Keynote – Framing Sustainable Adherence to HIV Prevention, Care & Treatment: The ICAP Approach

SUPPORTING SUSTAINABLE ADHERENCE TO HIV CARE AND TREATMENTRobin Flam MD DrPH

Director, ICAP Clinical Unit

Kigali, 2009

Burning question

If we deliver high quality care, will we always achieve great outcomes?

Delivering high quality care is a necessary, but not sufficient, factor in achieving optimal outcomes

What does it mean to receive care?

Patients must use and internalize the care in their daily lives Most care happens at home

Patients are at clinic once per month or less There is an “adherence continuum” It is complex, multidimensional, and needs

to be enduring over a lifetime

Why would poor adherence be a problem?

Poor outcomes on the individual level Treatment failure

Resistance and fewer treatment options Viral rebound Illness Death

Poor outcomes on the population level Resistant virus emergence and fewer treatment

options Increased transmission Higher morbidity and mortality burdens

The Back Story: 1990s - early 2000“Adherence seen as potential barrier to

ART in RLS”

AIDS 2003

• Self report mean Adherence = 90%• UDVL = 71%

Compared to Avg US Adherence~70-80%

The Response

We know it can be achieved

But there are complexities

1. Adherence declines over time

Most recent meta-analysisReview of Adherence at 2 years

Rosen et al. PLoS 2007 32 studies in SSA 1996-2007 ~75,000 patients in non-

research ART programs Average follow-up time reported

9.9 mo, 77% retention 6 mo = 80% pts retained 12 mo = 60% pts retained

At 2 Years*: BEST CASE = 84% WORST CASE = 46% AVERAGE = 61%

61% at 24 months

2. Resistance patterns are different with similar adherence to different regimens

NNRTI Resistance develops

quickly and nearly linearly

Boosted PIResistance develops more

slowly and in a bell shaped curve

Bangsberg NY PRN 2009

3. There are external reasons for treatment interruption

Unstable drug supply Access issues Life circumstances change

4. Adherence is complex

Social Structural:Patterns of Inequality,

e.g., stigma,gender inequality

Adherencefulfills

responsibility to helpers and

preserverelationshipsas a resource

Relationshipsas resources to

overcome economic

obstacles to adherence

Social Capital

Infrastructural:Few treatment sites

Distance to careCost/Availability of

Transportation

Cultural:Religious Beliefs

Respect for AuthorityImportance of

having children

Individual:HIV knowledge

Med side effectsCognitive function

Mental healthAlcohol Use

ResourceScarcity

ResourceScarcity

Improving Health

A Social Model of Adherence for sub-Saharan AfricaWare and Bangsberg PLoS Medicine (in press)

What can we do to support sustainable adherence?

Understand the importance of adherence Prioritize it as a PSYCHSOCIAL AND A CLINICAL

issue and a main determinant of outcome It requires a TEAM approach

Build program components that are sensitive and specific to supporting and enhancing sustainable adherence Only a certain amount can be accomplished in

the facility setting Linkages are critical Patient involvement and self-efficacy are critical

This is why we are here

To explore on a deep level HOW to build and implement these components Focus on five interventions, two of which have

been designated as priority Assessment of adherence within a counseling

framework Appointment systems

A structured approach CSM

Conceptualize, operationalize, implement, assess Model, derive goals and objectives, measure, monitor,

intervene, assess

For example

Operationalizing appointment systems What are the components of a functional

appointment system? Using these criteria, every site should have

one within one year of this meeting

Keep our eyes on the prize

The sequence Measuring—allows you to monitor Monitoring—allows you to intervene Intervening– allows you to achieve a good

outcome Assessing-- allows you to know if your

intervention is working The plan

Who? What? How?

Special Recognition

Pharmacists Part of patient care system Part of multidisciplinary team

Key in adherence Last or only person to see patients

Encourage the formation of a recommendation for two adherence or patient care-related things each pharmacist should do

How it will go

1. “Warm-up”• Frame• Define the problem specific to ICAP programs

2. “Starting Gate”: • Discuss in detail the goals, objectives, and

organization of the workshop• Explore CSM as a methodology for doing adherence

related work• Dive into issues and realities: Pharmacy work;

country programs and interventions; involving people with HIV in care programs, and more

3. “And you’re off….”• Do the work

o Begin hereo Continue at home