Potential Barriers for HIV
Medication Adherence Programs
Wayne A. Duffus, MD, PhD
June 21st, 2010
Why Focus on Medication Adherence?
• Intensified focus in HIV prevention and at CDC on:
– HIV testing
– PWP (“prevention with positives”) including
linkage to and retention in care, prevention
services, and improving adherence
• Promoting HIV medication adherence to
– Maximize benefits of treatment for HIV-positive
persons
– Likely reduce viral load at the population level
Flexibility Policy as it Relates to Access,
Adherence and Monitoring Services
• HAB Policy Notice 07-03
• No more than 5% of a states ADAP funding; 10%
under extraordinary circumstances
– Enable access to medications
– Supporting adherence to the medication regimen
– Services to monitor progress in taking medications
• Current, comprehensive coverage of HAART and OI
medications
• No current limitations to access ADAP in the state
– No client waiting list or limits on enrollment
– No restrictions or limitation on HIV medications
– Administrative support is maintained
Source of Information
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South Carolina
Washington, DC*
Kentucky*
Mississippi
Arizona
Texas
Colorado*
Virginia*
Nevada
NASTAD
*ADAPs with central office level adherence programs
State ADAP Operation
• South Carolina
– Contract pharmacy after years of having an in-house central
pharmacy
– Adherence monitoring not formally part of pharmacy
contract
– Individual facilities can use Ryan White funding as part of
core services for adherence monitoring
– Barriers to adherence are assessed at the provider level
using the standardized Ryan White Part B intake/assessment
tool
– Quality Management Steering Committee selected 10 priority
measures. Treatment adherence was not one of them for
state level monitoring. Requires a Quality Manager to visit
sites and thus enable completeness of reporting.
Selected State ADAP Operation
• Mississippi
– Medications are picked up by the patient from the
nearest County Health Department
– Central Office gets a report of who does/doesn’t
collect meds
– Information on med pick-up frequency is stored
but not actively relayed to provider
– New program: District Social Worker to be notified
– Contact patient and provider
State of Kentucky*
• Mail order pharmacy: contract with the University of
Kentucky Pharmacy
• Has 6 regional Ryan white subcontractor; every region
has an adherence counselor
• Individual facilities does own adherence counseling
• Statewide Quality Management Program: implemented
in 2009 with report to central office
– Training on adherence for case managers
– New intake form has assessment tool of barriers to treatment
and medication adherence
– Variables collected include: # refills in one year; time lapse
between diagnosis date and first prescription
ADAP Operation
• Washington, DC*
– Primarily a pharmacy network where medications
are picked-up. In some cases medications are sent
directly to the provider office
– Central office developed minimal guidelines for
medical case management that includes adherence
monitoring
– Have contract with the Center for Minority Studies:
monthly 2 hour treatment adherence roundtable
including funded providers, pharmaceutical reps,
clients, case managers, etc
– Overwhelming numbers of new cases and linkage
to care with adequate provider availability an issue
State ADAP Operation
• Texas
– Network of 480 local pharmacies and one mail
order pharmacy
– Central office sends medications to each pharmacy
after receiving faxed prescription from pharmacies
– Clinic sites have case managers who assess
adherence
– Geographic distance from central office to
individual providers makes on-site monitoring
prohibitive
State ADAP Operation
• Colorado*
– Co-located clinic and pharmacy
– Actively track utilization
– Contact patient and provider
• Nevada
– Two pharmacies (North and South): one pick-up
only, other pick-up/mail order
– Had formal adherence program in the past but with
decreased funding availability had to end program
– Current database does not store previous
medication history for long periods
State of Virginia*
• Medications are dispensed from central pharmacy and collected
from any of 135 local health departments (LHD)
• LHDs provide ADAP services in-kind (eligibility and medication
coordination)
• ADAP Adherence Pilot Project
– Six local health departments (LHD) funded for 18-months
– Two different approaches: Client-based vs Process-based
– Challenges at all level: LHD, administrative, service delivery
• Adherence services provided by a wide variety of staff which
results in variability across sites
• HIPAA regulations limit access to health records for staff from
other agencies
• Follow up between providers and case management is sporadic
Barriers to Adherence Programs
• State policy
– No legislative regulation that specifically prohibits
implementation
– No Board of Pharmacy rule that prohibits
implementation, however, may specify licensed
individual to perform duties related to medication
monitoring
– Treatment adherence services vary widely across
state and Ryan White programs
• Structural and Medical
– Transportation, housing instability, substance use,
mental health
Barriers to Adherence Programs
• Financial
– Resource availability (Part B only vs Part A and Part
B)
– Wait list and other cost containment measures
– Contract pharmacy cost to include adherence as
part of service delivery
– Choice between providing medications or providing
services
Barriers to Adherence Programs
• Providers
– Perceived intrusion into physician-patient
relationship
– Difficult to access or to be involved at the state
level
• Personnel
– Special skills not possessed by existing staff eg.
data analysis, in-house pharmacist, research
– Staff with multiple responsibilities and limited
availability at the local level
Barriers to Adherence Programs
• Administrative
– Understaffed, inertia to create another program
– Unclear on content of an adherence program at the
state level
– Insecurity on how to administer an adherence
program when the interaction is provider-patient
– Formal evaluations not yet conducted at existing
adherence programs
Path Forward
• Funding to allow implementation and sustainability
of programs
• Create adherence models at the state level, provider
level or case management level (dissemination of
best practices)
• Distinguish adherence monitoring at the patientprovider vs central office-population level
• Clear advice/discussion on what to do with the data
collected and how relevant to the mission at all
levels of care
Path Forward
• Improved communication needed between state,
provider and case management
• Define agency responsible for promoting change at
the facility, provider, or patient level
• Promote ADAP integration with HIV surveillance to
provide lab data eg. CD4/VL, genotypes
• Consider adoption of other measures of adherence:
mortality, community viral load, community
resistance