2. Burning question If we deliver high quality care, will we always achieve great outcomes?
3. Delivering high quality care is a necessary, but not sufficient, factor in achieving optimal outcomes
4. What does it mean to receive care? Patients must use and internalize the care in their daily lives Most care happens at home Patients are at clinic once per month or less There is an “adherence continuum” It is complex, multidimensional, and needs to be enduring over a lifetime
5. Why would poor adherence be a problem? Poor outcomes on the individual level Treatment failure Resistance and fewer treatment options Viral rebound Illness Death Poor outcomes on the population level Resistant virus emergence and fewer treatment options Increased transmission Higher morbidity and mortality burdens
6. The Back Story: 1990s - early 2000 “Adherence seen as potential barrier to ART in RLS”
12. Most recent meta-analysisReview of Adherence at 2 years Rosen et al. PLoS 2007 32 studies in SSA 1996-2007 ~75,000 patients in non-research ART programs Average follow-up time reported 9.9 mo, 77% retention 6 mo = 80% pts retained 12 mo = 60% pts retained At 2 Years*: BEST CASE = 84% WORST CASE = 46% AVERAGE = 61% 61% at 24 months
13. 2. Resistance patterns are different with similar adherence to different regimens NNRTI Resistance develops quickly and nearly linearly Boosted PI Resistance develops more slowly and in a bell shaped curve Bangsberg NY PRN 2009
14. 3. There are external reasons for treatment interruption Unstable drug supply Access issues Life circumstances change
16. A Social Model of Adherence for sub-Saharan Africa Ware and Bangsberg PLoS Medicine (in press) Adherence fulfills responsibility to helpers and preserve relationships as a resource Relationships as resources to overcome economic obstacles to adherence Social Capital Improving Health Social Structural: Patterns of Inequality, e.g., stigma, gender inequality Individual: HIV knowledge Med side effects Cognitive function Mental health Alcohol Use Resource Scarcity Resource Scarcity Infrastructural: Few treatment sites Distance to care Cost/Availability of Transportation Cultural: Religious Beliefs Respect for Authority Importance of having children
17. What can we do to support sustainable adherence? Understand the importance of adherence Prioritize it as a PSYCHSOCIAL AND A CLINICAL issue and a main determinant of outcome It requires a TEAM approach Build program components that are sensitive and specific to supporting and enhancing sustainable adherence Only a certain amount can be accomplished in the facility setting Linkages are critical Patient involvement and self-efficacy are critical
18. This is why we are here To explore on a deep level HOW to build and implement these components Focus on five interventions, two of which have been designated as priority Assessment of adherence within a counseling framework Appointment systems A structured approach CSM Conceptualize, operationalize, implement, assess Model, derive goals and objectives, measure, monitor, intervene, assess
19. For example Operationalizing appointment systems What are the components of a functional appointment system? Using these criteria, every site should have one within one year of this meeting
20. Keep our eyes on the prize The sequence Measuring—allows you to monitor Monitoring—allows you to intervene Intervening– allows you to achieve a good outcome Assessing-- allows you to know if your intervention is working The plan Who? What? How?
21. Special Recognition Pharmacists Part of patient care system Part of multidisciplinary team Key in adherence Last or only person to see patients Encourage the formation of a recommendation for two adherence or patient care-related things each pharmacist should do
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24. Explore CSM as a methodology for doing adherence related work
