PHYSICAL DISABILITY KNOWLEDGE DEFICIT. Reasons for Non-Adherence PERSONAL HEALTH BELIEFS

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1 HIV and Medication Adherence Competency Tool Human Immunodeficiency Virus (HIV) infects around 50,000 people in the US every year. As of 2012, about 1.2 million people in the US were infected with HIV, of whom approximately 12.8% of people did not know they were infected. It is important for medical providers to understand the issue of medication adherence as it relates to the control of HIV in order to mitigate the advancement of disease in their patients. Median HIV medication adherence in the US is between 60-70%, however researchers suggest that the Antiretroviral (ARV) adherence threshold be greater than 90%. 3,4 Non-adherence allows for viral replication of HIV and loss of immunological and clinical benefits of the ARVs. Non-adherence can also limit future treatment options for patients. 1 To view more EBI s visit the CDC website at REASONS FOR NON-ADHERENCE The first step in overcoming non-adherence is detecting any potential barriers to adherence. Potential barriers include: Patients may have disabilities that prevent them from continued adherence. This may include vision impairment, motor disability, and trouble eating or swallowing. 13 The Patient may not understand what the medication does and why they are being prescribed the medication. 13 PHYSICAL DISABILITY KNOWLEDGE DEFICIT Patients may be unable to read/ understand medication name and/or the medication instructions (i.e., frequency and doses). 13 ILLITERACY Reasons for Non-Adherence FINANCIAL CONCERNS Patients may limit the frequency of pill consumption in order to make medications last longer or abstain from refilling prescriptions due to finances. 13 Patients may forget to take medication as a result of a lack of organization or a lack of routine management. 13 MEMORY/ DISORGANIZATION PERSONAL HEALTH BELIEFS CULTURAL AND FAMILY BELIEFS Fear due to religious beliefs, or fear of discovery by a friend or family member, may cause patients to become less diligent with their regimen. 13 Patients may fear that the medication may do harm or cause addiction. 13 In collaboration with

2 Understanding why a patient is non-adherent will aid in pin-pointing the right intervention to increase his/her adherence. The following protocol was formed by the Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization to provide a standard approach in evaluating a patient s ability to optimize their medication adherence. 13 Utilize the tools on the following pages during patient visits to keep abreast of any issues that affect his or her medication adherence. MED TEACHING STRATEGIES Purpose: To promote a consistent approach to assessing, teaching, and evaluation the patient s knowledge and ability related to the Improvement in Management of Oral Medications outcome measure. ASSESS Make sure comprehensive assessment includes learning assessment and barriers: Sensorimotor barrier? Environmental barrier? Cognitive barrier Emotional barrier? Language barrier? Pain/discomfort? Cultural/religious practices? Poor motivation? TEACH Make sure teaching includes aspects that can improve self-administration: Visual recognition of the drug? Purpose? Dosing & administration? Brand & generic names? Expected duration of therapy? When to take medication relative to meals, sleep, etc. What to do in case a dose is missed? What to do if the condition being treated becomes/remains a problem? EVALUATE Make sure to evaluate and document the patient s or caregiver s response to your teaching: Needs review? Repeats knowledge with cue(s) OR performs actions under supervision? Verbalizes knowledge/performs actions spontaneously (without cueing/supervision)?

3 MANAGING YOUR MEDICINES Many people need help in managing their medicines. One of our goals is to help you understand the purpose of your medicines and how to take them correctly. I have new medicines. I have changed medicines. PLACE A CHECKMARK IN THE BOX ON THE RIGHT OF THE STATEMENT IF IT APPLIES TO YOU I don t understand the instructions related to my medications. I am not sure how my medicines help my condition. I don t think that my medicines help me. I am concerned about side effects. I don t always remember to take my medicines at the right time. I have trouble reading or seeing small print instructions on medicine bottles. I have trouble holding the small pills or opening the packaging or the medicine bottles. I have trouble paying for my medicines. Please write down any other concerns you may have:

4 MEDICATION ASSESSMENT PROTOCOL Purpose: To provide a standardized approach to evaluating patient ability to administer medications. INSTRUCTIONS Have patients demonstrate how he/she takes his/ her medication. Ask if the patient has any help to prepare or select the appropriate medications Once the medication supplies are available: Ask the patient to describe how he or she would proceed with taking his or her medicines (i.e., ask specifically, What would you do first? Second? etc.) CLINICAL OBSERVATION/ASSESSMENT Observe the patient performing preparatory activity (e.g., gathering medication supplies or moving to area where medications are routinely stored/organized). Is the process organized? Identify compliance aids used. If the patient does have assistance, determine (through observation and interview) if the assistance is necessary. Is the process appropriate as described? Correct dosage, time, and frequency? Check the patient s response against the directions for his or her specific medications. If ability to sequence the multi-step medication administration task is not evident: Ask the patient to demonstrate a multi-step medication administration task (i.e., Please show me how you would open your medicine bottles and take your medication. Check adherence: As part of the comprehensive assessments and on an ongoing basis. Does the patient demonstrate ability to appropriately complete all steps in the task? Selects the appropriate bottles Opens each one and selects the correct dosage prior to closing lid(s) Takes medication as directed Closes lid(s) and returns bottles to storage area. Review calendar, diary, list, pillbox, etc. to determine compliance. Select one medication with known start date and count pills to verify compliance. Does patient have any established daily routines which are, or could be, tied-in to medication administration? Promoting and practicing these tools can help alleviate the burden placed on healthcare providers. Also, encouraging patient discussion of potential barriers to adherence ensures that providers are informed, and increases the patients trust in his/her medication regimen.

5 References 1 Gordon, Lindsay L., Derenik Gharibian, Karen Chong, and Helen Chun. Comparison of HIV Virologic Failure Rates Between Patients with Variable Adherence to Three Antiretroviral Regimen Types. AIDS Patient Care and STDs 29.7 (2015): Web. 2 Van Dyk, Alta C., BSocSc, PhD. Differences Between Patients Who Do and Do Not Adhere to Antiretroviral Therapy. Science Direct. Journal of the Association of Nurses in AIDS Care, July-Aug Web. 3 Moitra, Ethan, James D. Herbert, and Evan M. Forman. Acceptance-based Behavior Therapy to Promote HIV Medication Adherence. AIDS Care (2011): Web. 4 Conway, Brian. The Role of Adherence to Antiretroviral Therapy in the Management of HIV Infection. JAIDS Journal of Acquired Immune Deficiency Syndromes 45.Supplement 1 (2007): n. pag. Web. 5 Gay, Caryl, Carmen J. Portillo, Ryan Kelly, Traci Coggins, Harvey Davis, Bradley E. Aouizerat, Clive R. Pullinger, and Kathryn A. Lee. Self-Reported Medication Adherence and Symptom Experience in Adults With HIV. Journal of the Association of Nurses in AIDS Care 22.4 (2011): Web. 6 Gaur, Aditya H., Marvin Belzer, Paula Britto, Patricia A. Garvie, Chengcheng Hu, Bobbie Graham, Michael Neely, George Mcsherry, Stephen A. Spector, and Patricia M. Flynn. Directly Observed Therapy (DOT) for Nonadherent HIV-Infected Youth: Lessons Learned, Challenges Ahead. AIDS Research and Human Retroviruses 26.9 (2010): Web. 7 Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention. Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 20 Apr Web. 22 Feb Stigma, Discrimination and HIV. Global Information and Advice on HIV & AIDS. AVERT, 20 Nov Web. 9 Scheurer, Danielle, MD, Niteesh Choudhry, MD, PhD, Kellie Swanton, BA, Olga Matlin, PhD, and William Shrank, MD, MSHS. Association Between Different Types of Social Support and Medication Adherence. Association Between Different Types of Social Support and Medication Adherence. American Journal of Managed Care, 18 Dec Web. 23 Feb Dayer, Lindsey, Seth Heldenbrand, Paul Anderson, Paul O. Gubbins, and Bradley C. Martin. Smartphone Medication Adherence Apps: Potential Benefits to Patients and Providers. Journal of the American Pharmacists Association 53.2 (2013): Web. 11 Graziani, Amy L., PharmD, John G. Bartlett, MD, and Jennifer Mitty, MD, MPH. Patient Information: Tips for Taking HIV Medications (Beyond the Basics). Tips for Taking HIV Medications. UpToDate, 12 Sept Web. 23 Feb Center for Disease Control and Prevention Medication Adherence (MA) Chapter Compendium of Evidenc-Based Interventions and Best Practices for HIV Prevention. Accessed February Quality Insights of Pennsylvania, the Medicare Quality Improvement Organization for Pennsylvania Best Practices for Improvement in Management of Oral Medications Medication Assessment Protocol Accessed March Additional Resources 1. Haberer, Jessica E., Nicholas Musinguzi, Yap Boum, Mark J. Siedner, A. Rain Mocello, Peter W. Hunt, Jeffrey N. Martin, and David R. Bangsberg. Duration of Antiretroviral Therapy Adherence Interruption Is Associated With Risk of Virologic Rebound as Determined by Real-Time Adherence Monitoring in Rural Uganda. JAIDS Journal of Acquired Immune Deficiency Syndromes 70.4 (2015): Web. 2. Ironson, G., S. Weiss, D. Lydston, M. Ishii, D. Jones, D. Asthana, J. Tobin, S. Lechner, A. Laperriere, N. Schneiderman, and M. Antoni. The Impact of Improved Self-efficacy on HIV Viral Load and Distress in Culturally Diverse Women Living with AIDS: The SMART/EST Women s Project. AIDS Care 17.2 (2005): Web. 3. Viswanathan, Shilpa, Amy C. Justice, G. Caleb Alexander, Todd T. Brown, Neel R. Gandhi, Ian R. Mcnicholl, David Rimland, Maria C. Rodriguez-Bar radas, and Lisa P. Jacobson. Adherence and HIV RNA Suppression in the Current Era of Highly Active Antiretroviral Therapy (HAART). JAIDS Journal of Acquired Immune Deficiency Syndromes (2015): 1. Web. 4. Cha, Eunseok, Judith A. Erlen, Kevin H. Kim, Susan M. Sereika, and Donna Caruthers. Mediating Roles of Medication taking Self-efficacy and Depressive Symptoms on Self-reported Medication Adherence in Persons with HIV: A Questionnaire Survey. International Journal of Nursing Studies 45.8 (2008): Web. 5. Rao, Deepa, Betsy J. Feldman, Rob J. Fredericksen, Paul K. Crane, Jane M. Simoni, Mari M. Kitahata, and Heidi M. Crane. A Structural Equation Model of HIV-Related Stigma, Depressive Symptoms, and Medication Adherence. AIDS Behav AIDS and Behavior 16.3 (2011): Web. 6. Gold, Deborah T. Medication Adherence. JMCP Journal of Managed Care Pharmacy 12.6 Supp A (2006): n. pag. Web.