The challenge of longterm adherence

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The challenge of long-term adherence

• Joseph Vyankandondera
• Gynecologist and Obstetrician /Kigali Teaching
  Hospital/ Belgian Technical Cooperation
• Associate Professor/National University of Rwanda

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Definition Adherence vs. Compliance

• Adherence
• Taking medication in the way prescribed by health
  provider
• Active participation of a patient in a plan of
  care
• Implies understanding, consent, and partnership
• Includes adherence to care and adherence to
  treatment
• Compliance
• Adherence seen in the perspective of passive
  attitude

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Non adherence and its implications

• Individual level
• Virus becomes resistant to available drug
• Treatment not effective
• Change of medication
• Increased morbidity and mortality likely
• Public Health level
• Transmission of resistant virus
• Increased treatment costs

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Incidence and magnitude of non adherence

• Lessons learnt
• Individuals adherence at the start generally
  good
• Long term adherence to treatment is 50 to 80
• Cohort studies lt 10 observe drug adherence of
  more than 95
• Challenges
• Variation of adherence rates within individuals
• Unreliable or non realistic/affordable tools for
  measurement
• Multiple predictors/factors

HIV Inside Knowledge Base Chapter by Edward L. et
al
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Reasons for non adherence

• Patient factors
• Some people just forget to take their pills
• Change of habits (travel, special occasions)
• Does not want to be reminded their HIV/AIDS
  status
• Does not want to take pills in presence of others
• Some people decide to skip pills to avoid side
  effects
• Reluctance to take pills that day
• Running out of pills

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Risk factors for non adherence

• Treatment regimen
• Side effects
• Complexity (multiple doses, elevated number of
  pills)
• Food instructions (empty stomach versus fatty
  food)
• Switching to a new regimen
• Health provider related
• Lack of convenience in scheduling appointments
• Absence of confidentiality
• Absence of integrated and comprehensive primary
  healthcare
• Negative attitude of some healthcare workers

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Conflicting facts

• From Acute disease to Chronic disease
• Lifelong care
• Adherence deteriorating over time
• More and more people under ARV
• Shortage of qualified personnel
• Better health
• Tendency to hide the disease
• Desire of child ?heterosexual transmission and
  MTCT

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Methods measuring adherence

• Self-report not accurate
• MEM-CAPS
• electronic device recording the removal of the
  cap
• Used in research, but not suitable for most
  clinical settings
• Pill counts Counting the remaining dose
• Time-consuming
• Rely on patients to bring their medication
• Pills identification test (PIT)
• Inviting patients to distinguish their pills from
  a display of antiretrovirals

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Measuring adherence biological markers

• Determining plasma drug levels
• Good method
• Many problems
• Cost
• NNRTI levels can be high while no close adherence
• Measures recent adherence behaviour, not
  necessarily long term adherence
• May be influenced by metabolism, malabsorption,
  etc.
• Other surrogate markers
• Elevated serum lactate levels correspond to good
  virologic response
• Increased mean corpuscular volume (AZT)
• Antiretroviral concentration in hair samples

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TDM Study done in Rwanda (TRAC and Luxembourg
development )

• 70 patients on HAART
• Women 62.3 , Men 37.7
• Most of them (80) indigents

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TDM

• Group 2
• 27 dosages (EFV)
• 100 with detectable levels of drug (EFV)
• 85 in therapeutic range
• 15 below therapeutic range

• Group 1
• 43 dosages (NVP)
• 90.5 with detectable levels of drug
• 88.5 in therapeutic range
• 2 below therapeutic range

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Compliance with appointment

• 76.8 attended the appointment
• 8.4 didnt attend the appointment
• 14.8 no data in questionnaire

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Social support Buddy

• Spouse 15
• Other family member 67
• Friend 11
• Association 1
• None 6

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Conclusions of the study

• High level of treatment adherence despite
  advanced clinical stages and indigence of
  patients
• Sub therapeutic levels could not be explained by
  
• Lack of support through a  buddy 
• Interaction of other medications

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What is done in clinical practice ?

• Self reporting
• Overestimates adherence
• Underestimates non adherence
• Needs improvement (assessment of longer period)
• Assessing the correct regimen
• Visual analogue scale (VAS) patient indicates a
  point on a line to indicate how much of each drug
  has been taken in the past 4 weeks (0 to 100)

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Preparing/monitoring for adherence

• Have non judgmental attitude during discussion
• Assess patients understanding of the importance
  of adherence
• Identify potential obstacles
• Understand reasons for missing doses
• Assess side effects
• Assess social support
• Define long-term life plans

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How to promote ART adherence

• Continued support (family, community, HCP)
• Target specific populations
• Directly Observed Therapy (DOT)
• potentially intrusive
• time consuming
• expensive
• not easily sustainable in the long term

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How to promote ART adherence (contd)

• Simplified Treatment Regimens
• Once or twice daily
• Adherence devices
• Medication organizers (pill box)
• Reminder devices (Alarms, SMS.)
• Visual medication schedules (VMS)

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Conclusions

• Assessing adherence is a very important component
  of long-term management
• Accurate measurements tools of adherence
  sometimes require creativity
• Challenges should be addressed as and when they
  occur
• Social support and simplified regimen are
  important contributors to effective management
• Reproductive health and desire to have children
  can be accommodated