HIV TREATMENT ADHERENCE AND SUPPORT. Leonard Anang Sowah, MBChB, MPH, FACP Asst. Professor of Medicine University of Maryland Medical School

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1 HIV TREATMENT ADHERENCE AND SUPPORT Leonard Anang Sowah, MBChB, MPH, FACP Asst. Professor of Medicine University of Maryland Medical School

2 The virus Virus uses host cell machinery to produce viral proteins and proviral RNA HIV virus produces more than a billion cells a day Reverse transcriptase enzyme has a very high error rate 1 every replication cycles 1 Mutant virus have characteristics that may be different from the wild-type virus HIV virus budding of from host cell 1 Coffin JM, Science 1995, 267; 5197: Image Credit -

3 Why is Adherence Important? 95% adherence required for viral suppression Resistance develops rapidly in setting of non-adherence HAART regimens in the setting of resistance more complex Risk of side-effects higher with patients with resistant virus Image credit -

4 Model of Adherence Patient Factors Disease Factors Treatment Compliance and Medication Adherence Social Cultural And Environmental Factors Treatment and Medication Factors

5 Development of Resistance HIV resistance develops when the virus replicates in non inhibiting drug concentrations Can happen in days for certain drugs may take longer with other drugs Viral resistance can affect a single drug or even multiple drugs of same class. Resistant virus may not be as healthy as wild-type virus Usually tends to reduce in relative numbers after the drug that selected for that mutation is withdrawn

6 Mechanisms of reducing resistance HAART (Highly Active Anti-Retroviral Therapy) Using drugs that rapidly reduce viral replication and achieve undetectable viremia Avoiding interactions that reduce drug concentrations or absorption of HIV drugs Using simple regimens and drugs that are well tolerated to ensure better adherence Providing supportive services for patients on ART therapy

7 The Disease Long asymptomatic stage in most individuals Development of drug resistance can occur due to poor compliance to HIV drugs Inherent variation and mutation rate of virus makes mono-therapy ineffective in the long term in most situations Disease manifestation makes it reasonable for people to doubt it is due to a single agent Inability to eliminate virus, thus need for lifelong treatment Mechanism of Infection

8 1. Denial of disease status 2. Lack of disclosure Patient factors 3. Poor insight and lack of education 1 about HIV 4. Lack of self efficacy 5. Depression 4 6. Anxiety disorder 7. Drug use and addiction 5 8. Mistrust of the provider and or health system 2 9. Spirituality Race/Ethnicity 1 Kalichman et al, J Gen Intern Med 1999; 14: Ickovics JR, Meisler AW, J Clin Epideniol. 1997; 50: Meredoth KL et al Health Edu & Behav 2001:28(1) Fairfield KM et al J Gen Intern Med. 1999; 14: Bangberg D. J Gen Intern Med. 1999; 14:

9 Patient Factors contd Reasons given for missing medication doses Kalichman et al, J Gen Intern Med 1999; 14:

10 Spirituality J Gen Intern Med 2006: 21 S62-68

11 Treatment and Medication Factors Regimen complexity 1 Pill burden Fitness of regimen into daily routine 1 Treatment related adverse events Route of drug administration Size of pill Storage of medications (refrigeration) Provider beliefs and expectations of patient 2 1 Gifford AL et al JAIDS (5) Paterson DL et al, Ann Intern Med 2000: 133; Image: wwwimage.cbsnews.com/.../01/24/image537878x.jpg

12 How to Prepare a Patient for ART! It is important to educate patients regarding the benefits and considerations regarding ART, and to address strategies to optimize adherence! On a case-by-case basis, ART may be deferred because of clinical and/or psychosocial factors, but therapy should be initiated as soon as possible.

13 When to Start ART! You have collected baseline labs! You have discussed with the patient the benefits of ART.! The patient is prepared to start therapy.! Genotype results are available.! What are your treatment options?

14 When to Start ART? Current DHHS Guideline! Antiretroviral therapy (ART) is recommended for all HIV-infected individuals, regardless of CD4 T lymphocyte cell count, to reduce the morbidity and mortality associated with HIV infection (AI).! ART is also recommended for HIV-infected individuals to prevent HIV transmission (AI).

15 Best time to Order Resistance Testing in virologic failure With virologic failure, obtain resistance testing while patient is on the failing regimen, or within four weeks of its discontinuation

16 Current FDA approved ART drugs

17 Treatment related Adverse effects Images:

18 1. Social support Socio-cultural 2. Spirituality 1 3. Employment situation 4. Stable housing 2, 3 5. Daily routine 6. Transportation preferences or availability 7. Child care and motherhood 8. Gender related issues 1 Ironson G; Ann of Behav Med. 2002; 24(1): Matinez J; J Natl Med Assoc. 2000; 92: Kiddler DP, Wolitsi RJ; Am J Public Health (12): Image:

19 Jan 42 yr old Caucasian female Active IV drug use Case 1 Heroin and cocaine last use yesterday HIV diagnosed 3 yrs prior to presentation Heterosexual in committed relationship with boyfriend of 2yrs Would like to get treatment for HIV Physical Exam Unremarkable except for scars from prior injection site abscess on left forearm

20 Labs Chem profile normal CBC, 11.8g/dl CD4 count 170 cells HIV Viral Load copies /ml Genotype revealed 2 minor Protease inhibitor mutations Referred for substance abuse counseling Counselor assessment patient willing to quit drug use, but does not feel ready Started on Bactrim and follow up in 4 weeks After 8 mths of some irregular follow up CD4 count dropped to 65 Started on Atripla after discussing adherence

21 Contd After patient was started on medications she was seen in 1mth and was not seen again for 4mths Attempts at reaching out were marginally successful Called patient several times, she promises to come to clinic but fails to show up What are you going to do?

22 Adherence Support by Mobile App

23 Follow up and goals of therapy! Improve quality of life! Reduce morbidity and mortality! Maximally inhibit HIV replication! Plasma HIV viral load lower than 20 c/ml! Prevent HIV transmission! Restore and preserve immunologic function

24 Summary Good adherence to HIV treatment is essential for healthy living in HIV patients The tools for success in ART therapy can be easily inculcated in patients The best outcomes are achieved when clients work well with their providers and support staff