Simi Padival MD November 3 2016 Objectives Learn about the importance of assessing adherence to antiretroviral therapy ART Learn about the components of assessing for ART adherence Discuss frequency of monitoring while on ART ID: 731419
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Slide1
Adherence Monitoring in HIV Care
Simi Padival, MD
November 3, 2016Slide2
Objectives
Learn about the importance of assessing adherence to antiretroviral therapy (ART)
Learn about the components of assessing for ART adherence
Discuss frequency of monitoring while on ARTSlide3
Case
A 37 y/o man with a history of depression and intermittent crystal methamphetamine use is recently diagnosed with HIV and presents for his first visit with you. He has been sober from drug use for the last 3 months and works as a waiter at a restaurant. His CD4 count is 270 and the HIV viral load is 183,000. He is withdrawn and tearful at times regarding the diagnosis. He has not told anyone else about the diagnosis of HIV. However he understands that ART is recommended and feels ready to start lifelong therapy.
What factors may affect his ability to adhere to ART?Slide4
Adherence to ART
Strict adherence to ART is important
Provides suppression of HIV
Improves overall health and survival
Decreases risk of drug resistance
Decreases risk of HIV transmission
Chesney MA
.
J
Acquir
Immune
Defic
Syndr
.
2006
.
Cohen MS, et
al.
NEJM
.
2011.Slide5
Adherence to ART
Bradley H, et al. MMWR 11/14.
36% with HIV
76% of those on ARTSlide6
Adherence to ART
Multiple factors influence adherence to ART
Social situation
Clinical condition
Side effects or pill burden
Psychosocial factors
Maturity of the patient/
age
Linking medication to daily
activities
Patient-Provider relationship
Thompson A, et al. Ann Intern Med. 2012.Slide7
Case
A 47 y/o man with HIV and a h/o intermittent noncompliance has recently started ART with
Truvada
and
Tivicay
after 2 years of being lost-to-
followup
. He returns 4 weeks after starting therapy for assessment while on treatment.
How would you assess for adherence? Slide8
Assessing Adherence
No gold standard…
Providers are bad at assessing adherence
In one study, providers incorrectly predicted adherence 41% of the time
Patient self report is most frequent method of assessment
But may overestimate adherence
Report of poor adherence associated with viremic breakthrough
Allows for immediate way to identify issues and try to correct them
Paterson DL,
e
t al
. Ann Intern Med
. 2000.DHHS Antiretroviral Guidelines for Adults and Adolescents. 2016.Slide9
Assessing Adherence
Nonjudgmental questioning
Think about specific questioning
“How many pills do you think you missed in the last 2 weeks?
”
“What time do you take your medication?”
Assist patient with understanding importance of adherence
Assess for comorbidities that may impact ability to take meds daily
Housing stability, mental health disorders, substance use disorders
DHHS Antiretroviral Guidelines for Adults and Adolescents. 2016.
Lazo
M, et al.
Clin Infect Dis. 2007.Slide10
Assessing Adherence
Viral load monitoring is a surrogate for adherence
Assessing pharmacy records may be helpful
Encourage use of pillboxes or alarms as a reminder
Pill counts, electronic device monitoring, serum drug levels not widely recommended but may have utility in special circumstances
Thompson A, et al.
Ann Intern Med
.
2012.
DHHS Antiretroviral Guidelines for Adults and Adolescents. 2016.Slide11
Case
A 37 y/o woman with a h/o HIV diagnosed 8 years ago from injection drug use. She has been sober from drug use for 8 years and started
Atripla
6 years ago. She has no other comorbidities and reports stable housing and works as a teacher’s assistant. Her CD4 count is 588 and HIV viral load has been suppressed since starting therapy.
How often would you monitor her?Slide12
Virologic Response
The goal of treatment is viral
load suppression below the limits of assay
detection
Virologic
Failure:
Viral load >200 copies/mL by 24 weeks of ART
Sustained
viremia
>200 copies/mL on 2 measurements after initial viral suppression
DHHS Antiretroviral Guidelines for Adults and Adolescents.
2016.Slide13
Viral Blips
Laprise
, C et al.
Clin
Infect Dis
.
2013
Virologic
FailureSlide14
Frequency of Monitoring
Depends on
Factors that influence adherence
How long they have been virally suppressed
ComorbiditiesSlide15
Frequency of Monitoring
If starting ART:
Followup
2-4 weeks later
Assess understanding of the treatment regimen
Assess side effects
Assess for adherence/how they take the ART
Check HIV viral load
If stable on ART:
Followup
every 3-6 monthsContinue to assess for adherence
Check HIV viral loadCheck CD4 count consider every 6-12 months after 2 years of HIV suppression
DHHS Antiretroviral Guidelines for Adults and Adolescents. 2016.Slide16
Conclusions
Strong adherence is necessary to suppress HIV and prevent transmission to others
Monitoring of adherence is an important part of HIV care and requires careful assessment of multiple factors that influence adherence
Viral load monitoring is the most reliable way to assess for response to treatment
Monitoring frequency is dependent on ability to maintain HIV suppressionSlide17
References
Chesney MA. The elusive gold standard. Future perspectives for HIV adherence assessment and intervention.
J
Acquir
Immune
Defic
Syndr. 2006; 43
Suppl
1: S149-155.Cohen MS, et al. Prevention of HIV-1 infection with early antiretroviral therapy.
NEJM. 2011; 365(6): 493-505.Vital Signs: HIV Diagnosis, Care, and Treatment Among Persons Living with HIV — United States, 2011
. MMWR. November 28, 2014 . Vol 63. No 47. Thompson MA, et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel.
Ann Intern Med. 2012. 156 (11): 817-833. Paterson DL, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection.
Ann Intern Med. 2000;133(1):21.Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://
aidsinfo.nih.gov
/
contentfiles
/
lvguidelines
/
AdultandAdolescentGL.pdf
(Accessed 10/31/16)Slide18
References
Lazo M, et al. Patterns and predictors of changes in adherence to highly active antiretroviral therapy: longitudinal study of men and women. Clin Infect Dis. 2007; 45(10):1377.
El-Sadr WM, et al. Strategies for Management of Antiretroviral Therapy (SMART) Study Group. CD4+ count-guided interruption of antiretroviral treatment. NEJM. 2006. 355: 2283.
Laprise C, et al. Virologic failure following persistent low-level viremia in a cohort of HIV-positive patients: results from 12 years of observation. Clin Infect Dis. 2013;57(10):1489.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at
http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf
Girard PM, et al. Can we stop CD4+ testing in patients with HIV-1 RNA suppression on antiretroviral treatment? AIDS. 2013. 27 (17): 2759-63.