Re: <I agree with this statement. That being said, a related concern I have with a discussion of patient compliance is that Doctors are deliberately withholding the best treatment available to patients based on their evaluation of whether that patient will not be compliant with the regimen. Although, this is certainly still in the best interest of the patient they are treating, what criteria is used to make this determination. Is it psycological, sociological, or medical>
This may clear the point.
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Adherence to HIV Treatments
By Eugene K. Wells, CSW
Adherence to treatment means continuing to take all medications as prescribed for the full duration of treatment. Adherence is critical to the success of any treatment, and it has become an especially hot issue in the current era of combination antiretroviral therapy (ART) for HIV infection. Poor adherence to an ART regimen can lead to the emergence of drug-resistant virus. If resistance occurs to one or more drugs in an individual's regimen, the drug combination may lose its ability to suppress HIV replication and decrease viral load. As a result, therapy may fail. HIV counselors, case managers, and treatment educators play a crucial role in helping clients adhere to treatment. In this issue of HIV Frontline, we focus on the challenges of adherence and how counselors can help.
Multiple Challenges
Adherence to HIV treatments means not only taking the proper medications in the proper doses at the proper times but following any other requirements indicated for a particular medication. These may include dietary requirements for the person taking the medication, as well as special storage requirements for the medication itself. Many people following combination ART regimens may be taking two, three, or more different drugs. These drugs may have different dosing schedules, and the regimen may necessitate taking many pills. Treatment or prophylaxis for opportunistic infections or other HIV-related conditions may further increase the complexity of an individual's regimen. The potential side effects of a drug may also impede adherence.
Psychosocial Barriers
Life circumstances of the client pose additional challenges to adherence. Normal day-to-day activities, such as attending school, working, doing household chores and daily errands, taking care of family, and socializing with friends, may affect a person's ability to adhere to treatment. Individuals with chaotic lifestyles, including factors such as homelessness, unemployment, drug use, domestic violence, or severe mental illness, may find adherence even more difficult. Many of the same psychosocial factors that affect access to care also impact adherence to treatment. For example, adherence may suffer if language barriers impede the flow of information from healthcare provider to patient. In addition, if the social stigma of HIV makes it awkward or difficult for a person with HIV to take his or her medication in public, adherence may suffer.
The Counselor's Role
The counselor's role is vital to promoting adherence to treatment. He or she can provide education and support to clients who are facing the challenges posed by complex treatment regimens. Counselors can help clients by providing clear and accurate information on such topics as
Dosing (what to take and when to take it)
Dietary restrictions
Medication storage and handling
Potential side effects
Drug interactions
Any other drug information that may affect adherence
Beyond providing information, the counselor's support can help the client put that information to use on a daily basis. It is important to remember that the counselor's role is to create a partnership with the client. Discussions about adherence should serve to empower the client regarding his or her own treatment. The first step is to talk one-on-one with the client to assess his or her particular situation. What potential barriers to adherence does this unique individual face? Gather information on how the client views medicine and how he or she feels about taking pills. Cultural issues related to healthcare, wellness, and medication are often relevant and should be taken into account. The following is a partial list of action steps clients can take to facilitate and enhance treatment adherence. The counselor's support and assistance can be very useful in accomplishing these objectives.
Develop a dosing schedule that makes sense in the context of the client's daily life.
Develop meal plans and menus that take into account any dietary restrictions required by the client's regimen.
Develop strategies for proper medication storage and handling, for example, ensuring that the client has access to a refrigerator at school or work to store supplies of ritonavir.
Develop strategies for dealing with side effects.
Develop strategies for dealing with any relevant drug interactions, which may include drug-drug or drug-food interactions.
Some interventions may require working closely with the client's medical provider, especially regarding side-effect and drug-interaction issues. If a client has severe side effects, should he or she stop taking a medication? If administration of one antiretroviral drug in a combination regimen is stopped, should all others be stopped? Answers to questions like these may vary depending on specific circumstances. The counselor may need to consult with the client's physician, nurse, physician assistant, or nurse practitioner.
See What Counselors Can Do at the end of this article for more specific suggestions about how counselors can help clients with adherence.
The Value of Teamwork
Many healthcare professionals believe that the best outcomes are obtained when medical, mental health, and psychosocial support services are integrated in a team approach to medical care. Integrating services in this way is often referred to as the biopsychosocial model. This is a term used in disciplines such as nursing and social work to describe an approach to care that addresses social factors, cultural influences, and other aspects of the patient's life circumstances, not just medical symptoms or conditions. A real-life example of comprehensive HIV medical care that addresses the challenges of adherence is the Primary Care Initiative (PCI) at Greenwich House, Division of Substance Abuse Services, in New York City. The services offered by PCI include primary medical care, harm reduction, HIV counseling and testing, partner notification, directly observed therapy for tuberculosis, intensive case-management services, and links to other programs at Greenwich House, such as the AIDS Mental Health Project and a variety of substance abuse treatment programs addressing alcohol and other substances. One goal of the program, according to medical director Randy Seewald, is to provide "one-stop shopping" for clients living with HIV. Greenwich House's PCI uses a team approach to care for clients who require the most intensive case management. The team includes a primary care physician, a psychiatrist, one or more nurse practitioners, a nurse, a phlebotomist, counselors, and case managers. Although the program is designed to address the primary care needs of people with HIV, it does not limit its services to HIV-related symptoms and treatment.
"What's the Difference?"
When faced with information about adherence, clients may ask, "What's the difference?" "Why must I take my medication at certain times?" "Why can't I take this drug with food?" Counselors may find it helpful to use analogies related to nutrition, exercise, and other areas of daily life to explain adherence. Many clients who question the rules of adherence may have no problem accepting the idea that "eating right" means not only getting the proper amount of protein, vitamins, and minerals but also storing food properly (refrigerate to avoid spoilage), handling food properly (clean the cutting board), preparing it properly (cook bacon at 375øF for 10 minutes), and eating it properly (don't eat too fast and don't exercise strenuously right after eating). Similarly, many fitness-conscious clients understand that "working out" means not only hitting the weights but also stretching and warming up properly, staying well hydrated during exercise, resting between sets, alternating muscle systems, and alternating muscle strengthening with cardiovascular conditioning. As a counselor, you can try talking to your clients about their families, interests, hobbies, and professions; then look for examples in their own lives where attention to details "makes a difference." The idea here is not to treat your clients like children; on the contrary, it is to treat them as adults and demonstrate to them that they handle complex sets of requirements and procedures all the time in their daily lives. E.K.W.
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Treatment Options
Managing the potential complexity of combination ART regimens is an important issue in providing medical care for people with HIV. At PCI, the medical team's goal is to provide highly active ART (HAART) whenever possible. By current standards, HAART usually means a triple combination regimen that can reduce viral load to below the level of detection. Such regimens generally include two nucleoside analog reverse transcriptase inhibitors (such as AZT, ddI, ddC, d4T, or 3TC) and one protease inhibitor (such as saquinavir, ritonavir, indinavir, or nelfinavir). Nonnucleoside reverse transcriptase inhibitors, such as nevirapine and delavirdine, may also be useful in such regimens. Some patients, however, have chaotic life circumstances or other factors, such as severe mental illness, that pose serious barriers to adherence. For these patients, the PCI medical team assesses the abilities and limitations of the individual patient; the team recommends the simplest treatment regimen that will still provide clinical benefit. For example, a combination regimen that necessitates taking three pills twice a day without regard to dietary restrictions has been found acceptable to many patients at PCI, including many with chaotic life circumstances. This approach allows PCI to provide ART to many persons who may have been discouraged from taking such treatment in other settings or who may have been denied treatment outright.
What Counselors Can Do
Listed below are specific things counselors can do to help clients adhere to treatment. Many of these strategies are adapted from the article "Adherence, Compliance, and HAART," by Ann Williams, RN, and Gerald Friedland, MD, which appeared in the July issue of the journal AIDS Clinical Care. Any intervention should be based on the counselor's assessment of the individual client and his or her specific needs.
Make sure clients understand why they are receiving ART and what the treatment goals are.
Ensure that clients understand how their medications work and why adherence is important.
Make sure clients understand what clinical benefits they can expect.
Make sure clients understand which side effects might occur and what to do if they experience these side effects (ie, some side effects can be treated symptomatically; others should be reported to a medical provider immediately).
Make sure clients know all the possible names of their medications (for example, AZT is also known as zidovudine and Retrovirr); this information can help clients avoid dosing errors.
Make sure clients know which drugs must be taken with or without food.
When dietary restrictions apply, make sure the client understands why the restrictions are important (that is, that absorption of the drug is affected by food intake); people may be more likely to follow a requirement when they understand the need for it.
Make sure clients understand why careful timing of doses is important (that is, the body must maintain adequate blood levels of the drug for the medication to be effective).
Provide all drug information in written form; pictures of the medications may also be helpful.
Whenever possible, help clients link their dosing schedules to cues from daily life, such as mealtimes, tooth-brushing times, or times of favorite television programs.
Help clients develop memory aids, such as medication boxes, alarms, and medication charts.
Whenever possible, use positive feedback about decreased viral loads and increased CD4 counts to reinforce adherence.
Involve the client's friends, family members, and significant others in an adherence-support network; make sure they have all the treatment information they need to be effective caretakers and sources of support.
Help clients set up buddy relationships with other clients who are on similar treatment regimens; peer support can be very useful in reinforcing adherence.
Refer clients to peer-counseling programs and support groups where available.
Monitor the level of communication between members of the client's care team, and make sure that all members have adequate information about the client's life circumstances and any special issues that may affect adherence (such as homelessness, child-care responsibilities, substance use, or mental illness).
Call the client frequently to assess adherence and provide support between in-person visits.
Refer clients to substance abuse treatment or mental health services as necessary; in the case of clients who are in recovery, monitor for relapse.
Help clients obtain Medicaid, ADAP, and other entitlements or social services as needed.
Eugene K. Wells, CSW, is a psychotherapist at Greenwich House in New York City who specializes in issues relating to substance use and HIV.
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