Title: Medication Adherence: What Can We Do to Help Patients Stick to Therapy
1Medication AdherenceWhat Can We Do to Help
Patients Stick to Therapy
- Lois Eldred, DrPH, MPH
- Special Projects of National Significance
- HIV/AIDS Bureau, HRSA
2Viral Suppression in Clinical Practice
Lucas, Annals Intern Med 1999
3Adherence 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
4How much adherence is enough?
Paterson, Ann Intern Med, 2000
5Viral Load by Adherence
Arnsten, 7th CROI, 2000
6Viral load and adherence (MEMS)
Thompson M, et al. XIII IAC, Durban 2000.
Abstract 1129
Mostly women and minorities viral load copies/ml, ARV naive
7Measuring 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
8Factors in Adherence
9Predictors of Adherence Patient
- Understanding of the regimen
- Alcohol/drug use
- Depression
- Appointment keeping
- Health beliefs and attitudes
- Perception of control (self efficacy)
- Social support
10Adherence and Illicit Drug Use
Adapted Cheever, ICAAC, 1999
11Drug Abuse Treatment Works
1 OR 1.88 (0.69- 5.28) 2 OR 4.91 (1.22-20.76)
Moatti, AIDS, 2000
12Health 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 dont take right, resistance will develop
Paterson, Abs 92 Kaplan, Abs 96 Wenger, Abs 98
6th CROI, 1999 Cheever, Abs 591, 39th ICAAC,
1999
13Interventions to Improve Adherence
- Barriers to adherence
- Differ among patients
- Vary over time
- Principles of interventions
- Multifaceted
- Repetitive
- Initiated prior to resistance developing
14Self 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
15Self Efficacy Counseling to Improve Adherence
Tuldra, JAIDS 2000
16Factors in Adherence
17Adherence Treatment Regimen
- Number of doses, medications, pills
- Length of time on therapy
- Dietary restrictions
- Side effects
18Side Effects Impact Adherence
Arnsten, 7th CROI, 2000
19Factors in Adherence
20Medical 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
21Engagement 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
22Non-engaged Patients
- More likely to be current/past injection drug
users (p0.002) - Nonadherent with
- Medication taking
- Medical appointments
- Following medical advice
- Not associated type of provider, sex, race
Bakken, AIDS Patient Care and STDs, 2000
23Satisfaction with Information
p0.02
Tuldra, 7th Euro. Conf. Clin. Aspect. And Tx of
HIV, 1999
24Asking about AdherenceWhat works
Steele , J Fam Pract 1990
25Asking 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 youve
missed? - Verify understanding of regimen Tell me exactly
how you take your medicines.
26Interventions 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
27Improving Access to Care
- 1/3 of patients in U.S. sample (HCSUS) went
without medical care due to1 - 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
28Support Services and Retention in Care
n2647
- 20 increase in regular visits (2/year) in an
urban clinic with support services, 1997-1998
Sherer R, AIDS Care, 2002
29Directly Observed Therapy
4
DOT directly observed therapy (incarcerated
cohort) SAT self-administered therapy (free
clinic cohort)
Fischl 7th CROI, SF, 2000. Abs 71
30Interventions Incentives Work
Chaisson, JAIDS, 1996
31Incentive 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
32Incentive to Improve Adherence
Rigsby, J Gen Intern Med 2000
33SPNS/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)
34 CASE Findings
- readiness component helps client maintain high
levels of adherence - Interventions based on Prochaskas 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
35Medication 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)
36Self Efficacy Counseling to Improve Adherence
Multivariate Analysis Adh. 95 at 48 wks
Tuldra, JAIDS 2000
37Adherence 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
38Adherence 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
39Adherence 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
40For more HIV-related resources, please visit
www.hivguidelines.org