The Pharmaceutical Journal
Vol 275 (Supplement) F20-F21
October 2005

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FIP Congress 2005

HIV/AIDS — models to help enhance adherence and positive outcomes

Gary Smith gave a presentation on the information needs of patients and pharmacists to support adherence. “Adherence in the context of patients with HIV/AIDS means the ability to adhere to a regimen of highly active antiretroviral therapy (HAART) to achieve and maintain a non-detectable viral load and a CD4+ cell count above 200. Although clinical trials indicate that 80 to 90 per cent of patients on HAART achieve and maintain undetectable viral loads, in practice less than 50 per cent of patients achieve this,” he said.

He emphasised that adherence is the most important factor in assuring successful outcomes with HAART. “Patients have the best outcomes when they adhere to their HAART regimen over 95 per cent of the time, he said. However, studies have shown non-adherence rates in HIV to range between 33 and 60 per cent with adherence falling over time on the regimen.”

Turning his attention to the barriers to adherence, he said these include patient access to the clinic, transportation, availability of the medicine, cost, communication and knowledge of the disease. Co-morbidities, especially poor mental health, as well as cultural and health beliefs and the strength of the patient’s support system also influence adherence. Of equal importance are the treatment-related factors such as the regimen, its side effects and how often the medicines have to be taken. “The importance of the patient provider relationship cannot be underestimated,” he said. “A therapeutic alliance must be developed with cultural sensitivity and understanding of the patient.”

Adherence should be assessed and reinforced at each clinic visit, he emphasised. “This involves asking questions in a non-judgemental manner to understand how patients are really doing with their pills, not what patients think we want to hear.” He went on to explain that patients can be helped by ensuring the availability of emotional and practical support. Patients must understand the relationship between adherence and resistance and the need to take all doses. Having the ability to fit medication into the daily routine and being comfortable taking medicines in front of others also contribute to good adherence. External cues such as pagers, mobile telephone text messages, medication charts and weekly pillboxes can also be used. The regimen should be as simple as possible, reducing the number and frequency of pills required. Administration of medicines can be linked to established daily routines. It is also important to manage side effects. Educational material written in the patient’s own language and appropriate to his or her literacy level should be provided, he said.

Adherence in Nigeria

Maria Eng, of the Institute of Human Virology, University of Maryland, US, gave a presentation on adherence materials developed for use in the PEPFAR-ACTION project in Nigeria. Nigeria has one of the highest burdens of HIV in the world, she said, but only 17,000 of the half million adults needing antiretroviral therapy (ART) actually receive it. “Challenges to ART adherence in Nigeria are numerous and include communication barriers due to language and cultural differences. Clinical issues, such as co-infection with tuberculosis and conflict with traditional medicine practices and beliefs, are also relevant,” she said.

She told participants about the PEPFAR-ACTION programme. This is part of the US government’s response to the AIDS epidemic in 15 countries. Enhancement of adherence to medication is a key part of the programme, she said. This is achieved by promotion of multidisciplinary collaboration, provision of home-based adherence follow-up and use of educational materials and reminders. Educational materials are tailored for each stage of the disease, presenting risks not just benefits, with the content appropriate for the target audience. Media used, or in development, include leaflets, videos, T-shirts, mobile phone reminders and various other visual aids.

“Achieving adherence requires a range of materials due to diverse learning and communication styles. It is important to be sensitive to cultural norms and local health terminology. Patients need to hear and be reminded about adherence by each member of the health care team. Successful adherence implementation and sustainability is built on listening, humour and collaboration,” Ms Eng concluded.

Incentives and other approaches

Kevin Moody, of the World Health Organization, Switzerland, discussed the role of incentives and other approaches to enhancing adherence. He began by identifying the range of factors that influence adherence to ART. Non-health determinants such as war, famine, migration and fear of stigma and discrimination should not be forgotten, he said.

He emphasised that patients’ need for information is high. Adherence is related to beliefs, attitudes and concern around the side effects of the medication and disruption of personal lifestyle. Knowledge is important to empower people on treatment so that they can manage their condition in a sustainable way. Self-management is the number one incentive to improve adherence. Knowing how to prevent and manage side effects and when to seek medical care are important problem-solving skills that will help to enhance adherence, he said.

Social support from family and friends is crucial to provide stability. “Psychological stress should be managed in a healthy manner and not through the use of alcohol or drugs. Disclosure of HIV status is another issue which can lead to either better or worse adherence outcomes depending on the individual’s specific situation. A supportive health care team is also important. Pharmacists can contribute enormously to the development of the patient’s skills and knowledge,” Mr Moody concluded.

New care delivery methods

Joseph Serutoke, of the Pharmaceutical Society of Uganda, said that adherence could be improved by using new methods for delivery of care. Home based care offers an accessible and affordable option for HIV/AIDS care, he said. This is because it promotes a holistic approach to care and ensures that health needs are met while reducing and sharing the costs within the system. Home-based care ensures that care givers (usually family members or community-based volunteers) are fully involved and informed about the patient’s care plan.

With careful planning, it is feasible to provide Home-based care services in poorer settings and achieve positive outcomes, he continued. “Families are a key factor for success, which is encouraged by a multidisciplinary approach among the health care team. These methods have the advantage of reducing pressure on health care institutions and hospital beds and they reduce costs. Community ownership as well as dignity and holistic care for the patient are also encouraged,” he concluded.

Role of counselling

Marja Airaksinen, of the University of Helsinki, Finland, discussed the role of counselling in enhancing adherence. In a life-threatening, long-term disease, such as HIV/AIDS, well-planned communication tailored to the patient’s situation is crucial for adherence, she said.

Concrete instructions should be given on how to take the medicines, simplify food requirements, treat side effects, avoid drug interactions and reduce dose frequency and number of pills needs to be discussed. Counselling aids, including a written schedule with pictures of medicines, daily or weekly pill boxes, alarm clocks, pictograms or other aids to adherence may be useful. Opportunity to ask questions and solve problems (eg, by telephone) should also be provided for patients between clinic visits. “Pharmacists have a big role in establishing a collaborative treatment relationship with patients,” she concluded.