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Examining Adherence Barriers in Pediatric and Adolescent HIV Patients. Melannie Cummings, PharmD Student Desiree Tomilo, PharmD Student Linda Catanzaro, PharmD Assistant Professor School of Pharmacy and Pharmaceutical Sciences. PACT Clinic, Women and Children’s Hospital of Buffalo .

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examining adherence barriers in pediatric and adolescent hiv patients

Examining Adherence Barriers in Pediatric and Adolescent HIV Patients

Melannie Cummings, PharmD Student

Desiree Tomilo, PharmD Student

Linda Catanzaro, PharmD Assistant Professor

School of Pharmacy and Pharmaceutical Sciences

PACT Clinic, Women and Children’s Hospital of Buffalo

University at Buffalo

© 2004 CDHS, College Relations Group BSC/SUNY Research Foundation

objectives
Objectives
  • Provide an overview of HIV infection and treatment options
  • Discuss opportunistic infections and prophylaxis
  • Discuss medication adherence and potential barriers to adherence
  • Discuss the health consequences of non-adherence
  • Describe tools and methods used to improve adherence
  • Discuss what to expect when caring for a child with HIV
  • Describe the pediatric and adolescent patient population at the PACT Clinic, at Women’s and Children’s Hospital of Buffalo
global estimates for adults and children end 2003
Global Estimates for adults and children end 2003
  • People living with HIV/AIDS 40 million
  • New HIV infections in 2003 5 million
  • Deaths due to HIV/AIDS in 2003 3 million

About 14,000 new HIV infections a day in 2003

  • Almost 2000 are children under 15 years of age
  • About 12,000 are 15-49 years of age
    • About 50% of these are 15 -24 years of age
slide4

HIV Global Estimates1

  • In the year 2003 – estimated 700,000 children under 15 years old became infected
    • mostly in sub-Saharan Africa
    • >90% were due to mother to infant transmission
  • 1. <AVERT.org> 3/3/04.
slide5

Incidence of Children with HIV in the United States1

  • Most are living in inner cities
    • poverty
    • poor housing
    • drugs
    • limited access to health care and social services
  • 1. National Institutes of Allergy and Infectious Disease <www.niaid.nih.gov> 2004.
slide6

Good News in New York State

  • 1996 - “Baby AIDS Law”
    • mandatory HIV testing added to newborn screening program
  • mother to infant transmission rates have decreased by 78%1
    • study of infants born from 1997-2002

1. NYS Dept. of Health. <www.health.state.ny.us/> May 2004.

methods of transmission
Methods of Transmission
  • sexual contact
  • contact with infected blood
    • needle sticks
    • unprotected administration of first aid
  • mother to child
    • perinatally - during delivery of the baby
    • through breast milk
prevention of perinatal transmission
Prevention of Perinatal Transmission
  • Early identification of maternal infection
    • goal: keep viral load <10001 to decrease risk of transmission to baby by up to 70%2
  • Antiretroviral prophylaxis with zidovudine during pregnancy, labor, and to newborns2
  • Cesarean-Section Delivery
    • Mother’s viral load >1,000, regardless of therapy1
  • Counseling and advisement of infected women to use an alternative to breast milk

1. Committee on Obstetric Practice. ACOG committee opinion scheduled Cesarean delivery and the prevention of vertical transmission of HIV infection. Number 234, May 2000. International Journal of Gynaecology & Obstetrics. 2001 Jun;73(3):279-81.

2. Sperling RS, Shapiro DE, Coombs RW et al. “Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant.” Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Eng J Med, 1996;335(22):1621-9.

effects of hiv on the human body
Effects of HIV on the Human Body
  • HIV attacks and weakens the immune system
  • If the virus is not suppressed and it continues to replicate, further damage to the immune system and progression to AIDS can occur.
  • The likelihood of developing AIDS or death within 12 months, when a child is not on antiretroviral therapy, can be as high as 51% and 30%, respectively1.

1. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. January 20, 2004.

diagnosis of hiv in infants
Diagnosis of HIV in Infants
  • All newborns are tested for HIV, regardless of the mother’s status.
  • In infants born to infected mothers, diagnostic testing should be done:
    • before the infant is 48 hours old
    • at 1-2 months old
    • at 3-6 months old
  • Six months after birth, all infected infants can be definitively diagnosed.
surrogate markers as predictors of disease progression
Surrogate Markers as Predictors of Disease Progression
  • Surrogate markers are obtained from an individual’s blood work.
  • CD4+ T-cells
    • cells in the immune system that are needed to fight off infection; higher CD4+ percentages indicate better immune status
surrogate markers
Surrogate Markers
  • Viral load (HIV-RNA)
    • measures how much virus is in the body; the lower the viral load the better
    • indicates if medication is effective; lower viral load limits the potential for development of resistance to medications
indications for when to initiate therapy in children 1 year of age 1
Indications for when to initiate therapy in children > 1 year of age1

1. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. January 20, 2004.

role of medications
Role of Medications
  • Antiretroviral medications work by suppressing viral replication
    • seen by low viral load
    • do not completely eradicate the virus (not a cure)
choice of antiretroviral medication regimens in pediatric patients
Choice of Antiretroviral Medication Regimens in Pediatric Patients
  • The first regimen that is chosen has the best chance of reducing the viral load to undetectable by assay or test(<50 copies/mL).
  • It is recommended that a regimen consist of:
    • 2 NRTIs + 1 PI

-or-

    • in children >3 years: 2 NRTIs + Efavirenz (a NNRTI)

in children <3 years or who can’t swallow

capsules: 2 NRTIs + Nevirapine (a NNRTI)1

1. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection. January 20, 2004.

classes of antiretroviral medications
Classes of Antiretroviral Medications
  • Nucleoside Analogue Reverse Transcriptase Inhibitors (NRTIs)
  • Nucleotide Reverse Transcriptase Inhibitors (NtRTIs)
  • Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
  • Protease Inhibitors (PIs)
  • Fusion Inhibitors- not approved for pediatrics
nucleoside analogue reverse transcriptase inhibitors nrtis
Nucleoside Analogue Reverse TranscriptaseInhibitors (NRTIs)
  • Mechanism of Action (MOA): block an enzyme that is needed by the virus in order to make DNA
  • can be taken without regard to meals
adverse effects seen with nrtis
Adverse Effects seen with NRTIs
  • Common side effects: nausea, vomiting, diarrhea, fatigue, weakness, headache, dizziness, loss of appetite, insomnia
    • with the exception of fatigue, these side effects usually go away
  • Severe side effects: pancreatitis, anemia (with AZT), hypersensitivity reaction/rash (with ABC), peripheral neuropathy (tingling and/or numbness in the extremities), liver damage
nrtis commonly used in pediatrics
NRTIs commonly used in pediatrics
  • zidovudine, AZT (Retrovir)
    • Available in capsules, tablets, syrup(strawberry)
  • lamivudine, 3TC (Epivir)
    • Available in tablets and oral solution(strawberry-banana)
  • stavudine, d4T (Zerit)
    • Available in
      • capsules
      • powder for oral suspension- once mixed, shake before use, refrigerate and discard after 30 days
nrtis
NRTIs
  • didanosine, ddI (Videx)
    • take on an empty stomach
    • Available in
      • chewable tablets (orange flavored)- Do not swallow tablets whole, must be chewed or crushed in water and 1 oz. apple juice; take on empty stomach; many children do not like these
      • powder for solution- mix with 4 oz. water; once mixed, store in refrigerator; shake well before use and discard after 30d
      • buffered powder packets for solution- mix with 4 oz. water and discard after 4 hours
      • enteric coated capsules- must not be opened, swallow whole
nrtis21
NRTIs
  • Abacavir, ABC (Ziagen)
    • Available in
      • tablets
      • oral solution(strawberry-banana)- may be refrigerated
    • A life-threatening allergic reaction can occur in 5% of patients; characterized by rash or flu-like symptoms; discontinue medication, do not try to give to patient again, and call MD
combination nrtis
Combination NRTIs
  • lamivudine+zidovudine, 3TC+ZDV (Combivir)
    • Available in tablets: 150mg 3TC + 300 mg ZDV
  • abacavir+lamivudine+zidovudine, ABC+3TC+ZDV (Trizivir)
    • Available in tablets: 300mg ABC + 150mg 3TC + 300mg ZDV
    • This drug contains abacavir
      • do not give if patient had a previous allergic reaction to abacavir
nrtis23
NRTIs
  • These NRTIs do not have sufficient data to support their use in pediatrics:
    • ddC- zalcitabine (Hivid)
    • FTC- emtricitabine (Emtriva)
    • TFV- tenofovir (Viread)
      • currently being studied in pediatrics
non nucleoside reverse transcriptase inhibitors nnrtis
Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs)
  • MOA: block an enzyme needed by the virus in order to make DNA
  • Side effects: rash, depression, insomnia, vivid dreams,
    • These symptoms usually resolve within the first few weeks
    • numerous drug interactions
  • A single mutation can cause resistance to the entire NNRTI class.
nnrtis
NNRTIs
  • Efavirenz (Sustiva)
    • Available in
      • tablets
      • capsules - can be opened and added to liquids or foods
    • Take on an empty stomach and give at bedtime
nnrtis26
NNRTIs
  • Nevirapine (Viramune)
    • once daily for 14 days, then titrated to 2x/day
    • increased risk of rash
    • Available in
      • tablets
      • suspension - sweetened, shake before using
  • Delaviridine (Rescriptor)
    • Insufficient data to support use in pediatrics
protease inhibitors pis
Protease Inhibitors(PIs)
  • MOA: block an enzyme needed to assemble the infectious virus particles
  • Side effects: fat maldistribution, liver damage, elevated triglycerides, diabetes
    • These usually occur over long periods of time.
    • numerous drug interactions
slide28
PIs
  • Nelfinavir (Viracept)
    • Available in
      • tablets - may be crushed and added to 3 oz. water or a small amount of food
      • powder - may be mixed in a small amount of food, milk, formula, soy milk or formula, dietary supplements, or soft foods; refrigerate solution and discard after 6 hours
    • Should be given with a meal or light snack.
slide29
PIs
  • Ritonavir (Norvir)
    • children 2-16 years of age
    • Available in
      • soft gelatin capsules - store in refrigerator or use within 30 days if at room temperature
      • solution - shake before use; can mix with milk, chocolate milk, Ensure and give within 1 hour of mixing; do not refrigerate
slide30
PIs
  • Amprenavir (Agenerase)
    • children >3 years of age
    • Available in
      • Soft gelatin capsules
      • Solution (grape-bubblegum-peppermint)
      • Keep both at room temperature
    • Do not give with a high fat meal
    • Avoid using supplements containing vitamin E
slide31
PIs
  • Lopinavir/ritonavir (Kaletra)
    • Children >6 months
    • Available in
      • capsules
      • solution
      • Keep both in refrigerator; if at room temperature, use within 2 months.
    • Give with food
slide32
PIs
  • These PIs do not have sufficient data to support their use in pediatrics:
    • Indinavir (Crixivan)
    • Saquinavir (Fortovase)
    • Fosamprenavir (Lexiva)
    • Atazanavir (Reyataz)
      • currently being studied in pediatrics
opportunistic infections
Opportunistic Infections
  • Cause of 90% of deaths in HIV infected patients
  • Caused by common organisms
  • Develop due to loss of cell-mediated immunity
  • Development can be predicted by CD4+ lymphocyte levels

1. Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy A Pathophysiologic Approach, 5th edition. The McGraw-Hill Companies, Inc. 2002.

opportunistic infections34
Opportunistic Infections

HAART (Highly Active Anti-Retroviral Therapy) was introduced in the United States in 1995 1

  • From 1996-1998
    • PCP rates decreased 21% per year 2
    • MAC rates decreased 39.9% per year 2
  • 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001
  • Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy A Pathophysiologic Approach, 5th edition. The McGraw-Hill Companies, Inc. 2002.
opportunistic infections35
Opportunistic Infections
  • Appropriate treatment of HIV is essential
  • Prevention and management of opportunistic infections is still a very important part of the care of HIV infected patients

1. Dipiro JT, Talbert RL, Yee GC, Matzke GR, Wells BG, Posey LM. Pharmacotherapy A Pathophysiologic Approach, 5th edition. The McGraw-Hill Companies, Inc. 2002.

opportunistic infections36
Opportunistic Infections
  • Pneumocystis carinii Pneumonia (PCP)
  • Mycobacterium avium Complex (MAC)
  • Vaccinations
    • Pneumococcal
    • H. influenzae type b (Hib)
who should receive pcp prophylaxis
Who Should Receive PCP Prophylaxis?
  • Infants 1-12 months old - if HIV-infected or HIV-indeterminate
  • Children 1-5 years old - with a CD4+ count

<500 cells/µL or CD4+ percentage <15%

  • Children 6-12 years old - with a CD4+ count

<200 cells/µL or CD4+ percentage <15%

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

who should receive pcp prophylaxis39
Who Should Receive PCP Prophylaxis?
  • Adolescents and Adults - with a CD4+ count

<200 cells/µL or a history of orophangeal candidiasis

  • Consider prophylaxis for adolescents and adults with a CD4+ percentage <14% or with a history of AIDS defining illness

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

recommended pcp prophylaxis
Recommended PCP Prophylaxis
  • Children
    • Trimethoprim/Sulfamethoxazole (TMP/SMZ)
      • 150/750 mg/m2/d in 2 divided doses given by mouth three times a week on consecutive days
    • Other options: varying doses of
      • Trimethoprim/Sulfamethoxazole (TMP/SMZ)
      • Dapsone
      • Aerosolized Pentamadine
      • Atovaquone

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

recommended pcp prophylaxis41
Recommended PCP Prophylaxis
  • Adolescents and Adults
    • Trimethoprim/Sulfamethoxazole (TMP/SMZ)

one double strength tablet per day

    • Other options: varying doses of
      • Trimethoprim/Sulfamethoxazole (TMP/SMZ)
      • Dapsone (with or without pyrimethamine)
      • Aerosolized Pentamadine
      • Atovaquone
  • 1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV  November 28, 2001
discontinuation of pcp prophylaxis
Discontinuation of PCP Prophylaxis

Children

  • Continue through first year of life
  • Children with a history of PCP infection should receive lifelong prophylaxis
  • Safety and efficacy of discontinuation has not been studied thoroughly

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

discontinuation of pcp prophylaxis43
Discontinuation of PCP Prophylaxis

Some clinicians consider discontinuing if:

  • a child 1-5 years old has had a CD4+ count >500 cells/µL or CD4+ percentage >15% for at least three months
  • A child 6-12 yearsold has had a CD4+ count >200 cells/µL or CD4+ percentage >15% for at least three months

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

discontinuation of pcp prophylaxis44
Discontinuation of PCP Prophylaxis

Adolescents and Adults

  • Discontinue when the CD4+ count has been >200 cells/µL for at least three months
  • 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001
who should receive mac prophylaxis
Who Should Receive MAC Prophylaxis?
  • Children
    • <1 year old: CD4+ count <750 cells/µL
    • 1-2 years old: CD4+ count <500 cells/µL
    • 2-6 years old: CD4+ count <75 cells/µL
    • ≥6 years old: CD4+ count <50 cells/µL
  • Adolescents and Adults
    • CD4+ count <50 cells/µL

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

recommended mac prophylaxis
Recommended MAC Prophylaxis
  • Children
    • Clarithromycin 7.5mg/kg (max 500mg) by mouth twice daily
    • Azithromycin 20mg/kg (max 1200mg) by mouth every week 1
  • Adolescents and Adults
    • Clarithromycin 500 mg by mouth twice daily 2
    • Azithromycin 1200 mg by mouth once weekly 2
  • 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001
  • Lexi-Comp Online, 2004. Available at: http://www.crlonline.com/crlsql/servlet/crlonline
discontinuation of mac prophylaxis
Discontinuation of MAC Prophylaxis

Children

  • Safety has not been studied in children
  • Children with a history of MAC infection should receive lifelong prophylaxis

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

discontinuation of mac prophylaxis49
Discontinuation of MAC Prophylaxis

Some clinicians consider discontinuing MAC prophylaxis in children if:

  • <1 year old: CD4+ count >750 cells/µL for at least three months
  • 1-2 years old: CD4+ count >500 cells/µL for at least three months
  • 2-6 years old: CD4+ count >75 cells/µL for at least three months
  • ≥6 years old: CD4+ count >50 cells/µL for

at least three months

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

discontinuation of mac prophylaxis50
Discontinuation of MAC Prophylaxis

Adolescents and Adults

  • CD4+ count >100 cells/µL for at least three months

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

vaccinations
Vaccinations

Children

  • Should receive all of the typical childhood vaccines
  • <5 years old: H. influenzae type b (Hib) and pneumococcal conjugate vaccine
  • >2 years old: should also receive the 23-valent polysaccharide pneumococcal vaccine
    • Revaccincate after 3-5 years if child ≤10 years old and after 5 years if >10 years old

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

vaccinations52
Vaccinations

Adolescents and Adults

  • CD4+ count ≥200 cells/µL: single dose of 23-valent polysaccharide pneumococcal vaccine (if they have not received it in the past five years)
  • Pneumococcal vaccine can be considered in patients with a CD4+ count <200 cells/µL but there is no proof of efficacy
  • H. influenzae type b (Hib) is not recommended

1. 2001 USPHS/IDSA Guidelines for the Prevention of Opportunistic Infections in Persons Infected with HIV - November 28, 2001

medication adherence
Medication Adherence

> 95% adherence is needed to adequately suppress viral replication

1. Esch LD. “Issues in Human Immunodeficiency Virus (HIV) Pharmacotherapy Practice. The Emerging Role of Pharmacotherapy Specialists in Enhancing Antiretroviral Success.” J Inform Pharmacother 2001;4:306-316.

potential barriers to adherence
Potential Barriers to Adherence
  • Pill burden
  • Drug use/alcohol abuse
  • Depression
  • Lack of education1
  • Unwillingness to disclose HIV status2
  • Unstable environment2
  • Side effects
  • Lack of palatability of medications2

1. Esch LD. “Issues in Human Immunodeficiency Virus (HIV) Pharmacotherapy Practice. The Emerging Role of Pharmacotherapy Specialists in Enhancing Antiretroviral Success.” J Inform Pharmacother 2001;4:306-316.

2. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infections-January 20, 2004

adherence
Adherence

Pediatric adherence is of special concern because the status of the caregiver as well as the patient has to be taken into account

consequences of poor adherence
Consequences of poor adherence
  • Virologic failure-incomplete (or lack of) HIV-RNA response
  • Incomplete virologic response
  • Virologic rebound
  • 1. Guidelines for the Use of antiretroviral agents in HIV Infected Adults and Adolescents – March 23, 2004
consequences of poor adherence57
Consequences of poor adherence
  • Development of resistance
    • inadequate levels of medication to suppress viral replication
    • selective pressure-resistant virus is able to replicate and repopulate patient1
  • Regimen changes
    • decreased medication choices for the future
  • Luber AD. “Pharmacotherapy of Human Immunodeficiency Virus Infection”. In: Koda-Kimble M, Young LY, Kradjan WA, Guglielmo BJ, editors. Applied Therapuetics. The Clinical Use of Drugs. Seventh Edition. New York: Lippincott Williams and Wilkins; 2001.
consequences of poor adherence58
Consequences of poor adherence
  • Resistance and virologic failure increase the risk of comorbidities and death
  • High HIV-RNA levels and low CD4+ lymphocyte counts - increased risk of progression to AIDS (see Table 1)

1. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infections-January 20, 2004

potential adherence interventions
Potential Adherence Interventions
  • Pill boxes
  • Calendars
  • Alarm watches
  • Home visits
  • Refill checks
  • Phone calls
  • Adherences visits/clinic appointments
  • See table 2

1. Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infections-January 20, 2004

education of foster parents of hiv children
Education of foster parents of HIV+ children
  • Universal precautions
    • Avoid contact with child’s blood
    • Use caution if child is vomiting or has diarrhea
    • Guidelines:
      • NIH (http://www.nih.gov/)
      • CDC (http://www.cdc.gov/)
  • Disease education
  • Education on medication regimens
slide61

PACT Clinic

Baseline Characteristics

(Total Number of Patients=24)

living situations
Living Situations
  • Of the 24 patients:
    • 79.2% (19) are living with a biological relative
    • 12.5% (3) are in non-kinship foster placements
    • 8.3% (2) are living alone
adherence70
Adherence
  • Good Adherence = 0-2 missed doses/month
  • Fair Adherence = 3-5 missed doses/month
  • Poor Adherence = >5 missed doses/month
reasons for missed doses
Reasons for Missed Doses
  • Other commons reasons for missed doses include:
    • forgetting
    • pill burden
  • At baseline no one in this population reported these reasons.
patient reported adherence vs medication administration81
Patient Reported Adherence vs. Medication Administration
  • 3 patients were not on anti-retroviral therapy
  • 6 patients were unknown
association between fair or poor adherence and depression and or substance abuse
Fair Adherence

Patient 1:

Patient-depression, Caregiver-no documented depression

No documented substance abuse in patient or caregiver

Patient and caregiver are involved in medication administration

Association between fair or poor adherence and depression and/or substance abuse
association between fair or poor adherence and depression and or substance abuse83
Association between fair or poor adherence and depression and/or substance abuse
  • Poor adherence
    • Patient 1:
        • Patient-Depression, Caregiver-no documented depression
        • Patient-Substance abuse, Caregiver-no documented substance abuse
        • Patient is in charge of medication administration
association between fair or poor adherence and depression and or substance abuse84
Association between fair or poor adherence and depression and/or substance abuse
  • Poor adherence
    • Patient 2:
        • Patient-Depression, Caregiver-Depression
        • Patient-no documented substance abuse, Caregiver-substance abuse
        • Patient and caregiver are in charge of medication administration
conclusions
Conclusions
  • Adherence appears to be better when both the caregiver and the patient are involved in medication administration
  • Substance abuse and depression in the patient and/or the caregiver appears to negatively effect adherence
slide86
Due to the small patient population of the PACT Clinic, the assessment of the baseline characteristics should not be extrapolated to the general population
slide88

During the appointed period (September 2003-May 2004) one patient was added, making our total number of patients 25

methods standard of care
Methods: Standard of Care
  • Bi-weekly or as needed adherence appointments
    • Patient interviews using follow-up questionnaires
  • Monthly case conferences with PACT nurses
  • Pharmacist and RN available by pager for questions
  • Adherence interventions
    • Pill boxes
    • Home visits and refill checks by adherence nurse
    • Medication administration schedule
pact clinic interventions
PACT Clinic Interventions
  • Of the 25 patients:
    • 96% (24) were seen during the appointed time
  • Of the 24 patients seen:
    • 12.5% (Cases 1,2, and 3) required interventions
      • Treatment of depression
      • Intensive follow-up (including home visits and refill checks)
      • Supplying adherence tools
        • Pillboxes
case 1
Case 1
  • History
    • 13 year old HIV+ male presented to clinic in January
    • Patient had previously seen a psychiatrist and was diagnosed with major depression. An antidepressant was prescribed.
    • Based on patient’s CD4+ count, PCP prophylaxis was also previously prescribed
    • After questioning it was determined that the patient was non-adherent to both medications
    • Currently not on ART and was being deferred until improvement was seen in depression and adherence
case 192
Case 1
  • Intervention
    • Pharmacist and patient came to written agreement stating that the patient would be adherent to both his medications
  • Results
    • At two week and six week follow-up visits, patient demonstrated significant improvements in mood and adherence
    • Patient showed interest in helping to choose an ART regimen
    • Currently waiting for most recent surrogate markers to evaluate need for starting ART
case 2
Case 2
  • History
    • 13 year old HIV+ male presented to clinic reporting excellent adherence
    • Surrogate markers suggested current regimen was failing and a change was considered
  • Intervention
    • Adherence nurse made a home visit and discovered multiple vials of all of his antiretroviral medications
      • Adherence was inaccurately reported by the patient
case 294
Case 2
  • Results
    • Change in ART deferred until patient demonstrates willingness to adhere to current regimen
    • Home visits and follow-up phone calls are still being used to evaluate adherence
case 3
Case 3
  • History
    • 18 year old HIV+ female
    • Unstable home environment, was living with sister
      • Friends over every night
      • Drinking alcohol frequently
    • Patient reported poor adherence for various reasons
      • Alcohol, confidentiality issues, oversleeping
case 396
Case 3
  • Intervention
    • Patient was given a pillbox and counseled to fill it at the beginning of each week
    • It was suggested to keep the pillbox in her dresser drawer so that she could take her medications privately
    • Good adherence was encouraged and consequences of poor adherence were discussed
  • Results
    • Currently waiting for follow-up visit to assess adherence
case 4
Case 4

The following case is an example of the impact the home environment and the caregiver can have on a child’s HIV status

case 498
Case 4
  • History
    • Five year old HIV+ male with increasingly elevated viral load (as high as 300,000 copies/mL), which suggested non-adherence to regimen
    • Living with mother during this period
      • Unstable home environment
      • Mother not giving patient medications
case 499
Case 4
  • Child went to live with father
  • Father took an interest in caring for child’s HIV
    • Attended adherence visits at PACT Clinic
    • Was educated on patient’s medications and the importance of adherence
    • At follow-up appointments, reported good adherence
  • Viral load has dramatically decreased to goal of undetectable (<50 copies/mL)
overall conclusions
Overall Conclusions
  • Adherence barriers include being away from home, sleeping through doses, side effects, forgetting, running out of medication and confidentiality
  • Depression and substance abuse may be significant barriers to adherence
  • Pharmacy-based interventions potentially improve adherence
overall conclusions101
Overall Conclusions
  • Basic education of potential caregivers regarding the disease itself and the medications used is crucial.
    • Universal precautions
    • Adherence education
    • Comprehension of regimen
    • Involvement of primary healthcare provider
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Caring for a child with HIV can be challenging, but with the support of members of the healthcare team and social services, a caregiver can provide everything that is needed for the child to live a normal, healthy life.