Page 168 - HIV/AIDS Guidelines

Measurement of Adherence

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There is no gold standard for the assessment of adherence, but there are many validated tools and strategies
to choose from. Although patient self-report of adherence predictably overestimates adherence by as much as
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20%, this measure still is associated with viral load responses. Thus, a patient’s report of suboptimal
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adherence is a strong indicator of nonadherence and should be taken seriously.
When ascertained in a simple, nonjudgmental, routine, and structured format that normalizes less-than-
perfect adherence and minimizes socially desirable responses, patient self-report remains the most useful
method for the assessment and longitudinal monitoring of a patient’s adherence in the clinical setting. A
survey of all doses missed during the past 3 days or the past week accurately reflects longitudinal adherence
and is the most practical and readily available tool for adherence assessments in clinical trials and in clinical
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practice. Other strategies also may be effective. One study found that asking patients to rate their adherence
on a six-point scale during 1 month was more accurate than asking them about the frequency of missed doses
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or to estimate the percentage of doses taken during the previous 3 or 7 days. Pharmacy records and pill
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counts also can be used in addition to simply asking the patient about adherence. Other methods of
assessing adherence include the use of electronic measurement devices (e.g., bottle caps, dispensing
systems). However, these methods may not be feasible in some clinical settings.

Interventions to Improve Adherence

Before writing the first prescriptions, the clinician should assess the patient’s readiness to take medication,
including information such as factors that may limit adherence (psychiatric illness, active drug use, etc.) and
make additional support necessary; the patient’s understanding of the disease and the regimen; and the
patient’s social support, housing, work and home situation, and daily schedules.

During the past several years, a number of advances have simplified many regimens dramatically,
particularly those for treatment-naive patients. Prescribing regimens that are simple to take, have a low pill
burden and low-frequency dosing, have no food requirements, and have low incidence and severity of
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adverse effects will facilitate adherence. The Panel considered both regimen simplicity and effectiveness
when making current treatment recommendations (see What to Start).
Patients should understand that their first regimen usually offers the best chance for a simple regimen that
affords long-term treatment success and prevention of drug resistance. Given that effective response to ART
is dependent on good adherence, clinicians should identify barriers to adherence such as a patient’s schedule,
competing psychosocial needs, learning needs, and literacy level before treatment is initiated. As appropriate,
resources and strategies that will help the patient to achieve and maintain good adherence should be
employed.

Individualizing treatment with involvement of the patient in decision making is the cornerstone of any
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treatment plan. The first principle of successful treatment is negotiation of an understandable plan to which
the patient can commit. 19-20 Establishing a trusting relationship over time and maintaining good
communication will help to improve adherence and long-term outcomes.
An increasing number of interventions have demonstrated efficacy in improving adherence to ART. A meta-
analysis of 19 randomized controlled trials of ART adherence interventions found that intervention
participants were 1.5 times as likely to report 95% adherence and 1.25 times as likely to achieve an
undetectable viral load as participants in comparison conditions. 21
In a more recent synthesis, CDC provides new guidance to assist providers in selecting from among the
many possible adherence interventions. According to efficacy criteria described by the CDC HIV/AIDS
Prevention Research Synthesis (PRS) project, CDC has identified a subset of best-evidence medication
adherence interventions. In December 2010, CDC published a new online Medication Adherence chapter of

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents K-2

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