International AIDS Conference

Internet paging system helps improve adherence

Counseling is combined with reminders

Special coverage

HIV patients who began a study with very low medication adherence made some improvements after several months of being prompted by an Internet-based paging system. But their adherence still was far from the 95% goal of HIV medication treatment programs, according to a study presented at the 14th International AIDS Conference in Barcelona, Spain.

"People’s adherence was really low at the beginning with 55% to 57%, and the pager system did improve adherence," says Steven Safren, PhD, a research scientist at Fenway Community Health in Boston. Safren also is an associate director of the Cognitive Behavioral Therapy Program at the psychiatry department of Massachusetts General Hospital and an assistant professor at Harvard Medical School, both in Boston.

After two weeks of being prompted by the pager system, adherence climbed to 70%, but it fell back to 64% after 12 weeks, he says. The group of HIV patients who did not receive the pager prompts had adherence rates of 56% at two weeks and 52% at 12 weeks.1

The pager system worked this way: A clinician or investigator had input a patient’s medication regimen into an Internet computer program; the patient carried a beeper that had a display window, and when it was time for the patient to prepare or take a pill, the beeper notified the patient with instructions, Safren explains. For example, the display might read: "Remem-ber, don’t eat for the next hour," or "Take your pill, and don’t eat for the next two hours."

Patients’ adherence to the program was assessed through a pill bottle system that recorded each time a patient opened the bottle to take out a pill. Although this system is considered more reliable than self-reporting, it could possibly underreport adherence because there may be times when a patient takes out more than one dose in order to put some pills away for when the patient will be away from home, Safren notes.

Ironically, the Internet-based paging system that was used for the study, called MediMom, no longer exists. The business folded during the dot.com failures, he says. Similar systems may exist in the United States, and in Europe, a paging system is being marketed that makes use of regular cell phones, so patients would not need to purchase or rent a pager, Safren says.

A combination of strategies more effective

Since the paging system hasn’t proven to be highly effective, clinics and physicians who want to improve patient adherence should consider an approach that uses more than one strategy. For example, a paging or reminder system could be combined with counseling and behavioral modification.

In the case of a patient with severe social and behavioral problems, there are alternative approaches to direct observational therapy, and these would be less resource intensive. For example, a program could have these patients return to weekly one-on-one meetings to work on their adherence skills, and they could be given both a pill box and a reminder system, such as a pager or watch alarm, Safren says.

Another strategy is for a counselor to have the patient go through a checklist of steps that help the patient plan for taking the medication. These steps may include memory cues, such as having the patient schedule to take pills during another daily task. The morning pill could be taken when the patient brushed his or her teeth, for instance, he says.

"A lot of HIV-related interventions involve three components: information, motivation, and behavioral skills," Safren says. The information component would include educational materials, as well as individualized education, but this by itself is not enough to help people change their health behavioral skills, Safren says.

Motivational interviewing is a technique sometimes used for people beginning or considering a behavioral change. This technique may include an exercise in which an interviewer asks a patient to examine the short-term and long-term pros and cons of behavior. This technique is based on the transtheoretical model of change characterized by acknowledging that people are at different stages of readiness to change, Safren says. "So one person might be at a pre-contemplative level where they don’t see the behavior as a problem," he explains. "The use of motivational interviewing is to try to motivate them to go to a higher level."

And the third focus on behavioral skills may include providing patients with assistance in achieving adherence, such as teaching them skills to cope with medication side effects, Safren says. A behavioral skill technique could include teaching patients to think about the reasons why they are taking their medications each time they begin to feel that the medication makes them feel worse or is too much trouble.

Reference

1. Safren SA, Hendriksen ES, Boswell S, et al. Twelve-week outcome of a cue-controlled paging system to increase ART adherence. Presented at the 14th International AIDS Conference. Barcelona, Spain; July 7-12, 2002. Abstract WePeB5864.