Indications for starting and discontinuation of OI prophylaxis
During the era of unboosted PIs, an adherence rate of more than 95% was recommended for successful ART outcome. However, with the use of more potent Drugs (e.g. boosted PIs) in regimens, this cutoff of 90% may be slightly reduced. Additionally, the longer half-life of NNRTIs may actually prevent the development of resistance because of continued exposure to the drug even after missing the dose. There is evidence to suggest that at least for an intermediate level of adherence (adherence rate 76%-99%), NNRTI-based regimens may be more forgiving than PI-based regimens. Nevertheless, physicians should encourage patients to achieve high rates of adherence to ART and work towards achieving the same.
Measuring adherence in clinical practice is difficult. Self-report is the easiest and cheapest method of assessing the same, and it may be quite reliable. Pill counts and other objective markers of adherence measurement like MEMS caps are rarely possible in clinical setups. Patients should be asked whether they have missed doses over the last 4-7 days and over the last follow-up period, rather than asking whether they have been taking Drugs regularly. If a patient accepts missing doses, then the reasons for doing the same should be explored and tried to address. Indirect markers of good adherence are keeping appointments and getting prescription refills. Another marker of adherence on a thymidine-based regimen (ZDV or d4T) is evidence of macrocytosis on a hemogram, although it is not uniformly seen in all patients.
The physician should use various strategies to achieve good adherence. One of the most important aspects is to develop a trusting relationship and rapport with the patient. Some of the strategies to achieve adherence are the following:
- Careful screening before starting: It is very important to screen for patient readiness before initiating ART. Cost is a major barrier to adherence in India, and the financial status of the patient should be assessed prior to prescribing ART. It may be worthwhile not to initiate therapy at the first visit and give some time for the patient to think.
- Emphasize adherence before starting: Explaining to the patient that a high level of adherence is needed, and that the treatment is lifelong, is crucial. The patient's comprehension must be ascertained.
- Demonstrate how to take drugs (e.g. NVP): Many patients make mistakes during the initial lead-in dose phase of nevirapine, as it can be quite confusing. Demonstrating how to take the regimen and ensuring that the patient has understood the same may be done by asking him/her to repeat what has been explained.
- Using fixed-dose combinations pills: Using fixed-dose combinations of ARV Drugs reduces the pill burden, potentially improving adherence. Additionally, using these combinations is associated with fewer prescription errors and ensures that the patient takes all Drugs in a regimen.
- Advise patients to buy monthly packs: Patients are more likely to take Drugs regularly if they buy monthly packs. Buying loose pills on an as-needed basis has a higher risk of missing doses.
- Follow up before supplies exhaust: One of the common reasons for missing doses is following up after the drug supplies are over. Patients should be encouraged to follow up 3-4 days before their Drug stocks are exhausted.
- Remind every time during follow-up: During follow-up, apart from assessing adherence, the importance of achieving good adherence should be re-emphasized.
- Using once-daily regimens/user-friendly regimens: There is evidence to suggest that adherence rates are higher if patients are prescribed once-daily or twice-daily Drugs as compared to thrice per day or higher frequencies.
- Anticipate and treat adverse events efficiently: Patients miss doses when they develop adverse events, which can be quite distressing. It is essential to inform patients about anticipated ARV adverse events, identify them early when they do occur, and manage them efficiently. This is particularly important with the CNS side effects of efavirenz or with GI intolerance of PIs, which wane on their own after 2-4 weeks, and patients should be told not to discontinue the Drug without informing the physician. Patients should be encouraged to contact the physician before contemplating any reduction of doses or changing their ARV Drugs due to any reasons.
- Reward the patient with positive feedback on:
- Declining viral load
- Improving CD4 counts
- medications with them when they travel.
- Involvement of spouse, a family member in treatment education and adherence issues only after the patient consents for the same.
- Patients should have access to physicians or other members of the care team so that any problem can be sorted out without interfering with adherence.
- Studies have documented numerous predictors of poor adherence, depression being one of the most important. Identifying and managing depression is essential for successful ART outcome.