December 3, 2013
Adherence to HIV treatment has always been important in maintaining the health of HIV-infected patients, but despite all of the potent antiretroviral regimens available today, adherence can still be a problem. Adriana Ammassari, M.D., gave a mini-lecture at EACS 2013 providing an overview and update on the issue.
Ammassari broke down reasons we still need to aim for good adherence, which include avoiding virologic rebound, treating HIV in the reservoirs, reducing the risk of common coinfections, lowering hospitalization rates and cutting health care costs.
In addition, Ammassari reviewed some of the research and hypotheses around current strategies to assure long-term adherence; we summarize her key points in the following slides.
Reducing a patient's pill burden has been strongly associated with better adherence. HIV treatment regimen simplification -- in particular, taking a single-tablet regimen -- was associated with better adherence, according to an earlier meta-analysis conducted by Jean-Jacques Parienti, M.D., Ph.D., and colleagues, and further supported by study results presented by Jean Nachega, M.D., Ph.D., at EACS 2013.
Additionally, we have known for a long time that reducing treatment symptoms and side effects can improve adherence and overall quality of life. Therefore, when selecting regimens, it's always important to pick regimens with the lowest pill burden and fewest side effects for the patient.
Reducing viral load to an undetectable level is one of the main goals of starting HIV treatment. However, the period of time that begins immediately after patient gets to undetectable is when he or she is most at risk of a viral rebound, according to study results by Viviane D. Lima, M.D., and colleagues.
This "risk phase" is shortest, at about 12 months, in patients with an adherence level of 95% or higher. At lower levels of adherence, that risk phase lengthens to between 48 and 60 months.
"Although perfect adherence remains an important goal of therapy to prevent disease progression, individuals with long-term viral suppression may be able to miss more doses without experiencing viral rebound," Lima et al write.
Empowering patients to be their own adherence advocates can itself be an effective intervention, Ammassari suggests. Active patient self-reports of adherence should be ascertained in a simple, nonjudgmental, routine and structured way. This is associated with better viral load responses and can help identify barriers -- although self-reports do tend to overestimate adherence.
Of course, an intervention such as this needs to have the patient on board. A patient's intention to adhere was significantly predictive of self-reported adherence to treatment, according to study results by A. Nelsen, M.D., and colleagues.
In terms of behavioral interventions, there have been many studies, but no results have been promising enough to implement on a clinical level. Out of 16,172 U.S. studies conducted between 1996 and 2011 that were intended to improve adherence, only 10 were identified as evidence-based interventions; others failed to meet the efficacy criteria primarily due to null findings, small sample sizes or low retention rates, according to a meta-analysis by Mahnaz R. Charania, Ph.D.
The use of technology can also be important, especially as mobile phones become more ubiquitous in our everyday lives. The implementation of short, automated text-message reminders helped increase patient adherence and viral suppression levels in a small study of 145 patients led by Ammassari herself. After nine months, the percentage of patients with an undetectable viral load increased from 42.3% to 76.2%, with most patients finding the reminders very helpful.
The text messages in Ammassari's program can be automated, are personalized based on the individual's needs and are provider independent, meaning it would not cost the clinic money.
Other studies have found that even weekly reminders through mobile-phone text messages can improve adherence when compared to standard care. "Policymakers should consider funding programs proposing to provide weekly mobile phone text messaging as a means for promoting adherence to antiretroviral therapy," says Ammassari.
Peer- and Public Opinion-Based Strategies
Because HIV stigma and difficulties with disclosure are associated with non-adherence, improving the public perception of HIV can enhance patient adherence, according to study results by J. Craig Phillips, Ph.D., and colleagues. The study found that people living with HIV who have higher levels of perceived social capita and who live in areas where HIV disclosure is required by law reported better average adherence.
In contrast, people living with HIV in areas where HIV transmission or exposure is considered a crime reported lower adherence. This suggests that better HIV education and awareness on a community level can help improve outcomes for individual patients.
Additionally, Ammassari noted that peer-to-peer support, even if it only takes place online, may add some benefit to adherence over time, as seen in one such intervention called "Thrive With Me."
Health Care-Based Strategies
Health delivery systems may affect adherence. "The 'net' around the patient has to be wide with different specialties," says Ammassari. A better provider experience, various optimized multidisciplinary care teams and the use of electronic health records were all associated with improved adherence.
Moreover, how and where a patient's antiretrovirals are dispensed also matters. When comparing HIV-focused pharmacies (HIV-P) to traditional pharmacies (TP), although HIV-P users traveled father (5.03 miles vs. 1.26 miles, P < .01), they had a higher median medication possession ratio (90% vs. 77%, P < .0001), an indicator of ART regimen refill adherence, according to study results by Jennifer Cocohoba, M.D., and colleagues.
After adjusting for age, gender, insurance, medication use and distance from pharmacy, use of HIV-P and the receipt of fixed-dose combination antiretroviral tablets were the two factors most strongly associated with having 95% or greater ART regimen refill adherence.
For More Information
For additional information and guidance regarding how to maximize treatment adherence among HIV-infected patients (and the importance of doing so), consult with the following resources on TheBodyPRO.com: