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Short & Long Term Adherence/Education Programs
Reported by Jules Levin
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A French research group reported on a study to evaluate an adherence counseling intervention on viral load and to identify psycho-social factors contributing to improvement in adherence to HAART. Short-term adherence counseling programs by dedicated, knowledgable & well-trained professionals have been shown to improve success with therapy in this study as well as in previoisly reported studies. We measure success by keeping viral load undetectable or well suppressed. However, ongoing education and support that includes quality treatment education by similarly dedicated, knowledgable & well-trained professionals is also crucial and is sometimes overlooked. That is because adherence and commitment to properly taking therapy often fades over time. Using only well designed short-term programs is good but not enough. It is important to reinforce learned information and skills. It is equally important to keep individuals informed and updated about a number of subjects including future hope for new therapies, complications such as lipodystrophy and ongoing research findings, and the continuous new findings about treatment interruptions. Being informed about subjects like these, which are of key importance to patients is also very relevant to maintaining good adherence.
In the French study, 244 patients who received HAART were randomized to receive the counseling intervention plus ordinary clinical follow-up vs patients who did not receive the counseling. The intervention consisted of 3 interactive counseling sessions focused on HAART regimens and on cognitive, emotional, and social and behavorial factors known to affect adherence by specially trained nurses. Study investigators looked at the percent of patients that were 100% adherent at 6 months. Another French study Išll describe below found that adherence in the first 4 months is crucial to success with therapy. Achieving undetectable viral load and maintaining it for the first year, 2 is better, is crucial to long-term success. One computer study by Andrew Phillips of England found patients who are undetectable at 1-2 years and maintain adherence can stay undetectable for 15-20 years.
Before this intervention program the percent of patients who were 100% adherent was the same in the intervention group & in the patients not receiving intervention (58% vs 63%). But after 6 months 75% the patients receiving the intervention program were 100% adherent vs 61% of the patients not receiving the intervention, and this difference was significant (p<0.01); and the patients receiving the intervention had a better viral load outcome. The study investigators reported the patients receiving counseling & learning more about HIV therapy developed specific skills in their daily routines and were more likely to use pill boxes; the patients receiving counseling were more involved in health care holistic approaches (complementary medicine services, relaxation, massages, etc). Interestingly, the study investigators reported that no difference was found between the counseling & noncounseling groups regarding depression, use of family networks, and negative emotional effects of adverse events such as lipodystrophy. Suggesting that ongoing support, intervention, education, and groups is important. Adherence counseling can help patients develop self-care skills.
The same French researchers (Spire et al) followed 600 patients and their adherence in the APROCO study. These investigators reported that among the 174 patients who had <350 CD4s when starting therapy, the patients who were initially adherent in the first 4 months after starting therapy were more likely to obtain a CD4 count of >200 (2 times more likely). This is similar information supported by other researchers who have reported that for patients who start therapy with lower CD4 counts adherence and the potency of the regimen become more crucial for success. For the patient starting therapy with low CD4s it is important to consider using a more potent regimen and full adherence is important.
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