Antiretroviral Adherence Strategies

May 9, 2016

ANTIRETROVIRAL ADHERENCE STRATEGIES

ANTIRETROVIRAL ADHERENCE STRATEGIES
Strategies	Examples
Use a multidisciplinary team approach Provide an accessible, trusting health care team	• Nurses, social workers, pharmacists, and medication managers
Strengthen early linkage to care and retention in care	• Encourage healthcare team participation in linkage to and retention in care
Establish patient readiness to start ART
Evaluate patient’s knowledge about HIV disease, prevention and treatment and, on the basis of the assessment, provide HIV‑related information	• Considering the patient’s current knowledge base, provide information about HIV, including the natural history of the disease, HIV viral load and CD4 count and expected clinical outcomes according to these parameters, and therapeutic and prevention consequences of non‑adherence
Identify facilitators, potential barriers to adherence, and necessary medication management skills before starting ART	• Assess patient’s cognitive competence and impairment • Assess behavioral and psychosocial challenges including depression, mental illnesses, levels of social support, high levels of alcohol consumption and active substance use, non‑disclosure of HIV serostatus and stigma • Identify and address language and literacy barriers • Assess beliefs, perceptions, and expectations about taking ART (eg, impact on health, side effects, disclosure issues, consequences of non‑adherence) • Ask about medication taking skills and foreseeable challenges with adherence (eg, past difficulty keeping appointments, adverse effects from previous medications, issues managing other chronic medications, need for medication reminders and organizers) • Assess structural issues including unstable housing, lack of income, unpredictable daily schedule, lack of prescription drug coverage, lack of continuous access to medications
Provide resources for the patient	• Resources to obtain prescription drug coverage, stable housing, social support, and income and food security • Referrals for mental health and/or substance abuse treatment
Involve the patient in ARV regimen selection	• Review regimen potency, potential side effects, dosing, frequency, pill burden, storage requirements, food requirements, and consequences of nonadherence • Assess daily activities and tailor regimen to predictable and routine daily events • Consider preferential use of PI/r‑based ART if poor adherence is predicted • Consider use of fixed-dose combination formulation • Assess if cost/co‑payment for drugs can affect access to medications and adherence
Assess adherence at every clinic visit	• Monitor viral load as a strong biologic measure of adherence • Use a simple behavioral rating scale • Employ a structured format that normalizes or assumes less-than-perfect adherence and minimizes socially desirable or “white coat adherence” responses • Ensure that other members of the health care team also assess adherence
Use positive reinforcement to foster adherence success	• Inform patients of low or non-detectable levels of HIV viral load and increases in CD4 cell counts • When needed, consider providing incentives and rewards for achieving high levels of adherence and treatment success
Identify the type of and reasons for nonadherence	• Failure to fill the prescription(s) • Failure to understand dosing instructions • Complexity of regimen (eg, pill burden, size, dosing schedule, food requirements) • Pill aversion • Pill fatigue • Adverse effects • Inadequate understanding of drug resistance and its relationship to adherence • Cost-related issues • Depression, drug and alcohol use, homelessness, poverty • Stigma • Non-disclosure • Other potential barriers
Select from available effective treatment adherence interventions	• Use adherence-related tools to complement education and counseling interventions (eg, pill boxes, dose planners, reminder devices) • Use community resources to support adherence (eg, visiting nurses, community workers, family, peer advocates) • Use patient prescription assistance programs • Use motivational interviews
Systematically monitor retention in care	• Record and follow up on missed visits
On the basis of any problems identified through systematic monitoring, consider options to enhance retention in care given resources available	• Provide outreach for patients who drop out of care • Use peer or paraprofessional treatment navigators • Employ incentives to encourage clinic attendance or recognize positive clinical outcomes resulting from good adherence • Arrange for directly observed therapy (if feasible)
NOTES
ART = antiretroviral therapy; ARV = antiretroviral; PI/r = ritonavir-boosted protease inhibitor Adapted from Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‑1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf Section accessed 3/2016 [Table 13]. (Rev. 4/2016)