Adherence Strategies: No shows: Expanding the concept of adherence
No shows: Expanding the concept of adherence
Medication adherence is tied to medical attendance
For too long medication adherence has been studied and viewed from the narrow perspective of how many and how frequently patients take their antiretroviral medications, an expert says.
While HIV clinicians and researchers intuitively know that patients who fail to show up for medical appointments also have greater health problems and medication adherence issues, too few interventions and studies address this issue.
"We need to try to expand the scope of what we consider when we think about adherence," says Thomas P. Giordano, MD, MPH, an assistant professor of medicine at Baylor College of Medicine in Houston, TX. Giordano's research found that HIV patients who fail to show up for medical appointments have poorer survival with HIV infection.1
"Adherence has to do with having an effective linkage to care after diagnosis, and it's related to keeping doctors' appointments and not having prolonged gaps in care," Giordano explains. "All of those are important predictors to medication adherence and survival."
This is why it's important that any adherence program include support for improving medical care retention, he notes.
Since people who abuse substances, have psychiatric disease, or struggle with socioeconomic issues, such as transportation and housing problems, often have more difficulty with meeting doctors' appointments, then some resources must focus on helping patients overcome these obstacles, Giordano says.
Also, researchers need to devote more time to studying retention in care issues, he says.
"The literature around that concept is light years behind where adherence to medication is," Giordano says. "There are no randomized studies about improving retention in care that have been published yet."
There are some studies underway, and there are many applications that have been submitted to conduct such research, but there isn't anything available at present, he adds.
Part of the problem is that the focus on HIV adherence evolved over the past two decades as drugs became more potent and increasingly available.
"When highly-active antiretroviral therapy (HAART) came out in the mid-1990s, it was made available to the sickest patients, who were in care," Giordano says. "Then we figured out how to use it most effectively and realized in the late 1990s that adherence was critically important."
So it's been only within the last decade that the HIV community has focused on medication adherence.
"There was some early recognition that retention in care was a problem, but it's really taken off in the last few years," Giordano says. "So we're trying to come up with ways to address that problem."
Using the Veterans Administration Immunology Case Registry, which draws on electronic medical records of nearly 60,000 HIV-infected patients cared for by the VA, Giordano's study analyzed retention in care and HIV disease progression.1
More than one-third of the more than 2,600 HIV-infected men included in the study had not received VA care for at least three months. Those out of care for as little as three months in their first year of antiretroviral therapy had worse survival, which was adjusted for age, CD4 cell count, HIV concentration, hepatitis C co-infection, and other comorbid conditions.1
"This study was done using VA data from across the nation, so that's pretty good data," Giordano says.
Although many investigators and clinicians will say that they expected these types of results, their intuition was not based on a body of research showing the connection to HIV outcomes and HIV care retention because this hasn't been the focus of previous adherence and outcomes research, he notes.
"People who are not in care are really hard to study because they're not showing up," Giordano says. "And how do you show that people who aren't in care are doing poorly?"
This is where the VA data is unique because it shows good survival data even when patients weren't using the VA health care system regularly, he adds.
The next step is for researchers and clinicians to start thinking about adherence in the global sense of a patient's entire HIV care and support, Giordano says.
"Our whole way of thinking about how to treat HIV is centered around what drugs to use and how do we get people to adhere better to these drugs, and people who are not on drugs are sort of missing from the equation," he says. "If you want to improve outcomes, then we need people who should be on the medications to be on them."
And one way to do this may be to look at the whole HIV care delivery system and find ways to make it easier to get people into care and to stay in care, Giordano says.
Reference
- Giordano TP, Gifford AL, White Jr. AC, et al. Retention in care: a challenge to survival with HIV infection. CID. 2007;44(1):1493-1499.
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