BACKGROUND/RATIONALE:
It is estimated that the VHA is caring for nearly 40 percent of all HIV-infected veterans. To benefit from recent improvements in anti-HIV therapy, patients need to take their medications consistently.

OBJECTIVE(S):
Optimizing health for HIV patients requires excellent adherence to antiretroviral medication regimens. However, its unclear how best to incorporate adherence education and support programs into VA HIV outpatient care. We implemented and evaluated a pharmacist program (ACE) and a Pager reminder program to support adherence in veterans with HIV.

METHODS:
We used a quasi-experimental design with pre-post evaluation at four VA Centers. Three treatment conditions (ACE, Pager, Usual Care) were rolled-in sequentially over two study phases, allowing for group comparisons between conditions. ACE is a multi-component manualized 4-session, individual patient education and support program by trained pharmacists. The Pager intervention used alphanumeric pagers to remind patients of dosing times. Electronically-monitored medication adherence (MEMS), self-report questionnaires, and pharmacy refill records were collected. Qualitative site interviews were collected before and after interventions to assist with program evaluation. Multilevel mixed models were used to analyze main study outcomes over time. Secondary analyses compared subgroup who actually received all ACE sessions (“as treated”) to controls.

FINDINGS/RESULTS:
We enrolled 291 HIV+ veterans. Medication adherence rates were far below guidelines, averaging 80-85% at baseline, and decreasing further over time to less than 60%. Veterans assigned to ACE did not have significantly better medication adherence than Usual Care across all adherence measures. Mean adherence in the Pager reminder group was not significantly different than Usual Care. In subgroup analyses, survival analyses of time to regimen failure showed significantly longer time to failure in those who received 4 ACE sessions than Usual Care (p= 0.023). Baseline antiretroviral-naïve patients who received 4 ACE sessions had higher levels of MEMS adherence than Usual Care.

Conclusions:
Referral to a 4-session pharmacist medication adherence support program did not improve short-term antiretroviral adherence, nor did provision of a pager to remind patients of doses.

IMPACT:
The problem of nonadherence to HIV medications within the VA is large, important, and challenging. More intensive interventions to improve medication prescribing in veterans with HIV are necessary and specific high-risk populations such as drug-naïve patients may be more likely to benefit. Future interventions should be tailored, using adherence assessments to better diagnose nonadherence and select problems to be addressed.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Gifford AL, Groessl EJ. Chronic disease self-management and adherence to HIV medications. Journal of acquired immune deficiency syndromes. 2002 Dec 15; 31 Suppl 3:S163-6. [view]
2. Shively M, Smith TL, Bormann J, Gifford A. Evaluating Self-Efficacy for HIV Disease Management Skills. AIDS and behavior. 2002 Dec 1; 6(4):371-379. [view]
3. Bormann J, Shively M, Smith TL, Gifford AL. Measurement of fatigue in HIV-positive adults: reliability and validity of the Global Fatigue Index. Journal of The Association of Nurses in AIDS Care. 2001 May 1; 12(3):75-83. [view]
4. Korthuis PT, Asch S, Mancewicz M, Shapiro MF, Mathews WC, Cunningham WE, McCutchan JA, Gifford A, Lee ML, Bozzette SA. Measuring medication: do interviews agree with medical record and pharmacy data? Medical care. 2002 Dec 1; 40(12):1270-82. [view]
5. Gifford AL, Bormann JE, Shively MJ, Wright BC, Richman DD, Bozzette SA. Predictors of self-reported adherence and plasma HIV concentrations in patients on multidrug antiretroviral regimens. Journal of acquired immune deficiency syndromes. 2000 Apr 15; 23(5):386-95. [view]

Conference Presentations

1. Gifford AL. Adherence measurement and reminders: Tools for researchers and clinicians. Paper presented at: Society of General Internal Medicine Annual Meeting; 2001 May 4; San Diego, CA. [view]
2. Gifford AL. Adherence to Antiretroviral medications. Paper presented at: Adult AIDS Clinical Trial Group Annual Meeting; 2000 Dec 11; Arlington, VA. [view]
3. Gifford AL, Chen Y, Looney D, Goetz MB, Ampel NM, Holodniy M, Bozzette SA. Estimating HIV Drug Adherence: Pharmacy Records and Patient Self-Reports. Paper presented at: VA HSR&D National Meeting; 2004 Mar 8; Washington, DC. [view]
4. Gifford AL, Chen Y, Looney D, Goetz MB, Ampel NM, Holodniy M, Bozzette SA. HIV Drug Adherence and Disease Response: Using Pharmacy Records and Patient Self-Reports. Paper presented at: VA QUERI National Meeting; 2003 Dec 10; Washington, DC. [view]
5. Bormann J. Reliability and Validity of HIV Medication History Questionnaire. Paper presented at: Association of Nurses in AIDS Care Annual Meeting; 2003 Nov 20; New York, NY. [view]

DRA: Health Systems
DRE: none
Keywords: Education (patient), Education (provider), HIV/AIDS
MeSH Terms: HIV