promoting adherence and retention in arv-based prevention

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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). Overview. Defining and measuring adherence Issues around adherence - PowerPoint PPT Presentation

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Promoting Adherence and Retention in ARV-based Prevention Dr. Seema Sahay, Ph.DDivision of Social and Behavioral ResearchNational AIDS Research InstituteIndian Council of Medical Research, Pune (India)

www.aids2014.org1OverviewDefining and measuring adherenceIssues around adherence

The adherence frameworkIndividual, 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

www.aids2014.orgWhat is adherence?WHO defines adherence:The extent to which a persons 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.www.aids2014.org3Measuring adherenceSelf-report use / recallDirect measures Smart applicatorsWise Pill/BagsUnannounced product countBiomarkers drug levelsTriangulation of measures combination of different measures

www.aids2014.orgIssues around ARV based preventionHow 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?

www.aids2014.orgAdherence FrameworkEnvironmentalEconomicwww.aids2014.orgIndividualMotivations for using the product perception of self riskTime when product use might be most desirable: Example: desire to conceiveConvenient to incorporate into lifestyleIs the product empowering?Relationship dynamicsAttitudes and beliefs towards the productwww.aids2014.org7ProductDelivery vehicleOral tabletsVaginal - gels, rings, filmsRegimenDosing and timingDaily vs coitally Product characteristicsSticky, drippy, dry, smell, color, taste, too large to swallowPotential side effects

www.aids2014.orgProviderIs the provider equipped with necessary information? Training / SkillsIs the provider community literate?Are appropriate educational aids available?Support of strengthened health care systemHow would linkages between ARV delivery and prevention programs be established?www.aids2014.orgCommunityDisclosure to partner and familiesFor TasP: partners support would be usefulStigma / discrimination Example: ARVs and TB drugsCommunity understanding of product Buy-in at all levels of government / DoH is critical Country, province, states, district, municipality

www.aids2014.orgLessons learnt from treatment adherenceBuddy system providing supportTreatment clubs delivery of drugs to patients homes and discussing experiencesPrescription and drug dispensing for longer periodPartner support Peer involvement and community educationEmpowered health educators, nurses or community health workersCell phone remindersUnannounced pill counts

www.aids2014.orgEffectiveness in PrEP trials is strongly correlated with adherence levelsPearson correlation = 0.86, p=0.003Source: Prof Salim Abdool Karim, CAPRISAwww.aids2014.orgPrep: hih adh hig effectiveness12Lessons 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 needEncourage honesty providers should not be judgementalwww.aids2014.orgKnown drivers of adherence

www.aids2014.orgRisk perception: a key indicator of adherenceShort message surveys for PrEP [K. Curran et al, 2013]Missed doses were correlated with sexual abstinenceUnprotected 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 adherencewww.aids2014.org15Promoting adherence: challenges aheadIndividual: 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 profileFrequency and timing of drug/product deliveryDo 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 discriminationDo we have buy-in at all levels of government?

www.aids2014.orgAdherence: Meet the challengeSocial science research:For understanding stigmaLearn about the social process that sustains stigmaImpact of stigma on health-related behavior.Develop and systematically test enhanced adherence counseling interventionsIdentify drivers of adherence to ARV based prevention to provide reliable explanation of variable adherenceThere 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

www.aids2014.orgRetentionRetention 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, individuals behavioral, family, societal and environment factors that can prevent retention in prevention program.

www.aids2014.orgRETENTIONProgram (INDIA)Retention committeeHCP, Social Scientist, Community Liaison

CLUB MessageCommitment to remain HIV freeLive and preventUnderstand personal challengesBelieve in yourself to adherewww.aids2014.orgAcknowledgementsIndian Council of Medical Research (ICMR)AIDS 2014 Dr. S. M. MehendaleProf. S. Abdool KarimDr. L. MansoorDr. S. ChariyalertsakDr. J. de WitMs. M. FrancoisDr. R. Paranjapewww.aids2014.org

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