Clinical Manual for Management of the HIV-Infected ... - myCME.com

adherence, such as mental health issues or depression,
must be treated initially. It is important to consider the
patient’s preferences in selecting the drug regimen. The
regimen must fit into the patient’s daily routine, and the
patient must believe in the potential success of ART.
Simplifying the ARV regimen to the extent possible
with once-daily regimens and the lowest number
of pills, while maintaining efficacy and minimizing
adverse effects, is important for maximizing adherence
and avoiding pill fatigue. Starting ART is rarely an
emergency, so taking time to identify the patient’s
wishes for care, make a thorough readiness assessment,
select the ARV regimen, and plan for adherence support
is important in maximizing the likelihood of treatment
success. (See Table 3 for additional suggestions.)
Table 3. Strategies to Improve Adherence to
Antiretroviral Therapy
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Establish readiness to start therapy
Provide education on medication dosing
Review potential adverse effects
Anticipate and treat adverse effects
Utilize educational aids including pictures, pillboxes, and calendars
Engage family, friends
Simplify regimens, dosing, and food requirements
Utilize team approach with nurses, pharmacists, and peer counselors
Provide accessible, trusting health care team
Source: U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in
HIV-1-Infected Adults and Adolescents. Table 16. October 10, 2006. Available online at http://aidsinfo.nih.
gov/Guidelines/GuidelineDetail.aspx?GuidelineID=7. Accessed July 7, 2007.
Patients who can identify their medications (in their
own words) and describe the proper dosing and
administration have higher adherence rates. Providing
patient education before writing a prescription helps
ensure adherence to ARV medications. Education can
be provided in oral, written, or graphic form to assist
the patient’s understanding of the medications and
their dosing. Basic information, including number
of pills, dosages, frequency of administration, dietary
restrictions, possible adverse effects, tips for managing
adverse effects, and duration of therapy will help
patients to understand their ARV regimens. Patients
should understand that the success of ART depends
upon taking the medications every day and that
adherence levels of >95% are important in preventing
virologic failure.
Close follow-up by telephone, clinic visits, or other
contact with the patient during the first few days of
Section 3—Antiretroviral Therapy | 3–13
therapy is useful in identifying adverse effects, assessing
the patient’s understanding of the regimen, and
addressing any concerns before they become significant
adherence barriers. Individualized interventions should
be designed to optimize outcomes for each patient.
Pharmacists, peer counselors, support groups, adherence
counselors, behavioral interventions, and communitybased
case managers are useful in supporting adherence
for the HIV-infected patient. Multidisciplinary teams
that include nurses, case managers, nutritionists, and
pharmacists, in which each care provider focuses
on adherence at each contact with the patient, are
extremely effective in supporting adherence.
Many physical devices can be used to support
adherence. The following are simple, inexpensive, and
easy to incorporate into the routine of the HIV patient:
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Medication organizers include pillboxes and
medisets. These are available in several shapes and
sizes to fit the needs of the individual patient. They
can be filled weekly so that the patient can easily
determine whether a dose of medication was missed.
Reminder devices include alarm watches, beepers,
or cell phone alarms. They are effective in reminding
the patient when to take medications. Medication
diaries may be used for the patient to record doses
that were taken.
Visual medication schedules: are calendars with
pictures of the patient’s medications on them to
remind the patient to take the doses.
Interventions for successful adherence are an ongoing
effort, not one-time events. Studies have suggested
that adherence rates decline when patient-focused
interventions are discontinued. Therefore, positive
reinforcement at each clinic visit or contact is extremely
important. Reinforce what the patient has done well
and assist the patient in identifying and problemsolving
areas for improvement. Whenever possible,
share positive information about the patient’s health,
such as improvements in quality of life, CD4 cell count,
and viral load, to encourage a high level of adherence.
Special Populations and Issues
Mental Illness
Patients with mental health issues may have difficulty
with adherence. In this population, it is particularly
important to incorporate ARV medications into
structured daily routines. Medication cassettes, reminder