Adherence Strategies

Study looks at adherence among alcohol abusers

Intervention addresses issues with this population

HIV patients who abuse alcohol as their primary substance are less likely to adhere to their antiretroviral treatment regimen as their alcohol use increases, a recent study finds.

Adherence was impacted by the amount of drinking, regardless of other problems.1

"We wanted to investigate adherence among HIV-positive alcohol abusers," says Jeffrey T. Parsons, PhD, a director of the Center for HIV/AIDS Educational Studies and Training (CHEST) and professor in the department of psychology at Hunter College and the Graduate Center of the City University of New York in New York, NY. Parsons is the study's lead author.

"So much work has been done with substance use in general, but much less has been done for those for whom alcohol was their primary drug," Parsons says. "To be in our study, your alcohol problems had to be more of an issue than other problems."

The study includes baseline information about the HIV-positive cohort.

"We found that baseline levels of adherence weren't necessarily as bad as we might have thought," Parsons says. "Forty-three percent of the population was at least 95 percent adherent in the last 14 days, and some individuals, despite significant alcohol use, were adherent to meds."

The nearly 60 percent who were not adherent needed assistance, particularly in building their confidence in their ability to adhere to their antiretroviral regimens.

"It's really about people who are confident about being able to take their medications are able to do so," Parsons explains. "Also, as the level of alcohol use increased, the person was less likely to be among the 43 percent who were 95 percent adherent."

The investigation will result in future studies about an adherence intervention that is based on information, motivation, and behavioral skills model, Parsons says.

The work was influenced by earlier research with alcohol-using men who have sex with men (MSM) in which researchers noticed that the population had some adherence difficulty, he notes.

The study's population was 75 percent people of color and 70 percent males, Parsons says.

"We found no gender difference in our results," Parsons says.

The theory behind the information, motivation, and behavioral skills model is that before people can change a behavior they first need adequate information. The information should lead to motivation, to change, and is followed by behavior changes, provided they are taught the appropriate skills.

"A lot of times people rush into skills building before a person is ready," Parsons says. "They either never put it into practice, or they don't pay attention and drop out, so we wanted people to be comfortable with the level of information they received before starting skills building."

Participants attended eight individual sessions. The intervention group met with a master's level therapist, and the control group met with a bachelor's degree-level health educator, he notes.

"The intervention sessions are based on principles of motivational interviewing and cognitive therapy," Parsons says. "It's client-centered, nonjudgmental, and it does not push any particular goal, such as abstinence if that's not what they want."

The therapist asks participants what kind of changes they want to make with their drinking, taking a perspective that is less threatening, he notes.

Therapists received training in the techniques of motivational interviewing, which includes a generally empathic approach, nonjudgmental interactions, and a client-centered approach, Parsons says.

"We didn't want therapists to argue with clients about why they should change," Parsons says.

Therapists ask participants open-ended questions and let them explore their ambivalence about wanting to adhere to their antiretroviral treatment regimen, Parsons says.

"We let them pick which behavior to focus on first to make it clear they'll be driving the agenda," Parsons says.

"We want them to explore the pros and cons of healthy and less healthy behavior, and we want to help them build self confidence around adherence," he adds.

"We had booklets that therapists could use to walk through each session, and these were given to the patient at the end of the session because they involved some in-session activities and some take-home assignments to think about," Parsons explains.

For example, one item in the booklet is about patient-provider communication.

"We found previously that this was a skills deficit with a lot of folks," Parsons says. "So part of the booklet provided factual information on why the patient provider communication is important."

It also asked patients to think about the last time they were with a provider and what questions they had asked and how they felt after the visit. It encourages role play and suggests other questions to ask in order to get their problems addressed, Parsons says.

There is a booklet for each skill, and some sessions will cover more than one skill. So there is a session that covers both patient-provider communication and managing side effects, Parsons says.

"Even though everyone got eight sessions, the actual content was very individualized based on their needs," he says.

The information part of the adherence strategy is very important, particularly with this population, Parsons notes.

"We found from previous work that with alcohol abusers a lot of time is spent correcting inaccurate information," he says. "We found in other research that alcohol users have a lot of concerns about the potential interactions between alcohol and HIV medication."

For instance, an alcohol user might tell a provider, "When I'm drinking I don't take my meds because I'm worried they'll negatively interact with alcohol," Parsons says.

"They think it's worse to take meds with alcohol than to not take meds at all," he says. "But, in fact, it's worse not to take the medication, and a lot of them don't realize that."

Therapists and educators also discuss the facts about the affects of alcohol on the liver, particularly if hepatitis C co-infection is an issue, Parsons says.

After giving patients information and helping to build their motivation for change, therapists address their goals, which lead to skills building.

"If the person says, 'Now I'm ready to make some changes,' then we ask what kind of things would be helpful and provide them with the skills," Parsons says.

Reference:

  1. Parsons JT, Rosof E, Mustanski B. Patient-related factors predicting HIV medication adherence among men and women with alcohol problems. J Health Psych. 2007:12:357-370.