Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

588 Abstracts 32335-32338

12th World AIDS Conference

poor adherence. However poor adherence was often due to treatment-related
side effects and psychosocial problems. Interventions to improve adherence and
durability of response must also address these additional barriers to effective
HAART.
446*/32335 Why is highly active antiretroviral therapy (HAART)
not prescribed or why is it discontinued -
A prospective analysis in the Swiss HIV cohort
study (SHCS)
Manuel Battegay1, Stefano Bassetti1, M. Rickenbach2, M. Flepp3, H.J. Furrer4,
A. Telenti2, P. Vernazza5, E. Bernasconi6, P. Sudre7. 1University Hospital of
Basel Petersgraben 4, 4031 Basel; 2University of Lausanne, 1011 Lausanne;
3University Hospital of Zurich, 8091 Zurich; 4University of Berne, 3010 Berne;
5Cantonal Hospital of St Gallen, St Gallen; 6Cantonal Hospital Lugano, 6900
Lugano; 7University Hospital of Geneva, 1211 Geneva, Switzerland
Objectives: To investigate why highly active antiretroviral therapy (HAART) was
not prescribed or why it was discontinued and to define predictors for abstinence
of HAART in the Swiss HIV Cohort Study (SHCS). HAART is always indicated
in HIV-infected individuals with CD4 cell counts <500//l according to Swiss HIV
guidelines. However, HAART defined as triple therapy combining one or two
reverse transcriptase inhibitors with one or two protease inhibitors may not be
offered or may be discontinued.
Methods: All individuals of the SHCS presenting at one of the 7 study centers in
a time period of two months in the second half of 1997. Individual was interviewed
and a two page structured questionnaire was filled out.
Results: 2,183 individuals were analyzed of whom 1,495 (68.5%) had HAART.
From 688 individuals without HAART, 378 (54.9%) had dual therapy, 287 (41.7%)
had no therapy, and 6 (0.9%) had monotherapy; (data missing n = 17). The physician's reasons not to prescribe HAART (multiple answers possible, n defines
answers) were mostly a) the prognosis was perceived as good without HAART (n
= 262) and b) anticipated non-adherence (n = 111). From the patient's perspective
HAART was not taken because a) treatment seemed to complicated (n = 105),
b) fear of side effects (n = 103), and c) HAART was viewed as not beneficial (n
= 96). In 130 of 688 individuals HAART was previously discontinued. Treatment
was stopped (physician's view) because of a) side effects or interactions with
other drugs (n = 86) and b) treatment failure (n = 13). HIV-infected individuals
selected a) fear of side effects (n = 31) and b) treatment is to complicated as
most important reasons (n = 30).
Conclusion: Non-adherence (doctor's perspective) and presumed difficulties
to take HAART (participants perspective) are important reasons why HAART is
not prescribed currently. Further analysis and relation to possible risk factors for
absence of HAART will suggest strategies to improve adherence to therapy.
S393*/32336 Increasing active drug users' adherence to HIV
therapeutics
Robert Broadhead, D.D. Heckathron1, P.G. O'Connor2, P.A. Selwyn2. Dept. of
Sociology, 1Univ. of Connecticut, Storrs, CT;2 Yale University School of
Medicine, New Haven, CT USA
Issues: Active drug users suffer from both low utilization of, and adherence to,
primary care for HIV disease. Combining drug treatment and primary care on-site
reduces these problems significantly because it creates a support structure in
which program staffs can monitor patients' adherence and provide ongoing encouragement. But in the US, only a very small minority of drug users with HIV
disease receive this demonstrably effective form of care.
Project: We report pilot-study results of an alternative support structure, termed
a "peer-driven intervention," that serves as a functional equivalent to drug treatment for increasing active drug users' adherence to HIV therapeutics.
Methods: The six month study included fourteen adult active drug users receiving medical care for HIV disease in New Haven, Connecticut: three White and
five African-American males, and one White and five African American females.
As Health Advocates, each subject was assigned and asked to meet with a
patient-Peer once a week at the project's storefront. The assignments were made
by a Health Educator (HE) who oversaw the study's daily operations. In the HE's
presence, each Advocate assessed his or her Peer's level of adherence using
a standardized questionnaire, and provided counseling. As Peers, each patient
was assigned and asked to meet with a peer-Advocate once a week in order for
the Advocate to assessed the Peer's adherence. No two patients played both
roles for one another. Advocates earned direct monetary rewards for eliciting
positive responses from their Peers in keeping clinical appointments, responding
to physicians' referrals, picking-up prescriptions on time, and attending weekly
meetings with the Advocate.
Results: The Peers succeeded in keeping 95% (130 of 137) of their appointments with clinicians and Advocates. Significant adherence to antiretroviral drug
regimens occurred among the subjects. For 30 or the 36 meetings in which
adherence scores were calculated, Peers' medication adherence scores for the
previous week averaged 80% or higher. Eight of the subjects enrolled in drug treat
ment, and significant reductions in drug-related risk behaviors occurred among
the remaining active users. None of the subjects dropped out of the study.
Lessons Learned: Active drug users receiving treatment for HIV disease
responded strongly to guidance and incentives to serve as Health Advocates
in helping Peers keep up with their treatments. The pilot demonstrates that an
alternative social support structure to drug treatment is possible for increasing
drug users' adherence to medical care. Innovative mechanisms that harness drug

users' peer pressure to promote positive behavioral changes are deserving of
greater study.
Supported by the National Institute on Drug Abuse R01 08014.
32337 Adherence to protease inhibitor (PI) therapy in clinical
practice: Usefulness of demographics, attitudes and
knowledge as predictors
Valerie E. Stone1, J. Adelson-Mitty2, C.A. Duefield1, K.A. Steger3, M.D. Stein4,
K.H. Mayer1. 1'Memorial Hospital of Rhode Island, 111 Brewster Street,
Pawtucket, RI 02860; 2Miriam Hospital, Providence, RI; 3Boston Medical Center,
Boston, MA; 4Rhode Island Hospital, Providence, RI, USA
Objectives: To describe adherence to PIs in clinical practice, strategies for
maximizing adherence, motivators for adherence, usefulness of knowledge and
education about PIs, and pt demographics as correlates of adherence.
Methods: Multi-center study of 248 pts in care for HIV/AIDS at one of five
urban sites. Structured interviews of patients (pts) and medical record review of
visits between 7/96 and 12/97 were performed. Of the pts on a PI, data was
collected on pt reported adherence, motivators for adherence, frequency and
reasons for missing doses, pt strategies for maximizing adherence, knowledge
about PI adherence and education received regarding PIs.
Results: Of the 248 patients enrolled, 151 (62.7%) were currently receiving a PI
containing regimen for >1 month. Ninety-three percent (93%) of pts were aware
of the importance of taking PIs as prescribed, and 73% described their adherence
as excellent or very good. Reported adherence was as follows: 119 (79%) missed
one or more doses of their PI; 21 (16%) missed a dose in the last day; 39 (26%)
missed one or more doses in the last 3 days, 33 (22%) took a "drug holiday" for
one or more full days. Most frequent reasons for missing doses were: forgot to
take dose (36%), feeling sick (13%), and too busy (7%). Two-thirds (102) of pts
used special strategies to enhance their own adherence, these include using a
pill box or special container (72%); a rigid schedule (33%); and beeper, timer, or
alarmed watch (23%). Motivators for taking PIs were: belief that PI will extend
their life (62%), family/partners (11%), health care provider (8%), and knowledge
of decreasing viral load (7%). All but 10 pts received education about PIs and
how to take them. Neither knowledge of necessity for adherence nor education
received about PIs was predictive of adherence. Analysis of pt demographics
(race, sex, risk factor, drug use, children at home, alcohol abuse, education,
employment status) showed a history of alcohol dependence or a history of drug
use predicted poorer adherence (p < 0.05).
Conclusions: In a diverse urban cohort of pts in clinical practice adherence
to PIs was not ideal, but was quite good, with 50% of pts missing a dose less
frequently than once a week. Knowledge of the necessity for close adherence to
PIs was nearly universal and most pts received education about PIs; neither of
these were significantly related to better adherence, perhaps because they were
so universal among this group. Alcohol and drug abusers were less adherent
than others; otherwise pt demographics were unrelated to PI adherence.
S32338 Self-reported adherence to combination antiretroviral
medication (ARV) regimens in a community-based
sample of HIV-infected adults
Allen L. Gifford, M.J. Shively2, J.E. Bormann2, D. Timberlake3, S.A. Bozzette1.
1SDVAMC and Univ. of California, San Diego, 2VA San Diego Health Care
System, San Diego, 3University of California, San Diego, CA, USA
Objective: To describe and determine the correlates of ARV regimen adherence
in a community-based sample of HIV-infected adults in clinical care.
Methods: Subjects enrolling in a randomized trial of HIV patient education
completed detailed self-administered instruments measuring demographics, clinical status, behaviors, beliefs, and ARV adherence. ARV-adherent subjects were
those with no missed or reduced doses of any ARV during the previous week.
Bivariate analyses were conducted to explore predictors of ARV adherence (x2
unless otherwise noted).
Results: Of 57 trial subjects enrolled to date, 50 were on ARVs, and 43 were
on highly-active (HAART) regimens (>3 drugs with >1 protease inhibitor [PI] and
>1 reverse transcriptase inhibitor). Most subjects were male (92%), white (60%),
gay (80%), and educated (72% completed high school); 62% had AIDS. Overall,
52% (26/50) were adherent to ARVs; adherence was similar (53%) in those on
HAART. In all 20 cases of HAART nonadherence, PIs were the drugs missed.
Adherent subjects had lower mean CD4 counts than nonadherent subjects (354
vs 474; p < 04 by t-test), and were less likely to contact the doctor by telephone
(p <.03). Self-efficacy for using ARVs was higher in adherent subjects (p < 01;
Wilcoxon rank-sum). Beliefs predicting adherence included: the medications fit
into my daily routine, my HIV is responding to the medications, and I will be able to
take my medications as instructed (all p < 01). Beliefs predicting nonadherence
were: if people take anti-HIV medications now they may not work later, and it's
hard to get the medication I need (all p < 03). Reasons for missing ARVs were:
busy/forgot (52% subjects), away from home (42%), change in daily routine (40%),
felt depressed (23%), felt the drug was toxic (19%), took a drug holiday (19%).

Conclusions: Even among educated patients motivated to enroll in patient
education, ARV nonadherence is very common. In this sample, all HAART nonadherence involved nonadherence to Pls. While drug toxicities and drug "holidays"
occur, daily distractions and changes in routine may be greater contributors to
ARV nonadherence. Prospective data should lead to a better understanding of
the causal relationships between clinical factors, beliefs, and ARV adherence,
and of how patient education influences medication use.