Interventions to improve adherence

As knowledge and experience in this area expands, healthcare providers are increasingly utilising a wide range of adherence interventions. These include the provision of information about HIV and treatments, building pill-taking skills and strategies, practical adherence tools, substance use interventions, and counselling about attitudes and expectations.

Adherence interventions are often individually focused, may be best suited for specific groups or individuals, and typically require significant resources. Also, data on intervention efficacy are still limited.¹ Many of the recent studies tackle the challenge presented by adherence by developing or strengthening the roles of specific professionals, including pharmacists, social workers, nurses and doctors, as well as those of community-based treatment supporters.

The role of pharmacists has been central to adherence since the introduction of highly active antiretroviral therapy (HAART). Two early studies evaluated an enhanced role for pharmacists. In a randomised controlled trial, pharmacists discussed adapting therapy to patients' lifestyles, explained the clinical benefits of adherence and provided telephone support. The result was much higher levels of adherence compared to the control group.² Similar outcomes were found for a pharmacist-led programme of support, education, and planning for everyday life.³ 

Nursing and social work professionals play a similar and central role in patient education and counselling and in developing home care plans for people with HIV.

In regard to physicians, one US study found that the most extensive adherence counselling came from those doctors who treated a greater number of HIV patients and felt that they had the skill, time, and space to do so.⁴

Very high adherence rates have been reported by a clinical practice where a range of interventions were implemented, including extended consultation time; tailoring the regimen to patient lifestyle; frequent follow-up; rapid viral load feedback; and reminder calls and alarms.⁵

Cognitive interventions are designed to teach, clarify, or instruct (e.g. treatment information). This information can be effectively delivered on a one-to-one basis, or through a support group, peer educator, printed material, or other media.

Behavioural strategies are designed to shape, reinforce or influence behaviour (e.g. pager system, individual assessment and counselling, drop-in programmes).

Effective strategies are designed to optimise social and emotional support (peer support, broadly targeted psychotherapy). In practice, many adherence programmes combine various elements of the three approaches. For instance, the 'Healthy Living Project' was an intensive programme of 15 individual counselling sessions covering environmental, emotional, and behavioural aspects of risk-taking behaviour that was provided to over 200 participants in the US. Adherence was later compared to that in a control group of over 3600 patients who did not receive the programme.

All participants had self-reported adherence of 85% or less before the programme began. At months 5 and 15 during the 15-month intervention, adherence was better in the group receiving counselling, but by month 25, adherence was no better in that group than it was in the control group.⁶