Strategies to Establish and Maintain Optimal Adherence

Clarify the regimen. Provide patients with their entire drug regimen -- in simple, easy to read, printed form. Identify the medications by color and shape as well as name. Indicate any restrictions or specific directions clearly and concisely. Include a 24-hour telephone number that patients can call if they questions, even if it is only a voice-mail number where the messages can be left and answers provided later. Write your name and the patient's name on the card -- because studies show that materials that the healthcare provider personalizes in some way are more likely to be saved.
Show the patient how to keep a medications diary. Emphasize that is important -- and easy -- to keep track of daily medications in a diary. For patients with personal calendars, demonstrate how medications can be tracked with a symbol or check mark in the calendar. For those who don’t use calendars, offer alternatives such as a set of sample diary cards that patients can keep in a pocket and "check off" when they takes their medications. Take the time to make up the schedule for a typical daily dosing schedule and give the patient a copy of this schedule before he or she leaves the office.
Tailor the regimen to the patient's lifestyle. This is probably the single most effective way to improve compliance. Work with the patient to identify daily routines that are reliably followed and that coincide (or can be made to coincide) with dosing intervals. These routine events can then be used as the "triggers" or "cues" to remind the patient to take his medications. Meals don't always work well in this regard, given food restrictions and the fact that individuals vary in eating habits. Routine events that should be considered include: going to the bathroom upon rising in the morning, television programs that are regularly watched, checking the mail, daily exercise routines, and flossing and brushing of teeth. Have patients agree to take their medication before the selected activity. Adherence will be greater if patients are instructed not to begin a particular event -- such as watching the early evening newscast -- until after they have taken their early-evening medications.
Establish a set time for pill dispensing. Encourage patients to choose a regular, fixed time -- say, Sunday evening, after a TV program they always watch -- to count out all of their pills for the following week. Suggest they do this in a well-lit place where there are minimal distractions (such as loud music or household pets), and urge them to take their time. This is especially important if you have prescribed drugs at escalating (or de-escalating) doses that must be carefully counted out in advance. Tell the patient to put each day's pills into separate compartments in one of those see-through plastic boxes that are designed to hold an entire week's supply of pills. Many drugstores have a version with four compartments for every day of the week and a snap-shut lid. If your local druggist does not stock these handy pill trays, ask him to order some.
Establish a set place for pill-taking. Instruct patients to plan each day's pill-taking 24 hours in advance. Before the patient goes to bed each night, he should take the next day's doses out of his plastic pill tray and place those pills where he will be sure to see them at the appropriate times. For example, he might want to set the morning doses next to the coffee-maker, pack the noon doses in an attaché case or gym bag, and stash the late-night doses by the toothpaste.
Plan any changes in routine well in advance. One week before the patient goes on vacation, have him write out exactly how he plans to remember which medications he will need to take with him, how he plans to pack the medications for the trip, and how he plans to store them when he arrives at his destination. (This is especially important for drugs that must be kept cold in transit and refrigerated upon arrival.) The patient should also know how to order a special meal in advance of a flight, how to alert a flight attendant that a particular kind of meal must be served at a particular time, and how to adjust his meal schedule for changes in time zone.
Recognize that weekends and holidays are times when compliance can falter. Adherence often declines on weekends and holidays, because they represent a break with the established routine. Patients often sleep later, eat at less regular intervals, indulge themselves in ways they do not do during the week, and stay up later. Patients need to be told what the tolerable limits of self-indulgence are, and they need to know what they should do if they inadvertently miss a dose.
Lower the barriers to care. Make it easy for patients to come to the clinic by arranging convenient parking and by holding clinic outside standard business hours at least one day a week. Use waiting time as educational time, by providing patients with a regularly updated array of reading materials or with health-related videos to watch. To promote a free and frank exchange during clinic visits, encourage patients to write out questions for their next visit by supplying them with cards on which to jot these questions.
Refer patients to appropriate social services. Some patients become depressed and/or socially isolated as their HIV infection progresses; others develop drinking problems or other forms of chemical dependency. It is the rare physician who is able to address such problems successfully during a standard clinic visit, and even if the physician is able to offer some on-the-spot counseling, he rarely has time to provide adequate follow-up. Patients experiencing these difficulties should be referred to the appropriate professional or community services.

Follow up. It is vitally important to reinforce these new strategies and skills as the patient learns them. A quick telephone call, made a day or so after every office visit, goes a surprisingly long way toward creating a healthcare environment that reinforces adherence. At each clinic visit patients should be reminded that they can "check in" with the staff whenever they feel the need -- that is what is meant by "partners in care." Patients will be more likely to call if the clinic staff also calls them, and the staff should obtain each patient's permission to makes these follow-up calls. They should find out which number (or numbers) to call at certain times of the day, and the best times to call. They should also know whether messages can be left for the patient and how discreet such messages should be. As a general rule, follow-up calls are particularly important during holidays, before and after vacations, when the patient is going through a stressful period, or when the patient has just changed regimens.

The Special Case of Indinavir

Indinavir should be taken on an empty stomach. While low-fat meals do not interfere substantially with the drug's absorption, many patients do not know what "low fat" means or how to read labels to check fat content. Healthcare professionals should therefore provide each patient who is prescribed indinavir with a list of low-fat or non-fat foods that can be taken in conjunction with indinavir if the patient must eat at a scheduled dosing time. One patient, familiar with heart disease prevention recommendations, interpreted "low-fat" to mean polyunsaturated fat, and was found to be using olive oil as the basis of his "low-fat" salad dressing. This sort of confusion is more common than might be imagined.

Back to the June 1997 HIV Newsline contents page.