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Strategies for Enhancing HAART Adherence in HIV Patients

Learn effective approaches to improve adherence to HAART, including education, regimen simplification, and addressing common side effects. Explore factors influencing adherence and the importance of social support in enhancing treatment outcomes.

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Strategies for Enhancing HAART Adherence in HIV Patients

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  1. Adherence to HAART

  2. Adherence Summary • Adherence is the Achilles Heel of HAART • Adherence requires education, a shared negotiation, & the optimal regimen for the individual patient • Simplify the regimen, BID or better, and anticipate, inform, and treat common side effects as part of adherence readiness • Access to trusted, knowledgeable MD & health care team is essential G Friedland and the CORE AETC NRC Training Slide

  3. 20 HIV prevention Housing, nutrition Family & reproductive counseling Chemical dependency Co-morbidities: Hepatitis C O.I. prophylaxis Goals of ARV therapy HHS Guidelines 1/00 Adherence When to start, with what? When to change? Drug toxicities Rx of experienced pts Resistance testing Immune reconstitution For the Primary HIV Clinician: Too Much to Do, Too Many Questions AETC NRC Training Slide R. Sherer

  4. Diabetes - 40-50%. Epilepsy - 30-40%. Hypertension - 40%. Asthma - 20%. Transplant - 18%. Oral contraception - 8%. The Extent of Non-Adherence

  5. Antiarrythmics - 76% Chemotherapy - 73% Antibiotics - 67% Antiasthmatics - 54% Antihypertensives - 47% Lipid lowering agent - 43% Anticonvulsants - 24% Immunosuppresants - 18% Non-Adherence Rates by Medication Type

  6. Prescriptions • 1.8 Billion prescriptions annually. • Over half of all prescriptions are taken incorrectly. • 21% never get their prescriptions refilled. • 11% of all hospital admissions are due to patients improperly taking their drugs

  7. Factors that Influence Adherence • Consistently predictive of non adherence • Symptoms and side effects • Negative life events/stress • Complexity of regimen • Consistently predictive of adherence • Family or social support • Self-efficacy Ammassari,JAIDS 2002

  8. Factors that Influence Adherence • Inconsistently predictive of adherence or non adherence • Age, race, Income • Unstable housing • Active injection drug use • Alcohol consumption • Depression • Psychiatric co-morbidity • Health related quality of life • CD4 cell count • Dosing frequency • Knowledge and beliefs about treatment • Patient satisfaction with healthcare/patient-provider relationship Ammassari, JAIDS 2002

  9. Factors that Influence Adherence • Factors not predictive of adherence or non adherence • Gender • Education • Living with others/children • Unemployment • Medical insurance • Risk factor for HIV • History of injection drug use • Length of HIV infection • CDC disease stage • Naïve to ART • Number of antiretrovirals • Type of ARV drugs • Number of pills Ammassari, JAIDS 2002

  10. Ex IVDU not in drug treatment N=114 25% non adherence 14.9% high social instability 37.7% medium social instability 47.4% low social instability Current IVDU /in drug treatment N=96 36% non adherence 31.3% high social instability 55.2% medium social instability 13.5 low social instability Adherence in IVDUsBouhnik, JAIDS, 2002

  11. Behavioral Correlates of AdherenceICoNA, JAIDS 2002

  12. Physician Estimate vs Measured Adherence

  13. Adherence and HAART • NNRTI vs PI based regimens • 51% non adherence - PI • 38% non adherence –NNRTI • 41% lower risk of non adherence with NNRTI • Compared with PI regimen • OR 0.53 Efavirenz non adherence • OR 0.63 Nevirapine non adherence AdICoNA and AdeSpall studies, JAIDS 2002

  14. 1.5 1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5 -4.0 -4.5 -5.0 2 3 4 5 6 What Degree of Adherence Is Needed? Weeks 40–52 HIV RNA* vs baseline HIV RNA NVP + ddI + AZT Adherent Nonadherent HIV RNAchange from baseline(log10 copies/mL) Baseline HIV RNA(log10 copies/mL) *Lower limit = 20 copies/mL. Source: Montaner, et al. JAMA 1998;279:930. AETC NRC Training Slide

  15. What Degree of Adherence Is Needed? Adherence to a PI-containing regimen correlates with HIV RNA response at 3 months Patients with HIV RNA<400 copies/mL, % PI adherence, % (MEMScaps) Source: Peterson, et al. 6th Conference on Retroviruses and Opportunistic Infections; 1999; Chicago, IL. Abstract 92. AETC NRC Training Slide

  16. Several trials indicate the need to achieve better viral suppression, i.e. < 50 cps/ml INCAS (AZT/ddI/NVP) AVANTI-2 (AZT/3TC/IDV) 100 80 60 40 20 0 0 8 16 24 32 40 48 0 8 16 26 32 40 48 Viral load Nadir 20 copies/ml 21–400 copies/ml >400 copies/ml Proportion of subjects with sustained virologic success* (%) AVANTI-3 (AZT/3TC/NFV) All trials combined 100 80 60 40 20 0 0 8 16 24 32 40 48 0 8 16 24 32 40 48 Weeks Weeks *HIV-1 RNA <1000 copies/ml Montaner J. 12th World AIDS Conference Geneva 1998 AETC NRC Training Slide

  17. Cochrane Review of Adherence Interventions • Adherence interventions for all types of diseases • Limited to Randomized Controlled Trials without confounding • Two HAART trials fit the criteria for inclusion • Many HAART trials excluded due to: • Limited follow-up time • Confounding • Missing data • Significant lost to follow up • Adherence intervention unclear • Lack of a control group

  18. Cochrane Reviewed HAART Adherence Interventions • Knobel, Enferm Infecc Microbiol Clin 1999 • Study design • ZDV+ Lamivudine + Indinavir + conventional care • ZDV + Lamivudine+ Indinavir + counselling and adaptation of treatment to patient lifestyle, telephone support, detailed medication information • Adherence measured by pill count, structured interview • Compliance = • 90% drugs taken • > 90% meds taken according to schedule • < 2 mistakes in pill intake /day • Study impact • Positive effect on adherence • Reduced viral load

  19. Cochrane Review of Adherence Interventions • Tuldra, JAIDS 2000 • Study Design • Usual medical follow up vs education • Psycho educative intervention to implement adherence • Dosing schedule with patients’ input • Phone support • Study Impact • No effect on adherence • No effect on outcome

  20. Limitations of HAART Adherence Studies • Lack of reliable measurements of adherence • Lack of consistent measurements across studies • Assessment of adherence predictors • Small sample size • Variation in study design • Ability to generalize study design • Applicability of other chronic disease studies to HIV • Wide variation in reported results • Limited time of follow up assessments JAIDS, 2002

  21. Adherence works best when: • Relationship between patient and provider is based on trust • Patient has adequate support • Multidisciplinary healthcare team • Multidisciplinary client centered approach • Approach individually tailored to patient’s needs • Adherence is a process, not a single event

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