A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

A Guide to Primary Care of People with HIV/AIDS
Chapter 7: Adherence to HIV Therapies
The provider should ask patients to recount exactly
when and how they are taking their medications in
order to identify any lack of understanding of the
regimen itself or of special dietary instructions.
INTERVENTIONS
What can be done to improve adherence?
The most important intervention is making sure
patients start medication only when they are “ready.”
Providers need to discuss with patients the risks
associated with nonadherence that can result from
starting medications before they are ready versus
waiting while they “prepare.” Preparing can mean
entering into substance abuse treatment, finding stable
housing, or attending a support group to overcome
fears of medication side effects and concerns about
confidentiality. Pregnant women and patients with
serious complications of HIV infection and very low
CD4 counts may not have the luxury of postponing
therapy, but for others, being ready to adhere may be
critical to the outcome of ART.
Interventions to improve adherence in chronic diseases
tend to have, at best, modest effects on adherence.
They are most effective if they are multifaceted, ie, they
target several aspects of the adherence behavior and
are repeated over time. Barriers to adherence differ
among patients. Thus, interventions should be tailored
to the patient’s specific needs. In addition, barriers to
adherence vary over time, so interventions need to
vary as well. Interventions can occur at the level of the
provider, care team, clinic, and/or pharmacy. Ideally,
interventions are occurring throughout the patient’s
medical visit and beyond.
The most commonly used interventions address
patient readiness using both one-on-one education and
support groups. Peer counseling and support are key
for many patients to work through concerns related
to medication-taking. Making patients partners in the
decisionmaking process about when to start and which
regimen to use is also important. The regimen should
be as simple as possible and should be the one least
likely to cause the side effects that the patient fears the
most. Substance abuse and mental illness should be
treated before starting medication whenever possible.
After the patient begins the regimen, close followup
and monitoring of adherence is critical, often through
frequent clinic visits during the first weeks of therapy
even if other medical interventions are not necessary.
Providers should ask patients about adherence and
address barriers to adherence at each followup visit.
Providers should be open to changing the regimen if a
patient has significant problems with it, whether related
to side effects or to scheduling. Patients should be
encouraged to use pill boxes and incorporate reminder
systems as needed. Various kinds of interventions have
been used in HIV and other chronic diseases (see
Table 7-2).
What is the role of Directly Observed Therapy
(DOT) for medication adherence?
Directly observed therapy (DOT) refers to medical staff
supervising patients taking each dose of medication.
DOT has increased treatment completion and
decreased the resistance rates of tuberculosis therapy.
Whether it is feasible in HIV therapy is currently under
investigation. A majority of ongoing studies are using
modified DOT, with only 1 daily dose of medication
observed over the first several months of therapy or
during the administration of methadone maintenance
therapy. The results of these studies will provide
valuable information about the long-term patient
acceptability, cost, and efficacy of this approach to
improve adherence over the long term.
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U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
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