Program increases HAART adherence in HIV patients

Nonadherence rates drop drastically

Clinicians at Miriam Hospital in Providence, RI, have drastically increased HIV patients’ adherence to highly active antiretroviral therapy (HAART) during a six-month pilot program.

About 75% of the patients reported prior to the program’s intervention that they had missed a dose of AIDS drugs within the previous four days. After one month of the program, only 22% said they had missed a dose. So far, only one month’s worth of data has been analyzed, but the outcomes look promising, says Jennifer A. Mitty, MD, MPH, assistant professor of medicine at Brown University in Providence and an attending physician at Miriam Hospital.

"Adherence is so important because poor adherence results in drug-resistant virus," Mitty says.

The program, which has grown to 23 HIV patients, began in June 1998. The patients were referred by physicians after they had reported nonadherence to their medications. The group’s demographics are:
• a mean age of 39;
• 76% female;
• 29% white;
• 33% black;
• 29% Hispanic;
• 65% have been in jail or prison;
• 26% are active substance abusers;
• 85% are not working.

At baseline, 48% accurately reported their medication, and 14% correctly reported their dosage; at one month, 60% accurately listed their medications and dosage.

Drugs delivered by community members

The program works this way: Two peer outreach workers who are not health care professionals deliver medications to the patients each day, Monday through Friday. They meet patients at their homes or at some other place that the patients choose. On Friday, they leave medication for the weekend. A nurse packages the medication in daily doses.

When they deliver the medication, they watch the patient take the morning dose, and they check to see if the previous day’s evening dose has been taken. One of the workers speaks Spanish, and both are members of the community in which the patients reside.

The program, which cost less than $40,000 for the first six months, was funded by a Lifespan/ Tufts Center for AIDS Research grant in Boston and Providence. The program received money from three pharmaceutical companies: Glaxo Wellcome, Bristol-Myers Squibb, and Merck. The patients’ AIDS drugs are covered through Medicaid or the Rhode Island Drug Assistance Program.

Mitty says the program began with the daily visits and eventually weaned the patients down to visits three times a week, then two times a week, and finally once a week.

HIV patients who have trouble adhering to their drug regimens probably should be followed indefinitely, Mitty says.

"We’d like to observe people by giving them a weekly pill pack, and if we see someone going through a major life stress, then we could increase the visits," she explains. "For example, if someone has picked up a substance abuse problem or has become homeless, then we could say that once a week is no longer good enough."

Although the pilot program was developed for six months, Mitty says it will be continued as a weekly outreach project.

The nine patients who first began on the program had an average viral load decrease of 1.2 log after one full month. Also, their average CD4 cell count increased from 215 to 283, Mitty says.

"The program’s effectiveness still needs to be determined, but it is feasible for others to implement a program such as this, and it’s been very well accepted by patients," Mitty says.

She suggests other communities and medical centers could start such a program fairly inexpensively, perhaps even using volunteers as outreach workers.

The program’s future may include incorporating patient education in the outreach work, Mitty adds. The outreach workers already serve as links to the medical clinic because if they see a patient has a medical problem, they’ll contact Mitty or another professional.

"I don’t know if this program is for everyone, but it definitely serves the needs of certain populations," Mitty says. "The whole point is to design interventions appropriate to the population being served."