Adherence Strategies

Program for couples improves adherence

Researchers study impact of bringing in partner

A couples’ adherence program called SMART for Sharing Medical Adherence Responsibilities Together significantly improves medication adherence over typical care, a recent study shows.1 SMART encourages HIV sero-discordant couples to support each other with both HIV prevention and the infected partner’s medication adherence.

Years of research into the dynamics of sero- discordant couples shows that such couples do well when encouraged to take care of each other’s health by keeping the uninfected partner free of HIV and keeping the infected partner as healthy as possible, says Robert H. Remien, PhD, a research scientist at the HIV Center for Clinical and Behavioral Studies at New York State Psychiatric Institute in New York City. He also is an associate professor of clinical psychology in the College of Physicians and Surgeons at Columbia University, also in New York City.

"We know there are a lot of factors related to adherence on the part of the patient: mood and beliefs and attitudes about treatment and understanding the need for high levels of adherence," Remien says. Other factors include medication side effects, adherence reminders, depression, and substance use, he adds.

"All can facilitate or be barriers to high levels of adherence," Remien notes. "But social support in general and having people in your life who care about you taking your medications and provide emotional support for your doing this is important."

SMART helps committed couples improve social support and reinforce the positive feelings that accompany an HIV-infected person who feels healthy despite side effects and disease, he reports.

The SMART study, which enrolled 215 HIV sero-discordant couples, found a significant difference in adherence change at the week 20 assessment among the proportion of doses taken within a specified time window, but did not find a significant difference at the week 32 assessment.

Investigators used the Medication Event Monitoring System cap (MEMS cap) method of measuring adherence, which provided information about the times the pill container was opened, with the goal of having subjects take their pills within a two-hour window of prescribed medication time, Remien reports.

"We looked at three months and six months post-intervention, and the effect wore off," he says. "I would argue that adherence interventions, particularly in challenging populations, are not a one-time or short-time deal; I think it needs to be integrated into clinical care on an ongoing basis."

Investigators also found that 47% of the intervention group demonstrated adherence greater than 90% post-intervention, compared with 25% of the control group achieving greater than 90% adherence.

"Even with these significant effects on behavioral outcomes, the effects were modest," Remien says. "It’s not like we got a majority of people up above 90%, and a lot of people didn’t improve substantially."

Adherence studies often show some disappointing results, such as having short-term but not long-term improvements, he reports.

"I would argue that interventions should coincide with regular, routine care, but at what kind of magnitude and at what intensity, we don’t know," Remien says. "We do know that without doing it, whatever effects you get aren’t going to be maintained."

The SMART program was designed with a collaboration of clinicians at St. Lukes Roosevelt Hospital Center in New York City, he says.

"We developed the intervention with nurse practitioners and psychologists in the clinic, and we wrote this intervention to be delivered by a health care provider such as nurse practitioners, as in our case," Remien explains.

Here’s how the program worked:

1. Recruitment: Providers referred patients for the study, and patients referred themselves from fliers dispersed in clinic waiting rooms, Remien says.

"They had to be on therapy for a minimum of a few weeks or a month, but there was no maximum amount of time," he explains. "Some of these patients had been on therapy for many years, and some participants were on their second, third, or more regimens."

So it’s likely that many of the participants had resistant virus caused by their previous poor adherence, Remien notes.

2. Spending time with medical provider: The couples who participated in the intervention had four sessions with medical providers. The process evaluation demonstrated that they largely enjoyed the process, Remien says.

Participants also reported that they liked learning more about their treatment, seeing the MEMS cap feedback, and receiving help with communication within their relationships.

They also said they would have liked even more sessions, Remien adds.

"The negative partner liked being able to come into the clinic setting, sitting down with medical providers and hearing all of the things about adherence and how HIV therapy works," Remien explains. "Both the patient and their partner liked spending that kind of time with the medical provider and being able to ask a lot of questions."

3. Discuss prevention: "Because these were sero-discordant couples, we addressed sexual risk behaviors," Remien says.

"The couples had a lot of questions about that, including the risk of transmission with an undetectable viral load and the risk of specific sex behaviors," Remien says. "The sample was predominantly heterosexual, but it included some same-sex couples."

Among the heterosexual couples, many had questions about pregnancy concerns, and the nurse practitioners could address and discuss these issues.

4. Focus on support and reminders: The uninfected partners were encouraged to remind their HIV-positive partners to take their medications, Remien says.

In the second session, for instance, couples were taught how to increase their communication skills and mutual support. (See outline of SMART intervention.)

At later sessions, the nurse practitioner would discuss the MEMS cap data and say to couples, "Let’s look at where we had problems: Was it the evening dose or on weekends?" Remien says. "What can we do to not miss the medication on Saturday night and that sort of thing?"

For SMART to be cost-efficient and effective, it would need to be provided by a health educator, who ideally is a nurse, social worker, or nurse practitioner, he suggests.

"I think it needs to be integrated into clinical care on an ongoing basis," Remien says.


  1. Remien RH, Stirratt MJ, Dolezal C, et al. Couple-focused support to improve HIV medication adherence: A randomized controlled trial. AIDS 2005; 19:807-814.