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Adherence Preparing to start ARVs. Dr. Kevin M Harvey MBBS, MPH (UWI), Dip. ID (Lon.) Treatment care and support 2006. What do we know?:HIV Treatment in 2004. Many regimens are active in people with no drug resistance

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adherence preparing to start arvs

Adherence Preparing to start ARVs

Dr. Kevin M Harvey

MBBS, MPH (UWI), Dip. ID (Lon.)

Treatment care and support


what do we know hiv treatment in 2004
What do we know?:HIV Treatment in 2004
  • Many regimens are active in people with no drug resistance
    • Measured as suppression of virus (lowering plasma viral load to under detection) or other response to treatment (CD4, clinical, weight etc)
  • But treatment after resistance develops is still a challenge and usually requires more complicated and/or more expensive regimens
  • In addition resistant virus can be transmitted
  • Failure carries a high price on an individual, financial and public health
  • Finding the reasons and preventing failure is therefor critical
why does antiretroviral therapy fail
Why does antiretroviral therapy fail?
  • Not a cure
  • Efficacy
  • Drug toxicity
  • Drug interactions
  • Drug resistance
  • Adherence issues – lifelong therapy
  • Cost
failure of therapy types of failure
Failure of Therapy: Types of failure
  • Clinical failure

Progression of disease, new infections

  • Immunologic failure

Decline in CD4 count

  • Virologic failure

Persistent viral replication (usually associated with resistance)

  • Drug toxicity

Severe side effects

  • Infrastructure failure

Lack of drug supply, lack of money to pay for drugs

art in the real world
ART in the “Real” World
  • Many clinical trials show suppression of virus in >80% of subjects
  • BUT, studies in a multitude of clinical settings have shown only 50-70% success rates with multiple-drug therapy at 1-2 years
  • WHY?
  • While baseline resistance and poor prescribing contribute, poor adherence accounts for many of these failures*
  • As HIV turns from a uniformly fatal illness to a chronic disease, adherence grows even more important

*Estimates from 40-80% report some non-adherence

  • Adherence
  • Compliance
  • Concordance
  • Taking the medication/following the regimen as directed (dose, timing, diet etc etc) with follow-up and care as directed
  • WHO: the extent to which a person’s behaviour – taking medication, following a diet,and/or executing lifestyle changes, corresponds with agreed recommendations from a health care provider.
adherence in other diseases
Adherence in other diseases*
  • Poor adherence to treatment of chronic diseases is a worldwide problem of striking magnitude
    • Average of 50% in most diseases
    • Ex. Non-adherence accounts for a significant percent of admissions in patients with heart failure
  • The consequences of poor adherence to long-term therapies are poor health outcomes and increased health care costs
  • Increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments
  • A multidisciplinary approach towards adherence is needed

*WHO. Adherence to long-term therapies: evidence for action, 2003.

who adherence to long term therapies evidence for action
WHO. Adherence to long-term therapies: evidence for action
  • Adherence is simultaneously influenced by several factors

Factors include:

    • Medication
      • Ex. Dose frequency, side effects
    • Patient
      • ex. Readiness, substance use
    • Health care system/providers
      • Ex. Patient provider relationship
      • Treatment education
      • DOT
      • cost
    • Community/environment
      • Ex. Stigma, transport
  • Adherence is a dynamic process that needs to be followed up
    • Improving long-term adherence is complex and required continuous support and monitoring
  • Health professionals need to be trained in adherence
  • Family, community and patients’ organizations: a key factor for success in improving adherence
why is hiv different
Why is HIV different
  • Excellent adherence in other diseases is considered >60-70%
  • Adherence rates for HIV need to be higher
    • >95%
  • Non adherence with HIV carries very high risk of virus developing drug resistance
  • Once resistance develops, that drug (and possibly others) will never work as well or may not work at all
  • Communicable disease
adherence and viral suppression
Adherence and viral suppression

Percentage of Medication Taken



80% to 95%

95% to 99%


Percent of

patients with

viral load

<500 copies






2 Months

6 Months

Haubrich RH, et al. AIDS 1999;13:1099-107.

hiv adherence and clinical significance
HIV, adherence and clinical significance
  • Better adherence is also linked with decreased risk of getter sicker from HIV infection, losing more CD4 cells, and dying from HIV
adherence in resource richer areas
Adherence in resource richer areas
  • Average rates of adherence vary widely, but generally fall well short
  • Percentage of patients with treatment failure in clinical practice reflect a combination of non adherence and resistance:
    • USA 50%
    • Amsterdam 40%
    • Swiss
      • naïve 38%
      • experienced 70%
    • Johns Hopkins 63%
    • Cleveland 53%
adherence to arvs treatment over time
Adherence to ARVs treatment over time

Percent reporting 100%


*p<0.01 for difference between months 1 & 4 and months 1 & 8

Mannheimer et al, CPCRA, 2000.

adherence in resource limited settings
Adherence in Resource-limited settings
  • In programs with self-pay, cost is not always the major barrier to adherence
  • Innovative approaches to support adherence before and during treatment are being used
Adherence to ARVs in resource-limited settings:*
  • Uganda: 88%
  • Cote d’Ivoire: 75%
  • Haiti: 88%
  • Senegal: 78%-88%
  • South Africa: 89%
  • Brazil: range: 57%-87%
  • Botswana: ~55%
  • Nigeria: 58%
  • Kenya: 59%

Adherence is as problematic in resource-limited settings as it is in resource-rich settings. No evidence to show that it is more problematic.

* NB: small studies, differing definitions of adherence

adherence in resource limited settings1
Adherence in resource limited settings
  • African Countries
  • Strong pre treatment education and screening, counselors and treatment buddy
  • High rates of adherence, viral suppression
  • Need to determine critical components for scale-up

Cootzee, AIDS 18 suppl 3, 2004

predictors of nonadherence medication related
Predictors of nonadherence: Medication related
  • dosing frequency
  • side effects
  • Number of pills
  • ?type of medication
  • ?complexity of regimen
patient related
  • Active substance abuse
  • Depression
  • HIV knowledge and knowledge and belief in medications
  • Literacy (?more of a system problem)
  • Non-adherence to care
  • Stage of readiness
  • ?Distance from site
  • ?age
  • ?disclosure
system related
  • Cost of care/treatment
  • Access to care and medications
  • provider/patient relationship
  • Stock-outs
  • ?employment out of the home
  • ?transportation
  • ?stigma
non predictors
  • Non-predictors include
    • Race
    • gender
    • prior substance abuse
    • social status or income
    • education
other reasons people do not take their art
Other reasons people do not take their ART
  • Pill fatigue
  • Forgot
  • Pills not with them
  • Transportation
  • Fear of disclosure
  • Concern with drug interactions (prescribed or other)
  • And others
preparing for adherence
Preparing for Adherence
  • More sustainable response to ARVs if adherence is optimized within the first three to six months
  • Must therefore prepare individuals to adhere prior to the start of ARVS
  • Must also have a strategy to sustain adherence throughout life
preparing for arvs
Preparing for ARVs
  • Culture
  • Access +Knowledge + Motivation+Cues to Action
  • Stigma & Discrimination
Potential Barriers

Distance from Clinic

Appointment system

User Fees

Availability of Service


Stigma & Discrimination

Cost for CD4,Viral Loads + other labs

Cost of other Medicines

Cultural Practices

Possible Solutions

Telephone Appointments

Waiver from User Fees (free does not =Access)

Waiver from General fees & lab cost via assessment Process

Refer closest acceptable Treatment site

Assistant with Bus Fares

Register with the NHF

Family support

Potential Barriers




Low literacy

Lack of Exposure to Specific HIV Education

Educational Material inappropriate

Possible Solutions

Appropriate Literacy Material for Individual

HIV Basic Facts

Condom Negotiation Skills

Name etc of Specific Meds

Potential Barriers


Number of pills

Frequency of doses per day

No Family support

No disclosure /fear disclosure

Negligence/ forgetfulness


Lack of privacy

Possible Solutions

Refer to Social Worker

Mental Health Professional

Reduce the number of pills If possible link meds to something the patient does that they enjoy

Refer to support groups

Encourage disclosure,

provide temporary support

encourage buddy system

Channel to income generating projects

cues to action

Non Disclosure and lack of support

Drug addiction

Stigma and Discrimination

Attention drawn by Reminders

Pill boxes can be too big

Late refills

Cognitive function

Possible Solutions

Family Support


Pill Boxes

Text Messages


Link to Favourite radio and TV programmes

Support at workplace

Cues to Action

Patients only listen to doctor

Alternative Medicine Can provide a Cure

Role of the Church



Patients will listen to Doctors

Alternative(Herbal Medicines) can be immune boosters

Education of Clergy

stigma discrimination
Potential Barriers

Fear Discrimination

Lack of or Low Public education

Remove Labels

Fail to take meds in Public

Move away from district

Do not want to attend Clinic in Own district

Visible side effects

Possible Solutions

Confidentiality at the work place is key

Reduced stigma and discrimination at work place

Refer to acceptable treatment site or facilitate easier access

Stigma & Discrimination
supportive environment
Supportive Environment
  • Knowledge Motivation
  • Positive Behaviour Change
  • Increased Adherence
family focused adherence support
Family-Focused Adherence Support
  • It may take several weeks and several visits to ready the family for treatment.
  • Before prescribing
    • Family is part of and agrees with treatment plan
    • Assess family life-style, priorities, beliefs
    • Ask about prior medication experience: build on success and work on problems
    • Educate about the disease, purpose of ARV, importance of adherence
    • Repeat information as many times as necessary
family focused adherence support1
Family-Focused Adherence Support
  • Planning for a good start:
    • Develop a simple schedule that fits the family’s daily activities. Consider differences between weekdays and weekends.
    • Clarify who will be responsible for giving or supervising each dose, each day of the week
    • Make the schedule visual. Use pictures of pills. Color-code everything. Consider literacy level of family members
family focused adherence support2
Family-Focused Adherence Support
  • Planning for a good start:
    • Demonstrate medication preparation:
      • measuring volumes of liquids
      • crushing or dissolving tablets
      • opening capsules
      • using foods or liquids to mask task
    • Do a trial run with “dummy” pills or liquid
    • Observe medication administration in the office. If possible, start the first dose under supervision
    • Follow-up with a phone call and/or home visit in the first few days
general lessons we have learned
General lessons we have learned
  • Adherence is hard for everyone and long term treatment present the most difficult challenges
  • Adherence is critical to the successful care of patients with HIV/AIDS
    • On an individual level, adherence to care and treatment can mean the difference between life and death
    • On a population level, adherence to treatment can minimize the emergence of viral resistance and prevent therapeutic failure
  • Adherence needs to be to medications and care.
more lessons
More lessons
  • Every HIV/AIDS treatment program should include processes to assess and support adherence
  • Adherence promotion must be multifaceted and multidisciplinary and adapt to changing needs and realities
    • Many models/approaches in use
    • Many also need to be evaluated and adapted for local needs
  • Simpler and more tolerable regimens which preserve efficacy are still needed
  • Sources for some of the slides or materials included:
    • KITSO AIDS Training Program (Botswana)
    • MTCT-Plus training (Columbia University)
    • Vietnam-CDC-Harvard Medical School AIDS Partnership (VCHAP)
    • Colleagues and most importantly,people living with HIV