OOCCUUVolume 14 Number 2 January 1999

FF A Guide toAIDSResearch and Counseling

SSTalking to other health professionals, I

am often struck by the way in which pooradherence is accepted as something thatis “natural,” an unfortunate fact of life thatno one likes but that you just have toaccept. I believe, however, that adherenceis achievable: it takes a large amount ofwork and there are no short cuts but thereare many things that health providers cando to assist adherence.

I am a primary care physician practicingin Sydney, Australia. My practice is com-posed almost exclusively of well-educat-ed, seropositive, gay men with effectivesocial support systems. Of the approxi-mately 500 seropositive patients I treat,about half of them were diagnosed priorto 1990 and one quarter diagnosed after1995. Almost all were diagnosed early inthe course of illness; few presented withan opportunistic illness. This articledescribes the approach I have taken tofacilitate adherence in this particularpopulation at three critical points in theprocess: before initiating treatment;immediately after initiating treatment;and at every point during therapy.

Building a Foundation for AdherenceWhat I do not do at any time is simply

give out information sheets about treat-ments. Information giving is necessary but,in itself, it is not sufficient to ensure thebehavior changes necessary for high levelsof adherence. It is not enough simply totell individuals what they should do.

Before a patient begins therapy, I spenda minimum of two hours with that individ-

ual making sure that he or she understandsthree things: why he or she needs to begintreatment, that he or she can do it, andhow he or she can do it. This task—as wellas others I discuss here—need not be theexclusive domain of doctors and could justas easily be done by other health staff:nurse practitioners, physician assistants,pharmacists, or counselors. (Other taskscould also be accomplished by communitygroups and peer support.) But someonemust make this commitment.

In my practice, I am the one who con-ducts this orientation. First, I go throughmy beliefs about treatments. I am veryclear that I believe the treatments workand that taking them makes a difference.I don’t think that any health provider canexpect patients to care about taking drugsproperly if the health provider is not ableto impart the belief that taking the drugsis important. When I have asked patientswhy they will begin therapy with me whenthey would not with another physician, Ihear the same response again and again:“When Dr. X said it was up to me—that Icould take them if I wanted—I never gotthe idea it was important, I never felt likeit was really going to make a difference.”

I spend time ensuring that each individ-ual understands why he or she needs totake the drugs with a high degree ofadherence, offering what I call HIV 101and the rules of HIV therapy. I begin byexplaining HIV, how it reproduces, whatmutations are, what resistance is, andwhat viral load is and why it is important.I begin with the knowledge an individualpatient brings, build on it, and individual-ize my approach. At the end of HIV 101,patients have to understand how HIVreproduces and why resistance is a prob-lem with this virus. If patients don’tunderstand these things, I believe it isunlikely they will adhere.

The Process of Supporting AdherenceCassy Workman, MBBS

From this, I proceed to my three rules of HIV therapy:

• Never give the virus an even break.(Keep drug levels up and HIV reproduc-tion down)

• Give HIV an inch and it will take acombo. (Let it reproduce and it willmutate, let it mutate and it will developresistance)

• Keep options, don’t throw them away.(Let resistance develop and you’vewasted an option).

The Capacity to Adhere The second task is to help individuals

understand that they can attain a highdegree of adherence. Different drug combinations require different thingsfrom different patients. The only way to respond to these requirements andachieve high rates of adherence is toindividualize regimens for each patient,which requires truly understanding the patient.

To individualize a regimen, I need toknow the earliest time and the latest timethe patient gets up and goes to bed,whether he or she eats as soon as getting

up, and what he or she normally eats.Does all of this change on weekends?Does the individual live with other peo-ple? Has the individual disclosed his orher serostatus to those people? Does theindividual feel the need to hide medica-tions? Where does the individual normallyeat breakfast and dinner: at home, at apartner’s house, at friends’ homes? Canthe individual keep treatments at his orher partner’s house? Does the individualcome home from work before going out,does he or she go out straight from work?Does he or she regularly travel for work?Does the individual drink alcohol, andhow much and how often? Does he or shesmoke or use recreational drugs? Howoften does the individual wake up some-where he or she did not plan to be?

I never assume anything and try toindividualize everything. If I do not fit acombination to my patients in this way, I am asking them not only to take treat-ments and not forget to take them, butalso to change their lives around. That is a lot to ask.

An example clarifies this process. A newpatient, I’ll call him Sam, came to see me:he said, “I just can’t take these treatmentsthe right way.” Sam was an occasional

FOCUS2 January 1999

In Geneva this past summer, it was not unusual to hear criti-cism of the World AIDSConference’s focus on adher-ence. Several sessions consid-ered a broad range of topicsrelated to the psychosocialissues faced by people trying tosustain difficult antiviral treat-ment regimens. But manybelieved that adherence wastaking precedence over a host ofother HIV-related psychosocialconcerns, including those facedby people in developing coun-tries, where treatment remainstoo inaccessible for adherence toeven begin to be an issue.

It is clear nevertheless thatadherence remains a centralconcern—not only in the worldof HIV disease, but also through-out medicine. To the extent thatmedications are accessible, the

challenges of complex regimenshave significant effects on thequality of life of people with HIVdisease (not to mention theability to sustain treatment andtherefore health).

The Role of ProvidersMuch of the adherence litera-

ture focuses on the role ofclients themselves in maintain-ing medication adherence. But, itis clear that providers, startingwith medical staff and includingmental health and social serviceprofessionals, can play animportant part in ensuring thatclients have the knowledge andskills to apply to the challengeof taking their medicationsregularly.

This issue of FOCUS dealswith this aspect of care: whatcan providers do to prepare and

support their clients takingmedications? Cassy Workman,an Australian physician whopresented on this topic at theWorld AIDS conference, is firmabout the obligation of medicalproviders to facilitate an ongo-ing process of education andproblem-solving. Her goal is to individualize therapy so herpatients have the best chance of adhering to regimens. TimTeeter, who works with disad-vantaged clients, sets similargoals for his efforts with home-less people with HIV.

The issue of adherence isimportant for another reason.Because it so clearly straddlesmedicine and mental health, itmay offer lessons to providersin both areas about the complex-ity of each field. In particular, byapplying some of Workman’sprinciples, medical providersmay better understand ways ofincorporating quality-of-lifeissues and mental health intomedical practice.

Editorial: Adherence and IndividualsRobert Marks, Editor

FOCUS3 January 1999

injection drug user with what could bestbe described as a chaotic lifestyle. He hadseen a hospital-based specialist prior tocoming to me. This doctor had prescribeddidanosine (ddI), staduvine (d4T), andindinavir, one of the most difficult anddemanding regimens for patients to take.Luckily, Sam took the combination onlyfor a day and when he just could notadhere, stoppedbefore a resistantstrain couldemerge. When Italked to Sam, Idiscovered that nomatter how chaotichis life became, healways ate twice aday and he alwaysate at home.Switching to nelfi-navir, ritonavir,d4T, and lamivu-dine (3TC), twice a day at the timeswhen he eats, Sam has notmissed a dose innine months.

Medication sideeffects have animpact on adherence, and almost allantiviral drugs we currently use havesignificant side effects. Anticipating theseside effects and how to handle them givespatients the belief and the capacity torespond to them without missing doses. Ifdiarrhea is a possible side effect of a drugI prescribe, I outline a treatment plan inadvance in case it emerges: I give thepatient prescriptions for the drugs he orshe might need to overcome this sideeffect—I don’t leave it to him or her tohave to come back to my office to treatthe diarrhea. I do everything I can to helppatients feel that they are in control. Thatincludes making them aware that there areother regimens we can choose if the sideeffects are severe or if there is some otherreason an individual cannot manage thiscombination.

Anticipating ObstaclesSome physicians prescribe a couple of

standard combinations, attempting to getall of their patients to fit into these combi-nations. I don’t believe that this works.Currently, we are using 18 different com-binations in my practice because what isright for one individual is not right for thenext. When a physician individualizestherapy, it shows patients that they can

incorporate their medications into theirlives rather than having their lives ruledby their medications.

As I point out to patients, there aredozens of things that they do everyday,often many times every day. They get up,they get to work or school on time, theyremember what time their favorite pro-grams are on television, they get dressed.

I tell them that they canremember to take their drugsas well, that the trick is tocome up with ways to helpthem do this.

To begin, I give everypatient written instructionsabout their combination:what it is, what it looks like,when to take it, whether it isnecessary to eat or not to eatwith it. The next thing I do isto try to minimize failure.Too often I hear doctors say,“But everyone is going tomiss doses.” I try to antici-pate when a person is likelyto miss a dose based on hisor her individual characteris-tics and to create safety netsbefore this happens. I suggesta variety of approaches

including: using beepers, storing drugs atfriends’ homes and at work, gettingreminder calls, getting their computer toremind them, and timing doses withmeals. I tell patients that they may stillmiss doses but that they need to dealwith each and everyone of these episodesas a problem-solving exercise and not as aguilt-producing opportunity. I suggestthat if an individual misses a dose once,it is likely that those same circumstances(or very similar ones) will arise again. Isuggest that they think “laterally,” encour-aging them to create a different safety netevery time they miss a dose so they won’tmiss it again.

I don’t expect my patients to fail. I don’tthink taking drugs is impossible forpatients. I don’t put patients on drugsuntil I have come up with a combinationthat they believe they can succeed intaking. I consider all of these thingsbefore a patient begins treatment.

Sustaining AdherenceIt is unreasonable to expect patients

to make major changes to their lives andcontinue to do so in a void. So I challengethe practice of instructing patients start-ing treatment to return in three monthstime. In my practice, we book an appoint-

I try to anticipatewhen a person is

likely to miss adose based on hisor her individual

characteristicsand to create

safety nets beforethis happens.

AuthorsDr. Cassy Workman isDirector of GroundZero Medical, an inner-city, community-basedHIV practice in Sydney,Australia. Dr. Workmanhas been involved inthe Australian re-sponse to HIV forseveral years, both asa medical practitionerand through communi-ty-based non-govern-ment organizations. Inrecent years, she hasbecome increasinglyinvolved in HIV clinicalresearch and is cur-rently Associate Direc-tor of AIDS ResearchInitiative (ARI) inSydney. Dr. Workmanadapted this articlefrom a speech given at the 12th World AIDSConference in Geneva.

ment for the patient one week afterbeginning treatment, with the under-standing that if all is going well thepatient can cancel the appointment andtalk to me by telephone instead. A visit atthe end of the second week is non-nego-tiable. At this point, we measure viralload and review all the problems thepatient may be having. I make sure thathe or she is taking the combination in theright way and that there are no problemsthat we did not foresee.

I expect viral load testing to demon-strate some improvement very quickly. Ifthere is not at least a half log drop in viralload in the first two weeks, then I considerchanging therapies. I believe that measur-ing viral load at this point and getting theresults back to patients within a week isone of the biggest single steps I take thatmakes a difference. Seeing a viral loaddrop from 600,000 to 15,000 after 14days provides an incredible boost toadherence. While patients may believethat the drugs are going to work, they alsoneed to be shown that they are working.

I routinely see my patients every six toeight weeks. If a combination is going tofail or if they are going to develop sideeffects, I want to know about it as soon asthey do; I want the best chance of successwith another regimen, and this occurswhen you switch at the lowest possibleviral load.

At every consultation I ask them abouttheir experience taking their regimens. Iused to ask them if they have missed anydoses and if so, how we can stop it nexttime. But, I found that I would get one-dimensional answers: “once” or “a coupleof times.” Now, I ask “In what situationshave you found it difficult to take yourdrugs since I last saw you?” I get a very

different type of answer: patients start totell me of the situations that have beendifficult, when they have missed dosesand when they think they might in thefuture. Most of my patients come in andtell me what they have changed before Iask: they are working it out by themselves.

Recently, one of my patients, I’ll callhim Terry, started off his consultationwith the following story: “I found I hadproblems on pay day. We all go out for afew drinks after work, and while I alwaysmean to go home after, it just doesn’thappen. We always end up going out todinner somewhere. So, I have to make adecision about going home to get myritonavir or going out to dinner, and Iwant to go out to dinner. But I’ve workedit out. The ATM machine where I get outthe money for dinner is next to where myfriend works. He’s got a fridge at work,and I’m storing extra doses there.”

ConclusionAll of this individualized attention takes

a lot of time, time that may be difficult tofind in any practice. Again, it is importantto note that delivering this level of serviceneed not fall on the shoulders of thephysician alone: nurses, physicians assis-tants, and counselors can undertake manyof the necessary tasks. Perhaps moreimportant is that while all of this efforttakes time, it saves time too. Terry, thepatient I described above, would probablyhave ended up missing doses once a week.He would have developed resistance and itwould have taken more time to find a newcombination that would work. The processto ensure an individualized regimen andsupport for patients in adhering savestime in the end—and it potentially saveslives.

FOCUS4 January 1999

ReferencesFowler ME. Recognizing thephenomenon of readiness: Conceptanalysis and case study. Journal of theAssociation of Nurses in AIDS Care.1998; 9(3): 72-76.

Gourevitch MN, Wasserman W, PaneroMS, et al. Successful adherence toobserved prophylaxis and treatmentof tuberculosis among drug users in amethadone program. Journal ofAddictive Diseases. 1996; 15(1): 93-104.

Huss K, Travis P, Huss RW. Adherenceissues in clinical practice. Lippincott’sPrimary Care Practice. 1997; 1(2): 199-206.

Ickovics JR, Meisler AW. Adherence inAIDS clinical trials: A framework forclinical research and clinical care.Journal of Clinical Epidemiology. 1997;50(4): 385-391.

Kalichman SC, Ramachandran B,Ostrow D. Protease inhibitors and thenew AIDS combination therapies:Implications for psychological ser-

vices. Professional Psychology:Research & Practice. 1998; 29(4): 349-356.

Kelly JA, Otto-Salaj LL, Sikkema KJ, etal. Implications of HIV treatmentadvances for behavioral research onAIDS: Protease inhibitors and newchallenges in secondary prevention.Health Psychology. 1998; 17(4): 310-319.

Malow RM, McPherson S, Klimas N, etal. Adherence to complex combinationantiretroviral therapies by HIV-positivedrug abusers. Psychiatric Services.1998; 49(8): 1021-1022.

Ngamvithayapong J, Uthaivoravit W,Yanai H, et al. Adherence to tuberculo-

Clearinghouse: Adherence

FOCUS5 January 1999

The factors that complicate medicationadherence among homeless people aresimilar in some respects to the factorsfacing other people with HIV disease—dealing with adverse side effects, handlingcomplex daily dosing schedules—but thesechallenges are often complicated by con-current substance abuse and mental ill-ness, and require different approaches in a population that has neither the financialnor social resources of more stable clients.This article presents strategies for workingwith homeless people, not only to increasetreatment adherence, but also—and moreimportantly—to help clients prioritizeregular health care. The approaches in thisarticle are informed by work with clients ofthe San Francisco AIDS Foundation (SFAF),which last year provided services to morethan 2,300 clients, many of whom fit theprofile mentioned above.

The Tiered ApproachWhile there are astonishing stories of

people who successfully adhere to treat-ment despite homelessness or marginalhousing, experience suggests that it ispremature to begin HIV treatment discus-sions with clients without also helpingthem to begin to meet their basic needs.Through focus groups and program evalua-tion interviews, many clients at SFAF reportthat they are not able to address regularmedical care until their lives begin to stabi-lize. While many homeless people havedifficulty establishing regular medical care

with a consistent health care provider,without this stabilizing link, adherence to HIV medications is not possible.

The connection with the client deter-mines all future work toward adherence.Supportive case management is a tool tofacilitate this connection and to assist the client to stabilize his or her life andaddress basic needs such as housing andfood, while assuring mental health, sub-stance abuse or domestic violence crisesare also addressed. For many clients, thenext tier of case management focuses onestablishing mental health and substanceabuse treatment. Medical care fits here aswell: the case manager plays a vital role inencouraging regular health care visits,contacting health care providers, monitor-ing the relationship between providersand clients, and arranging transportationto and from health care visits. As basicphysical and health care needs begin to beaddressed, the client’s level of trust in thecase manager or treatment advocate willincrease, and meaningful conversationsabout HIV treatment can begin.

Initiating Treatment ConversationsUnfortunately, not all primary health

care providers have the time to providesufficient HIV treatment education to theirpatients. But the knowledgeable casemanager or treatment advocate mustmake the time for these discussions.Experience shows that personal, one-on-one conversations may provide the bestlearning forum for the client.

A discussion about HIV treatment mayinvolve defining HIV infection for theclient. Begin by finding out what havingHIV means to the client. What are theclient’s beliefs about HIV disease? To

sis preventive therapy among HIV-infected persons in Chiang Rai,Thailand. AIDS. 1997; 11(1): 107-112.

Reijers MH, Weverling GJ, Jurriaans S,et al. Maintenance therapy afterquadruple induction therapy in HIV-1infected individuals: AmsterdamDuration of Antiretroviral Medication(ADAM) study. The Lancet. 1998;352(9123): 185-190.

Schlundt DG, Quesenberry L, PichertJW, et al. Evaluation of a trainingprogram for improving adherencepromotion skills. Patient Education andCounseling. 1994; 24(2): 165-173.

Wilkinson J. Noncompliance bypatients: A response to Professor

Diamond. Nursing Ethics. 1998; 5(2):167-172.

ContactsRick Hecht, MD, UCSF AIDS Program,San Francisco General Hospital,Building 80, Ward 84, 995 PotreroAvenue, San Francisco, CA 94110, 415-476-4082, ext. 431.

Michelle Roland, MD, UCSF AIDSProgram, San Francisco GeneralHospital, Building 80, Ward 84, 995Potrero Avenue, San Francisco, CA94110, 415-476-4082, extx. 432.

Tim Teeter, BSN, MA, TreatmentSupport Supervisor, San Francisco AIDSFoundation, 995 Market Street, 2nd

floor, San Francisco, CA 94103, 415-487-8022, tteeter@sfaf.org

Dr. Cassy Workman, Associate Director,AIDS Research Initiative, 48 LittleOxford Street, Darlinghurst 2010,Sydney, NSW, Australia, 011-61-2-9360-7172, drcw@rainbow.net.au

See also the Clearinghouse section in twopast issues of FOCUS: February 1998 andAugust 1997.

Adherence: Working withHomeless PopulationsTim Teeter, BSN, MA

whom has the client disclosed serostatus?Be prepared to help the client workthrough anger, guilt, and denial. Medicaland technical jargon can be overwhelmingfor clients, so use language and explana-

tions that match a client’s levelof understanding. Similarly, donot assume that a client can(or cannot) read; ensure thatany written materials matchthe client’s reading level.

Case managers must beknowledgeable about HIV. Whenthey are unable to answer all ofa client’s questions, case man-agers should research the infor-mation and get back to theclient with answers. During thisprocess, case managers shoulddiscuss the role and impor-tance of adherence. It may alsobe helpful for case managers toprovide incentives for clients toreturn regularly, both for edu-cation and support for theclient, and for regular monitor-ing contact for the case manag-

er. Successful approaches include: hostingregular lunches for clients as a forum todiscuss treatment issues; having a regis-tered dietitian conduct monthly nutritionclinics; and running a weekly drop-in treat-ment discussion group and providingsnacks or nutritional supplements toclients who attend. In all of this, a client’sattention span may be short, so informa-tion must be brief and easily understood.

When Clients Start HIV TreatmentTo successfully promote adherence, it is

essential to have a thorough understandingof a client’s daily routines, or to know thatthere is no regular pattern to the day andwhat to do when this situation exists.Taking medications more than twice a dayadds greatly to the challenge. Among thethree classes of drugs currently availableto treat HIV, many drugs can be taken twicedaily (all the nucleoside reverse transcrip-tase inhibitors; delavirdine; nevirapine;nelfinavir; combination saquinavir/riton-avir). The newest non-nucleoside drug,efavirenz, may be taken once daily.

Describe to clients common adverseside effects of each possible medication.This is an important step in helping clientsmake informed choices. Some side effectsmay be diminished with food, so workwith the client to ensure food is available.

Medication storage and ease of adminis-tration is critically important, especially forclients who are homeless. Medications

requiring refrigeration, such as the capsuleform of ritonavir, are not usually options.Medication sets (“medisets”) allow clients tolay out a week’s supply of medications at atime, and are particularly useful when theyare the type that have removable cassettesfor each day. An inexpensive watch with analarm may help remind clients to take thesecond dose of the day. Before startingtreatment, clients may wish to practicetaking placebos for a week. Filling a medisetwith a week’s supply of candy—using differ-ent colors or brands to represent differentmedications—is a good way to predict howwell a client will adhere to a regimen.

The most debilitating side effects mayoccur during the first two weeks of treat-ment. In preparing for this period, casemanagers can work with clients to definethe best ways to ensure success byaddressing housing, nutrition and stress-reduction needs. Ensure that housing willbe stable for two weeks. Develop strate-gies for dealing with diarrhea, such assupplying the client with adult diapers, ifneeded. Discuss ways to ensure that sub-stance use does not interfere with adher-ence. Encourage the client to nap whentired or not feeling well, and to drinkwater or juice frequently to ensure ade-quate hydration. Above all, be available tothe client during the introductory periodand to provide ongoing support.

ConclusionSpending adequate time with clients is

the key to working with HIV-infectedhomeless people. Homelessness is isolat-ing, so basic needs must be addressedbefore discussing treatment for HIV. Forclients who decide to initiate treatment,knowing their daily routines, informingthem of potential adverse side effects,and working through problems with themcan increase the probability of adherence.

FOCUS6 January 1999

AuthorsTim Teeter, BSN, MA, is the TreatmentSupport Supervisor at the San FranciscoAIDS Foundation.

Comments and Submissions We invite readers to send letters

responding to articles published inFOCUS or dealing with current AIDSresearch and counseling issues. Wealso encourage readers to submit arti-cle proposals, including a summary ofthe idea and a detailed outline of thearticle. Send correspondence to:

Editor, FOCUSUCSF AIDS Health Project, Box 0884San Francisco, CA 94143-0884

Before startingtreatment,

clients may wishto practice for a

week, usingdifferent candy

to representdifferent

medications.

FOCUS7 January 1999

Common Adherence IssuesMehta S, Moore RD, Graham NM. Potential factorsaffecting adherence with HIV therapy. AIDS. 1997;11(14): 1665-1670. (The Johns Hopkins University.)

A review of the literature details therange of variables involved in medicationadherence and suggests that the overlapamong these variables—for examplesocioeconomic status, psychiatric stress,social relationships, and health careaccess—requires multifaceted approaches.

The authors review the literature onadherence to medications for HIV and fortwo other conditions: chronic illness,because HIV has a median incubation peri-od of 10 years or more, and mental illness,because psychiatric diagnoses are commonin people with HIV. They identify correla-tions between adherence and a variety offactors, including demographic variables,psychosocial characteristics, medicationcharacteristics, and health care delivery.

Since non-adherence may result fromconfusion about correct dosage or aboutthe need to take medications continually,

including during asymp-tomatic phases, it is impor-tant for providers to educatepeople with HIV about theirdiagnoses and treatments.According to one study,subjects who learned thenames of their medicationshad higher levels of adher-ence than subjects who didnot. Regular communicationbetween providers andpatients is also important. A study of hypertensivesubjects found that adher-ence increased proportional-ly with the number of times a subject discussed hyper-tension with a doctor.

Education alone, however,may not improve the abilityto remember to take medica-tions on time. To respond to

this, providers need to help patients inte-grate treatment regimens into daily sched-ules, using devices such as timed pilldispensers and alarm clocks, andreminders from other people.

For many people, the cost of treatmentand related expenses contribute to non-adherence. In a study of diabetic patientswhose insulin costs were subsidized, 50percent of subjects who discontinued

treatment did so because they could notafford transportation to a pharmacy.Another study found that severelyimmunocompromised HIV-infected individ-uals were more likely than others to missscheduled doctor visits. According to thesame study, providing on-site child careservices greatly improved attendance rates.

Among people with HIV, psychiatricproblems often affect adherence to treat-ment regimens. According to one study,HIV-infected people who adhered to theirtreatment regimens at least 80 percent ofthe time had significantly less depressionthan people with lower rates of adherence.In another study, 52 percent of subjectsdiagnosed with psychiatric illnessachieved an 80 percent rate of adherenceto zidovudine (ZDV; AZT), compared with81 percent of patients without psychiatricdiagnoses. Research suggests that psychi-atric intervention is an effective way ofincreasing treatment adherence for HIV-infected individuals.

Adherence, Substance Abuse, and HIVSorensen JL, Mascovich A, Wall TL, et al.Medication adherence strategies for drug abuserswith HIV/AIDS. AIDS Care. 1998; 10(3): 297-312.(San Francisco General Hospital; and University ofCalifornia San Francisco.)

A study of a hospital-based methadonemaintenance program found that on-sitedispensing of HIV medications, whether ornot it is combined with medication man-agement (individualized assessment andproblem solving), does not produce signif-icant long-term increases in HIV treatmentadherence. On-site dispensing, however,did improve adherence during the courseof the intervention, and clinic attendanceincreased among participants undergoingthe medical management intervention.

The first phase of the San Franciscostudy evaluated on-site dispensing ofzidovudine (ZDV) to a group of 13 maleand 12 female HIV-infected hospitalpatients. The mean age of the sample was41 years, and all subjects had been pre-scribed ZDV for at least two months. Tenpatients were African American, eightwere White, five were Latino, and twowere Asian American.

Subjects met every weekday with a nurseto receive all three daily doses of ZDV—oneto be taken under the nurse’s supervision,and the other two to be self-administeredat the appropriate times. Daily interactionwith the nurse provided a critical environ-ment for participants to express concernsand receive non-judgmental support. Themeetings also enabled the nurse and the

On-sitedispensing of HIV

medications didnot produce long-term increases inadherence, but it

did improveadherence over

the course of theintervention.

Recent Reports

FOCUS8 January 1999

participant to examine progress and obsta-cles related to adherence. In comparison toa control group of regular care patients,participants in the study showed slightlyhigher adherence rates during the courseof the intervention. One month after theintervention, however, there were no sig-nificant differences in adherence levelsbetween the two groups.

The study’s second phase evaluated theeffectiveness of combining medicationmanagement with on-site dispensing toimprove long-term adherence. The sampleincluded six men and six women with amean age of 42 years. All subjects hadbeen prescribed HIV medications beforethe study began. Two patients were AfricanAmerican, six were White, two were Latino,one was Native American, and one was ofmixed ethnic background.

The combined intervention consisted ofnine interdependent medical managementstrategies, ranging from individual assess-ments and tailored regimens to teachingself-monitoring and building motivation.Participants had weekly one-on-one con-tact sessions with a provider, who was alsoavailable for unscheduled meetings. Onemonth after completing the intervention,participants reported self-improvementsin filling their prescriptions, systematizingtheir medications, and strengthening theirmotivation to maintain adherence.

Inconsistencies in Physician Care Heath KV, Hogg RS, Singer J, et al. Adherence toclinical guidelines for the therapeutic managementof HIV disease. Clinical Investigative Medicine.1997; 20(6): 381-387. (British Columbia Centre forExcellence in HIV/AIDS; University of BritishColumbia; and Canadian Trials Network.)

A Canadian study found considerabledifferences in the ways physicians treatpatients infected with HIV. In addition,some treatment practices and beliefsdiffered significantly from governmentguidelines for care.

The evaluation consisted of a 51-item,self-administered survey mailed to 659physicians participating in a program thatoffers free HIV treatments to all HIV-infect-ed people in British Columbia. Thirty-eightpercent of physicians completed the initialsurvey; an additional 27 percent complet-ed another survey in which they specifiedtheir demographic characteristics andexperiences with HIV-infected patients.Seventy-nine percent of the originalrespondents were male, and 40 percentwere younger than 40 years. Ninety-onepercent of responding physicians hadprevious experience treating HIV-infected

patients, and 72 percent were treating HIV-infected patients at the time of the survey.

Responses regarding non-HIV vaccinesgenerally correlated with therapeuticguidelines. Eighty-one percent of respon-dents endorsed annual influenza vaccina-tions, and 79 percent endorsed one-timeonly hepatitis B vaccination. For othergeneral disease prevention measures,however, levels of agreement with stan-dards of care were lower: 51 percentendorsed twice-yearly gynecologicalexams, 48 percent endorsed annual tuber-culosis skin tests, and 65 percent believedthat HIV seropositive patients shouldretest only once. Ninety-two percent ofphysicians agreed that HIV-infectedpatients should undergo CD4+ cell counts.

While the mean knowledge score was 62percent for preventive care, scores werelower in advanced disease management: 52percent for managing antiviral therapy, 40percent for opportunistic infection prophy-laxis, and 29 percent for opportunisticinfection treatment. Compared to the restof the sample, younger physicians had agreater understanding of preventive mea-sures, and physicians who had medicalspecialty training were more familiar withthe treatment of opportunistic infections.

Next MonthAs prevention interventions increas-

ingly target seropositive people, “part-ner counseling and referral services”(PCRS), formally known as partner man-agement and partner notification, havereceived increased attention. HIV poli-cy makers are developing approaches tohelp providers implement PCRS in waysthat support clients, protect confiden-tiality, and serve prevention goals. Inthe February issue of FOCUS, CatherineBaker, Drew Johnson, and HaroldRasmussen, officials at the CaliforniaState Office of AIDS, outline the con-cepts and strategies behind PCRS.

Also in the February issue, SandySchwarcz, MD, a policy maker at theSan Francisco AIDS Office, describes anew form of antibody testing—thedetuned assay—that distinguishesbetween recently infected people andthose infected more than four monthsprior to the test. She defines the assay’stechnique and its treatment and pre-vention implications, including its rolein partner counseling and referral.

Executive Editor; Director,AIDS Health ProjectJames W. Dilley, MD

EditorRobert Marks

Staff WritersAlex ChaseJohn Tighe

Founding Editor; AdvisorMichael Helquist

Medical AdvisorStephen Follansbee, MD

DesignSaul Rosenfield

ProductionAndrew TavoniShauna O’DonnellTania Lihatsh

CirculationShauna O’Donnell

InternsLaura MeyersRahim Rahemtulla

FOCUS is a monthly pub-lication of the AIDSHealth Project, affiliatedwith the University ofCalifornia San Francisco.

Twelve issues of FOCUSare $36 for U.S. residents,$24 for those with limitedincomes, $48 for individu-als in other countries, $90for U.S. institutions, and$110 for institutions inother countries. Makechecks payable to “UCRegents.” Address sub-scription requests and cor-respondence to: FOCUS,UCSF AIDS HealthProject, Box 0884, SanFrancisco, CA 94143-0884. Back issues are $3each: for a list, write to theabove address or call(415) 476-6430.

To ensure uninterrupteddelivery, send your newaddress four weeks beforeyou move.

Printed on recycled paper.

©1999 UC Regents: Allrights reserved.

ISSN 1047-0719

FOCUSA Guide toAIDSResearch and Counseling

DID YOU KNOW?FREE searchable archive

You can access a FREE searchable archive of back issues of this publication online! Visit http://www.ucsf-ahp.org/HTML2/archivesearch.html.

You can also receive this and other AHP journals FREE, at the moment of publication, by becoming an e-subscriber. Visit http://ucsf-ahp.org/epubs_registration.php for more information and to register!

ABOUT UCSF AIDS HeAlTH PrOjeCT PUBlICATIOnS

The AIDS Health Project produces periodicals and books that blend research and practice to help front-line mental

health and health care providers deliver the highest quality HIV-related counseling and mental health care. For more

information about this program, visit http://ucsf-ahp.org/HTML2/services_providers_publications.html.