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MANAGEMENT OF HIV INFECTION IN CHILDREN k) Adherence Prospective cohort studies both in adults and children including adolescents have demonstrated the importance of high level of adherence to HAART of >90% for viral suppression and durability of response. 33 201, Level 6 ;202 Level 9 ;203, Level 2 ;204, Level 6;205, Level 6 ; 199, Level 6; 206,Level 6 These studies also demonstrate improved immunologic response with adherence to therapy. Poor adherence is likely to result in subtherapeutic ARV levels with risk for virologic failure and emergence of drug resistance, thus not only affecting current regimen but also limiting future drug options. Adherence is a major issue in paediatric treatment and there is evidence that adherence problems are common in children. In one study, 43% of people caring for a child receiving HAART reported at least one missed dose in the past week. 207, Level 8 A number of factors could contribute to adherence problems: high pill/medication burden; refusal of young infants to take syrups due to unpleasant taste; unwillingness among caregivers to inform schools and care-centres that their child is infected, which could result in missing out on doses during the day; dietary restrictions; and toxic side effects of drugs. l) Adherence assessment and monitoring A comprehensive assessment for adherence should be carried out prior to initiation of therapy and should include social, behavioural, family and financial factors that may affect adherence by the child and family and to identify areas for intervention. A dialogue and partnership should be established providing information, obtaining agreement to treatment plan and to identify 46, Level 9 strategies for supporting adherence. m) Monitoring adherence Adherence is difficult to assess accurately. There is as yet no definite tool to reliably and accurately assess adherence. Multiple methods are 46,Level 9 recommended. Methods to monitor adherence • Viral load response • Quantitative report of missed doses by caregivers, child or adolescent (focusing on recent missed doses during a 3-day or 1-week period) • Descriptions of medication regimens • Reports of barriers to administration of medication • Targeted questions about stress, pill burden and daily routine • Pharmacy refill data and pill counts • Electronic devices (Medication Event Monitoring System) • Home visits • Hospitalization for supervision and monitoring • Therapeutic drug monitoring
n) Improving & Supporting Adherence Intensive follow-up and frequent assessment of adherence are important. Strategies to improve and support adherence should be identified and instituted. These include: o) Regimen Strategies • Choose the simplest regimen possible • Choose the regimen that best conforms to daily routines of patient and family • Choose the most palatable medicine possible • Choose drugs with fewest side effects • Simplify food requirements • Avoid drug interactions • Prescribe fixed-dose combinations with convenient once a day dosing if available p) Child/ family related strategies This emphasises patient / caregiver education about HIV-related disease, the need for adherence, providing tools such as written and visual materials, daily schedules, demonstrating use of syringes for liquid medications, pill boxes etc. Behavioural tools can be used such as positive reinforcements with small incentives. For children who are persistently non-adherent and averse to taking medications, a gastrostomy tube may be considered. Home nursing and directly observed dosing are also possible options for the difficult cases. q) Healthcare provider strategies Fostering trusting relationship and open communication are important. Positive characteristics for healthcare providers include consistency, providing information, asking questions, technical expertise and commitment. Recommendation for adherence MANAGEMENT OF HIV INFECTION IN CHILDREN A comprehensive assessment for adherence should be carried out prior to initiation of therapy and should include social, behavioural, family and financial factors (Grade C) Adherence should be supported by intensive follow-up and frequent assessment (Grade C) Strategies to improve and support adherence include: • Regimen strategies • Child & family related strategies • Healthcare provider strategies Adherence must be monitored with the use of multiple methods as outlined above. (Grade C) 34
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3.30 MB - Academy of Medicine of Malaysia

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