Friday, June 27, 2014

Adherence to HIV Antiretroviral Therapy

Review of Edward Machtinger's research paper

Main researcher
Edward Machtinger, MD is a Professor of Clinical Medicine and Director of the Women’s HIV Program at the University of California, San Francisco (UCSF)

Research objective
HIV Antiretroviral Therapy 

Virologic Implications of Adherence

While the ultimate goal of ART is to reduce HIV-related morbidity and mortality, the initial goal is full and durable viral suppression. Full viral suppression allows for maximal reconstitution or maintenance of immune function and minimizes the emergence of drug-resistant virus selected by ongoing replication in the presence of antiretroviral drugs.

Clinical Implications of Adherence

The primary goal of treatment with ART is to prevent HIV-related morbidity and mortality. Many studies have shown a strong correlation between adherence and clinical outcomes and/or laboratory markers (notably CD4 count). Nonadherence has been found to diminish the immunological benefit of ART and increase AIDS-related morbidity, mortality, and hospitalizations.

Adherence Devices

A variety of devices that may help patients adhere to their treatment regimens are available. Most of them are simple, inexpensive, and easy to integrate into the routine care of patients on ART. Because these devices are often provided free of charge by pharmacies or pharmaceutical companies, it is usually possible for clinicians to provide these devices or for patients to obtain them on their own. The following are examples of commonly used adherence devices.

Medication Organizers

Medication organizers (eg, pillboxes, medisets) are readily available and come in many different shapes and sizes appropriate to the needs of individual patients. They allow patients to organize their weekly doses of medication in 1 convenient location instead of carrying multiple pill bottles, and to verify whether they have taken a given dose. Patients taking pillboxes to appointments helps clinicians monitor for recent non-adherence. When a new regimen is prescribed, clinicians commonly supervise patients as they set up their first medication organizer. Some pharmacies also provide medications prefilled into weekly organizers. Medication organizers are a staple of adherence case-management programs for HIV and other diseases.

Reminder Devices
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Reminder devices are particularly important given that patents cite "simply forgot" as the primary reason for missed doses.(74) Common devices include alarms on watches, beepers, or other electronic items that allow for multiple daily reminders. Calendars, paper or electronic, allow patients to document scheduled doses and note when they have been taken.

Visual Medication Schedules

A visual medication schedule (VMS) shows pictures of prescribed medications superimposed upon a weekly calendar. Images of many prescribed medications are available in sticker sets provided by drug makers or in computer programs. It is also possible to create a VMS by affixing actual pills to a paper calendar. A VMS can help ensure that the patient understands the prescribed regimen and can help other caregivers assist in medication adherence. A VMS provided at each clinic visit has been shown to improve outcomes in patients receiving anticoagulation therapy, another situation requiring chronic treatment and exact adherence.(104)

What is likely required, however, is a commitment to ask about and support medication adherence regularly in an open, nonjudgmental, and collaborative manner.

To support adherence in pediatric populations, the authors suggest a focus on supporting the family in a collaborative effort at adherence. Specific suggestions include helping achieve disclosure within the family and enrollment of the child in a dedicated adherence case-management program.

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