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Addressing the Challenges of Adherence
Journal of Acquired Immune Deficiency Syndromes (02.01.02) Vol. 29; S2- S10 - Tuesday, March 05, 2002
John A. Bartlett
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Adherence to therapy for HIV infection and disease is uniquely challenging; few, if any, other medical conditions require regimens that are as complex or as demanding. However, adherence is as essential as it is difficult. The close connection between adherence and viral load, CD4 cell counts, drug resistance and mortality has been unequivocally demonstrated. At least 95 percent adherence is required to keep HIV at bay. Unfortunately, real-life adherence rates often fall short of this percentage, and the potential barriers to adherence are numerous. In this article, Bartlett discusses the research on adherence and its barriers and offers strategies for increasing adherence in patients.
Most studies show that 40 percent to 60 percent of patients are less than 90 percent adherent. Adherence also tends to decrease over time. Patients offer a range of reasons for non- adherence, but the most frequently cited one is simply that they forget. Other reasons include being away from home, being busy, or experiencing a change in daily routine. There are barriers to adherence in individuals with psychiatric disorders, especially depression and substance use, although the author advises against "profiling" individuals with mental problems or substance use because this attitude has a tendency to under-estimate the adherence of those without these conditions. Equally important as barriers are uncertainty about the effectiveness of treatment, regimen complexity and treatment side effects.
Efforts to support adherence are significant. According to the author, several strategies can be employed in this effort and are most effective when used in combination and continued over the term of treatment. These include: *Educate and Motivate - Treatment needs to be explained to patients, in terms they can comprehend. The objectives of antiretroviral therapy are suppression of viremia, restoration and preservation of the immune function, reduction of morbidity and minimization of drug toxicity, disruption of lifestyle and risk of resistance. Patients need to know the effects of non-adherence. Feedback on HIV RNA levels and CD4 cell counts are important. Patients need to be motivated by an overarching goal of treatment. This goal must be patient specific, e.g. a goal of death due to something other than AIDS-related complication; or seeing their children reach adulthood. *Simplify - Research has shown that the simpler the regimen, the better patients' adherence to it is likely to be. Minimize, as much as possible, pill burden, dosing frequency and dietary restrictions. *Tailor Treatment to the Patient's Lifestyle - Patients are less likely to adhere to regimens that require them to substantially alter their lifestyles. Clinicians need to identify regular activities that can serve as medication- taking cues, such as teeth brushing, dog walking or favorite daily television shows. It is important to problem- solve with patients about changes in their routines. *Prepare for and Manage Side Effects - Failing to prepare patients for medication side effects can compromise credibility and trust and lead to patients' unilaterally discontinuing therapy. *Employ an Adherence Team - Recruiting a group of individuals to act as an "adherence team" can minimize time spent by any individual clinician. Ideally, the team should be multidisciplinary, including the patient and involving the physician and nurse practitioner, caseworker, nutritionist or peer counselors. *Address Concrete Issues - Adverse life situations such as homelessness, lack of transportation, and inability to pay interfere drastically with adherence. Patients should be questioned about issues that may interfere with treatment, including issues around depression and substance use. Appropriate referrals should be made and these disorders recognized and treated. *Recruit an Adherence Monitor - If a friend or family member can carry out a form of directly observed therapy in a home setting, this is very helpful in reinforcing the patient's commitment to therapy. *Provide Adherence-Promoting Devices - Because forgetfulness is such an important component of non-adherence, the use of memory aids such as pillboxes, diaries, alarms or beepers should be considered for every patient. *Anticipate Course Corrections - Treatment fatigue and burnout is a substantial threat to antiretroviral adherence over time. Anticipate changes in attitude toward medication adherence around times of flux, such as a change in a job or relationship. *Gear Intervention Toward Reason for Non-adherence - Patients have a range of reasons for failing to adhere to their regimens. These reasons should be assessed for each patient and addressed.
020305
http://www.aegis.org/
Addressing the Challenges of Adherence
Journal of Acquired Immune Deficiency Syndromes (02.01.02) Vol. 29; S2- S10 - Tuesday, March 05, 2002
John A. Bartlett
--------------------------------------------------------------------------------
Adherence to therapy for HIV infection and disease is uniquely challenging; few, if any, other medical conditions require regimens that are as complex or as demanding. However, adherence is as essential as it is difficult. The close connection between adherence and viral load, CD4 cell counts, drug resistance and mortality has been unequivocally demonstrated. At least 95 percent adherence is required to keep HIV at bay. Unfortunately, real-life adherence rates often fall short of this percentage, and the potential barriers to adherence are numerous. In this article, Bartlett discusses the research on adherence and its barriers and offers strategies for increasing adherence in patients.
Most studies show that 40 percent to 60 percent of patients are less than 90 percent adherent. Adherence also tends to decrease over time. Patients offer a range of reasons for non- adherence, but the most frequently cited one is simply that they forget. Other reasons include being away from home, being busy, or experiencing a change in daily routine. There are barriers to adherence in individuals with psychiatric disorders, especially depression and substance use, although the author advises against "profiling" individuals with mental problems or substance use because this attitude has a tendency to under-estimate the adherence of those without these conditions. Equally important as barriers are uncertainty about the effectiveness of treatment, regimen complexity and treatment side effects.
Efforts to support adherence are significant. According to the author, several strategies can be employed in this effort and are most effective when used in combination and continued over the term of treatment. These include: *Educate and Motivate - Treatment needs to be explained to patients, in terms they can comprehend. The objectives of antiretroviral therapy are suppression of viremia, restoration and preservation of the immune function, reduction of morbidity and minimization of drug toxicity, disruption of lifestyle and risk of resistance. Patients need to know the effects of non-adherence. Feedback on HIV RNA levels and CD4 cell counts are important. Patients need to be motivated by an overarching goal of treatment. This goal must be patient specific, e.g. a goal of death due to something other than AIDS-related complication; or seeing their children reach adulthood. *Simplify - Research has shown that the simpler the regimen, the better patients' adherence to it is likely to be. Minimize, as much as possible, pill burden, dosing frequency and dietary restrictions. *Tailor Treatment to the Patient's Lifestyle - Patients are less likely to adhere to regimens that require them to substantially alter their lifestyles. Clinicians need to identify regular activities that can serve as medication- taking cues, such as teeth brushing, dog walking or favorite daily television shows. It is important to problem- solve with patients about changes in their routines. *Prepare for and Manage Side Effects - Failing to prepare patients for medication side effects can compromise credibility and trust and lead to patients' unilaterally discontinuing therapy. *Employ an Adherence Team - Recruiting a group of individuals to act as an "adherence team" can minimize time spent by any individual clinician. Ideally, the team should be multidisciplinary, including the patient and involving the physician and nurse practitioner, caseworker, nutritionist or peer counselors. *Address Concrete Issues - Adverse life situations such as homelessness, lack of transportation, and inability to pay interfere drastically with adherence. Patients should be questioned about issues that may interfere with treatment, including issues around depression and substance use. Appropriate referrals should be made and these disorders recognized and treated. *Recruit an Adherence Monitor - If a friend or family member can carry out a form of directly observed therapy in a home setting, this is very helpful in reinforcing the patient's commitment to therapy. *Provide Adherence-Promoting Devices - Because forgetfulness is such an important component of non-adherence, the use of memory aids such as pillboxes, diaries, alarms or beepers should be considered for every patient. *Anticipate Course Corrections - Treatment fatigue and burnout is a substantial threat to antiretroviral adherence over time. Anticipate changes in attitude toward medication adherence around times of flux, such as a change in a job or relationship. *Gear Intervention Toward Reason for Non-adherence - Patients have a range of reasons for failing to adhere to their regimens. These reasons should be assessed for each patient and addressed.
020305
