AIDS DRUG ASSISTANCE PROGRAM: WHAT ROLE IN ADHERENCE SUPPORT

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AIDS DRUG ASSISTANCE PROGRAM WHAT ROLE IN
ADHERENCE SUPPORT?
Center for Adherence Support Evaluation The New
York Academy of Medicine Ruth Finkelstein, ScD
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WHY SHOULD ADAP CARE ABOUT ADHERENCE?

• Drug effectiveness is partly dependent on
  adherence.
• The reduced effectiveness of HAART associated
  with poor adherence is partly due to the
  development of drug resistance.
• Resistance can occur to a class of drugs not just
  an individual drug.

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CONSEQUENCES OF RESISTANCE

• Clinical
• Public Health
• Cost

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CONSEQUENCES OF RESISTANCE
Clinical Poor viral suppression is associated
with increases in morbidity and mortality.
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CONSEQUENCES OF RESISTANCE
Public Health Concerns

• In a national survey of 1,080 HIV patients, among
  those with gt500 copies HIV RNA/ml, 78 had drug -
  resistant virus.
• Even among newly - infected, treatment - naïve
  patients, one in five had resistant virus --
  suggesting the transmission of drug resistant
  virus.

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CONSEQUENCES OF RESISTANCE
Cost

• Resistance to classes of drugs necessitates
  prescription of expensive and less effective
  salvage therapies (highly complex regimens with
  multiple therapeutic agents).
• Poor clinical outcomes result in increases in
  costly inpatient utilization.

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APPROACHES TO IMPROVE ADHERENCE
NOT Recommended

• Prescribe treatment only for adherent patients.
  
• Major Problems
• Dont know who will be adherent.
• In the absence of such knowledge, decisions are
  based on negative perceptions/assumptions.

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APPROACHES TO IMPROVE ADHERENCE
Recommended

• Multi-faceted approaches delivered in combination
  considering patient, physicians, other health
  care providers, regimen and system
  characteristics.
• Patients who face substantial barriers may
  achieve acceptable adherence with appropriate
  assistance and support.

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MULTI -FACETED APPROACHES TO IMPROVE ADHERENCE

• System
• Regimen
• Provider
• Patient

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SYSTEM APPROACHES

• Based on identified adherence barriers,
• system interventions should seek to reduce
• barriers associated with healthcare and
• treatment access
• Eliminate interruptions in insurance coverage.
• Monitor gaps in refilling prescriptions and
• follow-up in real time.
• Minimize prescription refilling burden.
• Facilitate appointment making and keeping.
• Reduce waiting time for appointments and
• clinic visits.
• Provide or reimburse for transportation and
  child care.
• Eliminate or reduce cost associated with
  medications.
• Offer DOT and modified DOT options.

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REGIMEN APPROACHES
Interventions addressing regimen issues should

• Prescribe regimen consistent with patient daily
  routine.
• Regimen tailoring and development of specific
• treatment plans.
• Simplify numbers of doses when possible.
• Evidence for adherence benefit of regimens
  without
• mid-day dose (once per day dosing has
  equivocal
• results complex issues).
• Treat side effects immediately and aggressively.
• Pill-swallowing practice (for pediatric
  patients).
• Pill boxes.
• Reminder tools and systems of recording
• medication-related behaviors.

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PROVIDER APPROACHES

• Provider/patient relationship has a strong
• potential to influence patient adherence.
• Interventions should target providers
• through
• Skills Training
• Professionals Guidance
• Implementation of multi-disciplinary
• teams or referral networks

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PROVIDER APPROACHES

• Interventions developed with providers in
• mind should seek to encourage the following
• behaviors
• Prescribe simpler regimens.
• Enhance communication skills
• (especially listening).
• Assess patients potential adherence barriers.
• Individualize written instructions.
• Use pictorial cues, reminders, instructions
• when language or literacy level requires.
• Screen for depression and substance use.

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PROVIDER APPROACHES

• Educate and motivate.
• Stabilize living situation when possible.
• Provide adherence tools beeper, pill boxes.
• Involve patients in treatment choices.
• Enlist family members, friends and/or parents.
• Aggressively anticipate and manage side
  effects.
• Evidence about provider trust suggests that
  patients
• convey different information regarding
  adherence
• problems to non-physicians and computers.
• Consider multiple methods of adherence
  assessment.
• Strong anecdotal/program level evidence about
• peer based programs.
• Both pharmacists and nurses are associated with
  
• effectiveness.

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PATIENT APPROACHES

• Patient centered approaches to
• adherence should be
• a combination of multiple
• interventions to address a range of
• adherence barriers
• delivered consistently over time
• linked to clinical care.

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PATIENT APPROACHES

• Certain barriers have been consistently
• associated with poor adherence
• Untreated mental health issues
• (particularly depression)
• Current substance use (crack and alcohol)
• History of poor adherence
• Medication side-effects

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PATIENT APPROACHES

• Methods to measure adherence
• include
• Self report
• MEMS caps
• Prescription refill monitoring
• Pill counts
• Physician/nurse assessment
• Plasma drug testing

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PATIENT APPROACHES

• Educational/informational strategies
• should be culturally specific and
• tailored to the individual.
• Materials usually include
• Visual aids
• Color-coded medication schedules
• Dosing diagrams

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PATIENT APPROACHES

• Behavioral strategies are designed to
• influence patient behavior through
• Incentives
• Reminders
• Skills training
• Patient motivation and enhanced
• self efficacy