Management>Antiretroviral Therapy>

DEFINITION

• Extent to which pt follows prescribed health care regimen.

INDICATIONS

• <95% adherence associated w/ increased risk of virologic failure in early studies of unboosted PI-based regimens. May not apply to NNRTI- or boosted PI-based regimens.
• Adherence strongly correlated with viral suppression.
• Adherence results in better CD4 response to therapy.
• Non-adherence associated with resistance. In some studies, risk of resistance highest with good but incomplete adherence (e.g. 80-90%). Little selective pressure with very poor adherence. Link between adherence and resistance also depends on potency/pharmacokinetics of regimen.
• Nonadherence limits future treatment options if it results in resistance.
• Nonadherence increases risk of HIV transmission.
• Behavioral intervention strategies addressing adherence are successful; approach should be tailored to address individual pt needs. 

• Complexity of medication regimen (pill burden, food restrictions, dosing frequency)
• Active substance or alcohol abuse
• Untreated psychiatric disorders (e.g., depression, anxiety, personality disorders)
• Side effects
• Poor patient-provider relationship
• Busy, chaotic lifestyle
• Patient lack of knowledge about HIV and rationale for therapy
• Cognitive problems (esp. poor executive functioning, memory, attention, psychomotor speed)
• Lack of social support and concerns about social stigma.
• Most studies show no relationship with race, sex, age, socioeconomic status, or educational level

CLINICAL RECOMMENDATION

• Determine pt readiness to begin HAART by assessing beliefs about therapy, social support, use of drugs or alcohol, mental health issues, daily routine, and ability to meet basic needs.
• Identify possible barriers to adherence prior to beginning treatment and identify ways to remove them (transportation to clinic, child care issues, need for stable housing).
• Refer pt for substance abuse/mental health treatment prior to beginning HAART (active substance use, depression, and anxiety disorders are strong predictors of nonadherence).
• Consider using techniques such as motivational interviewing (MI) to improve pt. readiness to begin treatment.
• Establish trusting clinician-pt alliance and invite pt collaboration in treatment decisions.
• Educate pt about treatment regimen, anticipated side effects, importance of adherence, and risk of resistance.
• Appropriately manage medication side effects as they emerge.
• Use written materials and audiovisual aides to help reinforce knowledge.
• If HAART not urgent, consider "trial run" using vitamins or prophylactic medications prior to beginning HAART to assess patient's ability to adhere to medication regimen.
• Schedule regular visits to monitor adherence.
• Questions about adherence should be asked in an open-ended, non-threatening manner.
• Provide available contacts between visits for questions/problems with side effects.
• Provide social support by enlisting help of family members, friends, peer counselors, pt role models, and members of the health care team to reinforce/monitor adherence.
• Simplify regimen as much as possible (high pill burden, food restrictions and increased dosing frequency correlated with lower adherence).
• Choose tolerable medications and be prepared to change drugs if needed.
• Monitor pt adherence with different measures (see below).

• Keep medication diary.
• Establish set time and place for taking medication.
• Identify medication taking cues linked to daily routine (e.g. prior to brushing teeth, eating a meal).
• Use of cell phones, pagers and alarms as reminders
• Use of pillboxes
• Plan ahead for changes in routine (vacations, holidays).
• Notify provider of side effects that may interfere with adherence or if considering discontinuation of therapy.
• Anticipate need for medication refills in advance.

• Pt self-report assessed through questionnaires, interviews, diaries, pills identification test (PIT)
• Pill counts
• Prescription refill monitoring
• Use of electronic devices that measure pt adherence (e.g., MEMS cap )
• Directly observed therapy (DOT)
• Therapeutic drug monitoring (not routinely recommended, but may be helpful in selected cases)
• Viral load/CD4 count (crude and late measures)

REFERENCES

REFERENCED WITHIN THIS GUIDE

• Baseline evaluation and Monitoring
• CMV retinitis
• Chlamydia trachomatis
• Cotrimoxazole Prophylaxis
• Cryptococcal Meningitis
• Depression
• Initial Evaluation (Zambia specific)
• Initial Regimen for ARV Therapy
• Nausea/Vomiting
• Toxicity & side effects: switching therapy (Zambia specific)
• Toxoplasmosis
• Vancomycin