Marie P. Schneider

An interdisciplinary HIV-adherence program combining motivational interviewing and electronic antiretroviral drug monitoring

Abstract To ensure successful treatment, HIV patients must maintain a high degree of medication adherence over time. Since August 2004, patients who are (or are at risk of) experiencing problems with their HIV antiretroviral therapy (ART) have been referred by their physicians to an interdisciplinary HIV-adherence program. The program consists of a multifactorial intervention along with electronic drug monitoring (MEMSTM). The pharmacists organize individualized semi-structured motivational interviews based on cognitive, emotional, behavioral, and social issues. At the end of each session, the patient brings an adherence report to the physician. This enables the physician to use the adherence results to evaluate the treatment plan. The aim of this study was to retrospectively analyze this on-going interdisciplinary HIV-adherence program. All patients who were included between August 2004 and the end of April 2008 were analyzed. One hundred and four patients were included (59% women, median age 39 (31.0, 46.0) years, 42% black ethnicity). Eighty (77%) patients were ART-experienced patients and 59% had a protease inhibitor-based treatment. The retention rate was high (92%) in the program. Patient inclusion in this HIV-adherence program was determined by patient issues for naive patients and by nonadherence or suboptimal clinical outcomes for ART-experienced patients. The median time spent by a subject at the pharmacy was 35 (25.0, 48.0) minutes, half for the medication handling and half for the interview. The adherence results showed a persistence of 87% and an execution of 88%. Proportion of undetectable subjects increased during study. In conclusion, retention and persistence rates were high in this highly selected problematic population.

Interdisciplinary Medication Adherence Program: The Example of a University Community Pharmacy in Switzerland

The Community Pharmacy of the Department of Ambulatory Care and Community Medicine (Policlinique Médicale Universitaire, PMU), University of Lausanne, developed and implemented an interdisciplinary medication adherence program. The program aims to support and reinforce medication adherence through a multifactorial and interdisciplinary intervention. Motivational interviewing is combined with medication adherence electronic monitors (MEMS, Aardex MWV) and a report to patient, physician, nurse, and other pharmacists. This program has become a routine activity and was extended for use with all chronic diseases. From 2004 to 2014, there were 819 patient inclusions, and 268 patients were in follow-up in 2014. This paper aims to present the organization and programs context, statistical data, published research, and future perspectives.

Exploring the implementation of a medication adherence programme by community pharmacists: a qualitative study

Background Medication adherence has been identified as an important factor for clinical success. Twenty-four Swiss community pharmacists participated in the implementation of an adherence support programme for patients with hypertension, diabetes mellitus and/or dyslipidemia. The programme combined tailored consultations with patients about medication taking (expected at an average of one intervention per month) and the delivery of each drug in an electronic monitoring system (MEMS6™). Objective To explore pharmacists’ perceptions and experiences with implementation of the medication adherence programme and to clarify why only seven patients were enrolled in total. Setting Community pharmacies in French-speaking Switzerland. Method Individual in-depth interviews were audio-recorded, with 20 of the pharmacists who participated in the adherence programme. These were transcribed verbatim, coded and thematically analysed. Process quality was ensured by using an audit trail detailing the development of codes and themes; furthermore, each step in the coding and analysis was verified by a second, experienced qualitative researcher. Main outcome measure Community pharmacists’ experiences and perceptions of the determining factors influencing the implementation of the adherence programme. Results Four major barriers were identified: (1) poor communication with patients resulting in insufficient promotion of the programme; (2) insufficient collaboration with physicians; (3) difficulty in integrating the programme into pharmacy organisation; and (4) insufficient pharmacist motivation. This was related to the remuneration perceived as insufficient and to the absence of clear strategic thinking about the pharmacist position in the health care system. One major facilitator of the programme’s implementation was pre-existing collaboration with physicians. Conclusion A wide range of barriers was identified. The implementation of medication adherence programmes in Swiss community pharmacies would benefit from an extended training aimed at developing communication and change management skills. Individualised onsite support addressing relevant barriers would also be necessary throughout the implementation process.

The Presence of Human Immunodeficiency Virus-Associated Neurocognitive Disorders Is Associated With a Lower Adherence to Combined Antiretroviral Treatment.

Abstract Background Human immunodeficiency virus (HIV)-associated neurocognitive disorders (HAND) are defined according to their diagnostic degrees as follows: asymptomatic neurocognitive impairment, mild neurocognitive disorder, and HIV-associated dementia. Because high adherence to combined antiretroviral therapy (cART) is required to maintain viral suppression among HIV-infected patients, it is important to investigate the impact of HAND on medication adherence. Our study hypothesis was that patients with HAND had a lower medication adherence than patients who did not have HAND. Methods This was an observational, exploratory, 2-center pilot study of patients who had a state-of-the-art neurocognitive assessment performed between January 2011 and June 2015 while also being followed at their respective adherence clinics. Adherence was measured with electronic monitors. Patients’ sociodemographic characteristics, HIV viral load, and CD4 counts were retrieved from the Swiss HIV Cohort Study database. At each time t, adherence was computed as the proportion of patients taking medication as prescribed at that time. Results We included 59 patients, with a median (Q1, Q3) age of 53 years (47–58) and 39 (66%) were male participants. Twenty-two patients (35%) had no neurocognitive deficits, 16 (27%) patients had HAND, and 21 (35%) patients had non-HAND (mostly depression). Implementation over 3 years showed a significant decline (50%) in medication adherence among patients diagnosed with HAND in comparison with patients who had a normal neuropsychological status or a non-HIV-related cognitive deficit (implementation stayed 90% during follow-up). Conclusions Our findings support the hypothesis that HAND is associated with reduced cART adherence.

Effect of Adherence on Pharmacokinetic/Pharmacodynamic Relationships of Oral Targeted Anticancer Drugs

The emergence of oral targeted anticancer agents transformed several cancers into chronic conditions with a need for long-term oral treatment. Although cancer is a life-threatening condition, oncology medication adherence—the extent to which a patient follows the drug regimen that is intended by the prescriber—can be suboptimal in the long term, as in any other chronic disease. Poor adherence can impact negatively on clinical outcomes, notably because most of these drugs are given as a standard non-individualized dosage despite marked inter-individual variabilities that can lead to toxic or inefficacious drug concentrations. This has been especially studied with the prototypal drug imatinib. In the context of therapeutic drug monitoring (TDM), increasingly advocated for oral anticancer treatment optimization, unreported suboptimal adherence affecting drug intake history may lead to significant bias in the concentration interpretation and inappropriate dosage adjustments. In the same way, suboptimal adherence may also bias the results of pharmacokinetic modeling studies, which will affect in turn Bayesian TDM interpretation that relies on such population models. Detailed knowledge of the influence of adherence on plasma concentrations in pharmacokinetic studies or in routine TDM programs is however presently missing in the oncology field. Studies on this topic are therefore eagerly awaited to better pilot the treatment of cancer with the new targeted agents and to find their optimal dosage regimen. Hence, the development and assessment of effective medication adherence programs are warranted for these treatments.

The ESPACOMP and its role in promoting knowledge and competencies in the matter of patient adherence

This commentary in the special issue of International Journal of Clinical Pharmacy devoted to patient adherence is a great opportunity to present the European Society for Patient Adherence, COMpliance and Persistence (ESPACOMP). It is a non-profit association, ‘established to promote the science concerned with the assessment of what patients do with medicines they have been prescribed’ (see www.espacomp.eu). As described on the website, since 1996, a group of scientists from Belgium and The Netherlands used to organise the ‘‘Lowlands’’ symposium. They shared their research on patient compliance and persistence with prescribed therapy. This symposium has grown over the years, reflecting the increased interest for adherence related issues across Europe. In 2009, the European Society for Patient Adherence, Compliance and Persistence was founded. The annual European ESPACOMP symposium has become a networking place for an increasing number of international adherence researchers, pharmacoepidemiologists, statisticians, physicians, pharmacists, nurses, psychologists as well as other interested healthcare providers, anthropologists, economists, policy makers and industry. Such an interdisciplinary symposium facilitates exchange of ideas across professional and regional boundaries. A wide range of topics are regularly debated at the annual symposium, with the aim of increasing and disseminating important knowledge and competences within the adherence area. Main topics are described below:

Content analysis of antiretroviral adherence enhancing interview reports.

OBJECTIVE To identify factors associated with low or high antiretroviral (ARV) adherence through computational text analysis of an adherence enhancing programme interview reports. METHODS Using text from 8428 interviews with 522 patients, we constructed a term-frequency matrix for each patient, retaining words that occurred at least ten times overall and used in at least six interviews with six different patients. The text included both the pharmacists and the patients verbalizations. We investigated their association with an adherence threshold (above or below 90%) using a regularized logistic regression model. In addition to this data-driven approach, we studied the contexts of words with a focus group. RESULTS Analysis resulted in 7608 terms associated with low or high adherence. Terms associated with low adherence included disruption in daily schedule, side effects, socio-economic factors, stigma, cognitive factors and smoking. Terms associated with high adherence included fixed medication intake timing, no side effects and positive psychological state. CONCLUSION Computational text analysis helps to analyze a large corpus of adherence enhancing interviews. It confirms main known themes affecting ARV adherence and sheds light on new emerging themes. PRACTICE IMPLICATIONS Health care providers should be aware of factors that are associated with low or high adherence. This knowledge should reinforce the supporting factors and try to resolve the barriers together with the patient.

Role of the Pharmacist in Supporting Adherence

In the era of chronic diseases and polypharmacy, patient nonadherence is a silent and worldwide endemic issue that contributes to extra morbidity/mortality and healthcare costs. Nonadherence can be reduced when addressed by educated healthcare teams, pharmacists being part of them. Pharmacists’ activities have switched from a medication-oriented activity to a patient-centred perspective in order to support patient’s self-management. In collaboration with other healthcare providers, they screen, resolve and prevent medication nonadherence. In parallel to a critical review and a reconciliation of the patient’s treatment, they provide patients with therapeutic education and behavioural support. Pharmacists are trained in communication skills and have many opportunities to monitor patient’s medication-taking behaviour and promote adherence from medication initiation to implementation and persistence. The pharmacist uses tools and strategies for screening (medication computerized histories) and for addressing both intentional and unintentional medication nonadherence. Leaflets are part of educational strategies, whereas medication synchronization approaches, pillboxes, Direct Observed Therapy (D.O.T.) or mHealth are more behavioural.