September 21, 2017
MM: What are the biggest mistakes HIV clinicians make regarding adherence?
SK: As we've already discussed, relying on viral load to predict adherence is a mistake because by the time viral load is going up, resistance can be developing and it's too late. I do think that's something that needs to be remedied in clinical practice.
Another example of faulty thinking about adherence in the clinic is that an adherence intervention is going to be labor-intensive, difficult to implement, and expensive. And that's just not true. Every patient does not require an adherence intervention. In the developing world the World Health Organization has established a standard for differential adherence care: On the one hand there are patients who are doing well, taking a regimen that's working for them, with HIV suppressed for 6 months and with no indicators of nonadherence. Those patients can continue routine care.
On the other hand, there are patients who have indicators of nonadherence or who are late picking up their antiretrovirals or who report specific indicators of nonadherence in response to validated questions (Table 1). Those patients require adherence intervention. But that assistance is not necessarily burdensome or expensive -- and it can be delivered by adherence intervention professionals.
MM: Can busy HIV clinics make time to conduct adherence interventions?
SK: HIV care clinics can develop the capacity to implement adherence interventions. We work in a very high-quality clinic in the middle of Georgia, which is a very under-resourced part of the country. You don't think of the middle of Georgia as a place that would have a state-of-the-science multifaceted infectious disease clinic like those in Atlanta, for example, where you have world-class comprehensive HIV care. But Macon, Georgia does too. In this poor setting the clinic has an adherence nurse, a community nurse, case managers, and peer advocates. Any one or all of those providers can deliver a brief, weekly or biweekly 15- to 30-minute adherence counseling session by phone to those patients who need it.
It's a mistake to wait until the 3-month routine viral load check and prescription refill to assess adherence. That's insufficient for patients who need assistance. It probably is sufficient for 65% of the patients at that clinic. But one third of those patients really need some support. And that support doesn't require an office visit. I think the billing for telemedicine is being worked out so that Ryan White can reimburse for those services. And if those services are not being reimbursed, certainly that needs to be addressed.
At the Macon clinic we're working with an infectious disease doctor, Harold Katner, at Mercer University, and our collaboration focuses on telemedicine-based adherence interventions. A 15- to 30-minute phone call every 2 weeks has demonstrated efficacy. These interventions are not hypothetical; they're not just ideas. The National Institutes of Health has funded multiple studies demonstrating the effectiveness of relatively brief phone counseling for medication adherence. And the CDC has deemed this an effective intervention and lists it among their medication adherence evidence-based behavioral interventions.4 [The CDC plans to post this phone-delivered adherence intervention around the time this issue of RITA becomes available.]
These brief adherence interventions exist, they're available, people can be trained in them. Even under-resourced clinics in the middle of Georgia and similar settings have providers who can do these interventions. I think it's a mistake for clinicians to think that early adherence detection and intervention are infeasible and expensive. That's just not true.
MM: Are there any adherence issues we haven't addressed that you'd like to emphasize for HIV clinicians?
SK: I should mention one thing that's come up an awful lot in our work, and that's intentional nonadherence. This is a significant problem. We usually think of nonadherence as people forgetting to take their pills. That's often true, but missing an occasional dose is not going to cause major problems with today's antiretroviral regimens. It's the longer gaps in adherence that we should worry about. These gaps can be caused by structural challenges -- things that a person can't readily change -- poverty and transportation issues, for example. Adherence support can really assist people in solving those problems and getting the structural barriers out of the way so they can adhere.
But the problem we don't think about very often is when the patient says, "I'm not going to take these drugs." And they don't necessarily tell their clinician. This can result from mistrust of the medications, but we're finding as many as half of patients who drink alcohol will skip taking their antiretrovirals when they're drinking -- and that may be for days -- because they believe it's toxic to do that.5-7 Sometimes patients who believe it's toxic to mix their medications with alcohol stop drinking, and that's not a bad thing. But people who continue to drink may stop taking their antiretrovirals, and that is a bad thing.
Unless a person has a compromised liver, there's no significant risk to taking antiretrovirals when they're going to be drinking. But some people believe mixing antiretrovirals with alcohol has serious health repercussions because there can be with other medications. We can't mix sleeping pills with drinking; that's pretty hazardous. But not antiretroviral therapy.
We're trying to address the intentional nonadherence frequently seen in people who use alcohol and other drugs. I think intentional nonadherence is like the third spoke in the nonadherence wheel that's often ignored. Instead we pay too much attention to forgetting. I think we can forget about forgetting.8 Occasionally forgetting an antiretroviral dose is not going to create a huge clinical problem. We should focus more attention on structural problems like ADAP reauthorization, and we also have to deal with intentional nonadherence, especially nonadherence related to substance use.
[Note from TheBodyPRO.com: This article was originally published by The Center for AIDS Information and Advocacy on in September 2017. We have cross-posted it with their permission.]
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