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Assessing Existing Efforts to Increase Adherence to Medication

About this initiative... Background Grantees Journal Articles Initiative's Website

SPNS-related publications... Listing of SPNS Products Download SPNS technical assistance publications (government- and grantee-produced) from the TARGET Center Library keyword: SPNS

Background  

The goal of this initiative is to assess innovative interventions being implemented to increase adherence to highly active anti-retroviral treatment (HAART) among underserved populations and consisted of two components:

• Twelve adherence support programs serving people with HIV receiving HAART
• The Center for Adherence Support Evaluation (CASE) at the New York Academy of Medicine

The twelve clinic-based programs currently deliver HIV medical care to underserved populations and have fully operational adherence support programs for their clients receiving HAART. The programs were selected to receive funding from the HRSA Special Programs of National Significance (SPNS) to evaluate their adherence programs because their adherence interventions were considered innovative. The programs serve a variety of populations, but all target uninsured or underinsured people with HIV who have difficulty accessing care. They use a range of different adherence interventions, but all seek to improve the ability of their clients to successfully adhere to HAART. In addition, they all provide some sort of non-cash incentive for participating in the research study. No clients are prevented from receiving the services of their programs if they choose not to participate in the study.

For more in-depth information, please see: The Case of Antiretroviral Adherence Support Interventions

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Grantees 

• Health Services Center (formerly AIDS Service Center)
• CASE New York Academy of Medicine
• Chase Brexton Health Services
• Columbia University SPH
• Columbia University Harlem Hospital Center
• Dimock Community Health Center
• Johns Hopkins University School of Medicine
• Mission Neighborhood Health Center
• Multnomah County Health Department
• New York Health Dept. (AIDS Institute)
• North Broward Hospital District
• St. Luke's-Roosevelt Hospital Center
• SUNY Health Science Center
• University of California
• Washington University

Health Services Center (formerly AIDS Service Center) 
Barbara J. Hanna, MD
P.O. Box 1392
Anniston, AL 36202
(256) 832-0100

Project Period: 10/99 – 9/02  

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 (ASC) provides HIV care to people with HIV/AIDS in a predominantly rural 14-county area of northeast Alabama. The adherence program ASC has developed provides three different interventions, including a modified directly observed therapy intervention, that differ in intensity to meet the specific need of the client. The baseline interview is used as a screening tool to assess which of the three interventions is most appropriate for each client. Clients enrolled in the most intense intervention have been paired with a trained buddy or buddy team. The buddy makes contact with the client daily by phone, and provides support for taking his or her medication. Clients enrolled the directly observed therapy intervention come to either ASC or a local health department five days a week to pick up their medications. Clients enrolled in the least intense interventions meet with a clinic adherence panel monthly at the time of their clinic visits. Periodic reevaluation occurs, and if the needs of a client change, s/he can be moved to a different level of intervention.

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Chase Brexton Health Services, Inc. 
Emily Richie, MD
1001 Cathedral Street
Baltimore, MD 21201
(410) 837-2050 x215

Project Period: 10/99 – 9/02

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

Description: Chase Brexton Health Services, Inc. (CBHS), a large comprehensive community-based provider of primary HIV care to underserved populations in Maryland, has recently developed a system-wide comprehensive program designed to improve client adherence to HAART regimens. Central components of the adherence program are: 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. The goal is to develop new standards for provision of HAART and adherence support for substance users and those at high risk for major depression.

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Dimock Community Health Center (DCHC) 
Lisa Hirschhorn, MD, MPH
55 Dimock Street
Roxbury, MA 02119
(617) 442-8800 x1255
hirschhorn@mediaone.net

Project Period: 10/99 - 9/02

Target Population: People 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 works to ensure treatment with and adherence to HAART for HIV infected
individuals, comparing a standard adherence strategy to an intensive strategy that involves community-based care. Patients are randomly assigned to receive either
the standard or the intensive strategy. The standard strategy, which includes multidisciplinary care as coordinated by an HIV nurse, HIV specialty care, use of
literacy-leveled educational materials, peer counseling, use of a programmable watch, and tailored interventions, is provided at both study sites. In the intensive
strategy, an HIV home care nurse also visits patients once or twice weekly for four to six weeks in their identified community setting, addressing specific
barriers to adherence in coordination with the multidisciplinary team.

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Columbia University Harlem Hospital Center 
Sharon Mannheimer
506 Lenox Avenue, Room 3101-A
New York, NY 10037
212-939-2948
sbm20@columbia.edu

Project Period:10/99 – 9/02

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. Each subject is 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 comparea 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.

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New York Health Department (AIDS Institute)  
Bruce D. Agins, M.D. , M.P.H.
1 University Place
Renssalaer, NY 12144-3456
(212) 613-2428

Project Period: 10/99 - 9/02

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

Description: The Institute has funded ten comprehensive adherence support programs throughout New York State. The programs all aim to increase adherence through the following measures: development of partnerships among clinical and non-clinical providers and clients; 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; provide access to support services tailored to clients’ needs. Data are already being gathered from the sites for evaluation, and for the purposes of the SPNS initiative, these data are now being statistically manipulated and combined with the data from the other SPNS sites for the national cross-site evaluation.

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Johns Hopkins University, School of Medicine
Richard D. Moore, M.D.
1830 East Monument Street, 4^th Floor
Baltimore, MD 21287
(410) 955-2144
rdmoore@jhmi.edu

Project Period: 10/99 – 9/02

Target Population: People 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 is an intervention program to increase adherence with HAART at the Moore Clinic, the Johns Hopkins Hospital HIV specialty clinic. This program specifically targets patients who are HAART candidates but are not prescribed or are failing HAART therapy. The intervention has four components: intensive case management, one-on-one nursing education, peer advocate support, and group education/support sessions. Clients are 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 will be compared with each other as well as with a separate comparison group. 

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Mission Neighborhood Health Center 
Ricardo Alvarez, MD
240 Shotwell Street
San Francisco, CA 94110
415-552-1013

Project Period: 10/99 – 9/02

Target Population: People with HIV who are predominantly Hispanic, many of whom speak no English 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 has developed an adherence intervention, the Medication Adherence Protocol, or MAP, which: emphasizes the client’s readiness to take HAART by having multiple discipline assessments; integrates cultural competency, social support and patients’ belief systems; and builds in a system of checks and balances. Clients are prepared to begin taking HAART through a series of meetings with the medical provider, case manager/social worker, and nurse or treatment advocate. When they are determined to be ready, they fill their prescriptions and return to the clinic for an assessment of their understanding of the medicines and how to take them, as well as for 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 provide continued adherence support for clients.

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Multnomah County Health Department 
John Dougherty, MD, PhD
426 SW Stark Street
Portland, OR 97204
(503) 248-3674

Project Period: 10/99 – 9/02

Target Population: People 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, health care professionals, and social workers jointly address the adherence needs of HAART clients. The pharmacist coordinates the program and serves as an integral part of the care of HIV clients. The pharmacy intervention is a series of educational interventions in which the pharmacist provides education, counseling, and adherence tools such as multi-sectioned plastic boxes, or Medisets, for storing a week’s supply of medicine. The program works to improve client readiness for antiretroviral treatment prior to prescription, and support client adherence to antiretroviral treatment after prescription.

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North Broward Hospital District 
Kathleen Graham
303 SE 17^th Street, Suite 100
Ft. Lauderdale, FL 33316
954-355-4952

Project Period: 10/99 – 9/02

Target Population: People with HIV, including women and African American and Hispanic people.

Description: North Broward Hospital District is implementing three outpatient interventions of increasing intensity to improve medication adherence: Standard, Provider Enhanced Intervention (PEI), and Home-based. The standard intervention is comprised of the interventions everyone attending the clinic receive, including a psychosocial assessment by a case management and a clinicalassessment by a health care provider. The PEI is comprised of the standard intervention plus two or three sessions with the pharmacist, who provides counseling, reminder tools, and training videos. The Home-based intervention is 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.

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Columbia University SPH 
Nancy VanDevanter, DrPH
600 West 168th Street
New York, NY 10032
(212) 305-1166

Project Period: 10/99 - 9/02

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

Description: The Northern Manhattan Women and Children HIV Project (NMWCHP) is conducting the Northern Manhattan Adherence Initiative. The initiative is based upon the framework of the Transtheoretical Model of Stages of Behavior Change. The goals of the program are to: 1) 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; 2) provide appropriate information and support to clients according to their stage of readiness for taking/administering these medications; and 3) improve adherence among clients already on antiretroviral therapy. 

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University of California, San Francisco 
Alex Karal, PhD and Don Ciccorone, MD
Urban Helath Study
Dept. of Family and Community Medicine
PO Box 1304
San Francisco, CA 94143

Project Period: 10/99 – 9/02

Target Population: Homeless or marginally homeless HIV (+) individuals

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. Major goals of the APAP are 1) To improve the health status and quality of life of HIV+ homeless or marginally housed individuals currently on antiretroviral treatment by enrolling 50 into the APAP 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, and 2) achieve the same goals for HIV+ homeless or marginally housed individuals not on antiretroviral medications, but who are planning to start antiretroviral treatment by enrolling 50 into the APAP and stabilizing them so they may successfully initiate and adhere to antiretrovrial regimens.

The goals of the APAP evaluation are to determine whether the program can serve as a model for the delivery of adherence support to this population and to assist policy makers in deciding whether similar projects should be implemented in other metropolitan areas.

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Washington University School of Medicine 
Linda Mundy, MD
Campus Box 8051
660 S. Euclid Ave.
St. Louis, MO 63110
314-747-1026

Project Period: 10/99 – 9/02

Target Population: Adolescent and adult women 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. The adherence program consists of the following components: 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.

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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. (2006) The CASE adherence index: A novel method for measuring adherence to antiretroviral therapy. AIDS Care, 18 (7): 853-861.

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

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

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

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

Tesoriero J, French T, Weiss L, Waters M, Finkelstein R, & Agins B. (2003) 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, 33 (4): 484-493.

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