Hannelie Meyer JC

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AdherenceHow good is adherence?How do we
know?How can we promote proper adherence?

• Hannelie Meyer (JC)
• Department of Pharmacy
• University of Limpopo, Medunsa Campus
• email hannelie.meyer_at_gmail.com or
  hmeyer_at_ul.ac.za
• Access to Health Care in Africa
• 16 18 April 2008
• Cape Town, South Africa

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Adherence
WHO (2003) defined adherence as
the extent to which a persons behaviour
taking medication, following a diet, and/or
executing lifestyle changes, corresponds with
agreed recommendations from a health care provider

• Correct dose, frequency dose interval
• Care plan
• Dietary restrictions
• Lifestyle modification

• Avoid risky behaviour
• Appointments
• Repeat prescriptions
• Education counselling
• Home visits outreach

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Adherence

• What do we know about adherence rates?
• Chronic illnesses ART
• Developing vs. developed countries
• Measurement and comparison of adherence rates

What is the single optimal method to measure
adherence?
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Other chronic medication 50 (WHO, 2003)
ART Higher than other chronic illnesses 70
Adherence to medication
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Are adherence rates the same
in developing and developed countries?

• Adherence in developing countries predicted to be
  a problem
• Research has shown adequate adherence
• Resource-poor settings Resource-rich settings
• Meta-analysis
• 27 sub-Saharan African studies 77 (n12 116)
• 31 North American studies 55 (n17
  573) (Mills et al., 2006)
• ?? Signs of possible decline in adherence in
  Africa (Bangsberg et al., 2006 Gill et
  al., 2005 Ware et al., 2006)

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Adherence ratesWhy is it difficult to measure
and compare adherence rates?

• Different thresholds and definitions for
• Optimal adherence e.g. 100, gt95, gt90, gt80
• Treatment defaulting e.g. 14 different
  definitions in use at 20 facilities in 5 East
  African countries (Chalker et al., 2008)
• Adherence as a continuous variable (mean/median
  ) or dichotomous variable (100 vs. lt100)
• Cross-sectional (mostly) or longitudinal measures
• Different recall periods (3-day 7-day 30-day)

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• Different methods of measurement - ?comparable

(Oyugi et al., 2004)
(Giordiano et al., 2004)
Variation between different methods

• Different types of adherence measured

Cannot be represented by a single average number
(Deschamps et al., 2004)
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• Adherence is a dynamic behaviour it varies over
  time and among individuals
• Non-adherence (lt100) measured with 3-day
  self-report (n435)
• Cross-sectional non-adherence NOT gt35
• Non-adherence across three interviews 53.6

P lt 0.05
Need for multiple, periodic measures
(Tesoriero et al., 2003)
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Adherence measuresIndirect measures

• Provider estimates not accurate
• Self-report (brief or detailed)
• (3-day 7-day)
• Visual analogue scale (VAS)
• Pill counts pill dumping time consuming
• Medication events monitoring system (MEMS)
  objective limitations expensive
• Pharmacy records long-term monitoring
• Treatment response (biochemical and clinical)
  not adequately informative expensive

Easy quick biased inflated
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Adherence measuresDirect measures

• Modified directly observed therapy (DOT)
• Directly administered antiretroviral therapy
  (DAART)
• Most accurate
• ART complex, compared to TB treatment
• Most expensive
• ? Potential stigmatisation - might hinder access
  to treatment

Each adherence measure is subject to error
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Adherence measuresComposite measures
Combine multiple measures

• Weigh options

• Greater precision of measurement
• Reduce error associated with single measure
• How to combine?
• Feasible in clinical practice?

Add qualitative methods in-depth information

• Beliefs about medication
• Reasons for non-adherence
• Problems with access
• Stigma
• Attitudes about health, wellness life

Need standardisation
(Chalker et al., 2008)
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Promoting adherence
What is the best tool or intervention to enhance
adherence? regardless of the person using the
tool or the setting in which it is used
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Dimensions of adherence
Complex health-related behaviour
More than simply remembering
Health system/ HCT-factors
Social/ economic factors
Condition-related factors
Therapy-related factors
Patient-driven Patients solely responsible
Patient-related factors
(WHO, 2003)
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Published reviews of adherence interventions

• Patient Support And Education for Promoting
  Adherence to Highly Active Antiretroviral Therapy
  for HIV/AIDS
• (Rueda, S., Park-Wyllie, L.Y., Bayoumi, A.M.,
  Tynan, A.M., Antoniou, T.A., Rourke, S.B.
  Glazier, R.H. Cochrane Database Syst Rev 2006,
  3CD001442)
• Efficacy of Antiretroviral Therapy Adherence
  Interventions A Research Synthesis of Trials,
  1996 to 2004 Cross-sectional or longitudinal
  measures
• (Amico, K.R., Harman, J.J. Johnson, B.T. JAIDS
  2006, 41(3)285-297)
• Efficacy of Interventions in Improving Highly
  Active Antiretroviral Therapy Adherence and HIV-1
  RNA Viral Load A Meta-Analytic Review of
  Randomized Controlled Trials
• (Simoni, J.M., Pearson, C.R., Pantalone, M.S.
  Crepaz, N. JAIDS 2006, 43(Suppl.
  1)S23-SS34)

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Published reviewsSummary findings

• Behavioural interventions had positive effect on
  adherence and viral load (Simoni et al., 2006)
• Interventions demonstrated beneficial effects
• targeting practical medication management skills
  vs. cognitive behavioural or motivational skills
• administered to individuals vs. groups
• delivered over at least 12 week period (Rueda et
  al., 2006)
• Patients reporting low levels of adherence at
  baseline benefited the most from interventions
  (Amico et al., 2006)
• Marginalised populations e.g. women or patients
  with past history of alcoholism - not successful
  at improving adherence
• may suggest a different approach (Rueda et al.,
  2006)

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Targeting adherence interventionsInformation-moti
vation-behavioral (IMB) skills model of adherence
X
X
(Adapted from Fisher et al., 2006)
Concept of health changed

• Theoretical models from developed world - not
  directly transferable to socio-cultural diverse
  settings
• Need to be adapted to fit the dynamics of
  adherence within the context where they will
  be applied

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Example from the South African context
Denial Speed up recoveryRelieve adverse
effectsWork, look after family Minimise
sufferingTake revenge
(Meyer, 2008)
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Example from the South African context (ctd)
Health system overload Distance time for
repeats Quality counselling? Continued free ART?

• Not in IMB Model
• Culture
• Social structural barriers

Disrupted lifestyle Struggle for incomeMigrant
work Disrupted families Stressful daily
life Health problems, deaths
Traditional beliefs Women blamed Family
continuity Makgome, ? stigma Cleansing (trad.
med)
(Meyer, 2008)
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Resource-limited settings
Can adherence measurements methods or strategies
to change behaviour be transferred from
resource-rich settings to resource-limited
settings?

• Tailor methods and materials to
• different cultural contexts
• environment where intervention be employed
• varying patient populations
• clinical structures and healthcare providers
• disease maturity

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Any gold standard for adherence assessment and
intervention strategies is elusive
and one size does not fit all
Chesney, M.A. 2006. The Elusive Gold Standard
Future Perspectives for HIV Adherence Assessment
and Intervention. JAIDS, 43(Suppl. 1)S149-S155
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AcknowledgementsExample from the South African
context

• Monika Zweygarth for her contribution as co-coder
  and with the interpretation of the data
• Dr Beverley Summers and Prof Rob Summers for
  their advice as supervisors of the study

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References (1)

• Amico, K.R., Harman, J.J. Johnson, B.T. 2006.
  Efficacy of Antiretroviral Therapy Adherence
  Interventions A Research Synthesis of Trials,
  1996 to 2004 Cross-sectional or longitudinal
  measures. JAIDS, 41(3)285-297.
• Bangsberg, D.R., Ware, N. Simoni, J.M. 2006.
  Adherence Without Access to Antiretroviral
  Therapy in Sub-Saharan Africa? Correspondence.
  AIDS, 20(1)140-141.
• Berg, K.M Arnsten, J.H. 2006. Practical and
  Conceptual Challenges in Measuring Antiretroviral
  Adherence. JAIDS, 43 (Suppl. 1)S79S87.
• Chalker, J.C., Andualem, T., Minizi, O.,
  Ntaganira, J., Ojoo, A., Waako, P. Ross-Degnan,
  D. 2008. Monitoring Adherence and Defaulting for
  Antiretroviral Therapy in Five east African
  Countries An Urgent Need for Standards. 3rd
  International Conference on HIV Treatment
  Adherence, Oral Abstract 21
• Chesney, M.A. 2006. The Elusive Gold Standard
  Future Perspectives for HIV Adherence Assessment
  and Intervention. JAIDS, 43(Suppl. 1)S149-S155.
• Deschamps, A.E., Graeve, V.D., Van Wijngaerden,
  E., De Saar, V., Vandamme, A., Van Vaerenbergh,
  K., Ceunen, H., Bobbaers, H., Peetermans, W.E.,
  De Vleeschouwer, P.J. De Geest, S. 2004.
  Prevalence and Correlates of Nonadherence to
  Antiretroviral Therapy in a Population of HIV
  Patients Using Medication Event Monitoring
  System. AIDS Patient Care and STDs,
  18(11)644-657.
• Fisher, D., Fisher, W., Amico, R. Harman, J.
  2006. An Information-motivation-behavioural
  Skills Model of Adherence to Antiretroviral
  Therapy. Health Psychology, 25(4)462-473.
• Gill, C.J., Hamer, D.H., Simon, J.L., Thea, D.M.
  Sabin, L.L. 2005. No Room for Complacency About
  Adherence to Antiretroviral Therapy in
  Sub-Saharan Africa. AIDS, 1912431249.
• Giordano, T.,Guzman, D., Clark, R., Charlebois,
  E. Bangsberg, D. 2004. Measuring Adherence to
  Antiretroviral Therapy in a Diverse Population
  Using a Visual Analogue Scale. HIV Clinical
  Trials, 5 (2) 74-79.
• Hardon, A., Davey, S., Gerrits, T., Hodgkin, C.,
  Irunde, H., Kgatlwane, J., Kinsman, J.,
  Nakiyemba, A. Laing, R. 2006. From Access to
  Adherence The Challenges of Antiretroviral
  Treatment. Studies from Botswana, Tanzania and
  Uganda. (WC 503.2). Geneva, Switzerland WHO
  Press.
• Lazo, M., Gange,S.J., Wilson, T.E., Anastos, A.,
  Ostrow, D.G., Witt, M.D. Jacobson, L.P. 2007.
  Patterns and Predictors of Changes to Highly
  Active Antiretroviral Therapy Longitudinal Study
  of Men and Women. Clin Infect Dis, 451377-85

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References (2)

• Meyer, J.C. 2008. Determinants of adherence to
  antiretrovirals in selected treatment centres in
  South Africa. Unpublished data PhD Thesis.
  Pretoria University of Limpopo, Medunsa Campus.
• Mills, E.J., Nachega, J.B., Buchan, I., Orbinski,
  J., Attaran, A., Singh, S., Rachlis, B., Wu, P.,
  Cooper, C., Thabane, L., Wilson, K., Guyatt, G.
  Bangsberg, D.R. 2006. Adherence to Antiretroviral
  Therapy in Sub-Saharan Africa and North America
  A Meta-analysis. JAMA, 296(6)679-690.
• Murphy, D.A., Belzer, M., Durako, S.J., Sarr, M.,
  Wilson, C.M., Muenz, L.R. for the Adolescent
  Medicine HIV/AIDS Research Network. Longitudinal
  Antiretroviral Adherence Among Adolescents
  Infected With Human Immunodeficiency Virus. Arch
  Pediatr Adolesc Med,159764-770
• Orrell, C., Bangsberg, D.R., Badri, M. Wood, R.
  2003. Adherence is Not a Barrier to Successful
  Antiretroviral Therapy in South Africa. AIDS,
  17(9)1369-1376.
• Oyugi, J.H., Byakika-Tusiime, J., Charlebois,
  E.D., Kityo, C., Mugerwa, R., Mugyenyi, P.
  Bangsberg, D.R. 2004. Multiple Validated Measures
  of Adherence Indicate High Levels of Adherence to
  Generic HIV Antiretroviral Therapy in a
  Resource-Limited setting. J Acquir Immune Defic
  Syndr, 361100-1102.
• Rueda, S., Park-Wyllie, L.Y., Bayoumi, A.M.,
  Tynan, A.M., Antoniou, T.A., Rourke, S.B.
  Glazier, R.H. 2006. Patient Support And Education
  for Promoting Adherence to Highly Active
  Antiretroviral Therapy for HIV/AIDS. Cochrane
  Database Syst Rev 2006, 3CD001442.
• Sankar, A., Golin, C., Simoni, J.M., Luborsky, M.
  Pearson, C. 2006. How Qualitative Methods
  Contribute to Understanding Combination
  Antiretroviral Therapy Adherence. JAIDS,
  43(Suppl. 1)S54-S68.
• Simoni, J.M., Pearson, C.R., Pantalone, M.S.
  Crepaz, N. 2006. Efficacy of Interventions in
  Improving Highly Active Antiretroviral Therapy
  Adherence and HIV-1 RNA Viral Load A
  Meta-Analytic Review of Randomized Controlled
  Trials. JAIDS, 43(Suppl. 1)S23-SS34.
• Tesoriero, J., French, T., Weiss, L., Waters, M.,
  Finkelstein, R. Agins, B. 2003. Stability of
  Adherence to Highly Active Antiretroviral Therapy
  Over Time Among Clients Enrolled in the Treatment
  Adherence Demonstration Project. J Acquir Immune
  Defic Syndr, 33(4)484-493.
• Ware, N.C., Wyatt, M.A. Bangsberg, D.R. 2006.
  Examining Theoretic Models of Adherence for
  Validity in Resource-Limited Settings A
  Heuristic Approach. J Acquir Immune Defic Syndr,
  43S18S22.
• World Health Organization (WHO). 2003a. Adherence
  to Long-term Therapies Evidence for Action.
  Geneva, Switzerland WHO Press.

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Example from the South African context (complete
model)
(Meyer, 2008)