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