Innovative techniques improve compliance

Programs include counseling, medical assistance

A Massachusetts HIV adherence initiative uses a wide variety of support and educational techniques at 17 sites to encourage patients to closely follow their medication regimens.

Each site, which includes health centers, AIDS support organizations, and visiting nurse associations, has developed its own program, using one or more of these support programs. So far, the initiative has successfully increased medication adherence.

The Community Research Initiative (CRI) of New England in Brookline, MA, which helped launch the initiative, offers these descriptions of the various adherence support techniques:

• Peer-based interventions: This is a response to consumer input that support from others who have "been there, done that" can make a significant impact on motivation and capacity to adhere to highly active antiretroviral treatment (HAART). People with HIV and AIDS who had been successfully managing combination therapies were recruited to work as buddies, usually on a one-on-one basis, with adherence project participants.

• Check-in support: Adherence participants were contacted by health care providers, peers, and volunteers to provide reminders, emotional support, and supplemental treatment education. This additional support also helps build self-confidence as consumers experience a growing capacity to manage their medications. Frequency of check-in varied by participant and took the form of phone calls as well as home visits.

• Group support and education: Educational and support groups were generally led by peers who were managing combination therapy or by project staff. The groups served as support mechanisms and less formal venues for treatment education. They provided adherence education, information, and emotional support.

• Provider training: Educational programs have been developed for medical providers who are less experienced with HAART and the associated adherence issues. Training programs were provided for clinicians within participating adherence project agencies, as well as for regional audiences of local community providers. In addition to strengthening the capacity to provide a higher quality of HIV care, particularly in outlying areas of the state, educational sessions have increased provider referrals to the adherence service projects. The program worked closely with the New England AIDS Education and Training Center.

• Individual adherence plans: Developed jointly by provider and client, this model identifies a strategy to assist each person with managing adherence to medications. Similar to a clinical care plan, adherence planning includes identification of the appropriate mix of adherence supports, strategies for side-effect management, and information regarding access to the health care provider between scheduled visits. Project staff developed individualized adherence plans in collaboration with clients, including health care providers, case managers, and health educators.

• Reminder systems: A variety of reminder devices have been made available to project participants, including watches with beepers and alarms; pill boxes that are often filled and counted by the provider; pill boxes that beep; calendars and reminder stickers; and treatment diaries for self-recording. Sites have worked closely with CRI to identify creative and cost-effective strategies for obtaining devices, including advocacy with pharmaceutical companies.

• Treatment education: Written, pictorial, and oral information is distributed to clients in order to explain the complexity of combination therapies, how the medications work, and the consequences of poor adherence. Written materials are being developed to reflect the language and literacy needs of diverse participants. Health care providers and educators with a special expertise in HIV therapies provide education. However, each interaction with a client, whether a social case manager or a peer, provides an opportunity to review and reinforce the material and identify the need for further education.

• Mental health services: Enhanced mental health services were provided, including individual and family assessment, diagnosis, and treatment services. These services were targeted toward HIV-infected people who were coping with dual diagnoses, including mental illness and addiction.

• Incentives: Some sites provided incentives in the form of vouchers for purchasing food and other basic need items. These were distributed as a way to enhance motivation whenever adherence markers or goals were reached.

• Nutritional counseling: Because appropriate nutrition is critical for maintaining a strong immune system, nutritional counseling and support is important. Successful adherence and maximum therapeutic benefit may depend upon the timing of meals and the inclusion or exclusion of certain dietary components. Nutritional counseling was provided on a one-to-one basis.

• Medical visit assistance: Complex treatment information from clinical providers is sometimes better understood when it’s also explained by a peer or volunteer who is present at the medical visit. On a one-to-one basis, individuals received medical visit escorts as support when patients were given complex treatment information.

• On-site pharmacist sessions: At sites providing this service, participants were able to contact a pharmacist who specialized in HIV at the adherence project site.

• Internet training: The World Wide Web has a vast array of treatment and adherence information. Project participants were provided access to the Web, and they were given training regarding how to find useful treatment and adherence information.

• Video teaching tool: One site designed a research intervention based upon the use of video as a key component of an adherence educational and support program. Clients view the video in conjunction with meetings with health care providers.

• Pill-taking skill development: This intervention was designed to teach children, even those as young as two and three years, how to take pills. It helped families address adherence issues with their HIV-infected children.