ADHERENCE Patrick Desmet HIV / Therapycounselor

• 1. What is adherence and why is it important?

• 2. The factors that influence adherence?

• 3. How can we improve adherence?

D V D - Testimonies

• “ …Stick to the times, having the right amount of drugs at all times in the system. Otherwise the virus will breakthrough and starts multiplying again…”

• “…Never missed a dose during my pregnancy…”

• “…Taking your medication as directed, to have a sufficient dose that will have the desired effect…”

• “…The ability to take your drugs to an extent that they will work…”

The medication adherence is the ability of the patient to be involved in:choosing , starting, managing and maintaining a given therapeutic combination regimen to control viral replication and improve the immune function. Jane M.Simoni Ph D

What is Adherence ?

• “ …Stick to the times, having the right amount of drugs at all times in the system. Otherwise the virus will breakthrough and starts multiplying again….”

• “ …Taking your medication as directed, to have a sufficient dose that will have the desired effect…..”

Electronic Event Monitoring (MEMS®)

6 10 14 18 22 26 30 4 8 12 16 20 24 28

04:00

08:00

12:00

16:00

20:00

24:00

September October

Tim

e

UZ LeuvenFabienne Dobbels

“….Otherwise the virus will breakthrough and starts multiplying again”

Adapted from: Paterson DL et al. Ann Intern Med 2000;133: 21-30

Mean adherence rate

Relationship of adherence (measured by MEMS® 81 patients / 45397 doses /

6 months of FU ) to virologic success

78

4533

2918

0

25

50

75

100

>95% 90%-95% 80%-90% 70%-80% <70%

Pat

ien

ts R

eac

hin

g U

nd

etec

tab

le

HIV

RN

A L

OQ

400

(%

)

P = <0.001

Greatest danger zone for developing resistance

1

10

100

1000

10000

Lo

g c

on

cen

trat

ion

(n

g/m

L)

day 1 day 2 day 3 day 4 day 5

dose dose dose missmiss dose

EC50Even 48 hours post-dose, plasma levels remain above EC50

Half life: >12 hours

Examples: EFV, TDF, ddI, Atazanavir

•“ …Taking your medication as directed, to have a sufficient dose that will have the desired effect….”

ADHERENCE vs. PHARMACY REFILLS

Hogg et al.7th CROI 2000/abs73.

Objective : HIV-disease progression / AIDS vs. Adherence

Methods : • 950 patients ARV naive• (85% PI and 15%NNRTI) + 2NRTI• Median follow-up 13 months• Pharmacy based records, refills

Conclusion For each 10% decline in adherence

16% increase in mortality

• “ …It’s difficult when I need to go to an event, wedding, party, …. Anytime where you are exposed taking your drugs…”

Disclosure

“… Absolutely terrible, it was worse going to therapy than having my AIDS diagnosis. For me it was the slippery slope downhill…”

Anxiety

• “…I forgot my medication for days, because I was living a very hard life. My mind was thinking of many other things than medication….”

• “….It was the most difficult thing I had to do in my life…”

• “… I was never been sick since my diagnosis it was very difficult to convince myself to start up therapy…”

Motivation

MOTIVATION

ESTABLISH : READINESS COMMITMENT

ASYMPTOMATIC vs. SYMPTOMATIC

MOTIVATION MOTIVATION

• Preventive Measures

• ART-SE Distress ART Stop = SE Relief

• Reinforce the Necessity

• OI-status, Pill Burden, Drug-drug Interactions

LONG-TERM TREATMENT

• “…Somethimes I rush to work, because there is an important meeting I need to go to and I forgot to take my medication…”

• “…Yes sometimes I forgot them because I was not at home and I was in a rush…”

Anticipation

Why do Patients Miss Doses?

Adapted from: Gifford AL et al. JAIDS 2000; 23: 386-395

Reasons given for missing antiretroviral doses

(structured questionnaire)

possible interventions

simplify dosing schedule

decrease pill burden

other

%

n=13352

46

45

27

20

20

19

19

18

17

17

16

14

13

10

9

0 10 20 30 40 50 60

Too busy/simply forgot

Away from home

Change in daily routine

Felt depressed/overwhelmed

Took drug holiday/medication break

Ran out of medication

Too many pills

Worried about becoming 'immune'

Felt drug was too toxic

Wanted to avoid side effects

Didn't want others to notice

Reminder of HIV infection

Confused about dosage direction

Didn't think it was improving health

To make it last longer

Were told the medicine is no good

ADHERENCE

•Denial HIV- status

•Negative beliefs (negative arv history partner)

•Fear of Short or Longterm - Side Effects

•Lack off trust towards Health-Care team

PATIENT FACTORS

•ARV = ongoing reminder of HIV status

HEALTHCARE FACTORS

• STAFF TRAINING

• INSUFFICIENT STAFF & SPACE for COUNSELLING

• CONFIDENTIALITY (reception, waiting rooms, personalised interviews vs. Multidisciplinary team)

• POOR ORGANIZATION OF DAILY CARE

•AUTHORITARIAN AND JUDGEMENTAL ATTITUDE

• CONFLICTING PATIENT-INFORMATION (EDUCATION)

Cultural and Socio-economic Status

•Drug (speed, ecstasy…) and Alcohol use

•Fear of Disclosure : ARV > trigger HIV-Status

•Welfare status: housing, financial support…

•Stigmatisation : cultural / religious beliefs

TREATMENT FACTORS

• CONCOMITANT /ALTERNATIVE MEDICINE

• DRUG TOXICITIES: SHORT AND LONGTERM SE

• COMPLEX REGIMEN / PILL BURDEN

• DOSING FREQUENCY / DRUG INTERACTIONS

• DIETARY RESTRICTIONS

• LOGISTICAL : APPROVALS / AVAILABILITY OF DRUGS

• ACCUMULATIVE TREATMENT CHANGES

“…It’s incredible important to get the right regimen for the right person, it’s really about looking at the individual patient….”

“…As a patient I need much more information…”

“…You need to prepare the patient properly…”

Fit the ARV’s into the lifestyle

PATIENT

EMPOWERMENT

BASIC KNOWLEDGE

SKILLS &MOTIVATION

HEALTHBELIEFS &CULTURAL /SOCIO-ECONOMICSTATUS

Flow Chart Counseling New HIV+

TRUST KNOWLEDGELIFESTYLEPotential ADHERENCE and ARV-BARRIERS

OPTIMISING HAART

PEOPLES LIVES = VARIABLE BEHAVIOR

IMPACT from ENVIRONMENT SOCIAL FACTORS NEW DIAGNOSES

DYNAMIC MONITORING

3 STEP APPROACH = a stepwise informationflow

Counseltopics

• Sec.Prevention: Safe sex,…

•HIV basics

•AIDS vs. HIV

•Disclosure

•CD4 & VL-interpretation before and during therapy

•Life expectansy

Evaluation 2 ARV proposals

Lifestyle:Diet, work, co-medication…

Potential Adherence and Therapy barriers

Social status check cf. social nurses!

Drug specific Side effects: short & longterm

• Initiate Dummy Run

• ARV support : community (sensoa)

• Adherence: timing, dosing, food, anticipation

• Adherence vs. Resistance

2 visits

Counseltopics

•Drugplanning: optimizing drugintake, identify ARV-reminders, ARV-storage, food recommendations….

•Patient rehearses drugplanning and potential SE

•Drug specific SEffects

• Supportive Tools

Counseltopics

•Telephone call patient / counselor

•Anticipate SEffects cf Dr.

•Adherence check:

= Timing , dosing, diet,anticipation, ARV_storage.

•Reasons for non-adherence

Initiation Haart and follow- up

READINESSCOMMITMENT

Pillbox and reminder system

UZ Leuven

Vibrating alarms, watches,

cell-phone alarm, SMS

ADHERENCE COUNSELING

MULTIDISCIPLINARY TEAM EFFORT

NEGOTIATIONINFORMATION EDUCATION

BEFORE, DURING and AFTER START of ART