Adherence to the Continuum of Care

Last Updated: October 17, 2017; Last Reviewed: October 17, 2017

Panel's Recommendations Regarding Adherence to the Continuum of Care

Panel’s Recommendations


Linkage-to-care and adherence to both antiretroviral therapy (ART) and clinic appointments should be regularly assessed. An individual’s barriers to adherence to ART and appointments should be assessed before initiation of ART and regularly thereafter. Patients with ART adherence problems should be placed on regimens with high genetic barriers to resistance, such as dolutegravir (DTG) or boosted darunavir (DRV). Side effects, out-of-pocket costs, convenience, and patient preferences also need to be considered. Patients having difficulties with adherence to appointments or ART should be approached in a constructive, collaborative, nonjudgmental, and problem-solving manner. The approach to improved adherence should be tailored to each person’s needs (or barriers to care). Approaches could include, but are not limited to: Changing ART to simplify dosing or reduce side effects Finding resources to assist with treatment costs to maintain uninterrupted access to both ART and appointments Allowing flexible appointment scheduling Assisting with transportation, or Linking patients to counseling to overcome stigma, substance use, or depression. Multidisciplinary approaches to find solutions to ART and appointment adherence problems are often necessary, including collaboration with social work and case management (to the extent available). The clinician’s role is to help the patient understand the importance of adherence to the continuum of care and reveal barriers to adherence, and link the patient to resources to overcome those barriers. A summary of best practice interventions to improve linkage, retention, and adherence can be found at a Centers for Disease Control and Prevention compendium (https://www.cdc.gov/hiv/research/interventionresearch/compendium/index.html).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional Rating of Evidence: I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Linkage-to-care and adherence to both antiretroviral therapy (ART) and clinic appointments should be regularly assessed.
An individual’s barriers to adherence to ART and appointments should be assessed before initiation of ART and regularly thereafter.
Patients with ART adherence problems should be placed on regimens with high genetic barriers to resistance, such as dolutegravir (DTG) or boosted darunavir (DRV). Side effects, out-of-pocket costs, convenience, and patient preferences also need to be considered.
Patients having difficulties with adherence to appointments or ART should be approached in a constructive, collaborative, nonjudgmental, and problem-solving manner.
The approach to improved adherence should be tailored to each person’s needs (or barriers to care). Approaches could include, but are not limited to:
- Changing ART to simplify dosing or reduce side effects
- Finding resources to assist with treatment costs to maintain uninterrupted access to both ART and appointments
- Allowing flexible appointment scheduling
- Assisting with transportation, or
- Linking patients to counseling to overcome stigma, substance use, or depression.
Multidisciplinary approaches to find solutions to ART and appointment adherence problems are often necessary, including collaboration with social work and case management (to the extent available). The clinician’s role is to help the patient understand the importance of adherence to the continuum of care and reveal barriers to adherence, and link the patient to resources to overcome those barriers.
A summary of best practice interventions to improve linkage, retention, and adherence can be found at a Centers for Disease Control and Prevention compendium (https://www.cdc.gov/hiv/research/interventionresearch/compendium/index.html).

Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion

Strategies to Improve Linkage to Care, Retention in Care, Adherence to Appointments, and Adherence to Antiretroviral Therapy

Strategies	Examples
Provide an accessible, trustworthy, nonjudgmental multidisciplinary health care team.	Care providers, nurses, social workers, case managers, pharmacists, and medication managers.
Strengthen early linkage to care and retention in care.	Encourage health care team participation in linkage to and retention in care. Use ARTAS training (if available).
Evaluate patient’s knowledge about HIV infection, prevention, and treatment and, based on this assessment, provide HIV-related information.	Keeping the patient’s current knowledge base in mind, provide information about HIV, including the natural history of the disease, HIV viral load and CD4 count and expected clinical outcomes according to these parameters, therapeutic and prevention consequences of poor adherence, and importance of staying in HIV care.
Identify facilitators, potential barriers to adherence, and necessary medication management skills both before starting ART and on an ongoing basis.	Assess patient’s cognitive competence and impairment. Assess behavioral and psychosocial challenges, including depression, mental illnesses, levels of social support, levels of alcohol consumption and current substance use, nondisclosure of HIV serostatus, and stigma. Identify and address language and literacy barriers. Assess beliefs, perceptions, and expectations about taking ART (e.g., impact on health, side effects, disclosure issues, consequences of poor adherence). Ask about medication-taking skills and foreseeable challenges with adherence (e.g., past difficulty keeping appointments, adverse effects from previous medications, issues managing other chronic medications, need for medication reminders and organizers). Assess structural issues, including unstable housing, lack of income, unpredictable daily schedule, lack of prescription drug coverage, lack of continuous access to medications, transportation problems.
Provide needed resources.	Provide or refer for mental health and/or substance abuse treatment. Provide resources to obtain prescription drug coverage (e.g., Common Patient Assistance Program Application (CPAPA): http://bit.ly/CommonPAPForm; Pharmaceutical Company HIV Patient Assistance Programs and Cost-Sharing Assistance Programs: http://bit.ly/1XIahvN Provide resources about stable housing, social support, transportation assistance, and income and food security.
Involve the patient in ARV regimen selection.	Review potential side effects, dosing frequency, pill burden, storage requirements, food requirements, and consequences of poor adherence. Assess daily activities and tailor regimen to predictable and routine daily events. Consider preferential use of PI/r-based or DTG-based ART if poor adherence is anticipated. Consider use of STR formulations. Assess if cost/copayment for drugs will affect adherence and access to medications.
Assess adherence at every clinic visit.	Monitor viral load as a strong biologic measure of adherence. Use a simple behavioral rating scale or self-reported assessment. Employ a structured format that normalizes or assumes less-than-perfect adherence and minimizes socially desirable or “white-coat adherence” responses. Ensure that other members of the health care team also assess and support adherence.
Use positive reinforcement to foster adherence success.	Inform patients of low or nondetectable levels of HIV viral load and increases in CD4 cell counts. Thank patients for attending their appointments.
Identify the type of and reasons for poor adherence and target ways to improve adherence.	Failure to understand dosing instructions. Complexity of regimen (e.g., pill burden, size, dosing schedule, food requirements, polypharmacy). Pill aversion or pill fatigue. Adverse effects. Inadequate understanding of drug resistance and its relationship to adherence. Patient is unaware of appointments or appointments are not scheduled with proper patient input. Cost-related issues (copays for medications or visits, missed work time). Depression, drug and alcohol use, homelessness, poverty. Stigma of taking pills or attending HIV-related appointments. Nondisclosure of status leading to missed doses, refills, or appointments.
Select from among available effective adherence and retention interventions.	See Compendium of Evidence-Based Interventions and Best Practices for HIV Prevention from CDC for a summary of best practice interventions to improve linkage, retention, and adherence. Use adherence-related tools to complement education and counseling interventions (e.g., text messaging, pill box monitors, pill boxes, alarms). Use community resources to support adherence (e.g., visiting nurses, community workers, family, peer advocates, transportation assistance). Use patient prescription assistance programs (see above, under “Provide needed resources”). Use motivational interviews. Provide outreach for patients who drop out of care. Use peer or paraprofessional treatment navigators. Recognize positive clinical outcomes resulting from better adherence. Arrange for DOT in persons in substance use treatment (if feasible). Enhance clinic support and structures to promote linkage and retention (reminder calls, flexible scheduling, open access, active referrals, and improved patient satisfaction).
Systematically monitor retention in care.	Record and follow up on missed visits.
Key to Acronyms: ART = antiretroviral therapy; ARTAS = Anti-Retroviral Treatment and Access to Services; ARV = antiretroviral; CD4 = CD4 T lymphocyte; CDC = Centers for Disease Control and Prevention; DOT = directly observed therapy; DTG = dolutegravir; PI/r = ritonavir-boosted protease inhibitor; STR = single tablet regimen