Starting Therapy and Adherence: Moving Beyond Pill Boxes and Timers

As mentioned in an earlier CATIE News story, the work of health maintenance can be very demanding for some people with HIV/AIDS (PHAs). Indeed, PHAs whose lives are chaotic, who are homeless, and/or who have mental health or substance abuse issues are usually not considered easy to treat or the type of people who can adhere to the demands of highly active antiretroviral therapy (HAART). This is because the requirements of day-to-day living can at times be so overwhelming that marshalling the energy and motivation for adherence to HIV medications may be difficult. As a result, these populations may sometimes not always be offered access to HAART.

To try to tackle this problem, a research team in Edmonton, Alberta, recruited at least 40 homeless PHAs who were not taking HAART. According to the researchers' presentation at the CAHR conference, these PHAs had chosen to live in that city's parks rather than in homeless shelters. The reason for this is that life in homeless shelters can, apparently, be very controlled. Residents have little choice as to when to eat, sleep and wake up. There is also little privacy in this highly regimented life.

Initially, the project was located in a nursing clinic. However, this location, with its structured environment, produced poor results. So the research team acquired a house where PHAs had choices and decisions to make about the timing and composition of meals, the furniture, and household meetings to help organize life. Policies embedded in the operation of the home included fostering a sense of respect, belonging, safety and a sense of worth. Alcohol and drug use was not encouraged in the home. Psychosocial and other support was provided and supervision of medication-taking was done.

In general, PHAs enrolled in this program have been able to maintain a high level of adherence to HAART. In turn, an improvement in their overall health has also occurred. These changes are remarkable when taking into account that this population was previously considered "untreatable." As word spread about the way in which PHAs were treated by the researchers, enrollment in the program increased.

If other cities adopted this model of care, then perhaps other previously "untreatable" PHAs could be helped.

References

1. Millard R, Monahan W, Akai P. Edmonton directly observed therapy (DOT) for highly active antiretroviral therapy (HAART) project III: inner city clients respond well if they get what they want. 12th Annual Canadian Conference on HIV/AIDS Research, April 10- 13, Halifax. Abstract 155.
2. Akai P, Lavender K and Foisy M. Edmonton directly observed therapy (DOT) for highly active antiretroviral therapy (HAART) project I: treating the untreatable in the inner city. 12th Annual Canadian Conference on HIV/AIDS Research, April 10-13, Halifax. Abstract 333P.