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STRATEGIES FOR IMPROVING ADHERENCE TO LIFELONG ANTIRETROVIRAL TREATMENT
MALLIKA MOOTOO, MDPEDIATRICIAN AND CLINICAL LEAD,POSITIVELY UNITEDTO SUPPORT HUMANITY (PUSH PROJECT)GUYANA
NOVEMBER 7,2019
CME Disclosures: Planning Committee And Speaker
Speaker: The following speaker has nothing to disclose in relation to this activity Mallika Mootoo, MD
Howard UniversityCME Accreditation
Sponsor Accreditation: Howard University Collegeof Medicine is accredited by the Accreditation Council
for Continuing Medical Education to provide continuingmedical education for physicians.
Credits for Physicians: Howard University Collegeof Medicine, Office of Continuing Medical Education,
designates this live activity for a maximum of 1.0 AMAPRA Category I Credit(s)TM . Physicians should claim
only the credit commensurate with the extent of their participation in the activity.
Goulda A. Downer, PHD, RD, LN, CNS – Principal Investigator/Project Director
CME Disclosures: Planning Committee And Speaker
AETC-Capitol Region Telehealth ProjectPlanning Committee: The following committee members have nothing to disclose in relation to this activity:
Goulda A. Downer, PhD, FAND, RD, LN, CNS Dr. Walter P. Bland, Assistant Dean, CMEJohn I. McNeil, MDDenise Bailey, M.EDMarjorie Douglas
Speaker: The following speaker has nothing to disclose in relation to this activity: Mallika Mootoo, MD
Howard University CME Accreditation Requirements For Internet Viewers
Intended Audience: Health service providers: Physicians, Physician Assistants, Nurse Practitioners, Pharmacists,
Dentists, Nurses, Social Workers, Case Managers and other Clinical Personnel.
Webinar Requirements: A computer, phone, etc., with internet accessibility and a telephone line.
ØYour presence on the call must be acknowledged at the start of each session. Please log in for the session announce your name loud and clear at the beginning of the session.
ØYou will not be able to receive CME credits if you leave the session early.
ØAt the end of the Webinar our Training Coordinator will email a CME Evaluation Survey.
ØAll participants are required to complete and return the CME Evaluation Survey at the end of each session. It may be scanned and emailed back to den_bailey@howard.edu, or faxed to: AETC-Capitol Region Telehealth Project (FAX#: 202.667.1382) ATTN: Project Coordinator. Please indicate in your email or FAX if you would like to receive CMEs.
GILEAD SCIENCES INC. FUNDING AND DISCLOSURE
“Supported by grant funding from Gilead Sciences, Inc. Gilead Sciences, Inc. has had no input into the development or content of these materials.”
STRATEGIES FOR IMPROVING ADHERENCE TO LIFELONG ANTIRETROVIRAL TREATMENT
LEARNING OBJECTIVES
By the end of this session participants will be able to:
1. Define adherence to ART
2. Recognize the importance of adherence to the 90-90-90 goals
3. Identify barriers to ART adherence in adult and pediatric populations
4. Propose solutions to ART adherence in the Caribbean
WHAT IS ADHERENCE?
ADHERENCE
ØAdherence is defined as the "extent to which a client's behavior coincides with the prescribed health care regimen as agreed through a shared decision-making process between the client and the health care provider" (KITSO Manual, 2004; Carter, 2004).
ØAdherence is an attachment or commitment to a person, cause, or belief.
GLOBAL SUMMARY - 2018
https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/
GLOBAL SUMMARY
https://www.kff.org/global-health-policy/fact-sheet/the-global-hivaids-epidemic/
CARIBBEAN SUMMARY
Ø In 2018, 72% of people living with HIV in the Caribbean were aware of their HIV status. Of those who were aware:
o 77% were accessing antiretroviral treatment (ART)
o Of those on treatment, 74% were virally suppressed
ØThe annual number of new HIV infections among adults in the Caribbean declined by 18% between 2010 and 2017, and deaths from AIDS-related illness fell by 23%.
HTTPS://WWW.AVERT.ORG/PROFESSIONALS/HIV-AROUND-WORLD/LATIN-AMERICA/OVERVIEWHTTPS://BARBADOSTODAY.BB/2018/12/01/WORLD-AIDS-DAY-2018-MESSAGE-FROM-UNAIDS/
STATUS OF THE HIV EPIDEMIC
A BRIEF REVIEW-THE CARIBBEAN:90-90-90 TARGETS
WHAT IS 90-90-90 TARGETS?
ØThe Joint United Nations Programme on HIV/AIDS (UNAIDS) and partners launched the 90–90–90 targets in 2014.
ØThe aim was to diagnose 90% of all HIV-positive persons, provide antiretroviral therapy (ART) for 90% of those diagnosed, and achieve viral suppression for 90% of those treated by 2020.
90-90-90
STATUS OF 90-90-90
18
90-90-90- BY GENDER
Men
WHERE THE CARIBBEAN STANDS IN 90-90-90
WHY IS ADHERENCE IMPORTANT TO 90-90-90 GOALS?
ØAdherence to ART is essential to ensure viral suppression in HIV patients.
Ø Poor adherence will result in sub therapeutic plasma ARV drug concentrations, which can lead to the development of drug resistance to one or more drugs in a given regimen.
Ø Suboptimal adherence can also limit the options for future effective drug regimens and increase the risk of secondary transmission of drug-resistant virus.
CARIBBEAN ADHERENCE
ØData is limited, although UNAIDS reports overall viral suppression to be 40% in the Caribbean.
Ø In the Caribbean viral suppression ranges from 17% of people on treatment in Jamaica to 43% in Cuba, Dominican Republic and Suriname.
ØKey populations (i.e. LGBT, Sex workers)and young people often face barriers to accessing treatment.
HTTPS://WWW.AVERT.ORG/PROFESSIONALS/HIV-AROUND-WORLD/LATIN-AMERICA/OVERVIEW
RESEARCH ON CARIBBEAN ADHERENCE
Ø In a study conducted among persons from living with HIV in Antigua and Barbuda, Grenada and Trinidad and Tobago,394 respondents, 69.5% were currently taking ART
Ø Of these, 70.1% took 95% to 100% of their prescribed pills
Ø One in 20 took more pills than prescribed, all of whom were prescribed fewer or equal to the median pill number
Ø Factors independently associated with adherence were use of a counselling service, revelation of HIV status without consent, alcohol consumption and side effects
Ø Drug resistance to ART was reported by 6% of users. HTTPS://WESTINDIES.SCIELO.ORG/SCIELO.PHP?PID=S0043-31442011000300005&SCRIPT=SCI_ARTTEXT&TLNG=PT
RESEARCH ON CARIBBEAN ADHERENCEØ Barrow and Barrow (2013) indicated that, once persons have accessed treatment, results are
more positive, with 75% retained in care and 94% of them with viral load suppression.
Ø However, there is some suggestion that “medical fatigue” may be an emerging factor affecting coverage rates.
Ø Data from the HIV treatment database (Barrow 2013) in Jamaica also suggest that attrition rates at 1 year in care are between 10% and 31%.
Ø Many persons diagnosed as HIV positive may not present to treatment programs.
Ø Members of the general public may be less receptive to starting lifelong ART when they show no signs of disease, in contrast, for example, to mothers-to-be who are generally highly motivated to protect their unborn children.
HTTPS://JOURNALS.SAGEPUB.COM/DOI/FULL/10.1177/2325957413511113
ADHERENCE
ØAdherence is dynamic in nature – previously adherent patients can become non-adherent
ØAdherence should be measured at every visit even in patients who are experiencing treatment success
ØAll missed doses should be addressed in a non-judgemental manner
ØEducation on non-adherence and resistance to ARVs is essential before initiation and during treatment.
CASE STUDY #1
Ø JR 43-year-old � patient
ØDiagnosed HIV+ in 2004 at a private medical clinic
ØART Htx: LSN 2005-2018o Atripla: 2018
o TLD: 2019
ØReferred to a Faith-based care and treatment site 2018
ØLabs: Viral Load: 28,910, CD4: 23 c/ul / 1%, Hepatitis C: positive,
ALT: 115, ALT :66, Creatinine :12.9
PATIENT’S BACKGROUND
TREATMENT
ØTreated for OI’s
ØStarted on Atripla, Septrin, Fluconazole, IPT and weekly Azithromycin
ØCondition deteriorated ( weight loss, recurrent candida)
INTERVENTIONS
ØCase discussion with medical team: Possible resistance to Atripla after unmonitored treatment with LSN
ØAdherence counseling done non-adherence denied
ØChange regimen to INSTI based regimen
ØEngage partner in treatment support
PATIENT FOLLOW-UP CARE
ØAfter 2 months weight loss continued, oral candidiasis still present
ØNon-Adherence denied
ØDecision made with partner to hospitalize JR for one week
ØClinic Nurse did DOTS with patient during hospitalization
ØCandida improved and appetite increased
ØCounseling was done daily during hospitalization
INTERVENTIONS TO IMPROVE ADHERENCE
ØOn discharge from hospital a strategy to improve adherence was implemented:
Ø JR’s son would do Directly Observed Treatment Support (DOTS) with his mother and would take her pill box to the clinic to be filled weekly.
Ø JR’s partner would call her every day to ensure that she had taken her pills
ØThe nursing staff at the clinic would use What’s App to contact JR daily to offer encouragement and support.
ØAt every clinic visit counseling was done
CASE 1 - OUTCOME
ØAugust 2019 VL:<20 copies.
Ø JR continues to gain weight and is enjoying a better quality of life.
ØBoth her partner and son are engaged in her care.
ØAdherence counseling continues at every visit.
BARRIERS TO ADHERENCE
ØLack of support and encouragement
ØStigma of HIV
ØNegative perception of medications/ART
ØComplicated regimens/Pill Burden
STRATEGIES USED TO IMPROVE ADHERENCE
ØFamily Involvement
ØCounseling at every visit
ØHospitalization
ØDOTS
ØPill box
ØDaily calls/messages by clinic staff to encourage
ADHERENCE IS COMPLEX AND MULTI-FACTORIAL
ADHERENCE ASSESSMENT
ØPotential barriers to adherence should be assessed and discussed before therapy is initiated or changed.
ØSocial, behavioral and medical factors that may influence adherence should be assessed.
ØDiscuss potential adverse effects of ARVs.
ØAssess for acceptance of diagnosis.
ADHERENCE ISSUES SPECIFIC TO CHILDREN
ØDependence on Caregiver
o Caregiver’s understanding of ARVs, adherence and resistance
o Caregiver’s dedication
ØPalatability of formulations
ØLimited availability of once daily regimens
ØLack of Disclosure
BARRIERS TO ART ADHERENCE
ØNon-Disclosure to partner/family
ØNew partner
ØChange in schedule
ØTravel
ØToxicities
ØDepression
ØAlcohol/substance abuse
ØPill burden
ØForgetfulness
ASSESSING AND COUNSELING IN ADHERENCE TO ART
METHODS OF MEASURING ADHERENCE (1)
Ø Self-reporting
Ø Pill counts
Ø Pharmacy records
Ø Provider estimate
Ø Pill identification test
Ø Electronic devices—MEMS
Ø Biological markers—Viral load
Ø Measuring medicine levels—TDM
METHODS OF MEASURING ADHERENCE (2)
Method Advantages Disadvantages Potential Bias
Physician’s assessment
§Simple, cheap, requires no structured tool
§Subjective, inaccurate: estimates affected by doctor-patient relationship
§No particular bias§Study showed correct est. in only 40%
Patient self-report § Simple, cheap, qualitative assessment possible
§Subjective, inaccurate: poor patient recall, lack of candor
§ Overestimates adherence
§ Most widely used currently
Pill counts § Simple, cheap, objective
§Pill dumping, pill sharing, timing of doses unknown, bottles needed
§ Overestimates adherence
METHODS OF MEASURING ADHERENCE (3)
Method Advantages Disadvantages Potential BiasPharmacy refill records
§Objective §Pill dumping, pill sharing, timing of doses unknown; good records, patient tracking, and overtime needed
§Overestimates adherence
Drug level monitoring
§Objective §Expensive, requires lab, invasive, unknown timing of doses; PK profile of population needed
§Can over- or underestimate depending on behavior immediately prior to test; genetic variations in drug metabolism
Electronic drug monitoring (EDM)
§Objective, data on timing of doses, monitoring over longer periods
§Pill dumping, pill sharing, timing of doses unknown
§Underestimates adherence; taking out multiple doses for later use
ADHERENCE COUNSELING: MULTIDISCIPLINARY TEAM
Same message from all!
Adherence message for the
client/patient
DoctorsAdherence
nurse
Pharmacist Family and friends
Counselor Social worker
Source: Horizons/Population Council, International Centre for Reproductive Health, and Coast Provincial General Hospital, Mombasa, Kenya. 2004. Adherence to Antiretroviral Therapy in Adults: A Guide for Trainers. Nairobi: Population Council.
ADHERENCE COUNSELING: PURPOSE
ØHelp clients/patients develop an understanding of their treatment and its challenges.
ØPrepare clients/patients to initiate treatment.
ØProvide ongoing support for clients/patients to adhere to treatment over the long term.
ØHelp clients/patients develop good treatment-taking behavior.
ØHelp clients/patients set goals for their treatment.
ADHERENCE COUNSELING: NATURE
ØNeeds to occur before and be ongoing throughout treatment period sessions.
Ø Involves highly personal and intimate matters and behavior.ØRequires recognition of barriers to and challenges of
adherence. ØNeeds reinforcement or constructive intervention as
appropriate.ØAvoids negative-messaging, judgmental attitudes, and “pill
policing.ӯEncourages participation by family and friends.
SLEPTIN
AWAYFROM HOME
RAN OUT OF PILLS
FELT ILL FELT BETTER
PILLS DO NOT HELP
FEAR SIDE EFFECTS
DID NOT WANT
OTHERS TO SEE
FAMILY SAID NO TO MEDICATION FORGOT or
TOO BUSY
DID NOT UNDERSTAND
INSTRUCTIONS
MISSED DOSES
WHAT TO DO?
TAKING PILL HOLIDAYS
UNABLE TO CARE FOR
SELF
• No double dose
• Within 3 hours, take the missed dose
• If >3 hours, go for the next
COUNSELING FOR ADHERENCE PROBLEMS
WENT FOR PRAYERS AND GOT CURED
RECAP ON ADHERENCE TO ART
Ø Excellent adherence is key to successful ART programs.Ø The consequences of poor adherence are poor health
outcomes and increased health care costs.Ø Adherence is a dynamic process that needs to be followed
up.Ø Client/patient-tailored innovative interventions are required
and must fit into the sociocultural context of each setting.Ø Family, friends, and community are key factors in improving
adherence.Ø A multidisciplinary approach toward adherence is needed.
STRATEGIES AND INTERVENTIONS for ADHERENCE
INITIAL STRATEGIES TO IMPROVE ADHERENCE
Ø Establish trust and identify mutually acceptable goals for care.
Ø Client must be involved in the decision for the need of treatment and adherence.
Ø Identify depression, substance abuse, or other mental health issues in the client and/or the caregiver that may affect adherence. o Evaluate and initiate treatment for
mental health issues before starting ARV drugs, if possible.
Ø Identify a support person/team.Ø Educate the patient/family /support
person about the role of adherence to ARVs in treatment in outcomes.
Ø Educate on the relationship between partial adherence and resistance and the potential impact on future drug regimen choices.
Ø Develop a treatment plan that the patient and family understand and to which they feel committed.
STRATEGIES TO IMPROVE ADHERENCE
ØSimplify the regimen
ØDecrease pill burden
ØChoose the regimen with the fewest AEs
ØChoose the more palatable formulations for children
ØConsider drug-drug interactions with other medications
STRATEGIES TO IMPROVE ADHERENCE
Ø Have more than one member of the multidisciplinary team monitor adherence at each visit and in between visits by telephone, text, what’s app as needed.
Ø Provide ongoing support, encouragement, and understanding of the difficulties associated with maintaining adherence to daily medication regimens.
Ø Provide ongoing patient education of medication, HIV. Ø Use reward system to encourage children, stickers, lucky-dip, Ø Encourage use of pill boxes, reminders, mobile apps, alarms, and timers.Ø Provide access to support groups or peer groups for caregivers and patients.Ø Consider DOT at home, in the clinic, or in certain circumstances, such as
during a brief inpatient hospitalization.
ASSESSING EFFECTS OF INTERVENTIONS
ØOnce an intervention is implemented, it must be assessed to see if it has yielded the desired outcome.
ØThe HCP should assess 1-2 weeks after intervention was discussedo Was it implemented
o Did adherence improve
ØMonitor improvement in adherence with VL.
ASSESSING EFFECTS OF INTERVENTIONS
Ø If still non-adherent
o Work with patient and team to find another strategy that may work better.
ØVL still detectable but adherent
o Consider resistance testing.
CASE STUDY # 2
ØCO is a 3 ½-year-old � child born to a HIV+ mother.
ØMother attended PMTCT clinic during pregnancy.
ØChild’s DNA-PCR test HIV- at birth and 4 months
ØMother and child defaulted from care in 6th month.
ØReturned to care when child was 21 months.
ØChild malnourished, with oral candidiasis, muscle wasting.
ØHIV +
PATIENT’S BACKGROUND
TREATMENT
ØMother counseled on child’s diagnosis and on ART for child
ØEncouraged to bring child’s father for testing.
ØChild started on ART: Lamivudine, Abacavir and Lopinavir/ritonavir.
ØBaseline VL: 5,642,820; CD4:157/2% o Weight: 9.1kg
PATIENT FOLLOW-UP (THREE MONTHS)
Ø Three months later:
o Father has not come for testing.
o Calls to fathers alleged number proved futile.
o Child’s physical condition not improving.
o VL:3,562,298.
o Adherence counseling with clinic nurse reveals child is vomiting with LPV/r.
o LPV/r stopped NVP started.
PATIENT FOLLOW-UP ( SIX MONTHS)
ØSix months later:
o Father still hasn’t come to clinic VL: 1.
o Child’s condition very slightly improved.
o ,970,565.
o Mother is counseled by counselor, nurse and physician, she reveals that father does not know her nor child’s status.
o She does not give the medication if father is at home.
o Father is the sole bread winner in the family, she is scared he may leave if he knows the truth.
INTERVENTIONS
ØClinical Team works together with mother to encourage father to come for testing and counseling.
ØMother discloses to father in presence of social worker and nurse.
ØFather tests HIV+.
ØFather and mother are counseled.
INTERVENTIONS
ØChild still not gaining weight after more than 12 months on ART.
ØPediatric Nurse counsels’ mother regarding medication regimen, dosage delivery mode.
ØMother does not like giving the child the medication, because seeing him take them reminds her that she infected the child.
ØMother is referred for counseling.
ØPediatric Nurse does DOTS for child.
ØChild does not take medication willingly. Nurse employs reward system (stickers, fruit, candy) to encourage child.
INTERVENTIONS
ØDOTS is continued for 6 months VL:1,196,650.
ØCase discussion with medical team: Possible NVP resistance
ØRegimen change to INSTI.
ØOne month after regimen change weight gain and increased appetite and activity is noticed.
ØThree months later: weight gain continues, child is able to attend nursery school. Both mother and child have pill boxes filled weekly. Father has started ART.
BARRIERS TO ADHERENCE
ØMother’s Guilt
ØSide Effects of ART
ØViral Load
STRATEGIES USED TO IMPROVE ADHERENCE
ØAssisted Disclosure to partner
ØMultidisciplinary Approach to counseling for mother
ØRegimen Change
ØDOTS/Pill box
ØFamily centered care and treatment
SUMMARY
ØOur patients face multiple barriers to adherence, and no single intervention will be sufficient to ensure that the high levels of adherence needed for virological suppression are sustained.
ØFor better adherence and higher rates of viral suppression, health providers should consider a more structured multidisciplinary approach that first identifies patients at risk of poor adherence and then seeks to establish the support that is needed to overcome the most important barriers to adherence.
REFERENCES
1. Joint United Nations Programme on HIV/AIDS, Joint United Nations Programme on HIV/Aids. 90-90-90: an ambitious treatment target to help end the AIDS epidemic. Geneva: UNAIDS (2014).
2. Patient-Reported Barriers to Adherence to Antiretroviral Therapy: A Systematic Review and Meta-Analysis
Zara Shubber, Edward J. Mills, Jean B. Nachega et al
3. Adherence to antiretroviral therapy and factors affecting low medication adherence among incident HIV-infected individuals during 2009–2016: A nationwide study
Jungmee Kim, Eunyoung Lee,
4.Predictors of non-adherence to antiretroviral therapy among HIV infected patients in northern Tanzania
Seleman Khamis Semvua , Catherine Orrell, Blandina Theophil Mmbaga,Hadija Hamis Semvua,John A. Bartlett, Andrew A. Boulle
5.Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection : AidsInfo.
6. Evaluating Adherence to Antiretroviral Therapy and Managing the suboptimally adherent patient
https://www.infectiousdiseaseadvisor.com › ... › Infectious Diseases
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