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What is the relationship between adherence to care and adherence to ART?
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The New York City Health Department recognizes that a patient who maintains stable housing and keeps his or her medical appointments is one who is more likely to take his medications on a regular basis. Launched in December, the Department’s HIV Care Coordination Program consists of teams of care coordinators and patient navigators who educate patients on their health care and medications regimen as well as assist them in obtaining the services they need. These services may include obtaining health care, insurance coverage, food supplementation or subsidized housing. The navigators have day-to-day contact with the patients in their charge and the care coordinators oversee a team of navigators.
The treatment adherence aspect of the program involves teaching patients about their illness through a standardized curriculum. This curriculum covers a wide range of topics from basic facts about HIV and what antiretroviral medications achieve biologically, to navigating the health care system and finding support services. Both staff of the Care Coordination program and HIV primary care providers who are participating in the Program are trained to deliver these education outcomes.
The overall goal of the program is to achieve stable health in its patients and to help patients gain self-sufficiency. Patients with HIV infection will be required to take antiretroviral medications for decades, so it is important that we teach them how to manage their health and life circumstances as much as possible.
Fabienne Laraque, MD, MPH, is the Director of the Care, Treatment and Housing Program in the Bureau of HIV Prevention and Control at the New York City Department of Health and Mental Hygiene.
Adherence to care is more fundamental than adherence to medications. Of course the two are related, but if you adhere to care across the board, the likelihood is that you are going to adhere to your medications.
It is important to develop systems of care. We need to make sure that patients have access to the treatment facility. We have to make sure that the life and the job of patients allow them to make appointments and to have systems in place to deal with changes in these circumstances. We need to keep in mind the career of the person in care. A lot of adherence to ART is based on structural factors that retain the patient in care.
Another key is to get patients into care early and get them used to the routines of treatment as soon as possible. Once they are on our radar, we need systems that provide constant reminders: phone calls, emails, text messaging, whatever it takes. If it works, do it.
The other key factor is the relationships between the patient and the provider, the patient and the case worker, and so forth. As providers we need to be prepared to make negotiations to support our patients and keep them coming to appointments. We should also have communication with other providers caring for our patients.
A final point is that there is a science to adherence. We have been thinking about this for 20 years at UCSF. Part of the process was learning from the experiences of others. As providers for patients with HIV, we should be open to using strategies employed by caretakers of patients with other chronic conditions.
Paul Volberding, MD, is a Professor and Vice Chair of the University of California San Francisco Department of Medicine and an Infectious Disease News Editorial Board member.