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HIV TherapyAdherence: Strategies for Success. Kirsten B. Balano, PharmD National HIV/ AIDS Clinician’s Consultation Center. Case Presentation. 28 yo man with AIDS comes to triage nurse requesting refills D4T/3TC/Nevirapine CD4 count 76, VL 1,064

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hiv therapyadherence strategies for success

HIV TherapyAdherence: Strategies for Success

Kirsten B. Balano, PharmD

National HIV/ AIDS

Clinician’s Consultation Center

case presentation
Case Presentation
  • 28 yo man with AIDS comes to triage nurse requesting refills D4T/3TC/Nevirapine
      • CD4 count 76, VL 1,064
      • Saw primary MD 3 months ago as first visit to SFGH clinic and was supposed to return in 1 month (2 months late for appt)
      • Has next primary appt 2 weeks from now.
      • Also taking Septra DS & Itraconazole (for disseminated histoplasmosis infection)
challenges associated with antiretroviral therapy
Challenges associated with antiretroviral therapy:
  • When to start medications?
  • When to change medications?
  • What medications to start with?
  • What medications to change to when fail?
“The achilles heel of HAART”
    • G. Friedland
  • “Drugs don’t work if people don’t take them.”
    • C. Everett Koop
adherence to antiretroviral medications using actg tools
Adherence to antiretroviral medications using ACTG tools

Skipped Taking Pills% (n=75)

Within Last 2 Days 17

Yesterday 11

Day before yesterday 13

Last weekend 21

Within last 2 weeks 36

Chesney, et al, AIDS Care 2000, 12;(3): 255-266

factors independently associated with nonadherence in 3 day history
Factors Independently Associated with Nonadherence in 3 day history

Variable Odds ratio p value

Nausea 4.47 (1.66-12.1) 0.003

Anxiety 2.63 (1.32-5.23) 0.006

Younger age 2.28 (1.26-4.15) 0.007

Unemployment 2.92 (1.55-5.49) <0.001

Not recalling name, 2.18 (1.21-3.92) 0.009

color and timing

Running out between 2.62 (1.42-4.86) 0.002


Being too busy 2.04 (1.07-3.89) 0.03

Ammassari etal, JAIDS Dec 2001;28(5)

patient factors affecting adherence
Patient factors affecting adherence
  • Understand purpose of therapy
  • Belief in treatment efficacy
  • Confidentiality/Disclosure
  • Social Support
  • Lifestyle fit with medication routine
  • Mental Health Issues
  • Substance Use/Abuse
  • Housing
medication factors affecting adherence
Medication factors affecting adherence
  • Identify medication (name, color, purpose)
  • Frequency of dosing
  • Number of pills taken with each dose
  • Size of pills
  • Taken with regard to meals?
  • Side-effects of medications and the ability to manage these side effects
  • Drug-drug interactions
reasons for missed doses using actg tools
Reasons for Missed Doses using ACTG tools

Reason% (n=51)

Simply forgot 66

Away from home 57

Busy with other things 53

Change in daily routine 51

Fell asleep/slept through dose 40

Felt ill or sick 28

Wanted to avoid side effects 24

Felt depressed/overwhelmed 18

Too many pills 14

Did not want others to notice 14

Felt drug toxic/harmful 12

interventions associated with improved adherence
Interventions Associated with Improved Adherence
  • Pharmacist-based adherence encounters/clinics
  • Adherence encounters at each visit, often multi-disciplinary
  • Reminders, alarms, pagers, timers on pillboxes
  • Patient education aids, including regimen pictures, calendars, stickers
  • Clinician education aids (e.g., medication guides, pictures, calendars)
center for hiv prevention care adherence program
Center for HIV Prevention & Care Adherence Program
  • Multidisciplinary
  • Client-centered
  • Goals:
    • Provide support
    • Provide education
    • Develop trusting relationship
    • Manage side-effects
    • Assess Adherence

Providers asked to estimate the % of pill pt miss in typical week

Provider estimates explained 26% of variance in pill count.

Bangsberg, et al. JAIDS April 2001;Vol 26, No 5


Face-to-face interviews with patients reviewing missed doses over the last 3 days.

Patient report explained 72% of variance in pill count

Bangsberg, et al. JAIDS April 2001;Vol 26, No 5


Sensitivity, specificity, PPV and NPV for detecting nonadherence

Bangsberg, et al. JAIDS April 2001;Vol 26, No 5

adherence challenges
Adherence Challenges
  • >95% adherence desired
  • Regimens are complicated with many side effects
  • Difficult predicting non-adherent/adherent
  • Interventions multidisciplinary and time-intensive
  • Assessing adherence difficult
not so helpful questions
Not-So-Helpful Questions
  • “You’re taking your medications aren’t you?”
  • “You haven’t missed any doses have you?”
  • “Everything is going great, right?”
  • “This looks really easy to me – what’s the problem here?”
helpful questions
Helpful Questions
  • “What reminders do you use to help remember?”
  • “How do you manage/control side-effects?”
  • “How do you like working with your pharmacy?”
  • “What do you find most difficult about taking your medications?”