August 7, 2003
The authors, concerned that lack of adherence to HAART therapy among adolescents with HIV was causing increased morbidity and premature death in their clinic population, developed a pilot program to involve families and peers in the effort to increase drug adherence among HIV-positive youth.
The researchers recruited participants from a specialty clinic within a full-service adolescent health center in an urban children's hospital. The clinic has served more than 200 HIV-positive youth, ages 15 to 22, of whom 94 percent are African American, 64 percent are female, and 85 percent are impoverished. Twenty-three HIV-positive youths and 23 family members/"treatment buddies" (unrelated family surrogates) agreed to participate in one of three 12-week programs. Mode of HIV transmission was sexual for 91 percent of participants, and perinatal for 9 percent. The intervention had six biweekly family and youth education sessions and six biweekly youth-only education sessions. Group curriculum covered the dynamics of HIV, the purpose of antiretroviral therapy, medication choices/managing side effects, nutrition/exercise/alternative treatments, communication with doctors/health care providers, and the media: separating fact from fiction. Eighteen of the 23 youths completed a group.
Treatment teams consisting of one physician, one nurse practitioner, two case managers, and two mental health professionals conducted a 12-week session in 1998, 1999, and 2000 for three groups. Devices such as pillboxes, calendars and watch alarms were introduced at youth-only group sessions, where participants also discussed issues with taking multiple medications in a group psychotherapy format.
Ninety-one percent of youths self-reported increased adherence to their drug regimens after completion of a group. Four participants from the 1999 and 2000 groups experienced a reduction in viral loads to undetectable levels during the group, but none had a one-log reduction in viral load to undetectable levels at the three-month follow-up. Nevertheless, at the 6-month follow-up, four patients (43.5 percent) had improved immune functioning, with CD4 counts above 500. Two of the study participants continued to decline antiretroviral therapy at the end of the group. They showed no decrease in viral load.
"The greatest change," the authors wrote, "among youths and caregivers was in the belief that medication works to fight the virus and would help them to live longer." Another benefit of the study was an increase in flu shots, hepatitis B vaccine completion, and attendance at medical and dental appointments. Group participants exhibited increased trust in their health care providers, which has been shown to improve adherence. "Forgetting a dose" remained the most common reason for missing medication.
"These findings may not generalize," the researchers cautioned, "because of the recruitment procedure, the lack of a control group, and youth who were all African American."
They concluded, "Using a family peer group approach to increasing adherence to antiretroviral therapy in HIV-infected youth appears to be a useful intervention for many adolescents. ... This pilot highlights the importance for medical care providers to: (1) simplify the medical regimen for HIV-infected youths whenever possible; (2) try to increase medical knowledge using a variety of developmentally appropriate methods and materials; and (3) engage peers and family to help with adherence."
AIDS Patient Care and STDs
06.03; Vol. 17; No. 6: P. 299-308; Maureen E. Lyon, Ph.D.; Connie Trexler, R.N.; Carleen Akpan-Townsend, C.P.N.P.; Maryland Pao, M.D.; Keith Selden, A.A.; Jean Fletcher, R.N.; Irene C. Addlestone, M.A.; and Lawrence J. D'Angelo, M.D.