www.aids2014.org
Promoting Adherence and Retention in ARV-based
Prevention
Dr. Seema Sahay, Ph.D
Division of Social and Behavioral Research
National AIDS Research Institute
Indian Council of Medical Research, Pune (India)
www.aids2014.org
Overview• Defining and measuring adherence• Issues around adherence
• The adherence framework– Individual, Product, Provider and Community
• Lessons learnt from treatment adherence
• Adherence in HIV prevention trials
• Known drivers of adherence
• Meeting the adherence challenges
• Addressing retention
• The CLUB message
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What is adherence?
• WHO defines adherence:• ‘The extent to which a person’s behavior – taking
medication, following a diet, and/or executing lifestyle changes – corresponds with agreed recommendations from a health care provider’ .
• Multidimensional: Interplay of participant behavior, adverse effect profiles, patient fatigue, and integration of therapy into the routine of daily living.
Adherence in HIV prevention – To take / use the drug as prescribed in order to achieve optimal drug levels at the time of exposure to virus.
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Measuring adherence
• Self-report use / recall• Direct measures
• Smart applicators• Wise Pill/Bags• Unannounced product count
• Biomarkers – drug levels• Triangulation of measures – combination of different
measures
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Issues around ARV based prevention
• How do we ensure that the drug/ product is available at the time of potential HIV exposure (when it relies on self-directed use)?
• Who would be the potential users? Key populations?
• In real life scenarios, how should PrEP products be positioned?
• How do we promote adherence to drugs/ interventions in non-therapeutic situations?
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Adherence Framework
Adherence
Individual
Product Provider
Community
Environmental Economic
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Individual
• Motivations for using the product – perception of self risk
• Time when product use might be most desirable: Example: desire to conceive
• Convenient to incorporate into lifestyle• Is the product empowering?• Relationship dynamics• Attitudes and beliefs towards the product
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Product
• Delivery vehicle• Oral – tablets• Vaginal - gels, rings, films
• Regimen• Dosing and timing• Daily vs coitally
• Product characteristics• Sticky, drippy, dry, smell, color, taste, too large to
swallow
• Potential side effects
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Provider
• Is the provider equipped with necessary information? – Training / Skills
• Is the provider community literate?• Are appropriate educational aids available?• Support of strengthened health care system• How would linkages between ARV delivery and
prevention programs be established?
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Community
• Disclosure to partner and families• For TasP: partner’s support would be useful
• Stigma / discrimination • Example: ARVs and TB drugs
• Community understanding of product • Buy-in at all levels of government / DoH is
critical • Country, province, states, district, municipality
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Lessons learnt from treatment adherence
• Buddy system – providing support• Treatment clubs – delivery of drugs to patient’s homes
and discussing experiences• Prescription and drug dispensing for longer period• Partner support • Peer involvement and community education• Empowered health educators, nurses or community
health workers• Cell phone reminders• Unannounced pill counts
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Effectiveness in PrEP trials is strongly correlated with adherence levels
0 20 40 60 80 100-60
-40
-20
0
20
40
60
80
Adherence by drug levels
Eff
ec
tiv
en
es
s (
%)
Pearson correlation = 0.86, p=0.003
Source: Prof Salim Abdool Karim, CAPRISA
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Lessons learnt from ARV prevention trials
• * Respect the individual *• Identify barriers to adherence and help the
individual come up with solutions • Product must suit the individual's lifestyle,
i.e. if sex is infrequent then a daily dose may not suit the need
• Encourage honesty – providers should not be judgemental
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Known drivers of adherence
Risk perceptionHealth seeking behavior
Followingprotcolsfor changing risk
behaviors
CommunityInvolvement
Social supportHealth caresystemAccess to health
resources
Diseasecharacteristcs
Illness-relevantcognition,
perceptions ofdisease factors, and
beliefs
Attributesof patient
Patient'senvironment
Adherence
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Risk perception: a key indicator of adherence
• Short message surveys for PrEP [K. Curran et al, 2013]
• Missed doses were correlated with sexual abstinence
• Unprotected sex was not associated with decreased PrEP adherence
• Low perception of HIV risk could explain low PrEP adherence [Van Damme et al, 2012]
• Self-perception of risk might increase PrEP use [Grant et al, 2010]
Perceived self risk would be an indicator of adherence
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Promoting adherence: challenges ahead• Individual:
• Self-perceived HIV risk: generally healthy! • Personal needs, priorities, motivations, and behavior • How do we promote adherence to drug in non-therapeutic condition?
• Products: • Unknown efficacy and incomplete safety profile• Frequency and timing of drug/product delivery• Do we have options available?
• Provider:• Are providers empowered to educate their patients?• Are providers working within a strengthened health care system?• Are there linkages between ARV delivery and prevention program?
• Community:• Addressing stigma and discrimination• Do we have buy-in at all levels of government?
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Adherence: Meet the challenge• Social science research:
• For understanding stigma• Learn about the social process that sustains stigma• Impact of stigma on health-related behavior.
• Develop and systematically test enhanced adherence counseling interventions
• Identify drivers of adherence to ARV based prevention to provide reliable explanation of variable adherence
• There is a need to leverage upon existing routines and establish client-centered relationships/ environments to support promote adherence and accurate reporting [Vitamin pills…]
• Development of products that do not depend on human behaviors: Injectable PrEP.
• Strategies to identify target population
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Retention
• Retention and adherence should go beyond individual boundaries
• Lessons from Link ART centre [LAC] program for retention might be useful
• At program level, linkages between ARV for prevention and ARV for treatment needs to be planned
• Identify individual, individual’s behavioral, family, societal and environment factors that can prevent retention in prevention program.
RETENTIONProgram (INDIA) Retention committee
HCP, Social Scientist, Community Liaison
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CLUB Message
• Commitment to remain HIV free• Live and prevent• Understand personal challenges• Believe in yourself to adhere
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Acknowledgements• Indian Council of Medical Research (ICMR)• AIDS 2014 • Dr. S. M. Mehendale• Prof. S. Abdool Karim• Dr. L. Mansoor• Dr. S. Chariyalertsak• Dr. J. de Wit• Ms. M. Francois• Dr. R. Paranjape
