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

12th World AIDS Conference

Abstracts 32376-32379 597

pain, and no change in health status) were predictive of non-adherence to lifeextending HIV combination therapies; whereas gender, level of education, and
income were not predictive.
Conclusions: Non-governmental AIDS service organizations may need to
develop interventions to assist certain subsets of the HIV/AIDS population adhere to complicated drug routines. Such targeted efforts will help decrease the
development of resistance to HIV medications and help improve the overall efficacy of drug therapies among particularly vulnerable subgroups of the HIV/AIDS
population.
32376 Poor medication adherence extends to opportunistic
infection prophylaxis
Jane Settle, Michael Wong, V.M. Watson, M.R. Goolsby, L.G. Kaplowitz. Medical
College of Virginia Hospitals PO. Box 980019 Richmond VA 23298, USA
Issue: Antiretroviral adherence is a major concern for the sustaining viral suppression and limiting the development of multi-drug resistant HIV-1 mutants.
However, adherence issues are not limited to antiretroviral agents, and may
further tax medical resources. We report one project in which the prescription and
adherence patterns to prophylaxis for Pneumocystis carinii were studied.
Setting: The Medical College of Virginia Hospitals is an 800 bed tertiary care
university based medical center in Richmond, Va. That serves a city of 203,000
and surrounding area of -1 million. The Infectious Diseases Clinic is the primary
site for HIV care for -50% of the HIV infected persons in the Central Virginia
region and the State Department of Corrections. Of the 1200 patients seen, 650
patients have an AIDS diagnosis.
Methods: 25% (n = 150) of charts of those persons with CD4 counts -250 or
thrush were reviewed retrospectively for orders for PCP prophylaxis (daily or every-other-day trimethoprim/sulfamethoxazole, daily dapsone, monthly aerosolized
pentamidine or other medication combinations). Appropriateness of medication
ordered was evaluated by reported side-effects or laboratory profiles, and when
indicated, G6PD documentation for dapsone. Adherence was determined by patient compliance with follow-up appointment, request for medication refills, and
documentation after direct questioning in the chart.
Results: PCP prophylaxis was provided and ordered appropriately for 100%
of patients according to the USPHS guidelines. Side effects were addressed in
a timely fashion. Patient compliance with follow-up (within 4-6 weeks of initial
visit) was poor. When questioned, we found patients compliance with written
instructions to be low. Several potentially preventable hospital admissions for
PCP were also identified; there were no potentially preventable deaths.
Conclusions: Medication adherence is a universal problem not limited to antiretroviral agents. This one study underscores the need for newer adherence
programs to improve patient understanding and improving patient willingness
to accept prescribed medications. The problem is clearly multifactoral, and not
limited to the "ease of administration".
32377 Patient adherence to antiretroviral therapy
Nikola Ostrop1 2, K. Hallett2, M.J. Gill1. 1Southern Alberta Clinic, 231, 906 8
Avenue S.W., Calgary, Alberta, T2P 1H9; 2Southern Alberta Clinic, Foothills
Medical Centrem, Calgary, Alberta, Canada
Background: Patient adherence to a prescribed drug regimen affects patient
specific outcomes, clinical drug research and pharmacoeconomics. It especially
plays a critical role in antiretroviral therapy, where the avoidance of resistance is
of great importance.
Methodology: Patients starting new antiretroviral agents and not partaking in
clinical trials were enrolled into a one-year retrospective, one-year prospective
study addressing patient adherence. Tools used included prescription refill data
and 2 questionnaires in the prospective phase. Data analyzed includes overall
compliance, compliance with individual antiretrovirals and change in compliance
over time, as well as factors influencing compliance.
Results: 100 patients were enrolled into the study, scheduled to terminate in
April 1998. Overall adherence was higher than reported in previous studies. As
well, trends over time were seen and a number of events attributed to these identified. Box plots show the medians and distributions of adherence rates. There are
few subjects with poor adherence as shown by the adjacent and extreme values.
Total number of medications a patient was taking did not have a significant impact,
while other factors including compliance tools, side effects, regimen design and
patients' attitude toward therapy played a role. Final data will be obtained in April
1998 and presented.
Conclusion: Overall adherence to antiretroviral treatment regimens was higher
than previously reported. However, a number of patients with less than adequate
adherence remains, underlining the importance of addressing this issue. Factors
affecting adherence have been identified and may guide further efforts in the
improvement of compliance.

S32378 Adherence to antiretroviral medications in HIV-infected
children: A collaborative approach with guidelines for
care
Ann-Margaret Dunni, J.P. Navarra2, J. Cervia3. 1Cornell University Medical
College, New York, NY 2Town Total Health, New York, NY, USA
Issue: The recent scientific advances on the pathogenesis of HIV (Human Immunodeficiency Virus) disease have resulted in combination antiretroviral treatments

as the standard of care. Adherence to such regimens often proves difficult for
the HIV infected child who may be required to take antiretroviral medications
unavailable in pediatric formulations. Medication adherence is an indispensable
component of the treatment plan, due to the potential for the development of
resistant HIV strains from missed doses.
Project: These guidelines were developed after five years of clinical experience using antiretroviral treatment regimens in >175 children with congenital HIV
infection.
(1) Be knowledgeable of side effects and adverse reactions of the prescribed
antiretroviral medications, and communicate this information to the child and
family. Unexpected side effects may result in the family's discontinuation of the
treatment drug(s).
(2) Utilize educational materials and a printed schedule of the treatment regimen. Demonstrate use of any tools (i.e. pillbox) given to family, and ask for a
return demonstration.
(3) Provide illustrations of increases in CD4 counts and decreases in viral loads.
These can serve as an important means of positive reinforcement.
(4) Tailor treatment plans to meet individual needs of the child and family.
(5) Utilize the support of other professionals such as pharmacists who are
a key resource for drug information. They can review medication profiles, discuss potential drug interactions, provide medication consultations, and reinforce
instructions prior to dispensing the drug.
(6) Offer telephone support and continuing education when prescribing a complicated treatment plan.
Results: Implementation of these guidelines has resulted in improved adherence to complex treatment regimens, with an 89% decrease in mortality and an
8% decrease in the number of hospitalized days in 1997.
Lessons Learned: It is more important than ever for children and families facing
chronic illness to be active participants in treatment plan. Collaboration not only
supports adherence to treatment regimens, but also improves self-esteem and
ultimately quality of life. Improved adherence to therapy may result in measurable
decreases in morbidity and mortality for HIV-infected children.
S32379 Self reported treatment adherence and drug/alcohol use
are associated with virologic outcomes in CCTG 570:
A clinical strategy trial of HIV RNA antiretroviral (ARV)
monitoring
Richard Haubrich', Susan Little2, M. Dube3, D. Forthal4, G. Beall5, C. Kemper6,
J. Hwang2, J.A. McCutchan2. 12760 Fifth Avenue Suite 300 San Diego
California 92103-6325; 2University of California San Diego, San Diego, CA;
3University of California Los Angeles, Los Angeles CA: 4 University of California
Vine, Orange, CA; 5University of California Harbor, Torrance, CA, 6Santa Clara
Valley Medical Center, San Jose, CA, USA
Objectives: To evaluate the relationship between virologic and immunologic
outcomes of ARV therapy and self-reported adherence.
Methods: In a randomized trial of intense HIV RNA (. 6 x/yr) vs mostly
CD4 monitored (RNA 2x/yr) and unrestricted ARV therapy (CCTG 570), patients
completed a self-report questionnaire at months 0, 2 and 6. Reported adherence
during the past 4 weeks [categorized as adherent (>-95% = ADH) or not (-_95%
= NA)] was compared to change in log10 HIV RNA (ARNA) and CD4 (ACD4)
from baseline to months 2 and 6. Reported use of recreational drugs or alcohol,
satisfaction with provider, and the provider's assessment of subject ADH were
also evaluated.
Results: Neither assignment to RNA or CD4 monitored group nor satisfaction
with the provider effected ADH (p > 0.05), but use of drugs or alcohol reduced
ADH (47% vs 84%, p = 0.0006 at month 6). Patients who reported ADH and
NA at baseline (n-140) had similar ARNA and Aat months 2 or 6. Patients who
reported ADH at month 2 had greater ARNA (-.9 vs -.4, p = 0.009) and ACD4
(+37 vs; +19, p = 0.09) at month 2 than NA subjects, but these outcomes were not
sustained at month 6. Subjects who reported ADH at month 6 had a better month
6 outcome (i.e, ARNA -1.1 vs --.5, p = 0.02). The provider's estimation of patient
ADH did not predict HIV RNA or CD4 response while use of alcohol or drugs
was associated with poor response (ARNA 0.1 vs --1.1, p * 0.01 at month 6).
Sustained ADH (adherent at 2 of 3 questionnaires) and assignment to the RNA
monitoring group were found to be independent predictors of viral suppression.
Average HIV RNA reductions were.82 vs 0.57 in ADH vs NA patients (p = 0.04).
Conclusion: Self reported ADH and drug or alcohol use were associated with
virologic and immunologic outcomes of ARV therapy. Reported ADH predicted
outcome independent of monitoring assignment (RNA vs CD4) in CCTG 570.
Patients with consistent ADH had sustained HIV RNA suppression. Provider
estimation of subject ADH did not predict treatment response. Self reported adherence can predict treatment outcome over the short term and may be useful to
identify patients at risk for nonadherence.
S32380 Adherence and antiretroviral responses to highly active
antiretroviral therapy (HAART) in patients infected with
human immunodeficiency virus (HIV): Comparison

between an outpatient clinic and a clinical trials unit
Terhi Heinasmaki1, Q. Shi2, T. Creagh3, U. Mathur-Wagh2, A. Marshak2
T. Kanmaz2, D. Mildvan2. Lisankatu, 19 E 20, 00170, Helsinki, Finland, 2Beth
Israel Medical Center, New York NY; 3Clinical and Epidemiology Consultants,
Atlanta GA, USA
Objective: To compare adherence indicators and antiretroviral responses to