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The 2nd International Conference on
Adherence to Antiretroviral Therapy, dedicated to sharing and
demonstrating experiences and mechanisms of improving adherence,
was held in Richardson (just outside Dallas), Texas, December
4-7, 2003. Once again, this conference brought in attendees
from around the world who have decided to take action against
complacency in adherence initiatives by developing novel assessment
techniques, make improvements to patterns of adherence to antiretrovirals
in historically difficult populations, creatively institute
programs in environments with limited resources and be confident
enough to share that data over three days with others in related
practice and outreach settings. Clinicians and others presented
findings of their initiatives to enhance adherence, medication
tolerability and outcomes in their respective institutions that
dealt directly with patients. A small sample of those presentations
is summarized here.
Pharmacist counseling
Dr. Lamberjack of the Children’s
Hospital of Columbus, Ohio provided attendees with approaches
to enhancement of adherence in a family practice setting serving
42 counties in central and southern Ohio. Dr. Lamberjack’s
study’s objective was to increase adherence in recognized
non-compliance by providing pharmacist-based medication and
adherence counseling. After interviewing patients and families
regarding antiretrovirals, medication-taking patterns and reasons
for missing doses, a compliance score was determined (scale
1-3: 3 = > 90% compliant, 2 = 50% - 90% compliant, 1 = <50%
compliant).
If patients fell into the categories
of 1 or 2, they were scheduled for intervention by the pharmacist.
Interventions were: 1) provision of medication-specific counseling
and adherence importance, 2) written information on drug, dosing
and adverse effect, 3) distribution of pill boxes and assorted
reminders, and 4) follow-up phone calls and visits. Results
were presented after 12 months of the program.
Twenty-six patients were targeted for
interventions. The population was 85% female, 62% African-American,
8% Hispanic and ages ranged from 7-41 years. Where were they
when they started? Eight percent were 3’s, 27% were 2’s
and 65% were 1’s (remember—it’s not good to be
#1 here!). After the interventions? Sixty-one percent were 3’s,
31% were 2’s and only 8% were 1’s. Accompanying the
score changes were 62% of patients with reduced viral loads
and improvements in CD4 counts.
Conclusions? Improvement in clinical
markers and compliance can be realized by pharmacist counseling
and interventions after those patients are identified. For more
information on the scoring process and results, contact Dr.
Lamberjack at lamberjk@chi.osu.edu.
Multiple avenues
Non-adherence was the reason Dr. Lee
and a team of providers of the McAuley Health Center at St.
Mary’s Mercy Medical Center in Grand Rapids, Michigan became
involved in a multi-disciplinary approach to improving outcomes
in the patients. This presentation described the initiatives
just underway at this clinic.
A readiness assessment is performed
by the team prior to any antiretroviral regimens being prescribed
at this center. Potential barriers are addressed and the patient
is encouraged to recruit friends and family members to assist
in the treatment program. After this is completed, a one-on-one
session with the clinical pharmacist is scheduled. This one-time
educational session provides in-depth information, appropriate
for the patient’s understanding and education level, on
the medications, side-effects, dosing and diet requirements.
Once completed, the patient receives:
a one week follow-up phone call, a week two laboratory assessment
and a visit with nurse-case management, a week 4 phone call
from the clinical pharmacist, nurse-case management visits at
weeks 6 and 12 and finally back to see the physician at week
14.
Multiple measures of adherence are done
by self-report, pharmacy logs, pill counts and biological markers.
Patients also receive a 24-hour prior to appointment reminder
phone call and have access to clinical staff during non-clinic
hours. Some limited results were presented that included prevention
of ER visits due to on-call consultations with the pharmacists
regarding adverse effects of medications and that adherence
is improved. As mentioned in the most recent DHHS guidelines
(U.S. Department of Health and Human Services), using multiple
approaches, disciplines and levels of intervention are being
shown to positively influence adherence.
Readiness
Using readiness as a predictor of adherence
is a sound approach to deciding if it is time to start antiretrovirals,
according to a formal presentation by Dr. Enriquez of the University
of North Carolina, Chapel Hill. This real-time observational
study examined the level of readiness for health behavioral
change and adherence in 36 HIV-positive persons who had previously
failed therapy. An index of readiness was completed by patients
prior to beginning new antiretroviral regimens. After six months
of therapy, patients were divided into those who reached and
sustained viral suppression and those who had not. A higher
index of readiness was a significant predictor for virologic
success (p<0.05). The researchers propose this follow-up
study to a previously completed one reinforces the clinical
utility of an index of readiness as a valid predictor for adherence.
They also suggest that interventions enhancing readiness prior
to prescribing antiretrovirals can improve adherence. These
types of interventions were not provided however.
The buddy system
“Project HAART” was a small
study conducted by Plummer and Simoni at an outpatient HIV clinic
in the Bronx that targeted improving adherence by enhancing
social services for patients. This project established “buddies”
for four domains of support: affirmational, emotional, spiritual
and informational. Participants (study subjects) were patients
recruited from the clinic and randomly assigned to the buddy
program or to a control group.
The buddy group has six meetings (one
every two weeks) with other buddies and others. Phone calls
from a designated buddy were done two to three times per week.
Participants completed questionnaires at the start, half-way
through the program and at the end of the six-month study period.
One-hundred thirty-six patients were enrolled. Forty-six percent
were African-American, 44% Hispanic, 45% female, average age
was 43, 85% were unemployed and 75% acknowledged heavy drug
use. Results are based on the 86 participants completing the
program. They reported an improved adherence at 6-month follow
up based on patient self-reporting, although exact numbers were
not provided nor were viral load and CD4 changes. This component
of the conference was to provide proof-of-concept studies and
not necessarily medical outcomes. This is, however, another
reinforcement of how providing more than just direct medical-associated
interventions can improve adherence.
Peer support in the clinic
Along similar lines, but seemingly a
more formal program was presented by Micki McCaffery of the
Kansas City Free Health Clinic based in Kansas City, Missouri.
This clinic provides HIV and primary medical care to approximately
400 medically indigent HIV-positive adults. A peer-adherence
program was put in place in late 2001. Eight clinic-based, peer,
paraprofessional counselors (one Caucasian, five male) provide
engagement support for medical care and adherence to patients
on either an individual or group basis. These individuals, by
maintaining contact with patients on a routine basis, provide
the medical team critical information with respect to the patient’s
understanding and state of medical, social and economic status.
Peer counselors, being on-site, are incorporated into each primary
care visit and bring to the visit unique support, insight and
skills to patients. Further information on this invaluable component
and how to integrate it into a medical service model can be
gained by contacting Ms. McCaffrey at mickim@kcfree.org.
More peer support
Another peer-counselor program is going
on at the University of Maryland’s Evelyn Jordan Center.
At this other Ryan White-funded clinic, a social worker and
three to four peer counselors provide interventions to patients
identified by providers to be non-adherent (missing more than
three medical appointments per year or difficulty with a prescribed
regimen). Here an adherence intervention care plan is set-up
after an interview with the patient. These interventions include
the list of usual suspects: pill boxes, phone calls, case management,
group education, and others. The findings of this project were
based upon four years of follow-up and beyond the scope of this
summary. Conclusions made by the researchers reinforce the need
for continual assessments and ongoing interventions.
Sharing experience
These and many other incredible success
stories were presented over the three-day conference. The primary
source of funding for the conference was pharmaceutical companies,
but the vast majority of presenters were not easily recognized
names on a national level. Instead, they are irreplaceable in
their respective practice settings as was evident by the passion
and level of excitement in learning mechanisms to improve adherence
in resource-poor settings. The conference will be held once
again this December, likely again in Dallas. More information
on this conference can be found at: http://elements.netsos.com.
Patrick G. Clay, PharmD, is an Assistant
Professor at the University of Missouri, Kansas City and HIV
Clinical Pharmacist at the Kansas City Free Clinic.
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