1. “Stephen, I’m taking my meds, I
swear”
Adherence as a Path to Virologic Suppression
Stephen Perez, RN, NP, AAHIV-S
HealthHIV

2. Objectives
• Define adherence as it relates to
antiretroviral therapy
• Discuss current positive and negative
predictors of adherence
• Describe methods for improving
adherence
• Identify effective strategies for
increasing patient adherence in the
clinical setting
2

3. Adherence
• How do we define adherence?
– Taking medications or treatments as prescribed
or advised by a health care provider
– Average ART adherence rate in the United
States is approx. 70%.1
– Earlier studies of adherence showed resistance
associated with <95% adherence.2
– Providers assessments are often inaccurate! 1,2
– There is no gold standard for assessment3
3

4. Why does adherence matter?
• Reduced Rates of Resistance
• Improved Quality of Life
• Improved Virologic Suppression
U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and
Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012.
4

5. Predicting Adherence
• Positive Predictors
– Ability to identify medications
– Ability to describe the proper dosing
– Lower pill burden
– Ummmmmmm…………
1. Matchinger, E & Bangsberg, D. 2006. Adherence to Antiretroviral Therapy. UCSF HIV inSite.
http://hivinsite.ucsf.edu/insite?page=kb-03-02-09 accessed April 3, 2012.
5

6. Predicting Aherence
• Factors Associated with Non-
Adherence
– Younger age
– Age-related changes
– Mental health/Social issues
– Non-disclosure of HIV status
– Active substance abuse
– Side Effects
– Complex regimens
– Non-adherence to clinic appointments
6
U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and
Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012.

7. Assessment of Adherence
• No gold standard
• Keep it simple and non-judgemental
• Normalize less than perfect adherence
• Try to minimize “socially desirable”
responses
• Survey about a finite time: “last 3
days”, “Last week”
• Ask about missing other meds or
treatments
• Pill boxes, bottle cap counters, dispensing
systems, biological markers
U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected Adults and
Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April 3, 2012.
7

8. Questions to Assess Adherence
• Do you manage your own medications? If not, who manages
them for you?
• What HIV medications do you take and what is their dosage?
When do you take these?
• What is your average daily schedule like? How well does taking
your HIV medications at this time fit into your daily schedule?
• How do you remember to take your medications?
• How many doses of your HIV medication have you missed in the
past 72 hours, past week, past 2 weeks, and past month?
• When are you most likely to miss doses?
• Do you have any adverse effects from your HIV medications? If
so, what are they?
• Are you comfortable taking medications in front of others?
• What is most difficult about taking your medications?
• How do you like working with your pharmacy?
1. Health Resources and Services Administration, HIV/AIDS Bureau, 2011. Guide for HIV/AIDS Clinical Care.
“Adherence”. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-406_adherence.html accessed April 3, 2012
8

9. Interventions to Improve Adherence
• Assessment of the patients readiness for ARV’s
• Use critical thinking when prescribing ARV
therapy
• Simplify a patients regimen
• Educate around side effects and adverse drug
reactions
– Let the patient know they are supported
• Talk about the risks/benefits of therapy
• Identify barriers they may not have considered
• Get creative!
9

10. Strategies for Improving Adherence
• Patient-centered approach
• Educate your patients
• Assess for use/need for specific
interventions (medisets, pill boxes, text
reminders)
• Multi-disciplinary approach if/where
available
• Expect the unexpected
• Hang in there
10

11. Case Study in Adherence
• Ms. D
– 44 y.o. HIV positive African American
female
– HIV-positive for 9 years
– Presenting for first HIV care visit in 3 years
• No meds, can’t remember her last meds
• Feels sick. CC: “Has sore on her stomach”
• BP is 86/54, Pulse is 130, Temp: 101.4
• Intake labs, were CD4 32, VL 132,000
• Actively drinking 6-10 beers a day, using crack
cocaine off and on weekly
11

12. Case Study in Adherence
• Ms. D
– Physical exam:
• In addition to the vitals noted, she has a large open abscess
and cellulitis on her abdomen, abscesses on her upper
thigh/buttocks, palpable femoral nodes.
• Height is 5’3”, wt. 86 lbs
• ED referral, and admission for 4 days, discharged on TMP-
SMX and azithromycin
– She returns 4 months later
• Wt. has remained the same, no meds, t 98/60, p110, afebrile.
• Substance use pattern is the same
• Is indifferent about meds, and indifferent about care in
general
• Hx: has been on meds before (can’t name them) records
say Lopinavir/ritonavir and emtricitabine/tenofovir DF (She
says they “tore up her stomach”)
• Previous records say that she has M184v but was <75.
• Sexually active, inconsistent condom use
• Uninsured 12

13. Case Study in Adherence
• Ms. D
– Daughter won’t speak to her because of
her substance use
– Recently was arrested for “something”, Has
court case pending
– Wants to get sober before the hearing
13

14. Case Study in Adherence
• Plan for Ms. D
– Prescribe her darunavir/ritonavir and
emtricitabine/tenofovir DF (once daily).
– Recheck labs for baselines (CD4 75, VL 89,000)
– Enroll her for one visit with SAC, RNCM, and SW
– Bactrim daily for PCP prophylaxis until meds
arrive
– Preemptively give her OTC for diarrhea and RX
for nausea meds
– Work out a visit schedule and assist her with
transportation arrangements
– Agree to write a letter of support for her court
case
– I made her a deal
14

15. Case Study in Aherence
• Plan for Ms. D (continued)
– Adherence education and counseling
session with RNCM and subsequent
monthly meetings
– Counseling about diet
– Sees provider every 2-3 months
– SAC and SW every 2 weeks
– Took a year before she came back
undetectable, misses about 1-2 doses a
month
15

16. Adherence
• Today Ms. D is still undetectable
• She weighs 130lbs
• Still struggling with ETOH
sobriety, stopped crack altogether
• Avoided jail time
• Was maid-of-honor at her daughter’s
wedding
• Brought in pictures of her 4th grandchild
the following Christmas
16

17. Adherence Take Home
• Virologic suppression begins with
adherence.
• Ultimately its up to the patient, but
providers play a crucial role
• Be creative
• Be determined
• Be realistic
17

18. References
1. Matchinger, E & Bangsberg, D. 2006. Adherence to Antiretroviral Therapy. UCSF HIV inSite.
http://hivinsite.ucsf.edu/insite?page=kb-03-02-09 accessed April 3, 2012.
2. Health Resources and Services Administration, HIV/AIDS Bureau, 2011. Guide for HIV/AIDS Clinical Care.
“Adherence”. http://hab.hrsa.gov/deliverhivaidscare/clinicalguide11/cg-406_adherence.html accessed
April 3, 2012
3. U.S. Dept of Health and Human Services, 2012. Guidelines for the Use of Antiretroviral Agents in HIV-1 Infected
Adults and Adolescents. www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf accessed April
3, 2012.
18

19. QUESTIONS?

20. AETC NCHCMC Contacts
Stephen Perez, RN, NP, AAHIVS
HIV Clinical Specialist
stephen@healthhiv.org
(202) 507-4740
20

21. HealthHIV
AETC NCHCMC
2000 S Street NW
Washington, DC 20009
www.NCHCMC.org
202-232-6749