Carmina R' Fumaz

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Promoting adherence to HAART

• Carmina R. Fumaz
• Lluita contra la Sida Foundation
• Germans Trias i Pujol University Hospital
• Barcelona, Spain

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Changes in the Context of HIV Infection/AIDS
Determining Factors
Health Care and Adherence to Treatment
Basic Interventions in Adherence
HIV/HCV Coinfection
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Changes in the Context of HIV Infection/AIDS
Determining Factors
Health Care and Adherence to Treatment
Basic Interventions in Adherence
HIV/HCV Coinfection
4

• Decrease in mortality rate
• Illness considered a chronic process
• - Adjustment to current situation (long-term
  patients)
• - New and old mourning loss of health, status,
  significant relationships

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• Important changes in the group of affected
  people
• - ?Heterosexuals, women, teenagers through
  vertical transmission
• - Immigrant population
• Social changes that have an impact on health
  care
• - Promotion of risk behaviours in different
  scenarios

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• Increase in quality of life
• - Immunosuppressed individuals or current
  opportunistic infections
• - Not in assymptomatic patients initiating
  treatment (the majority despite the new tendency)

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• The illness in the family and its new models
• - Serodiscordant couples
• - Parenthood in HIV/AIDS
• - Homosexual couples
• - Children and teenagers (HIV disclosure)
• The illness in the society
• - Support / marginalisation contradiction

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• Emergence of new concomitant pathologies
• - Lipodystrophy
• - Osteoporosis
• - Neurocognitive dysfunctions
• - Sexual dysfunctions
• - Hormonal disorders/Early menopause
• The aged patient

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Changes in the Context of HIV Infection/AIDS
Determining Factors
Health Care and Adherence to Treatment
Basic Interventions in Adherence
HIV/HCV Coinfection
10
Determining factors
Psychological characteristics, Emotional status,
Social support  
Antiretroviral complexity, Adverse events,
Cost/benefit
ADHERENCE
Health professionals, Interaction with patient
Demographic characteristics Age, sex,
socio-cultural status, job
Health status, Illness perception
VIRAL SUPPRESSION
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Simplified therapies

• Increase the patients satisfaction with their
  therapy
• Improve the practical aspects related to quality
  of life
• Bring hope for a more optimistic future

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Simplified therapies

• 24-week randomized open-label study
• Once-daily regimen based on the d4T
  prolonged-release capsule
• Patients with complete virological suppression on
  regimens including EFV and 3tc
• QOL, efficacy, tolerability or toxicity
• Adherence declined less at wk 24 in the group
  that switched to once-daily therapy
• Portsmouth et al. HIV Med 20056(3)185-90

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Simplified therapies

• Patients switched to once-daily ddI/TDF/NVP in a
  non-randomized fashion
• High levels of adherence observed in both groups,
  as well as a good quality of life
• At wk 48, reduction in effort to take medication
  (Plt 0.001) and increment in the satisfaction with
  treatment (Plt 0.001) only seen in the QD group
• Negredo et al. Antivir Ther 20049(3)335-42

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Simplified therapies
What about long-term non-adherent patients?
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If only life was so easy
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Simplification helps, but its not always THE
solution
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Why Do Patients Miss Doses?

0
10
20
30
40
50
60
Too busy/simply forgot
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Away from home
46
Change in daily routine
45
N133
Felt depressed/overwhelmed
27
Took drug holiday/medicine break
20
20
Ran out of medication
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Too many pills
19
Worried about becoming immune
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Felt drug was too toxic
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Wanted to avoid side effects
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Didnt want others to notice
POSSIBLE INTERVENTIONS
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Reminder of HIV infection
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Confused about dosage direction
Simplify dosing schedule
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Didnt think it was improving health
Decrease pill burden
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To make it last longer
Other
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Were told the medicine is not good
Gifford et al. JAIDS 200023386395
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Determining factors
Psychological characteristics, Emotional status,
Social support  
Antiretroviral complexity, Adverse events,
Cost/benefit
ADHERENCE
Health professionals, Interaction with patient
Demographic characteristics Age, sex,
socio-cultural status, job
Health status, Illness perception
VIRAL SUPPRESSION
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Changes in the Context of HIV Infection/AIDS
Determining Factors
Health Care and Adherence to Treatment
Basic Interventions in Adherence
HIV/HCV Coinfection
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• PROCESS OF ADAPTATION TO ILLNESS

DEPRESSION
ANXIETY
Conflicts of relationship with social setting
Somatization
Repeated intolerance to treatment
Inadequate adherence
Denial
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• ADAPTATION
• TO ILLNESS

• GENERAL CARE

• ADAPTATION
• TO TREATMENT

• ILLNESS CARE

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General care and illness

• Self-esteem, self-perception
• Moral / ethical values
• Relationships with others (fundamental with an
  infectious illness!)
• The care beyond medication

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Adjustment and adaptation to illness

• Changes in life style
• Sexuality
• Work in irrational and / or erroneous beliefs
  that may become an obstacle for health care
• Prevention and / or treatment of anxiety and
  depression processes

LEARNING TO LIVE IN THE UNCERTAINTY
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Changes in the Context of HIV Infection/AIDS
Determining Factors
Health Care and Adherence to Treatment
Basic Interventions in Adherence
HIV/HCV Coinfection
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Basic Aspects to be covered by the Healthcare
Staff
- Multidisciplinary intervention, tailoring the
resources to the individuals necessities
(injecting treatment, coinfection, social
setting) - Use of external resources, if lack
of internal (amplifying horizons)
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Basic Aspects to be covered by the Healthcare
Staff
- Assessment and adaptation to the patients
situation Information always
individualized Illness awareness Social
support net
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Basic Aspects to be covered by the Healthcare
Staff
Emotional status (anxiety / stress)
Adjustment factors (psychiatric pathology,
abuse of toxic substances...) - Communication
and supervision between the different services
(role of pharmacy unit)
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Changes in the Context of HIV Infection/AIDS
Determining Factors
Health Care and Adherence to Treatment
Basic Interventions in Adherence
HIV/HCV Coinfection
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HIV / HCV Coinfection adding fuel to the
fire?
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• Collaborative intervention with psychiatry and
  psychology services
• - Distinguish between psychotherapeutic approach
  (illness acceptance, disthymic disorders, coping
  strategies...) versus psychiatric treatment
• - Possibility of prophylactic approach with
  antidepressants to diminish abandons

Musselman et al. N Engl J Med 2001344961-6
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• Citalopram is the best pharmacological option
• - Inhibits serotonine reception (main mechanism
  involved in interferon induced depression)
• - Less fixation to plasmatic proteins and less
  influence in the hepatic P-450 isoenzymes (less
  risk of drug interactions)

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• Reduction of depression, anxiety and stress in
  chronic patients through
• - Group Interventions
• - Cognitive-conductual Interventions

Carrico, et al. Ann Behav Med 200631(2)155-64
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• Fundamental role of the nursing team for the
  technical management of the treatment
• - False myth of injection in intravenous drug
  ex-users
• Agreement between clinician and patient about the
  suitability of treatment beginning
• - Effort without benefit if there are pending
  issues (active alcoholism, psychiatric
  pathology, emotional problems, socio-economic
  situation)

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Influence of the type of Pegylated Interferon on
the onset of Depression and Neuropsychiatric
disorders in HIV-HCV coinfected patients
CR Fumaz, JA Muñoz-Moreno, AL Ballesteros, R
Paredes, MJ Ferrer, A Salas, D Fuster, E
Masmitjà, N Pérez-Álvarez, G Gómez, C Tural, B
Clotet
(Pending publication AIDS Care)
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Percentage of Patients with gt95 Adherence to
Antiretroviral Therapy
74
70
56
52
Fumaz et al. AIDS Care.
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Percentage of Patients with gt95 Adherence to
anti-HCV therapy
98
98
99
98
99
99
Fumaz et al. AIDS Care.