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