Interventions Drastically Improve Adherence in Minorities with HIV

Lack of adherence remains a major source of health care costs among HIV patients.

Treatment interventions were found to be an effective tool in improving medication adherence among minorities infected with HIV, according to researchers from New York University College of Nursing.

A study published recently in the journal AIDS and Behavior noted that 60% of persons living with HIV in the United States are not taking antiretroviral therapy (ART) and are not engaged in primary care for HIV. Additionally, racial and ethnic minorities have been found more likely to experience barriers to engagement than Caucasians within the HIV care continuum.

The study noted that just 30% of US HIV patients are able to achieve viral suppression. HIV patients who are poorly engaged with primary care and who are not receiving ART face an increased risk for poor health outcomes, such as more frequent hospitalizations, lower quality of life, earlier mortality, and an increased risk of transmitting HIV to their partners.

Lack of engagement in HIV care and non-adherence to ART are both significant causes of high health care costs, the study noted.

The researchers indicated that barriers existing among African American and Latino HIV patients include the fear of ART side effects, medical mistrust, depression, low adherence, substance abuse, mental health distress, and the fear of social stigma. All of these factors are further complicated by low socioeconomic status.

As a result of these factors, researchers note the need for sustainable behavioral interventions to improve outcomes for the most vulnerable HIV patients. To address this problem, researchers evaluated a novel behavioral intervention program customized for 95 African American and Latino HIV patients who were not taking ART and were not well engaged in HIV care, randomized 1:1 with a control group.

The researchers developed a multi-level social-cognitive theory focused on individual-, social-, and structural-levels of influence with components to mitigate barriers to care and adherence commonly experienced by these patient groups.

The researchers utilized a counseling approach called Motivational Interviewing, which is a flexible, collaborative method that “actively engages, focuses, and guides participants in order to elicit and strengthen intrinsic motivation for behavior change.”

Another intervention called Heart to Heart was tailored to the individual needs of each patient.

"This is a novel 'pre-adherence' intervention designed for those who are not appropriate for most adherence programs and services, because they have refused or do not believe they are ready for ART,” principal investigator Marya Gwadz, PhD, said in a press release. “Heart to Heart is unique in its focus on the underlying emotional, social, and attitudinal barriers to ART and HIV care, including fear and mistrust, which act simultaneously to reduce initiation and adherence to ART and engagement in HIV care. These individuals are generally opposed to the idea of going on ART, and even afraid to do so, and as a result they avoid HIV care because they don't want to discuss ART with their health care providers, or have to explain, once again, why they are not on these life-preserving regimens."

The patients participated in 3 individual sessions, up to 5 focused support groups with other participants and a peer who experienced success in HIV care, and individualized patient navigation for up to 2 months.

"Participants wanted to hear about these issues from their peers who had been there, who had struggled with this decision themselves, gone through the same apprehensions, and who had gotten over the mountain and were doing well on ART and making their HIV care appointments regularly," study co-Investigator Noelle R. Leonard, MD, said in a press release. "This was one of the most successful aspects of the intervention."

Eight months into the study, 60% of patients in the intervention group were adherent 7 days per week compared with 26.7% in the control group. Patients in the intervention group also had a lower HIV viral load than the control group at a statistically significant level.

"Interventions to support ART initiation and continuation are vital, for individual PLHA, their loved ones, and the public health," concluded a co-investigator Charles Cleland, MD. "Although this was a small study, the intervention demonstrated efficacy with a large effect size on the most critical HIV endpoint, viral load suppression, assessed with objective biomarker data. We believe this study sheds light on new approaches to addressing ART adherence -- the 'Achilles' heel' of HIV treatment."