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Adherence Works • In 1998, knew missed doses led to resistant virus. • Since 1998, studies have demonstrated that adherence leads to lower viral loads, decreased AIDS progression, and increased survival. • For example, clients followed for 7 months demonstrated virologic failure: – 22% with 95% adherence – 61% with 80-95% adherence – 80% with 80% adherence Major Changes in Treatment Since 1998 • More understanding of long term side effects and toxicity. • New guidelines start treatment later. • Resistance testing (genotype and phenotype) may inform prescribing • Some evidence on: – Structured treatment interruptions – Intermittent treatment – Rotating regimens Associations of Characteristics and Adherence: Consistent • • • • Active psychiatric illness Depression Heavy drinking Adherence at baseline Associations of Characteristics and Adherence: Inconsistent • • • • • • • • • • Race Age Sex Mood Drug use Homelessness Health beliefs Coping skills Rapport with providers Poor communication with provider • • • • • • • Pill burden Away from home Side effects Mistrust of system Pre-existing conditions Self efficacy Frequency of stressful life events • No recent clinic visit • Health literacy • Economic barriers Associations of Characteristics and Adherence: Ever • • • • Income (MACS) Education Meaningful life Comfortable and well cared for • Using time wisely • Taking time for important things • Joy • Fear Reasons for Differences in Findings • Very different populations • Different measures of adherence • Different things are measured/asked Reasons for Non-Adherence and Barriers • • • • • Forgetting Side effects Complexity Knowledge Reminds of HIV status • Don’t want others to know • Don’t like the way I feel • No one to help Reasons for Adherence and Supports • • • • • • Mechanical devices Commitment Belief in medications Social support Professional support Regular meals • Use bedtime, other routine to remind • Store in a bag to take everywhere • Store where others won’t see Patterns of Reasons that Vary for Different Groups • IDU history (JHU) – IDU history: stress; heroin use – No IDU history: less than 2 meals per day; less belief in efficacy of drug • Health Literacy (WI) – 12+ years of education and low health literacy: more confused, side effects, depressed, overslept, cleansing body – Below 12 years education: forgot, no pills, busy Patterns of Reasons that Vary for Different Groups Adherence Level (WI) Adherent Non-Adherent Confused/how many 5 31 Need more than Dr. says 0 39 Instructions too complex to understand Instructions too complex to follow Hard to travel to appointments Don’t think treatment helps 25 69 3 23 12 39 0 23 Patterns of Reasons that Vary for Different Groups • Confidential vs. Anonymous Disclosure (CDC- in Bronx) – Confidentially: forgot, medication inaccessible, perceived toxicity – Anonymously: perceived lack of drug efficacy Interventions with Demonstrated Effectiveness: Directly Observed Therapy (DOT) • Florida retrospective study comparing 50 treatment naïve prison inmates to 50 similar controls. – Found 100% in DOT group with less than 400VL at 24 weeks and at 90 weeks. – 80% in controls with less than 400VL at 24 weeks and at 90 weeks. • 10 person pilot (Mitty et. al) showed 1.2 log drop in VL with DOT. Interventions with Demonstrated Effectiveness: DOT (cont.) • Miriam Hospital (Providence, RI) pilot shows “drastic” improvements in adherence with peer outreach workers delivering drugs. • Caveat: DOT cannot reverse resistance, treatment failure. – Analysis of very experienced patients in NYS LTC facilities showed 1/3 never got to VL<400 copies; 1/2 virologic failure. Interventions with Demonstrated Effectiveness: Mechanical Devices • Small study randomizing patients with under 90% adherence into: – Online paging reminder (“medimom”) and MEMS: 16% improvement from baseline level of 52% adherence. – MEMS alone: no change • Small trial (N=36 at start; 10 at 24 weeks) of people with cognitive dysfunction: – Mechanical verbal reminder: 99% adherence at 24 weeks. – Control: 69% adherence at 24 weeks. Interventions with Demonstrated Effectiveness: Multifaceted Educational, “Psychoeducational” Support • SUNY Buffalo/Erie Medical Center show big effect from 16 week multifaceted intervention (intensive, multifaceted, education, readiness, tools, support). 16 weeks - 93% intervention patients had VL <400 copies. - 37% SOC patients had VL <400 copies. 32 weeks - 100% of those in (16/23) had VL <400 copies. - 20% of those in (14/37) had VL <400 copies. Interventions with Demonstrated Effectiveness • Spain: 116 patients followed for 48 weeks in randomized groups: – Psychoeducative intervention: 94% had 95% adherence. 89% VL<400. – SOC intervention: 68% had 95% adherence. 60% VL <400. • Bandura self efficacy includes education on handling medications; “solving” doubts; input on dosage schedule; tackling problems like forgetting, delays, changes, side effects; given phone number to call for questions; follow up reinforcement and problem solving. • Note: Effect not evident until week 48. Interventions with Demonstrated Effectiveness • San Fransisco Action Point: pilot intervention with 68 homeless urban poor. – No appointments, open six days per week, $10 cash incentive weekly, pager, prescriptions delivered and held at center, acupuncture, referrals to mental health, substance abuse treatment, housing. – 62% retained at 5months: 25/44 knew VL; of these 16 had VL below 500. Interventions with Demonstrated Effectiveness • San Diego: 168 patients randomized and followed for 6 months. Intervention focused on self management, education, and support through group patient education. Post Intervention Six Months Intervention 85% (excellent) 47% (fair) 13% (poor) 72% (excellent) 41% (fair) 15% (poor) SS Control 76% (excellent) 34% (fair) 8% (poor) 67% (excellent) 35% (fair) 12% (poor) PM Control 64% (excellent) 22% (fair) 5% (poor) 78% (excellent) 48% (fair) 20% (poor) Themes about Effectiveness • Flexibility/problem solving/different approaches for different clients. • Little evidence on long term effects: some suggestion that interventions maintain initial high level • Very different results if analyzed as treated or intend to treat. • Need interventions that help keep people connected. Conclusions/Implications • Adherence predicts adherence • People are different. Their issues are different. Different issues require different solutions. • This kind of intervention very difficult to evaluate. • Short term and long terms effects not the same.