Enhancing Patient Adherence: Promoting Engagement via Positive Patient-Provider Relationships in HIV/AIDS Care

Abstract

The face of HIV/AIDS has shifted. Traditionally disenfranchised groups including African Americans and those known to be current or past substance-users are disproportionately infected and affected by the domestic HIV/AIDS epidemic. While caring for all people living with HIV/AIDS (PLWHA) is a public health priority, there are vast disparities in HIV/AIDS care and outcomes linked to treatment engagement and medication adherence. Historically, providers and researchers have focused heavily on seeking effective interventions to promote medication adherence among patients engaged in care. After having modest success when concentrating solely on outcomes pertaining to medication adherence (i.e., medication taking), the definition of adherence is broadening. Adherence to medications is now thought to occur along a continuum of engagement in care with regard to chronic illnesses such as HIV/AIDS. Patient-provider communication styles that are consistent with a motivational interviewing (MI) style are useful in enhancing active engagement in care, with potential to promote better medication adherence. Positive patient-provider relationships may be conduits for positive changes in vulnerable patients’ lives. Positive changes in individual patients’ lives culminate to reduce disparities in health status between PLWHA on a population level.

The challenges of treatment engagement and medication adherence in HIV/AIDS care in the U.S. are becoming clearer as the epidemic continues, as new treatment regimens are developed, and as the population in care shifts to those with fewer resources and a history of discrimination in medical care. Traditionally disenfranchised sub-groups such as African Americans and current/former substance-users are disproportionately affected by the domestic HIV/AIDS epidemic. For example, the proportion of adult and adolescent HIV/AIDS cases among African Americans has risen from under 20 percent in 1985 to 49 percent in 2005, while African American people make up only 13 percent of the total United States population. (1) African Americans and current/former substance-users have poor prognostic treatment outcomes for a host of reasons, including inadequate treatment engagement. (2, 3) For example, coopered with Caucasians, African American patients overwhelmingly present for care at later stages in HIV disease. (4) The important shift in the population affected by HIV/AIDS and related disparities in care and treatment calls for a new focus on engaging traditionally disenfranchised target populations in care and promoting medication adherence. (5, 6)

Treatment engagement, ideally, would mean that the patient is an active participant in care. Therefore, engagement would include: presenting for care, keeping appointments, participating actively in discussions with clinicians, and seeking information and resources to help with medication adherence and other wellness behaviors. Adherence is a set of behaviors among many along a continuum of active engagement in treatment. Treatment providers have multiple opportunities to engage and re-engage patients within flexible and fluid systems of care and within systems of HIV/AIDS care. To the extent patients are engaged, life-saving Highly Active Antiretroviral Therapy (HAART) can be offered and providers work to promote patients’ understanding of and adherence to regimens. (2, 7) However, due to insufficient engagement, only approximately 56 percent of patients who are eligible for medication actually receive it, let alone begin a trial of it. (8) Although many interventions have been developed and tested, improving medication adherence behavior has proven to be very challenging, especially when outcomes (and intervention targets) are defined narrowly as medication-taking behavior. (9, 10, 11) Most adherence interventions have modest and transitory effects on medication taking. It is becoming clear that medication adherence is contextualized within overall engagement in care. Not surprisingly, a strong dose-response relationship has been found between clinic visits and reduced mortality. (8)

Given the limited success of medication adherence-promoting interventions and the urgent need to engage traditionally disenfranchised patients in care, it is time to rethink HIV/AIDS treatment adherence broadly and to consider how clinicians could interact with patients in ways that promote all aspects of engagement in care and adherence to treatment. (4) As such, the definition of HIV/AIDS treatment adherence is expanding to include a host of engagement markers; an array of promising strategies to engage patients better at every choice point, and for specific sub-populations, should be articulated and tested. Systems-level barriers to patient engagement will require a comprehensive approach to promoting testing and early diagnosis for those at risk for HIV. This approach will help promote initial treatment entry. In the meantime, the patient-provider relationship should be examined, as it may be a powerful influence that could overcome entrenched systems-level barriers to treatment engagement and retention in care.

Increasingly, researchers are looking at the role of patient- provider communication in HIV/AIDS care, and more specifically, certain ways providers communicate with patients. (12) Communication methods that are consistent with a Motivational Interviewing (MI) style may prove useful in enhancing active engagement in care, eventually leading to better medication adherence. (13) The MI counseling style, when applied alone or as a prelude to care, is associated with positive patient- provider relationships as well as increased treatment engagement and retention in care in the area of substance use treatment. (14, 15, 16, 17, 18, 19, 20)

In randomized controlled trials of MI to promote HIV/AIDS treatment adherence, as in most other trials of behavior change in HIV/AIDS adherence, medication-taking behavior has served as the primary outcome variable. Several studies have demonstrated improved medication taking after MI but others have not.(21, 22, 23, 24, 25) While the results of published pilot and feasibility studies on this application are promising, MI is unlikely to provide a “magic bullet” in changing medication- taking behavior if it is only used to target medication taking as if it were isolated from a host of other treatment engagement behaviors. Moreover, the communication style of MI may be most promising as a method to more broadly engage patients in care. (10, 26)

Incorporating MI into usual care may enhance and extend the positive relationships between providers and patients, especially when they come from majority/minority racial, ethnic or cultural groups, respectively. Reduction of health disparities is a priority area that requires innovative and tailored interventions that include attention to cultural beliefs and expectations. (27) When majority group providers incorporate the patient-centered spirit of MI, they may restore psychological power back to those who have been traditionally disenfranchised through institutionalized discrimination and the great stigma often associated with HIV/AIDS. In fact, a recent meta-analysis showed that MI tended to yield the best outcomes when majority providers used it in interacting with minority patients. (28) The MI spirit, principles and techniques facilitate a respectful way of being with patients; patients are viewed as experts in their own lives and the provider’s role is to create a collaborative therapeutic environment within which to conduct an “inter-view.” In this way of being with a patient, the MI provider implicitly and explicitly integrates the important socio-cultural factors the patient brings into the therapeutic relationship. For example, in exploring difficulties in keeping appointments, a patient may state that transportation is a barrier, yet later reveal (once trust is built) that it is necessary to hide the reason for appointments from the people who can usually provide a ride to care, and that few people in their daily lives can be trusted with the knowledge of the patient’s HIV/AIDS status. In this case, as is very common among rural and Southern African Americans, appointment keeping depends on the patient devising a more socially acceptable and believable “cover story” for the need for an appointment. Similarly, in gently probing a patient’s perspective on taking medicines, the clinician may learn that the patient holds several contrary beliefs about medication: that it could be a lifesaver, but it could be a poison. In this case, ambivalence about medication taking may result in the very pattern of non-adherence (on and off) that is the most health threatening.

Within positive patient-provider relationships, clinicians seek to understand patients’ perspectives. They convey the belief that patients sit as expert on their own situations, building a foundation for mutual respect and constructive conversations about care in the future. (12) In the context of developing trust in a collaborative relationship, patients may reveal the real issues present in their lives as they struggle with motivation to adhere to medication over the course of chronic illness. When patients rate their relationships with physicians as more collaborative and when providers incorporate aspects of patients’ beliefs about medication into discussions about adherence, patients report significantly higher levels of adherence to medication. (29)

In conclusion, positive patient-provider relationships have potential to engage patients from traditionally disenfranchised sub-groups in HIV/AIDS care. An MI style of communication can facilitate positive patient-provider relationships, leading to increased adherence. Although health disparities among PLWHA are attributable to a host of systemically-entrenched factors, positive patient-provider relationships incorporating an MI style of communication have enormous potential to impact lives of individuals infected and affected by HIV/AIDS. (4, 18, 30)