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STRATEGIES TO INCREASE ADHERENCE TO HIV MEDICATIONS Adherence to Antiretroviral Medications is critical for treatment success. " Almost perfect adherence to HIV medications is critical for successful treatment (see Katzenstein, 1997; Carpenter et al., 1997; Decks et al., 1997; Descamps et al., 2000). " One recent study found that 81% of HIV positive individuals with greater than 95% adherence showed complete viral suppression, whereas only 64% of those with 90-95%, 50% of those with 80-90%, and 30% of those with less than 80% adherence showed viral suppression (Paterson, et al., 1998). Predictors of Poor Adherence Studies of persons with HIV and other diseases have identified a variety of predictors of poor medication adherence (e.g. Becker, 1985; Chesney & lckovicks, 1997; Griffith, 1990; Haynes 1979; Ikovics & Meisler, 1997; Safren et al, 2000). Many of these features are present in individuals being treated for HIV, and may be of particular concern to minority and disenfranchised populations. They include: " Complex treatment regimens " Large numbers of medications or high frequency of dosing " Longer illnesses " Less severe or noticeable symptoms " Poor doctor-patient relationships " Substance use " Depression and mental health concerns " Patient beliefs " Homelessness When asked about reasons for non-adherence to HIV medications, studies show that one of the most frequently sited reason is "forgetting" (Chesney, 1998; Roberts, 2000). To address the critical problem of adherence to WV antiretroviral medications, we have developed and initially tested several interventions at Fenway Community Health. Life-Steps Life-Steps (manual published in Cognitive and Behavioral Practice. 1999, volume 6, pp. ) is a brief intervention based on the cognitive- behavioral therapy, problem-solving therapy, and motivational interviewing. One of the main theories behind the intervention is that a seemingly overwhelming task (medication adherence) can be accomplished by breaking it down into concrete manageable steps. Intervention Approach The first part of Life-Steps is Psychoeducation and Motivation (includes video). This step involves making sure the patient fully understands the consequences of non- adherence (that partial adherence may be worse than no medications at all due to the possibility of replicating resistant strains). This part of the intervention also includes asking the patient to identify personal reasons for staying adherent. For each of the remaining steps, the clinician and the patient define the issue, develop and generate a plan, develop and generate a back-up plan, and identify and discuss any potential barriers to implementing each plan. The issues discussed include: 1) Getting to appointments; 2) Communication with health care provider; 3) Coping with side effects, 4. Obtaining Medications; 5) Scheduling Medications with Meals and Daily Activities; 6) Storing Medications, 7 Reminder Cues for Adherence; 8) Guided Imagery (in-session rehearsal); 9) Handling Slips (missed doses) 10) Review and Summary. Efficacy Patients with identified adherence problems who completed the Life-Steps counseling intervention (total N = 56, over 50% ethnic minority background) showed significantly greater self-reported improvements in adherence over a two-week period than patients that monitored their medications with a pill diary alone(2000 Retrovirus Conference, manuscript under review). Both those who received the Life-Steps intervention and those who monitored their medications showed improvements in adherence over a 12-week period. MediMom MediMom (www.medimom.com) is a web-based paging system which helps individuals with one of the most frequent reasons patients give for missed doses "forgetting" (Chesney, 1998- Geneva AIDS Conference; Roberts, 2000). Intervention Approach MediMom discretely sends text-pages to a pager, cell phone, or palm-pilot. The system allows any specified message to be sent including the number and names of pills and food restrictions (whether to take the pills on an empty stomach or with food). The system also allows for pager reminders for physician or other appointments. Efficacy Our current study is a randomized controlled trial of MediMom in a sample of patients (current n = 26) with severe adherence problems (baseline adherence for first two-weeks = 49%). The major outcome variable is percent adherence for two weeks using the electronic pill cap data. After two weeks of baseline monitoring with the electronic pill-bottle cap, we randomize those with less than 90% adherence to either MediMom or continued monitoring. The two-week outcome data indicates a strong effect size for the intervention, such that with only 13 participants in each condition, those who received MediMom showed significantly greater improvements (almost 20%) in adherence than those who monitored their medications (almost at 5% decrease). Anecdotal data from patients who were given MediMom openly suggests that this reminder system can result in clinically significant improvements in adherence to antiretroviral medications for HIV. Poster presented at the U.S. Conference on AIDS sponsored by the National Minority AIDS Conference, October, 2000. Correspondence regarding this study can be addressed to Steven A. Safren, PhD. via email at |
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