Antiretroviral Adherence Strategies

ANTIRETROVIRAL ADHERENCE STRATEGIES
Strategies Examples
Provide an accessible, trustworthy, nonjudgmental multidisciplinary health care team

• Care providers, nurses, social workers, case managers, pharmacists, and medication
managers

Strengthen early linkage to care and retention in care

• Encourage healthcare team participation in linkage to and retention in care

• Use Anti-Retroviral Treatment and Access to Services Intervention (ARTAS) training, if available

Evaluate patient’s knowledge about HIV disease, prevention and treatment and, on the basis of the assessment, provide HIV‑related information

• Considering the patient’s current knowledge base, provide information about HIV, including the natural history of the disease, HIV viral load and CD4 count and expected clinical outcomes according to these parameters, and therapeutic and prevention consequences of non‑adherence

Identify facilitators, potential barriers to adherence, and necessary medication management skills before starting ART

• Assess patient’s cognitive competence and impairment

• Assess behavioral and psychosocial challenges including depression, mental illnesses, levels of social support, high levels of alcohol consumption and active substance use, non‑disclosure of HIV serostatus and stigma

• Identify and address language and literacy barriers

• Assess beliefs, perceptions, and expectations about taking ART (eg, impact on health, side effects, disclosure issues, consequences of non‑adherence)

• Ask about medication taking skills and foreseeable challenges with adherence (eg, past difficulty keeping appointments, adverse effects from previous medications, issues managing other chronic medications, need for medication reminders and organizers)

• Assess structural issues including unstable housing, lack of income, unpredictable daily schedule, lack of prescription drug coverage, lack of continuous access to medications, transportation problems

Provide resources for the patient

• Resources to obtain prescription drug coverage, stable housing, social support, transportation assistance, and income and food security

• Referrals for mental health and/or substance abuse treatment

Involve the patient in ARV regimen election

• Review regimen potency, potential side effects, dosing, frequency, pill burden, storage requirements, food requirements, and consequences of nonadherence

• Assess daily activities and tailor regimen to predictable and routine daily events

• Consider preferential use of PI/r-based or dolutegravir-based ART if poor adherence is anticipated

• Consider use of single tablet regimen formulations

• Assess if cost/co‑payment for drugs can affect access to medications and adherence

Assess adherence at every clinic visit

• Monitor viral load as a strong biologic measure of adherence

• Use a simple behavioral rating scale or self-reported assessment

• Employ a structured format that normalizes or assumes less-than-perfect adherence and minimizes socially desirable or “white coat adherence” responses

• Ensure that other members of the health care team also assess adherence

Use positive reinforcement to foster adherence success

• Inform patients of low or non-detectable levels of HIV viral load and increases in CD4 cell counts

• Thank patients for attending appointments

Identify the type of and reasons for nonadherence

• Failure to understand dosing instructions

• Complexity of regimen (eg, pill burden, size, dosing schedule, food requirements)

• Pill aversion

• Pill fatigue

• Adverse effects

• Inadequate understanding of drug resistance and its relationship to adherence

• Unaware of appointments or appointments not scheduled with proper patient input

• Cost-related issues

• Depression, drug and alcohol use, homelessness, poverty

• Stigma

• Non-disclosure

Select from available effective adherence and retention interventions

• Use adherence-related tools to complement education and counseling interventions (eg, pill boxes, dose planners, reminder devices)

• Use community resources to support adherence (eg, visiting nurses, community workers, family, peer advocates, transportation assistance)

• Use patient prescription assistance programs

• Use motivational interviews

• Provide outreach for patients who drop out of care

• Use peer or paraprofessional treatment navigators

• Recognize positive clinical outcomes resulting from better adherence

• Arrange for directly observed therapy (DOT) in patients in substance use treatment, if feasible

• Enhance clinic support and structures to promote linkage and retention (eg, reminder calls, flexible scheduling, open access, active referrals, improved patient satisfaction)

Systematically monitor retention in care

• Record and follow up on missed visits

NOTES

ART = antiretroviral therapy; ARV = antiretroviral; PI/r = ritonavir-boosted protease inhibitor

Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. Department of Health and Human Services. Available at https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/
AdultandAdolescentGL.pdf
. Accessed January 6, 2022 [Table 19].

(Rev. 1/2022)