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Assessing Existing Efforts to Increase Adherence to Medication

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The goal of this initiative was to assess innovative interventions to increase adherence to highly active antiretroviral treatment (HAART) among underserved populations. The twelve clinic-based demonstration projects were already engaged in delivering HIV medical care to underserved populations, and they had fully operational adherence support programs for their clients receiving HAART. The grantees were funded to evaluate their adherence programs based upon their innovative approaches. The programs served a variety of populations, but all targeted uninsured or underinsured people with HIV who had difficulty accessing care. They used a range of different adherence interventions, but all sought to improve the ability of their clients to successfully adhere to HAART. In addition, they all provided some sort of non-cash incentive for participating in the research study. No clients were prevented from receiving the services of their programs if they choose not to participate in the study. 

The New York Academy of Medicine served as the Center for Adherence Support Evaluation (CASE) for this SPNS initiative. For more information regarding the cross-site evaluation implemented by CASE, see:  Cross-Site Evaluation as a Methodology: The Case of Antiretroviral Adherence Support Interventions



Health Services Center

Chase Brexton Health Services

Columbia University Harlem Hospital Center

Columbia University School of Public Health

Dimock Community Health Center

Johns Hopkins University School of Medicine

Mission Neighborhood Health Center

Multnomah County Health Department

New York State Health Department (AIDS Institute)

North Broward Hospital District

St. Luke's-Roosevelt Hospital Center

SUNY Health Science Center

University of California, San Francisco

Washington University

Center for Adherence Support Evaluation (CASE)


Health Services Center, Anniston, AL

Target Population: People with HIV who are poor and uninsured and who live in rural northeast Alabama, many of whom are African-American

Description: Health Services Center provides HIV care to people with HIV/AIDS in a predominantly rural 14-county area of northeast Alabama. The adherence program HSC developed provided three different interventions, including a modified directly observed therapy intervention, that differ in intensity to meet the specific needs of each  client. A baseline interview was used as a screening tool to assess which of the three interventions was most appropriate for each client. Clients enrolled in the most intense intervention were paired with a trained buddy or buddy team. The buddy made daily contact with the client by phone, and provide support for taking his or her medication. Clients enrolled the directly observed therapy intervention came to either HSC or a local health department five days a week to pick up their medications. Clients enrolled in the least intense interventions met with a clinic adherence panel monthly at the time of their clinic visits. Periodic reevaluation determined if the needs of a client changed, so that the client could be moved to a different level of intervention. 


Chase Brexton Health Services, Baltimore, MD

Target Population: People with HIV who are substance users or at high risk for depression, including women

Description: Chase Brexton Health Services, a large comprehensive community-based provider of primary HIV care to underserved populations in Maryland, developed a system-wide comprehensive program designed to improve client adherence to HAART regimens. Central components of the adherence program were periodic screening for substance use and depression risk for early intervention and follow-up; proactive multi-departmental coordination of intervention plans and follow-up for those identified as high risk; and standardization and integration of HAART education and other adherence support into the care provided by CBHS. They sought to develop new standards for provision of HAART and adherence support for substance users and those at high risk for major depression.


Columbia University Harlem Hospital Center, New York, NY

Target Population: The Harlem Adherence Treatment Study (HATS) is a study that randomly assigns subjects to either a group that receives an enhanced adherence intervention or the current clinical practice for adherence. The experimental (enhanced) intervention consists of two main components: peer-centered social support and assistance in overcoming barriers to adherence. The intervention is based on the Transtheoretical Model of Change, with each subject assessed and identified as being in a specific stage of behavior change, and provided interventions designed for that stage. The interventions are provided by study peers workers, social workers, and support groups. The program evaluation involves two components: a self-administered touch-screen adherence questionnaire with an audio component; and, a qualitative assessment of the peer-client interaction. The study compares two data collection methods, a face-to-face interview and the touch-screen computer interview. 

Description:The Harlem Adherence to Treatment Study: Evaluation of a Touch-Screen Computer Adherence Questionnaire and a Qualitative Assessment of the Peer-Client Relationship.


Columbia University School of Public Health, New York, NY

Target Population: HIV-infected women, including adolescents, and caregivers of HIV-infected children.

Description: The Northern Manhattan Women and Children HIV Project conducted the Northern Manhattan Adherence Initiative. The initiative was based upon the framework of the Transtheoretical Model of Stages of Behavior Change. The project sought to integrate adherence boosting services into the comprehensive medical care and social support services being provided to HIV-infected women, adolescents, and caregivers of HIV-infected children.  It also provided appropriate information and support to clients according to their stage of readiness for taking/administering these medications, and improved adherence among clients already on antiretroviral therapy. 


Dimock Community Health Center, Roxbury, MA

Target Population: People living with HIV, including women, African Americans, Hispanics, and people who have problems of mental health and/or substance use.

Description: The adherence project at the Dimock Community Health Center worked to ensure treatment with and adherence to HAART for HIV infected individuals, by comparing a standard adherence strategy to an intensive strategy that involves community-based care. Patients were randomly assigned to receive either the standard strategy or the intensive strategy. The standard strategy, which included multidisciplinary care coordinated by an HIV nurse;  HIV specialty care; use of literacy-leveled educational materials; peer counseling; use of a programmable watch; and tailored interventions; was provided at both study sites. In the intensive strategy, an HIV home care nurse also visited  patients once or twice a week for four to six weeks in their community setting, addressing specific barriers to adherence in coordination with the multidisciplinary team.


Johns Hopkins University School of Medicine, Baltimore, MD

Target Population: People living with HIV who have poor medical adherence, active substance use problems and mental illness, high rates of unstable housing and poverty, and low educational level.

Description: Project LINK was an intervention program to increase adherence with HAART at the Moore Clinic, the Johns Hopkins Hospital HIV specialty care clinic. This program specifically targeted patients who were HAART candidates but were not prescribed or were failing HAART therapy. The intervention had four components: intensive case management; one-on-one nursing education; peer advocate support; and group education/support sessions. Clients were assigned to receive two, three, or four of the intervention components, with all clients receiving case management and nurse education. Adherence of the clients receiving different combinations of interventions was  compared with each other as well as with a separate comparison group. 


Mission Neighborhood Health Center, San Francisco, CA

Target Population: People with HIV who are predominantly Hispanic, many of whom are monolingual and experience multiple psychosocial barriers.

Description: Clinica Esperanza is an HIV clinic with an interdisciplinary team that provides medical and psychosocial services, health and nutrition education, treatment advocacy, peer support, and complementary therapies to its clients. The Clinic developed an adherence intervention, the Medication Adherence Protocol, or MAP.  MAP emphasizes the client’s readiness to take HAART by having multiple discipline assessments, integrating cultural competency, social support and patients’ belief systems, with a built-in system of checks and balances. Clients were prepared to begin taking HAART through a series of meetings with their medical provider, case manager/social worker, and nurse or a  treatment advocate. When they were determined to be ready, they filled their prescriptions and then returned to the clinic for an assessment of their understanding of their medicines and how to take them.  They also received assistance with putting the medications in a multi-chambered container with dividers for times of day and days of the week (a medi-set). Ongoing appointments with medical providers, case managers and peers provided continued adherence support for clients.


Multnomah County Health Department, Portland, OR

Target Population: People living with HIV who have problems with substance use, mental illness, or homelessness.

Description: The Multnomah County Health Department HIV/AIDS Health Services Center developed the Multidisciplinary HAART Adherence Assistance Program in June of 1998 to increase client acceptance of and adherence to HAART. The cornerstone of the program is its multidisciplinary approach. A clinical pharmacist worked with health care professionals, and social workers to jointly address the adherence needs of HAART clients. The pharmacist coordinated the program and served as an integral part of the care of HIV clients. The pharmacy intervention is a series of educational interventions in which the pharmacist provided education, counseling, and adherence tools such as multi-sectioned plastic boxes, or Medisets, for storing a week’s supply of medicine. The program sought to improve client readiness for antiretroviral treatment prior to prescription, and support client adherence to antiretroviral treatment after prescription.


New York State Health Department (AIDS Institute), Renssalaer, NY

Target Population: A wide range of people living with HIV at the various sites 

Description: The AIDS Institute funded ten comprehensive adherence support programs throughout New York State. The programs all aimed to increase adherence through: the development of partnerships among clinical and non-clinical providers and clients; the development of collaborative management and operational structures; empowerment of clients to make informed treatment decisions; integration of treatment into the continuum of care; enhancement of client skills; and providing access to support services tailored to clients’ needs.


North Broward Hospital District, Fort Lauderdale, FL

Target Population: People living with HIV, including women and African Americans and Hispanics

Description: North Broward Hospital District implemented three outpatient interventions of increasing intensity to improve medication adherence: Standard, Provider Enhanced Intervention (PEI), and Home-based. The Standard intervention was comprised of the interventions everyone attending the clinic received, including a psychosocial assessment by a case management and a clinical assessment by a health care provider. The PEI was comprised of the Standard intervention plus two or three sessions with the pharmacist, who provided counseling, reminder tools, and training videos. The Home-based intervention was comprised of all the previous components plus two or three home visits by a pharmacist or nurse, medicines delivered to the home, and training of the client’s caregivers to help with adherence.


University of California, San Francisco 

Target Population: Homeless or marginally homeless people living with HIV

Description: For the urban poor, successful adherence is especially challenging given the high prevalence of drug addiction and mental illness, the inconsistency of adequate food, and the instability of shelter. The City of San Francisco established the Action Point Adherence Project (APAP) to assist individuals living with poverty and HIV disease with adherence to HIV therapy. The APAP sought to improve the health status and quality of life of HIV+ homeless or marginally housed individuals currently on antiretroviral treatment by enrolling 50 clients and helping them develop the skills to adhere to their medication regimens, with the aim of helping them become able to take their medications independently. It also sought to achieve the same goals for HIV+ homeless or marginally housed individuals not on antiretroviral medications, but who were planning to start antiretroviral treatment, by enrolling another 50 clients into the APAP and stabilizing them so they could successfully initiate and adhere to antiretrovrial regimens.


Washington University School of Medicine, St. Louis, MO

Target Population: Adolescent and adult women living with HIV, many of whom are African American

Description: The Helena Hatch Special Care Center (HHSCC) offers one-stop comprehensive HIV services, including primary HIV medical care, OB/GYN services, social work and nursing case management, patient education, and psychosocial and spiritual support. The Take Charge ADHERE Program is the Center’s structured adherence program, and it included Assessment of patients’ readiness for taking HAART; selection of the best Drug regimen for each patient; development of tailored Helping strategies; Evaluation of adherence and regimen effectiveness based upon current treatment guidelines; Reinforcement or Readjustment of treatment or adherence strategies; and Development of Endurance strategies.


Journal Articles 

Mannheimer SB, Mukherjee R, Hirschhorn LR, Dougherty J, Celano SA, Ciccarone D, Graham, KK, Mantell JE, Mundy LM, Eldred L, Botsko M, & Finkelstein R. The CASE adherence index: A novel method for measuring adherence to antiretroviral therapy. AIDS Care, October 2006; 18 (7): 853-861. PubMed Abstract

Weiss L, French T, Waters M, Netherland J, Agins B, & Finkelstein R. Adherence to HAART: Perspectives from clients in treatment support programs. Psychology, Health & Medicine, May 2006; 11 (2): 155-170. PubMed Abstract

Schackman BR, Finkelstein R, Neukermans CP, Lewis L, Eldred L, and the Center For Adherence Support and Evaluation Team. The cost of HIV medication adherence support interventions: Results of a cross-site evaluation. AIDS Care, November 2005; 17 (8): 927-937. PubMed Abstract

French T, Weiss L, Waters M, Tesoriero J, Finkelstein R, & Agins B. Correlation of a Brief Perceived Stress Measure with Nonadherence to Antiretroviral Therapy Over Time. Journal of Acquired Immune Deficiency Syndromes, April 2005; 38 (5): 590–597. PubMed Abstract

Weiss L, French T, Finkelstein R, Waters M, Mukherjee R, & Agins B. HIV-related knowledge and adherence to HAART. AIDS Care, October 2003; 15 (5): 673-679. PubMed Abstract

Tesoriero J, French T, Weiss L, Waters M, Finkelstein R, & Agins B. Stability of adherence to highly active antiretroviral therapy over time among clients enrolled in the treatment adherence demonstration project. Journal of Acquired Immune Deficiency Syndromes, August 2003; 33 (4): 484-493. PubMed Abstract


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