HIV/Adheresm
A-CASI for self report of compliance with HAART therapy.
HIV links
Overview
Study results to date have shown that the HIV/Adhere A-CASI HAART adherence
intervention met its original objectives, and can be a useful clinical tool.
We describe its objectives, the elements that comprise the A-CASI,
the study results achieved to date, and acknowledge participating researchers and scientists.
Introduction
Antiretroviral (ARV) medications for HIV/AIDS are among the most efficacious,
and the most life-transforming of therapeutic innovations of recent years.1
However a high level of patient adherence to ARVs is needed to suppress plasma HIV,
prevent drug resistance, control disease progression, and prevent transmission of
drug-resistant HIV.2,3 ARV adherence problems are common: objectively measured adherence
averages about 63-75%,2,4 and only about 60% of HIV patients on ARV therapy achieve
viral suppression in many studies,5 though suppression rates may be improving in recent
years.6 Accordingly, national treatment guidelines are clear that HIV providers should
assess, educate, and support their patients’ ARV adherence as part of good HIV care.7,8
Notwithstanding, as many as 30-40% of patients may be mistakenly judged by their
providers to be fully adherent to their ARVs, when in point of fact those same patients
are missing many of their doses.2,9
A substantial body of research is underway developing and testing behavioral
interventions to improve patients’ ARV adherence.10-12 But none of the many approaches
being tested will work well in real-world clinical settings if providers have difficulty
detecting nonadherence, identifying rectifiable risk factors for nonadherence, and
initiating education and support discussions and interventions. Evidence is clear that
providers have difficulty “diagnosing” adherence problems accurately and counseling
about behavior change.13,14 Time for careful medication history-taking is limited in
busy practices,15-17 patients (especially those taking many medicines) need help
remembering to adhere,18,19 and some patients hesitate to disclose nonadherence to
providers whom they wish to please, or do not fully trust.20 Integrating patient
information technologies into care may help improve this situation in two ways:
First, there is increasing evidence that individuals will have better recall, and
therefore will more often disclose sensitive health behaviors when responding to
computers, than they will when speaking directly to providers.21-25 Second, a
systematic approach to clinical quality improvement will assure that adherence is
assessed consistently and uniformly across all ARV-using patients receiving care.26
Informatics, the science of computer information systems in clinical care,
has expanded greatly in recent years.27 However, applied clinical informatics
is usually doctor-focused, emphasizing clinical care reminders, information
and decision aids, and electronic medical records.28 In contrast, patient-focused
clinical informatics computer systems have received much less attention.
Well-designed computer systems could collect important information directly from
patients about medication adherence, knowledge, and experiences to improve
delivery of high-quality patient care.
The current general state of research on ARV adherence interventions is that
there are many promising, but resource-intensive adherence education and support
methods being tested. Clinicians will need practical aids to systematically
identify and communicate with nonadherent patients, so as to connect patients
with enhanced adherence services. HIV/Adhere can address this need.
The next page provides a description of the HIV/Adhere A-CASI. 
1. Holtzer C, Roland M. The use of combination antiretroviral therapy in HIV-infected patients. Annals of Pharmacotherapy 1999;33:198-209.
2. Paterson DL, Swindells S, Mohr J et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med 2000;133:21-30.
3. Haubrich RH, Little SJ, Currier JS et al. The value of patient-reported adherence to antiretroviral therapy in predicting virologic and immunologic response. California Collaborative Treatment Group. Aids 1999;13:1099-107.
4. Liu H, Golin CE, Miller LG et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Ann Intern Med 2001;134:968-77.
5. Lucas GM, Chaisson RE, Moore RD. Highly active antiretroviral therapy in a large urban clinic: risk factors for virologic failure and adverse drug reactions. Ann Intern Med 1999;131:81-7.
6. Moore RD, Keruly JC, Gebo KA, Lucas GM. An improvement in virologic response to highly active antiretroviral therapy in clinical practice from 1996 through 2002. J Acquir Immune Defic Syndr 2005;39:195-8.
7. Adherence to potent antiretroviral therapy. Guidelines for the use of antiretroviral agents in HIV-infected adults and adolescents. 2006 vol: Department of Health and Human Services and Henry J. Kaiser Family Foundation; 2005.
8. Jani AA. Adherence to HIV Treatment Regimens: Recommendations for Best Practices. 2004 vol: APHA; 2004.
9. Murri R, Antinori A, Ammassari A et al. Physician estimates of adherence and the patient-physician relationship as a setting to improve adherence to antiretroviral therapy. J Acquir Immune Defic Syndr 2002;31 Suppl 3:S158-S162.
10. Simoni JM, Frick PA, Pantalone DW, Turner BJ. Antiretroviral adherence interventions: a review of current literature and ongoing studies. Top HIV Med 2003;11:185-98.
11. Simoni JM, Pantalone DW. Randomized controlled intervention trials to improve antiretroviral adherence: An updated review of the field. Elements of Success: An International Conference on Adherence to Antiretroviral Therapy. Dallas, TX.; 2004.
12. Simoni JM. State of the ART: Regimens, Assessment, and Interventions. NIMH/IAPAC International Conference oh HIV Treatment Adherence. Jersey City, New Jersey; 2006.
13. Miller LG, Liu H, Hays RD et al. How well do clinicians estimate patients' adherence to combination antiretroviral therapy? J Gen Intern Med 2002;17:1-11.
14. Bangsberg DR, Hecht FM, Clague H et al. Provider assessment of adherence to HIV antiretroviral therapy. J Acquir Immune Defic Syndr 2001;26:435-42.
15. Roberts KJ, Volberding P. Adherence communication: a qualitative analysis of physician-patient dialogue. Aids 1999;13:1771-8.
16. Roberts KJ. Physician beliefs about antiretroviral adherence communication. AIDS Patient Care STDS 2000;14:477-84.
17. Morrison I. The future of physician's time. Ann Intern Med 2000;132:80-4.
18. Simon PA, Sorvillo FJ, Lapin RK. Racial differences in the use of drug therapy for HIV disease [letter; comment]. N Engl J Med 1994;331:333-4.
19. Bartlett EE, Grayson M, Barker R, Levine DM, Golden A, Libber S. The effects of physician communications skills on patient satisfaction; recall, and adherence. Journal of Chronic Diseases 1984;37:755-64.
20. Tugenberg T, Wyatt MA, Ware NC. Paradoxical effects of provider emphasis on adherence to highly active antiretroviral therapy (HAART) (Abstract #ThPeB7263). XV International AIDS Conference. Bangkok; 2004.
21. Des Jarlais DC, Paone D, Milliken J et al. Audio-computer interviewing to measure risk behaviour for HIV among injecting drug users: a quasi-randomised trial. Lancet 1999;353:1657-61.
22. Gerbert B, Bronstone A, Pantilat S, McPhee S, Allerton M, Moe J. When asked, patients tell: disclosure of sensitive health-risk behaviors. Med Care 1999;37:104-11.
23. Perlis TE, Des Jarlais DC, Friedman SR, Arasteh K, Turner CF. Audio-computerized self-interviewing versus face-to-face interviewing for research data collection at drug abuse treatment programs. Addiction 2004;99:885-96.
24. Mensch B, Hewett P, Erulkar A. The reporting of sensitive behavior by adolescents: a methodological experiment in Kenya. Demography 2003;40:247-68.
25. Cooley PC, Rogers SM, Turner CF, Al-Tayyib AA, Willis G, Ganapathi L. Using touch screen audio-CASI to obtain data on sensitive topics. Computers in Human Behavior 2001;17:285-293.
26. Saitz R, Horton NJ, Sullivan LM, Moskowitz MA, Samet JH. Addressing alcohol problems in primary care: a cluster randomized, controlled trial of a systems intervention. The screening and intervention in primary care (SIP) study. Ann Intern Med 2003;138:372-82.
27. Shortliffe EH, Cimino J. Medical informatics: computer applications in health care and biomedicine. 3rd ed. New York: Springer; 2006.
28. Mikulich VJ, Liu YC, Steinfeldt J, Schriger DL. Implementation of clinical guidelines through an electronic medical record: physician usage, satisfaction and assessment. Int J Med Inform 2001;63:169-78.