Improve Medication Adherence in Patients with HIV

HIV infection continues to be an epidemic in the United States. Progress in HIV prevention has stalled, with decreases in incidence in some groups and increases in others, according to the CDC.¹ The agency is concerned about the phenomenon of a new infection stabilization as a result of the lack of prevention and treatment in populations who could benefit most.

The groups that account for the highest number of new cases of HIV infection are African American and Latino bisexual and gay men between 25 and 34 years.¹ Many initiatives are under development to diagnose HIV early and treat it effectively and rapidly to achieve sustained viral suppression, and strategies to improve medication adherence in HIV-infected individuals are crucial to reaching this goal.

Medication adherence is imperative for controlling all chronic diseases in general. However, it is especially important for transforming HIV infection into a manageable chronic condition. Medication non-adherence accounts for 125,000 preventable deaths each year and nearly $300 billion in avoidable health care costs.² Sources have noted that for every 100 prescriptions written, 50% to 70% make it to the pharmacy to be filled, about 50% come out of the pharmacy, 25% to 30% are taken properly and as prescribed, and 15% to 20% are refilled as prescribed.² These statistics correlate to the 3 phases of medication adherence: initiation, persistence, and maintenance.

Patients with HIV must take their medications daily and as prescribed to maintain proper medication adherence and decrease the risk of drug resistance, prevent morbidity and mortality, and prevent the transmission of the disease to noninfected individuals. Additionally, patients with HIV must keep all their medical appointments and try to stay otherwise healthy. Proper adherence to the HIV medication regimen prevents the immune system from doing further damage to the body and leaving it unable fight off certain cancers and other infections.³

The question, then, for pharmacists is how they can improve medication adherence in the population with HIV. A review of literature for best practices related to improving medication adherence shows several methods.

In 2018, Wilkes HK et al ⁴ conducted a rapid review of 45 theory-based electronic health (EH) interventions related to continuum-of-care outcomes in patients living with HIV, and results showed that self-regulation counseling via cell phone resulted in significant improvements in self-reported antiretroviral therapy (ART) adherence. This rapid review demonstrated evidence of efficacy for using EH applications to improve HIV medication adherence.

At an academic HIV clinic and community-based organization, Spielberg KA et al⁵ performed a longitudinal randomized control trial (RCT), whose results showed a statistically significant difference in change from baseline to the 9-month follow-up between study arms (P = .046) in self-reported ART adherence by 30-day visual analog scale. Participants were randomized and assigned to one of 2 groups, either assessment only or computerized counseling. Those in the computerized counseling group received CARE+, a computerized tablet-based program equipped with audio-narrated assessment, tailored feedback, skill-building videos, personalized health plans and printouts, and standard of care. Controls received assessment only on computerized tablets and standard of care.CARE+ intervention participants had an average increase of 4.71 points in the percentage of medication doses taken (P = .014; 95% CI, 0.95- 8.48), whereas control participants had a decrease of 1.39 points (P = .556; 95% CI, −6.03 to 3.24). Results from this RCT also showed that the intervention effect was driven by those most in need. Among those with a detectable virus at baseline (>30 copies/mL, n = 89), ART adherence at the final follow-up was 13 points higher among intervention participants versus controls (P = .038). Investigators concluded that computerized counseling is promising for integrated ART adherence, especially for individuals with problems in these areas.

Shah R et al⁶ performed a meta-analysis and a systematic review of RCTs of EH interventions delivered via mobile phones through mobile phone call or imagery, text message, or mixed interventions, which showed a moderate effect of improved adherence (standard mean difference = 0.42, 0.03-0.81; P = .04) when interventions were pooled. Results also showed mixed evidence of the effect of text messages delivered daily or weekly at scheduled or triggered times. However, messages with a link to interactivity, support, and 3 or more behavioral change techniques all improved adherence. Investigators concluded that only certain mobile phone—based interventions resulted in improved medication adherence. Practitioners should consider specific interventions of proven effectiveness for implementation rather than mobile phone–based interventions in general.

Beach MC et al⁷ reviewed the impact that patient-provider interventions had on improving communication about medication adherence with patients with HIV. Providers were trained in motivational interviewing (MI) prior to patient engagement. After the MI training, providers engaged in a dialogue with the patients that led them to brainstorm with the providers and was found to be associated with more patient satisfaction than in the control arm. In the control arm, providers had greater verbal dominance with traditional interactions of telling the patient what they needed to do, which was associated with lower patient satisfaction. Patients did not talk more or ask more questions in the MI sessions. The overall results showed that 62% of providers thought the MI intervention was extremely or very helpful, 23% thought it was somewhat helpful, and 13% thought it was a little helpful or not helpful at all. On the patient side, 62% thought the MI intervention was extremely or very helpful, 24% thought it was somewhat helpful, and 14% thought it was a little helpful or not helpful at all.

Boucher LM et al⁸ completed a systematic review on the use of peer-led self-management interventions and their effect on adherence to ART among people living with HIV. The review identified 1 study, the results of which showed that peer-led interventions did lead to an improvement in adherence, with a significant improvement at weeks 12 and 24 in relation to post—viral load decreases in the test group versus the control group. Overall, results of this review showed that many studies had mixed results when it came to adherence, indicating the need for more studies. Some of the studies had a high risk of bias or an unclear risk of bias.

CONCLUSION

A great need exists to continue to study and determine the best methods that promote adherence to HIV medications to decrease viral load and prevent further transmission of the disease. The results of many of the studies reviewed seemed to convey the message that providers should consider various factors and that interventions need to cater to individual patients. Patients must feel respected, valued, and comfortable enough to have an open dialogue with those leading the interventions. Regarding the best way to engage patients, MI has been successful for many health-related conditions. Having a dialogue with patients that leads them to consider their own ambivalence to situations and see situations as they are can truly lead them to consider their behaviors. Understanding the importance, impact, and long-term consequences of managing the chronicity of HIV must become important to the individual. It is imperative that health care professionals couple this concept with identifying the true barriers to adherence and the best solutions for improving ART adherence to provide the greatest overall effect on improving HIV suppression.

REFERENCES

• HIV incidence: estimated annual infections in the U.S., 2010-2016. CDC web- site. cdc.gov/nchhstp/newsroom/docs/factsheets/hiv-incidence-fact-sheet_508.pdf. Published February 2019. Accessed October 22, 2019.
• DiPersio, LJ. Increasing medication adherence with multi-channel communica- tions. DTC in Focus website. dtcperspectives.com/increasing-medication-adher- ence-multi-channel-communications. Published July 20, 2016. Accessed October 22, 2019.
• Youn B, Shireman TI, Lee Y, Galárraga O, Wilson IB. Trends in medication adher- ence in HIV patients in the US, 2001 to 2012: an observational cohort study. J Int AIDS Soc. 2019;22(8):e25382. doi: 10.1002/jia2.25382.
• Henny KD, Wilkes AL, McDonald CM, Denson DJ, Neumann MS. A rapid review of eHealth interventions addressing the continuum of HIV care (2007—2017). AIDS Behav. 2018;22(1):43-63. doi: 10.1007/s10461-017-1923-2.
• Kurth AE, Spielberg F, Cleland CM. Computerized counseling reduces HIV-1 viral load and sexual transmission risk: findings from a randomized controlled trial. J Acquir Immune Defic Syndr. 2014;65(5):611-620. doi: 10.1097/QAI.0000000000000100.
• Shah R, Watson J, Free C. A systematic review and meta-analysis in the effec- tiveness of mobile phone interventions used to improve adherence to antiretroviral therapy in HIV infection. BMC Public Health. 2019;19(1):915. doi: 10.1186/s12889- 019-6899-6.
• Han HR, Kim K, Murphy J, et al. Community health worker interventions to pro- mote psychosocial outcomes among people living with HIV-a systematic review. PLoS ONE. 2018;13(4):e0194928. doi: 10.1371/journal.pone.0194928.
• Boucher LM, Liddy C, Mihan A, Kendall C. Peer-led self-management inter- ventions and adherence to antiretroviral therapy among people living with HIV: a systematic review [published online October 9, 2019]. AIDS Behav. doi: 10.1007/ s10461-019-02690-7.