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Research provides clues to adherence strategies
Study looks at its impact
HIV clinicians often work with patients who have such an overwhelming number of barriers to optimal treatment adherence that it's difficult to know where an adherence intervention should begin.
There are issues of homelessness, substance use, mental illness, stigma, drug side effects, etc. Primary care physicians will see the chief problem as being one particular barrier, while specialists and case managers might think a different problem should be targeted.
Now at least one researcher who approaches treatment adherence from the perspective of a nurse believes the best possible intervention will incorporate a variety of disciplines and approaches in one package.
"I remember having a few conversations with the medical director, saying, 'What you need in a program like this is a theoretical approach that different disciplines can agree on and to approach care from this perspective,'" says Donald Gardenier, DNP, FNP-BC, a nurse practitioner, assistant professor, and clinical program director in the division of general internal medicine at Mount Sinai School of Medicine in New York, NY.
"That's not an unusual approach for a nurse; but the medical director being a physician was intrigued and unfamiliar with this," Gardenier recalls. "So, I dove into this a little bit further and came up with a social support theory as a way to contextualize care in this setting."
Gardenier's work has led to research into an adherence intervention approach for HIV-infected patients who qualify for enhanced services based on one or more threats to optimal adherence or health outcomes in terms of their HIV disease.
"These can be multiple medical problems, decreased social support based on family systems, homelessness, incarceration, and almost all of them have at least one psychiatric diagnosis and substance use issues either currently or in the past," Gardenier says.
The patients attend an AIDS day health care (ADHC) program to which they are referred by providers based on their need for psychiatric services.
"The services are based on the statistical or evidence-driven needs of people with HIV, including housing services and nutrition services," Gardenier says. "These are in addition to being basically a psychiatric day treatment program with onsite primary care."
Gardenier first studied the ADHC's population, comparing patients' participation and reported adherence and measured social support.1
"I used the Social Provisions Scale [Cutrona & Russell, 1987], which was uniquely suited to this population," Gardenier says. "So, it seemed to me in looking at it as a nurse that different disciplines could look at different aspects of social support and design different interventions around them."
It's not as useful to ask clients if they have social support, because clients might list having a spouse, although their mate is not socially supportive, or they might not think to mention the social support they receive from peers in the day program, he explains.
"Some studies say it doesn't matter where you get social support so long as you're getting it," Gardenier adds.
In the Social Provisions Scale, social support is measured with 24 items, divided between six subscales, including: reliable alliance, attachment, guidance, nurturance, social integration, and reassurance of worth.
Reliable alliance and guidance are the types of support an HIV patient might receive from the medical professionals who help him or her, Gardenier says.
The more emotional support provisions involve attachment, nurturance, social integration, and reassurance of worth, he adds.
"Attachment is the closeness and intimacy that fosters a sense of security," Gardenier says. "Social integration is a sense of belonging to a group with similar interests and concerns."
HIV patients who experience reassurance of worth are given recognition of their abilities and competence, and nurturance is the feeling that one is needed by others, he adds.
When Gardenier measured social support among the ADHC population, he found that the highest social support scores were among the instrumental provisions of reliable alliance and guidance.
"This was not a surprise, because people are in this intensive program receiving guidance," he says. "And among the emotional provisions, the highest scores were in social integration, which is belonging in a group and also was not a surprise."
The HIV clients reported the lowest social support in the area of nurturance, suggesting they did not feel needed, he says.
"If you think about how someone experiences life during and after substance use, I think it's fairly common in the pathology of substance use to find that people who otherwise rely on you learn not to," Gardenier says. "So, even when you go through a recovery period, you lack this social support."
HIV patients struggle with the feelings that they're unneeded, but this also is a social support that a comprehensive HIV/AIDS program can foster, he notes.
"We had one man in the program that really had his life together, and he came to the day program every day for years, participating in all the groups," Gardenier recalls. "He had a key spot in social integration in the place, and you had to ask what he was doing there, because he had his life together."
The answer was that the man showed up each day because he felt needed, and so his attendance fostered the experience of nurturance, he adds.
"Once I saw the limitations of what I could do in correlating social support and adherence in using this instrument, there was more than enough material to use and apply toward the design of an intervention," Gardenier says.
There's considerable potential for such an adherence intervention, he notes.
"I can see how a case manager would look at this and see how to teach services to clients, who could then provide services for each other," Gardenier explains. "For example, a peer could lead an HIV group, and then you'd re-measure adherence and see how that has changed with the peer."
1. Gardenier D, Andrews CM, Thomas DC, et al. Social support and adherence: differences among clients in an AIDS Day Health Care program. J Assoc Nurses AIDS Care. 2009; E-publication.