You are on page 1of 20

ADHERENCE TO ANTIRETROVIRAL THERAPY AMONG HIV-INFECTED PATIENTS WITH

MENTAL HEALTH DISORDERS

I. INTRODUCTION
RECOMMENDATION:
Patients with mental health disorders should be considered candidates for HAART if they
meet the medical eligibility criteria for HAART and demonstrate readiness to begin
therapy. Clinicians should determine treatment readiness on a case-by-case basis, weighing
such factors as whether the patient attends the majority of his/her appointments and
whether he/she expresses an interest in receiving ARV therapy.
Patients with mental health disorders should be considered candidates for HAART if they meet
the medical eligibility criteria for HAART and demonstrate readiness to begin therapy. Whether
a patient is ready to begin therapy needs to be determined on a case-by-case basis; however,
factors such as whether the patient attends the majority of his/her appointments and expresses
interest in receiving ARV treatment will help to determine whether the patient is ready.
Achievement of the benefits of HAART requires careful adherence to regimens that may be
complex and/or cause unpleasant side effects. Non-adherence to ARV therapy may result not
only in reduced treatment efficacy but also in the selection of drug-resistant HIV strains and
increased progression to AIDS and death.1,2 Because the exact level of adherence that is
necessary to prevent the emergence of drug-resistant virus or to delay disease progression to
AIDS and death is unknown, near-perfect adherence (>90% to 95%) remains the goal for all
HIV-infected patients,3,4 including those with mental health disorders or a history of mental
health disorders.
Appropriate identification and treatment, or referral for treatment, of underlying mental health
disorders will facilitate optimal adherence among this patient population. Depression, the most
studied mental health disorder, has been shown to be predictive of poor adherence.5,6 However,
an improvement of depressive symptoms should result in improved adherence.7

Key Point:
The most effective means of promoting adherence in patients with mental health disorders is
through adequate stabilization of their mental health and integration of mental health treatment
into the comprehensive treatment plan.

1

II. COORDINATION OF CARE
RECOMMENDATIONS:
Primary care clinicians should refer patients to licensed mental health providers when:
• Initial mental health treatment by the primary care clinician is ineffective
• Complex mental status evaluations become necessary or a patient’s behavior
jeopardizes effective treatment
• The patient has co-occurring mental health and substance use disorders
Primary care clinicians and mental health care providers should collaborate to develop a
step-by-step treatment plan. The treatment plan should delineate the frequency of followup visits with both providers as well as the frequency of team meetings to reevaluate
effectiveness of the overall medical and mental health treatment.
Primary care clinicians should initially consult with a psychiatrist when managing patients
with mental health disorders who refuse mental health care. Throughout the patient’s care,
the clinician should communicate with a psychiatrist or a licensed mental health
professional who can provide consultation.
Primary care clinicians should notify the mental health care provider when there is a
change in medical or mental health treatment.
The care for HIV-infected patients with mental health disorders should be a collaborative effort
involving patients, primary care clinicians, and mental health providers. Extra attention and
involvement of the care team may be required to ensure that these patients adhere to their ARV
regimens. When patients are also taking psychotropic medications, adherence may be more
difficult, which can make coordination of care even more critical. When necessary, case
managers, substance use counselors, relatives, pharmacies, insurance companies, and domestic
violence service providers should also be involved.
Regular communication between primary care clinicians and the mental health provider(s) offers
a chance to discuss techniques for approaching patients with mental health disorders. For patients
who have established a therapeutic alliance with their mental health provider, a meeting
involving the patient, the primary care clinician, and the mental health provider can help
“transfer” the trust from the mental health provider to the primary care clinician. The same
strategy can be used to transfer the trust from the primary care clinician to the mental health
provider. This can help the patient feel that the care team takes a genuine interest in the his/her
health.
When patients with mental health disorders do not agree to mental health evaluation and
treatment by a mental health professional, the primary clinician should establish a “silent
partnership” with a licensed mental health professional who can help the primary clinician
develop a treatment strategy for the patient. Because psychiatrists are physicians and are familiar
with medical illnesses and their treatment, initial consultation with a psychiatrist would be ideal
for the primary care clinician to establish the patient’s overall care. A licensed mental health
professional may play the primary role as silent partner thereafter.

2

panic disorder. The patient should also be asked to notify the medical staff at the drug treatment program that he/she is initiating ARV treatment. has been shown to be affected by mental health and psychosocial factors. Active substance or alcohol use is one of the few relatively consistent predictors of poor adherence. such as bipolar disorder and depression • Anxiety disorders. such as pessimism. such as generalized anxiety disorder. If symptoms occur. PREDICTORS OF AND BARRIERS TO ADHERENCE A. and poor coping styles Although mental health disorders and/or history of substance use disorders are not contraindications for initiation of treatment.11. including ARV treatment. which may interfere with a patient’s ability to follow directions • Personality characteristics. Barriers Adherence to medication regimens. However. apathy. at least in one large study. Predictors Predictors of adherence that have been consistently identified among persons with HIV infection with and without mental health disorders include the following: • Social stability and support • Beliefs and knowledge about medications • Confidence in their ability to adhere successfully to an ARV regimen • A regimen that works (“fits”) with their daily activities8-10 • A strong and trusting patient-provider relationship Key Point: Patients with mental health disorders may have learned skills related to adherence to psychiatric medications that they can use to help them adhere to HIV treatment.A mental health patient who is enrolled in a methadone treatment program should be educated about drug-drug interactions because he/she may develop opiate withdrawal symptoms after initiating ARV treatment or other medications. it is noteworthy that. adjustment of methadone dose may need to be made with ongoing coordination between the primary care clinician and the patient’s methadone program. Mental health factors that may affect adherence include: • Substance use disorders • Affective disorders. B.13 3 . III. these factors may make adherence more challenging.12 Patients with severe affective disorders have also been found to have lower rates of adherence. patients with schizophrenia were found to be as adherent to ARV therapy as those without a serious mental health disorder. post-traumatic stress disorder (PTSD) • Fluctuations in mental health status or impairments in cognitive function.

they should discuss this decision with the patient and document it in the medical record. Clinicians should discuss the following with patients before initiating HAART: • Clinician and patient treatment goals • Patient’s concerns about treatment and ability to adhere • Potential side effects of ARV therapy and potential interactions with psychotropic and other medications. it may be appropriate to initiate HAART. particularly if the patient has AIDS or is at risk for advanced progression of HIV.14 IV. such as moving from a residential hotel to a shelter. Identification and management of potential barriers to adherence before initiating HAART in HIV-infected patients with mental health disorders are critical (see Table 1). designated AIDS centers. In patients with advanced AIDS. or not having a refrigerator for certain medications. Listings of local pharmacies. In these cases. not having a secure place to keep medications. Clinicians should identify and address potential barriers to adherence before initiating HAART. Determination of a patient’s ability to adhere and promotion of adherence are processes that begin before patients actually start taking medications.Psychosocial factors that may affect adherence include: • Lack of social support • Homelessness • Family instability • Domestic violence • Poor self-image and fears of stigma Among homeless individuals. and local HIV/AIDS social service organizations can be found in Appendix A. 4 . Primary care clinicians should refer patients with mental health disorders to specialized adherence services when adherence barriers cannot be resolved. even if barriers to adherence are present. adherence may be compromised when they experience increased housing instability or stay in settings not conducive to adherence. If clinicians elect to defer HAART while addressing potentially modifiable barriers to adherence. Clinicians may choose to defer HAART while addressing potentially modifiable barriers to adherence. as well as how the side effects and interactions will be managed should they occur Clinicians should use translator or sign language services when language barriers exist. IDENTIFYING AND ADDRESSING POTENTIAL BARRIERS TO ADHERENCE BEFORE INITIATING HAART RECOMMENDATIONS: Clinicians should carefully assess each patient to evaluate his/her ability to adhere to HAART. referrals to specialized adherence programs should be made for intensified adherence support.

the clinician’s main goal may be viral load suppression. whereas the patient’s main goal may be to look healthier. For example. how can they bridge the difference? • How realistic are the patient’s goals? • Which symptoms might impede him/her in achieving his/her goals? After discussing treatment goals. For example.An initial step in the identification and management of barriers to adherence involves a discussion with the patient about his/her treatment goals. the patient may be afraid of: • The stigma associated with receiving HAART • Losing government benefits if his/her medical status improves • Giving up psychological or material benefits associated with the “sick role” • Returning to an anxious state of uncertainty about the length of time that the medications will be effective By expressing interest in the patient’s concerns and goals. the clinician may both strengthen the patient-provider relationship as well as provide means for supporting HIV treatment adherence. 5 . The patient’s commitment to HIV care may be strengthened by the clinician showing an active interest in learning about the patient’s anxiety and related social concerns: • Who in the patient’s life is aware and supportive of his/her mental health problems? • What kind of experience has he/she had with mental health professionals and psychiatric medications? • Does the patient have health beliefs or cultural beliefs about western medicine that are causing additional anxiety about taking medication? When assessing readiness for treatment in patients with mental health disorders. a patient with a history of trauma might be too anxious to put a potentially toxic medication into his/her body. the clinician should give the patient the opportunity to discuss his/her concerns about treatment readiness: How hopeful is the patient about adherence to both HIV and psychotropic medications? Some patients may fear the consequences of initiating HAART. Discussion points may include the following: • If the clinician and patient have different goals. the factors in Table 1 should be considered as potential barriers. The clinician should not assume that the patient’s goals are the same as the clinician’s goals. For example. Discussions about treatment goals involve the patient in the decision of when to initiate therapy.

g. Cognitive-Behavioral Strategies) Language barriers Translator or sign language interpreter. friends. legal issues)? Are children or other dependents in the home? Is there domestic violence? History of abuse or violence See Trauma and Post-Traumatic Stress Does the patient have PTSD symptoms? Disorder in Patients With HIV/AIDS Medication concerns Consider regimen that accommodates Has the patient had poor past lifestyle. “silent health disorder? partner” with mental health provider Cognitive function See Cognitive Disorders and Does the patient understand HIV/AIDS. Are any of the following particular symptoms screen for common mental health symptoms present? disorders. HIV social from family and friends? Is service organization. consider referral for counseling Mental health Treat the underlying mental health Is there an untreated mental symptoms. D. refer for treatment. lack of motivation. depression. see below instructions? (Section VI. Do the clinician and patient someone who does not know the speak the same native patient may be preferable language? Is the patient deaf or does the patient have a hearing impairment? Substance use See Substance Use Guidelines Is there active substance use or inadequate substance use treatment? Presence and severity of Treatment adherence support program. low self-esteem.16 Support network and social With patient’s consent. stigma and shame mental health evaluation about HIV or mental health disorders. case management there lack of social stability services (e.15. consider full fatigue. see Table 2. low energy and easy Management of Patients with Personality Disorders. personality disorder. especially under stress. motivational Is the patient in denial? interviewing. medication education support group.TABLE 1 ASSESSMENT AND APPROACHES TO POTENTIAL BARRIERS TO ADHERENCE Barriers Assessment Possible Approaches Stage of acceptance Educational approaches. see apathy. avoid regimens with possible experiences handling side side effects that would likely lead to effects? Would the regimen poor adherence “fit” with the patient’s daily routine? Is there a risk of drug-drug interactions? 6 . hopelessness.. if symptoms are due to a Helplessness. and inadequate coping styles. consider What is the degree of support stability involving family. negativity. housing problems.

Incentives to keep appointments. designated AIDS centers. such as food and travel vouchers . the more important improved treatmentsetting characteristics and supportive services become: • Optimizing Treatment-Setting Characteristics Offer the following: .nyhiv. Some programs may target particular issues related to adherence.To various services.To case-management services for assistance in obtaining financial support. and transportation for traveling to appointments . mental health residential programs.The more disorganized and chaotic a patient’s life is. medical care. and welcoming clinic setting . private.Improved waiting time in the clinic. particularly for patients with personality disorders. and correct number of doses per day. 7 . For example. V.To adherence support groups and adherence research projects . Listings of local pharmacies. MEASURING.Assurances of confidentiality . such as outpatient mental health clinics. and local HIV/AIDS social service organizations can be found in Appendix A and at http://www. Clinicians should use finite time intervals when inquiring about and quantifying the patient’s self-report.More frequent follow-up monitoring . correct number of pills per dose. Clinicians may consider arranging these patients’ appointments at the beginning of the day or arranging a special “slot” because patients who feel shamed and stigmatized may feel too uncomfortable to wait in an area with other patients. who often have poor coping skills and a very low tolerance for frustration. INITIATING. housing. and select pharmacies offer educational programs and support groups designed to help patients with medication adherence. Clinicians should calculate an average response rate based on information obtained at multiple visits to determine a more accurate estimate of adherence. psychiatric day programs. AND MONITORING ADHERENCE TO ARV THERAPY RECOMMENDATIONS: Clinicians should assess adherence at every routine monitoring visit by verifying that patients are taking the correct medications. HIV adult day programs. stress-management services. some target their services to patients who are starting their first ARV regimen.A comfortable.org/resources_programs. • Referrals for Services Refer patients as needed: . Patients experiencing uncontrollable muscle movement or who have difficulty sitting still for any reason may be disruptive to the waiting area. HIV/AIDS social service organizations.html. and childcare and help with managing the cost or coverage of drugs. and professionally or peer-led support groups Designated AIDS centers.For food and nutritional supplements . nutritional programs.

permission should be obtained from the patient and the patient should be involved in these discussions. primary care clinicians may need to involve input from licensed mental health providers. the factors described in Table 1 should be considered. supportive manner when patients report non-adherence. For example. permission should be obtained from the patient and the patient should be involved in these discussions. Despite its tendency to overestimate adherence. Self-report is most valid when patients are asked about the number of missed doses within a short time frame (1-7 days). Clinicians should encourage patients to be honest by responding in a nonjudgmental. friends. When clinicians find it necessary to speak with the patient’s friends or family to assess adherence. Patient-Provider Interaction Strategies RECOMMENDATIONS: Clinicians should encourage patients to state in their own words what they understand about treatment instructions and to ask questions when additional information is needed. finite time intervals should be used. case managers. but some studies have found that asking about adherence within the past month is also valid. STRATEGIES TO IMPROVE ADHERENCE A.17. and/or family members of patients with active mental health disorders. 8 .Clinicians should reassess potential barriers to adherence at least every 3 to 4 months and whenever adherence problems are identified. VI.18 In addition to the usual means of assessing adherence. When clinicians find it necessary to speak with the patient’s friends or family to assess adherence. the clinician should ask about the number of doses taken and missed in the past day or past week. Measurement of adherence is challenging in both clinical and research settings and usually relies on any one or a combination of the following methods: • • • • • • Self-report Pill counts Pharmacy records Electronic pill bottle monitors Therapeutic drug monitoring Computer-assisted self-interview (CASI) assessment The advantages and disadvantages of each method are discussed in Appendix B. self-report remains the most practical measure in most clinical settings and is most likely to facilitate discussion between patients and providers about the reasons for non-adherence. As ongoing adherence to treatment is monitored. When adherence is assessed.

and ongoing availability. communication skills. number of times) • Having the patient develop a calendar or schedule for taking medications • Performing a practice run without active medication (e. openness to questions.19 Table 2 lists communication strategies for the enhancement of adherence in patients with mental health and/or substance use disorders. Factors that facilitate the relationship include the provision of understandable information. interest and trust in the patient. repeat key points. Clinicians can be supportive by acknowledging that treatment for multiple disorders is challenging because of the increased pill burden and added responsibility and stress of adhering to more than one regimen. Interventions work best when they are practical. mental health provider.Factors such as the clinician’s language. and case managers in treatment recommendations and supervision • Having the patient and provider agree on an accepted regimen and encouraging the use of the simplest effective regimen (e. initiated promptly. have patients repeat back instructions in their own words • Teach science in simple terms • Allow honest reporting of non-adherence • Use translator or sign language services when language barriers exist • Use pictures and/or written material Involvement of the patient as a partner in his/her care will help foster trust and build a strong patient-provider relationship. TABLE 2 COMMUNICATION STRATEGIES FOR CLINICIANS TREATING PATIENTS WITH MENTAL HEALTH AND/OR SUBSTANCE USE DISORDERS • Proceed slowly. sensitivity and respect for the patient.g. the clinician should respond in a way that enhances an open and honest partnership. Being actively supportive by welcoming the patient’s honesty will mitigate any shame that the patient may feel about his/her poor adherence. Key Point: A strong patient-provider relationship.. number of doses. ability to listen. 9 . has been associated with improved ARV adherence.. and individualized to the patient’s characteristics and needs. vitamins) When a patient reports non-adherence.g. eye contact. using candy. Strategies to involve patients as partners in their care include the following: • Asking the patient to repeat medication information regularly • Encouraging the patient to ask questions and providing clarifying information • Inviting the patient’s feedback and opinions and role-playing problem scenarios • Involving the patient’s family or friends. and consultation style can foster or hinder collaboration with the patient. including trust and engagement with the provider.

and/or alcohol The importance of treating comorbid disorders. which drugs do not have any known risks for or lack of likelihood for drug-drug interactions with prescribed and alternative medications. recreational drugs. with easy-to-understand brief statements. Through use of motivational interviewing. Health Educational Strategies RECOMMENDATION: Clinicians should provide adherence information in an organized manner. Clinicians should convey education points through the use of brief statements. These tools need to be tailored to the patient (using lay language or native language). B. Important educational topics for clinicians and patients to discuss are given in Table 3.Best Practices booklet. that is well organized and easy to understand. with special attention to psychiatric side effects—how to address or avoid Drug-drug interactions—how to determine whether interactions are occurring and what to do about them. and social and community organizations. (See Adherence . It will help us understand the best way for you take your pills regularly. both orally and in written form. such as mental health and substance use disorders The possible impact of HIV on mental health symptoms Educational tools can be helpful. the clinician attempts to stimulate change by identifying discrepancies in the patient’s current behavior and the patient’s goals of healthier behaviors. yet these should complement and enhance the direct communication and not replace it. Everyone has difficulty taking medications. When the patient begins 10 . methadone. Motivational Strategies Motivational strategies can help to address attitudinal barriers and may include providing psychosocial support and involving family members. So. The fact that you sometimes remember to take your pills is great. ƒ ƒ ƒ ƒ ƒ TABLE 3 HEALTH EDUCATION POINTS FOR ENHANCING ADHERENCE The treatment regimen and treatment options Drug side effects.The clinician might say. A therapeutic treatment style that may be used when exploring issues of ambivalence and conflict regarding adherence is motivational interviewing. Health educational strategies are most effective when the patient receives information. let’s review when you do remember and when you don’t. partners. both orally and in written form.) C.

and experiences of another. With this approach. The four key components of motivational interviewing are shown in Table 4. Accomplished through reflective listening. When the patient feels strong support from the clinician. Expressing Empathy: To gain a better understanding of the patient’s perspective. 11 . the clinician reflects the discordance back to the patient. Working collaboratively with the patient to develop his/her input regarding the treatment plan. the clinician may find that the patient is not ready or willing to stop engaging in a particular behavior or to adopt a new behavior. The clinician should support the patient’s belief in his/her ability to change by giving the patient examples of positive change and emphasizing the importance of taking responsibility. it enhances his/her sense of self-efficacy. For patients who have difficulty tolerating direct communication or who may not be able to identify their own needs. instead of verbally suggesting change. the clinician actively listens without being judgmental. Avoiding argumentation and rolling with resistance Listening to the patient’s resistance to change. Through this reflective listening. Supporting self-efficacy: Self-efficacy refers to a person’s belief in his/her ability to successfully carry out a specific task. Principles of Motivational Interviewing Clinicians should understand the underlying principles of motivational interviewing before using it. until the patient realizes that change is necessary and makes the decision to commit to change. thoughts. Discovering discrepancies Helping patients identify discrepancies between their current behavior and desired future behavior. clinicians do not give advice or directives. use of motivational interviewing may not be suitable. Supporting self-efficacy Supporting the patient with the sense that an individual can identify and meet one’s needs and goals. 1.to understand how the consequences of current behavior conflict with personal values. TABLE 4 KEY COMPONENTS OF MOTIVATIONAL INTERVIEWING Component Involves Expressing empathy Understanding and being aware of and sensitive to the feelings. the initial focus is on building therapeutic rapport and supporting the patient. In this case. Direct persuasion and aggressive confrontation are not part of motivational interviewing. This approach encourages patients to describe their behaviors and develop their own solutions.

the goal is to discover and amplify discrepancies between present and past behavior and future goals. Reflective listening is often challenging because the clinician may need to form assumptions about the meaning of the patients’ statements in order to articulate them back to the patient. Double-sided reflections acknowledge both what the patient has said and the ambivalence. This strategy lets the patient know that the clinician is interested in his/her situation. Amplified reflections reveal the patient’s ambivalence in a slightly exaggerated form. This is achieved through examination of the consequences of continuing an unhealthy behavior and often involves discussing the advantages of adopting a new behavior. The summary can also be used to shift focus or direction when the patient is expressing impassible resistance. Through this process. he/she should invite the patient to make any corrections. Summaries will emphasize the main points of the discussion and should capture both sides of the patient’s ambivalence. More resources on motivational interviewing are available at http://www.g. Reflective listening helps the clinician identify areas of ambivalence. 2. Simple reflections acknowledge the patient’s statements about disagreements. does not feel defeated in sharing his/her concerns. Discovering discrepancies: Once patient-provider rapport has been established.Avoiding argumentation and rolling with resistance: Motivational interviewing differs from other approaches to behavior change in that it does not label patients (e.. and is able to take the risk to express feelings.motivationalinterview. feelings.org. The patient will then be able to present the argument for change and begin to realize the need for change. Motivational Interviewing Approach The acronym OARS outlines the basic approach to interactions in motivational interviewing: Open-ended questions invite patients to provide more information than yes or no and will encourage them to explore their own motivators for change. When faced with a patient’s resistance. After the clinician summarizes. while allowing the clinician to obtain needed information and insight into the patient’s issues. It is particularly important to reflect back any statements that indicate that the patient is motivated to change. the clinician reflects the patient’s questions and concerns back to the patient. so that the patient may further examine the possible alternatives to this resistance. “non-compliant” or “difficult”). The patient then becomes the source of the positive actions that could be taken. or perceptions. it is important for the clinician to allow the resistance to be expressed. Affirmations provide opportunities for clinicians to recognize the patients’ strengths. 12 .

For more information regarding cognitive impairment among HIV-infected patients. after evaluation by a neurologist. see Cognitive Disorders and HIV/AIDS: HIV-Associated Dementia and Delirium. Although shown to be effective in several non-randomized trials.21 published data are limited that compare the efficacy of DOT with other modalities for successful treatment of HIV disease. and development of drug resistance in an indigent population. double-blind trial comparing combinations of nevirapine. DOT and modified DOT (MDOT) may facilitate adherence through direct supervision of pill-taking. Bangsberg DR. Hecht FM. Charlebois ED. REFERENCES 1. Non-adherence to highly active antiretroviral therapy predicts progressions to AIDS. link medications to daily activities • Using reminders: written instructions or illustrations. These programs may also include psychoeducational and social service components. Bangsberg DR. deliver medications. Practical strategies include the following: • Simplifying regimens: decrease dosing frequency. A randomized. Cognitive-Behavioral Strategies Cognitive-behavioral strategies can be used when mild memory difficulties are present or when the individual feels overwhelmed by the pill-taking challenge. Montaner JSG.14:357-366. Chaisson RE. JAMA 1998. HIV-1 viral load. pill boxes. diaries. 13 . Charlebois ED. phone calls from family or friends • Using available pharmacy services: pharmacies may call patients to remind them about need for refills. et al. decrease number of pills • Personalizing drug schedules: tailor treatment to lifestyle. as well as behavioral reinforcements. timers. AIDS 2000. Ann Intern Med 1999. Directly Observed Therapy Some medical programs and HIV/AIDS social service organizations have programs that provide ARV directly observed therapy (DOT) for outpatients (see Appendix B). or visiting nurses should be sought. 2.D. et al. Adherence to protease inhibitors. provide professional regimen reviews If memory deficits are pronounced. E. Highly active antiretroviral therapy in a large urban clinic: Risk factors for virologic failure and adverse drug reactions. a practice run without active medication can help a client feel confident about his/her ability to adhere to ARV therapy. the assistance of relatives.15:1181-1183. and those who are living in unstable and disorganized social conditions.279:930-937. et al. 3.131:81-87. and zidovudine for HIV-infected patients. Perry S. didanosine. Before initiating treatment or when switching regimens. DOT and MDOT may be the only effective means of ensuring treatment adherence in some patients with severe and persistent mental health illness.20. Moore RD. Cooper D. those with dual mental health and substance use disorders. Lucas GM. Reiss P. 4. AIDS 2001. home health aides.

10. Clark R. 16. et al. Holzemer WL. Otto MW. Directly observed therapy to treat HIV infection in prisoners. 21.3(Suppl 3):S136-S139. Enhancing adherence to HAART: A pilot program of modified directly observed therapy. Sambamoorthi U. September 1997. AIDS 1999. Self-reported adherence to antiretroviral medications among participants in HIV clinical trials: The AACTG adherence instruments. 8. Chesney MA. McKenzie M.353:487-497. Babudieri S. 6. Evolving HIV Treatments: Advances and the Challenge to Adherence. Stenzel MS. et al. et al. AIDS 2002. J Acquir Immune Defic Syndr 2002. Determinants of compliance with antiretroviral therapy in patients with human immunodeficiency virus: prospective assessment with implications for enhancing compliance.10:69-78. Demas PA . Squier C. Ickovics JR. AIDS Care 2000.39:1151-1162. Two strategies to increase adherence to HIV antiretroviral medication: Life-steps and medication monitoring. Community Health Advisory and Information Network. J Gen Intern Med 1999. New antiretroviral therapies: Adherence challenges and strategies. Singh N. Avants SK. JAMA 2000. Canada. del Amo J. and adherence to therapeutic regimen in persons with HIV/AIDS.14:267-273. Behav Res Ther 2001.12:255-266. Grant RW. Haubrich RH. Blaschke T. Arnsten JH. Aceti A. 20. 7. Catz S. et al.284:179-180. Soriano V. J Gen Intern Med 2002. et al.17:377-381. 11.org/pdfs/chain/CHAIN%20Service%20Gaps%20Report%202004_12. D’Offizi GP. Wagener M. New York: HIV Health and Human Services Planning Council. et al. AIDS Care 1996:8:261-269. Margolin A.65:1180-1189. Ammassari A. Trotta MP. Impact of active drug use on antiretroviral therapy adherence and viral suppression in HIV-infected drug users.pdf. Sivek C. Depression is a risk factor for suboptimal adherence to highly active antiretroviral therapy. J Clin Psychiatry 2004. Use of newer antiretroviral treatments among HIV-infected Medicaid beneficiaries with serious mental illness. Responses to a 1 month self-report on adherence to antiretroviral therapy are consistent with electronic data and virological treatment outcome. 15. et al. AIDS 1999. Brown MA. N Engl J Med 2005.5:74-79. et al. Relationships between perception of engagement with health care provider and demographic characteristics. Walsh JC. Report 2004-1: Service Gaps and Utilization in the Continuum of Care in NYC. 17. Currier JS.nyhiv. Guzman D. Walkup JT. Ramachandran B. Starace F. 12. Available at: http://www. Crystal S. et al. Chambers DB. Sociodemographic and psychological variables influencing adherence to antiretroviral therapy.11:317-328. health status.5. Warburton LA. 9. Giordano TP. Toronto. et al. Measuring adherence to antiretroviral therapy in a diverse population using a visual analogue scale. Safren SA. HIV Clin Trials 2004.14:189-197. 13. Bakken S.13:1763-1769. Adherence to medication.16:269-277. 19. 37th ICAAC Symposium. Am J Addict 2001. et al. Adelson-Mitty J. Adherence to combination antiretroviral therapies in HIV patients of low health literacy. Predictors of nonadherence to HIV-related medication regimens during methadone stabilization. et al. AIDS Reader 2001. 14.13:1099-1107. FURTHER READING Osterberg L. The value of patient-reported adherence to antiretroviral therapy in predicting virologic and immunologic response. Chesney MA. AIDS Patient Care STDs 2000. Worth JL. 14 . Gordillo V. Little SJ. 18. Kalichman SC.

amc.APPENDIX A NEW YORK STATE ADHERENCE SERVICES CONTACT LIST AIDS Community Resources Casey Cleary-Hammerstadt Deputy Executive Director 627 West Genesse St. Daniel Kaswan Director. Laurie Greenberg-Cardillo Manager.D. AIDS Program Administrator 47 New Scotland Av M Code 158 Albany. NY 12208 (518) 262-4432 Cliffog@mail. Mental Health and Treatment Adherence First Avenue at 16th Street New York. NY 13204 (315) 475-2430 cch@aidscommunityresources.org Beth Israel Medical Center Dr.edu Albert Einstein College of Medicine Dr. Ph. Syracuse.Grugett@bellevue. HIV Medical Services 1300 Morris Park Ave Bronx.nychhc. New York 10461 (718) 665-7000 Bellevue Hospital Center Lucy Grugett Assistant Director.org 15 . NY 10016 (212) 562-5201 Lucy.com Albany Medical College George Clifford. 12 E 12 New York. Grants Management 462 First Avenue. New York 10003 (212) 420-2617 lgreenb@bethisraelny.

4th Floor Rochester.edu Community Health Network Danita Djelosk Treatment Adherence Program Coordinator 87 North Clinton Ave.org 16 . NY 14604 (585) 244-9000.edu Kings County Hospital Center John Krevitt. 247 ddjeloski@achcrochester.org Erie County Medical Center Kathleen Walsh MSW. NY 11203 (718) 245-2821 Krevittj@nychhc.. Room 3101A New York. ext. CSW AIDS Program Administrator 462 Grider St Buffalo. NY 10037 (212) 939-2948 Sbm20@columbia. MD Program Director Harlem Adherence to Treatment Support in Primary Care 506 Lenox Avenue. Project Director 722 West 168th Street.Columbia University School of Public Health Emilyn Nishi.edu Harlem Hospital Center Sharon Mannheimer. NY 10032-2603 (212)305-4104 EN2008@Columbia.org Montefiore Medical Center Jorge Rodriguez Administrative Director HIV/AIDS Services 111 East 210th Street Bronx. MPH Associate Director 451 Clarkson Avenue Brooklyn. Rm 1111 New York. NY 10467-2490 (718) 920-2199 Jorrodri@montefiore. NY 14215 (716) 898-4481 kwalsh@ecmc.

edu SUNY Downstate Medical Center Alexa Kazim Administrative Director STAR Health Center – HIV Service Box 1240. NY 11021 (516) 622-5070 or 5064 Schuval@lij. NY 11203 (718) 270-3818 Alexa.org 17 . 450 Clarkson Avenue Brooklyn.edu Village Center of Care Laurie Newman. #624 New York. NY 10014 (212) 337-5854 laurien@vcny. NY 10032-3710 (212) 305-8925 Ant9009@nyp.org North Shore Long Island Jewish Medical Center -Schneider Children’s Hospital Dr.edu New York Presbyterian Medical Center Andrew Torres Coordinator. Infectious Diseases 2201 Hempstead Turnpike Mailbox 73 East Meadow. Suite 101 Great Neck.Nassau University Medical Center Getachew Feleke Chief. Education and Outreach 180 Fort Washington Avenue. NY 11554 (516) 572-6506 gfeleke@ncmc. MPH Director of Research 154 Christopher Street Suite 3A New York. Susan Schuval Section Head – Pediatric Immunology 865 Northern Blvd.kazim@downstate.

MS Coordinator.com 18 . HIV Clinical Education and Adherence AIDS Care Center BHC-S022 Valhalla.Westchester Medical Center Richard Birchard. NY 10595-1689 (914) 493-1362 birchardR@wcmc.

residential treatment programs.Method Directly Observed Therapy APPENDIX B ADVANTAGES AND DISADVANTAGES OF ADHERENCE MEASURES Advantages Disadvantages ƒ 100% adherence. in theory ƒ Labor intensive ƒ Ideal method for ambulatory settings ƒ Concern for development of resistance if plan not followed ƒ Easy. in theory ƒ Labor intensive ƒ Ideal method for institutional settings (prisons. Stavudine (increased MCV).) Electronic monitoring ƒ Best correlation with virologic outcomes ƒ Allows more detailed view of non-adherence patterns ƒ Most accurate measure ƒ Not practical for complex regimens with multiple doses and/or dietary restrictions ƒ May compromise confidentiality ƒ Expensive and generally reserved for clinical trials ƒ Precludes use of pillbox ƒ Fails if multiple medications are kept in a single bottle or if multiple doses are taken out at one time ƒ Requires carrying the container ƒ Subject to “pocket doses” (removing more than one dose at a time) ƒ Does not guarantee that the patient took the medication Hematologic monitoring using either complete blood counts or expanded chemistry panels ƒ Confirms patient reporting ƒ Only effective for certain drugs: Zidovudine. minimal time commitment ƒ Patients may use more than one pharmacy ƒ Timely refilling of prescriptions correlates well with adherence ƒ Most successful when limited to patient using one pharmacist ƒ Is a useful adjunct to self-report ƒ Effective in understanding adherence behavior in large populations 19 ƒ Does not equate with medicationtaking . nursing homes. Indinavir (increased bilirubin) ƒ Not always reliable Modified Directly Observed Therapy (observation of most but not all medication doses) Pharmacy refill monitoring ƒ 100% adherence. etc.

“right” responses ƒ Inexpensive Therapeutic drug monitoring ƒ Overestimates adherence ƒ Low drug levels confirm nonadherence. but therapeutic drug levels do not confirm adherence ƒ Pharmacokinetic levels for most drugs have not been well established ƒ Only confirms the pre-measurement adherence.Pill counts ƒ Useful adjunct to self-report ƒ Unannounced pill counts may be more accurate ƒ Direct costs minimal ƒ Tends to overestimate adherence because of “pill dumping” before visit ƒ Casts provider in the role of medication monitor and not ally or advocate ƒ Indirect costs a concern due to time constraints ƒ Does not prove that patient actually took medication ƒ Most poorly correlated with actual adherence Provider estimation Self-report ƒ Easily obtained using patient interview or questionnaire (report of non-adherence is more reliable than report of adherence) ƒ Correlation is dependent on patient’s relationship with staff ƒ Individuals may give providers what they perceive as socially desirable. not all individuals with virologic failure will be poor adherers 20 ƒ Does not necessarily indicate nonadherence ƒ May overestimate adherence ƒ Virologic failure can be indicative of drug resistance . long-term adherence still unknown Viral load ƒ Can correlate with adherence ƒ Although poor adherence is associated with virologic failure.