Table 2.
Strategies for promoting antiretroviral adherence
| Prior to initiation |
| Establish patient’s readiness to take medication before prescribing—assess experience with past regimens and consider practice trials with sugar pills |
| Evaluate the regimen—limit complexity as much as possible. |
| Tailor the regimen schedule—map out daily routines of the patient and superimpose potential dose times and impact of suspected side effects. If possible, link dose time(s) to regularly occurring events. |
| Involve patients in the decision-making process for dose timing and regimen |
| Facilitate conversations with peers currently on the regimens to allay fears and temper expectations |
| Explore common concerns (ie, stigma, privacy, disclosure, toxicity) and more ideographic ones (what will pose the greatest challenges for you?) in a strength-based approach (what resources and support do you have to help you when you start the regimen?) |
| Provide necessary information about ART agents, common side effects, management of side effects, regimen requirements, resistance, and what to do if doses are missed or problems are encountered |
| Provide a list of resources for community and clinic-based support |
| Assess and address any cultural beliefs or misinformation that might detract from adherence (eg, the misconceptions that ART cannot be taken with alcohol or nontraditional medicines and that brief self-imposed treatment interruptions are harmless) |
| Provide as comprehensive an approach as possible—use multidisciplinary treatment planning including case management, social work services, dietary services, pharmacist consultation, and medical care |
| Address situational concerns that may serve as major barriers to adherence (eg, mental health issues, homelessness, substance use) |
| At initiation |
| Provide information and support for the management of potential side effects—prepare patient for possible adverse reactions, recognize their impact (particularly those that are disfiguring), and treat aggressively and prophylactically if possible |
| Adopt a neutral stance when inquiring about adherence—avoid overly enthusiastic reinforcement of reported perfect adherence or negative responses to missed doses; creating an environment for patients to report nonadherence comfortably and to feel supported in their efforts is critical in long-term patient-provider relationships |
| Regularly collect adherence data and use this information to give targeted feedback about improving medication taking |
| Ask questions and listen to answers. Ask patients what gets in the way and what helps and allow for them to respond fully. Wait to move to problem-solving; listening can be therapeutic and can offer an opportunity to patients to identify their own strategies for addressing barriers. |
| Offer strategies and tools as needed—including memory prompts (alarms, cell phones, linking objects to medications, linking dose times to recurring events); storage and carrying tools (portable pill cases); organizational tools (journal, pill box, calendar); monitoring tools (tracking cards for lab values or identification of barriers); informational tools (websites, videos, written material, ART cards with summaries of medication requirements and interactions); and referral to support services (mental health, housing, case management) |
| Avoid close-ended questions about adherence that quickly terminate the discussion (you’re taking your medications, right?). |
| Promote social support, including appropriate disclosure and the involvement of a designated treatment adherence partner, peers, family members, partner, and friends |
| Long-term and at periodic intervals |
| Continue exploration of potential facilitators and barriers of adherence with neutral inquiries about adherence (You’ve been on this regimen for a while now, what are your greatest challenges for taking the doses every day? What is the hardest part?). Barriers and facilitators of long-term adherence can be different than those initially encountered. |
| Build a toolbox of adherence strategies based on cumulative experiences of patients and colleagues |
| Inquire about reinforcement of continued adherence (Do you do something special for yourself when you’ve had a period of really consistent adherence? What keeps you going?) Incorporate recognition of success into clinic procedures (eg, staff standing ovations for achieving undetectable virus levels). |
| Facilitate sharing among patients of successful strategies. Partner with local community-based organizations in such endeavors. |
ART antiretroviral therapy