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Lecture 9:

Adherence in ARV Therapy

delivered byDr. Ndwapi Ndwapi, BHP

KITSO AIDS Training Program

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Objectives

• Define adherence.

• Understand importance of adherence in ARV therapy.

• Identify factors that influence adherence.

• Identify potential barriers to adherence.

• Discuss strategies to maximize adherence.

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Definition of Adherence

The extent to which a client’s behavior

coincides with the prescribed health care

regimen as agreed upon through a

shared decision making processbetween the client and the health care

provider.

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Compliance vs. Adherence (the old way) (the new way)

Compliance is defined as acting in accordance to a command.

The doctor/nurse tells the patient what to do and he/she must do it without question.

Adherence is defined as mutual decision making.

The patient understands and together with the doctor/nurse agrees to make behavior changes to improve health.

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COMPLIANCE ADHERENCEWilling submission to the commands of others

Shared decision making

Compliance vs. Adherence (2)

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Overview of Adherence

• Adherence to most drug regimes is poor across all populations and all diseases.

• Most information we have about adherence comes from studies of diabetes, heart disease & TB.

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• The percent of patients who fail to take their medications as ordered can range from 20% to 100%. The average being 50%.

• Adherence is considered successful for most other chronic diseases when the patient takes their medications > 80% of the time.

Overview of Adherence (2)

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HIV treatment is DIFFERENT

To be successful ARV medications must be taken 100% of the time…

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Why is this different in HIV?

• The virus rapidly multiplies in the absence of the drugs.

• With the increasing viral load, more mutations will occur that cause resistance to the drugs.

• Once resistance develops, the drugs stop working.

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Relationship between Adherence and Successful Outcome

Adherence Viral Load <400

>95% 81%

90-95% 64%

80-90% 25%

<70% 6%

(INCAS data, Paterson, et al. One year on combination therapy with protease inhibitors.)

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Maintaining adherence is the

MOST IMPORTANT factor for

success in ARV therapy

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ARV Adherence Research Studies Show:

• Health Care Workers are often unable to predict who will adhere correctly and who will not.

• Health care workers usually overestimate the number of patients who will adhere correctly.

• Patient self-reports of excellent adherence may or may not be true.

• However, patient self-reports of sub-optimal or poor adherence are probably true and should be taken seriously.

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Why is Adherence with ARV therapy such a challenge?

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The Drugs

• Complicated dosing regimens, number of pills.

• Interference with daily life.

• Requires commitment to lifelong therapy.

• Side effects.

• Requires ongoing availability of medications

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The Provider

• Must have up to date knowledge of HIV, ARV, side effects and drug-drug interactions.

• Must understand the relationship between adherence and resistance.

• Must display confidence in the therapy.

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The Provider (2)

• Must have effective communication skills to create trusting relationships with patients.

• Must have skills in patient education.

• Must understand and use the Botswana National Program guidelines for proper use and combination of ARV medications.

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The Patient

• Requires knowledge of HIV pathogenesis and treatment options.

• Must develop confidence in the treatment.

• May need to overcome distrust of the medical system.

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The Patient

• May have numerous psychosocial/ lifestyle issues that could impact on adherence.

• May have competing cultural beliefs and practices.– i.e., Traditional medicine

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Adherence ResearchReasons for Missed Doses

Just Forgot

Did not understand the regimen

Slept through dose time

Travel

Change in daily routine, weekend

Felt sick

Depression (ACTG-Adherence to Combination Therapy)

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Successful Adherence

• With so many challenges, is good adherence even possible?

• Is it realistic?

• What is the best approach to maximize success ?

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Botswana ResearchIn a study of 94 adults on ARV therapy, responses

showed that good adherence was associated with:

– Belief that medications help

– Understanding of risks of not taking medications correctly

– Advice and support from doctors

– Family support

– Personal determination

– Improvement of symptoms on therapy(Weiser, Marlink, 2001)

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Strategies for Successful Adherence

Strategies MUST be individualized.

A combination of interventions is most effective.

Adherence must be addressed at EVERY patient visit.

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Adherence Strategies must be:• Ongoing -- every visit.

• Repetitive -- consistent information.

• Revised -- to meet the changing needs of each patient.

• Multidisciplinary -- involving doctors, nurses, pharmacists, counselors.

Doctors MUST address adherence at every visit and not just refer the patient to other providers for counseling.

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The question is never WHETHER to start treatment but WHEN and HOW.

Before ANY medications are started, every patient must be assessed for treatment readiness with all potential barriers identified and addressed.

Never rush to treat, always assess carefully.

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Assessing Patient Readiness:

Determine level of understanding of:

– HIV pathogenesis and its implications.

– Purpose and effect of ARV therapy.

– Treatment options and limitations.

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Also Determine:

- Cultural beliefs and practices regarding disease and treatment.

- Previous experiences with illness and treatment.

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Stability of environmentIncome, food, shelter, access to clean water and refrigeration

LifestyleSingle, married, children

- potential for other positive or sick family members

Family, friends, community- potential supports and/or barriers

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TransportationAbility to return to clinic for follow up.

RoutinesWork/job – time off to attend clinic.Migration/travel – cattle post, lands.

Use of alcohol, other recreational drugs.

Educational levelAbility to read Setswana or English.

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Current state of physical health

- Can they manage treatment on their own or will they need other caregivers.

Mental health

- Depression related to HIV status.

- Stigma, discrimination.

- HIV related neurological effects.

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Starting Treatment

Reaffirm the patient’s choice to begin therapy.

- Lifetime commitment.

Review relationship between adherence and resistance.

- Goal = 100% adherence.

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Explain the medications, timing, and any

restrictions.

Discuss use of other medications:

- Drug/drug interactions.

- Traditional medicines.

- Always inform other providers of ARV use.

- Always inform clinic staff of other

medications.

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Side Effects

Prepare for potential side effects and offer practical coping strategies.

Make sure that patient understands exactly what to expect from each drug.

Reassure that side effects can be managed medically.

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Practical Support

Adherence is enhanced if the regime fits into the person’s daily routine.

Ask the patient to decide on the best times within the dosing guidelines.

Provide a picture schedule for the drugsAsk patient to repeat schedule.

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Show samples of the medications

Have patient do a return demonstration of each drug and time of administration.

Pediatric tip:

Have family give child first doses in clinic.

- This allows for immediate problem solving.

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Assist patient to plan ahead for changes in routine, travel.

- Problem solve for different situations.

Use adherence helpers:

- Pill boxes.

- Alarm clocks.

- Cell phone alarms.

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Adherence Buddies

Patient should involve family member or friend to assist with medication regime.

Explain how patient can access support from clinic.

- Clinic phone numbers, contact persons.

- Health care providers MUST be accessible.

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IMPORTANT

Patients need to understand:

ARV treatment is NOT a CURE

HIV TRANSMISSION can still occur

- If resistance develops, this can also

be transmitted.

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Ongoing Treatment

At EVERY visit assess:

Medication regime- what pills are to be taken and at what times

Doses missed- how often and why- problem solve with patient for future success.

Side effects -- patient response

Use of other medications, traditional medicine

Positive reinforcement of patient efforts, challenges

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ARV Management in the setting of Non-Adherence

• If non-adherence is believed to be the cause of treatment failure, HAART should be stopped, and the cause of non-adherence should be addressed.

• Once adherence has been reestablished and HAART has been restarted, viral load should be checked after 4 weeks of treatment.

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Remember

Reasons for missing doses

change over time:

- Lifestyle changes.

- Pill fatigue.

- Improved health.

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Summary• Never start treatment without assessing patient

readiness.

• Educate patient on all aspects of HIV/AIDS, treatment options and outcomes.

• Be directive in counseling to promote the goal of 100% adherence.

• Be accessible, approachable, supportive and KIND.

• Monitor and counsel for adherence at EVERY VISIT.