Guidelines developed to help boost rates of entry into HIV care, retention in care and levels of adherence

New guidelines have been developed to improve the entry of patients into specialist HIV care and assist in their retention in this care. Published in the Annals of Internal Medicine, the guidelines make 37 specific recommendations and outline priorities for future research. The guidelines were developed by an expert panel convened by the International Association of Physicians in AIDS Care (IAPAC) in consultation with physicians in North America and Europe, and are based on the results of clinical studies.

“Entry into and retention in medical care is a prerequisite for providing lifesaving treatments to persons with HIV,” write the authors. “To assure that implementation is feasible for evidence-based recommendations, it will be necessary to strengthen resources, including multidisciplinary linkages dedicated to ART [antiretroviral therapy] and care adherence.”

Improvements in HIV treatment and care mean that the prognosis of many HIV-positive patients is now near normal. However, research conducted in the US suggests that approximately a third of patients are not linked to specialist care within the first year after their diagnosis. Moreover, a significant proportion of  patients who do enter care are subsequently lost to follow-up. Many patients also find it difficult to adhere to their antiretroviral therapy. These factors help explain why only 28% of HIV-positive individuals in the US have an undetectable viral load.

IAPAC therefore convened a special panel to develop guidelines to improve rates of entry into care, retention in care and adherence to therapy. They also made recommendations for the support of specific groups of patients, including pregnant women, incarcerated individuals, children and adolescents, the homeless and those with unstable housing.

The recommendations are based on the results of 325 published studies. These were either randomised controlled trials or observational studies with a comparator group. To be considered by the authors the studies also had to report on at least one biological or behavioural outcome.

A poor evidence base in some areas meant that the investigators also made recommendations outlining future research priorities.

Recommendations: entry and retention into HIV care

• Systematically monitor successful entry into care and retention in care for all patients.

• Case management is recommended for all newly diagnosed patients.

• Intensive outreach should be implemented for individuals not linked to care within six months of their diagnosis.

• Peer support has been shown to improve retention rates for cancer patients and there is some evidence that it improves outcomes among patients with HIV.

Monitoring adherence to antiretroviral therapy

• Self-reported adherence should be routinely monitored in HIV care. To ensure that patient recall is reliable, questioning should focus on adherence over a short time interval (i.e. the previous week).

• Pharmacy refill monitoring is also recommended.

• Routine monitoring of drug levels is not recommended. This is because of the variable levels of concentrations between products and individuals.

• Routine pill counts are not recommended.

• Routine directly observed therapy is not recommended.  However it may be considered in specific circumstances.

• Electronic drug monitoring is not routinely recommended.

Improving adherence

• Once-daily regimens are recommended when regimens have similar efficacy and tolerability.

• Patients taking poorly-tolerated or complex combinations should be switched to once-daily therapy if a potent and safe regimen is available.

• Fixed-dose combinations are recommended when regimens are of equal efficacy and safety.

Adherence tools for patients

• Alarms and text message reminders are recommended, especially if they have an interactive component, for example requiring a reply.

• Adherence counselling that incorporates adherence tools has been shown to be beneficial.

Health system and service delivery interventions

• Nurse- or counsellor-lead adherence support provided in the community  has outcomes similar to those provided by a doctor or in a clinic. This form of support is recommended in resource-limited settings.

• Support and case management should address issues including food insecurity, housing and transport need.

• Support should be provided by an integrated team of professionals, which includes physicians, nurses, dietitians, pharmacists and social workers.

• Directly observed antiretroviral therapy is not routinely recommended. However, it can have benefits for some vulnerable and marginalised populations.

Support for pregnant women

• Targeted treatment for the prevention of mother-to-child transmission improves adherence to HIV therapy for this purpose and is recommended over an untargeted approach.

• Labour ward-based treatment to prevent maternal transmission is recommended for women who are not taking HIV therapy before labour.

Individuals with substance misuse disorders

• Methadone replacement therapy is recommended for individuals with opioid dependence.

• Directly observed antiretroviral therapy is recommended for patients with substance use problems.

• Integration of directly observed HIV therapy and methadone replacement therapy is recommended for individuals with opioid dependence.

Mental health

• Patients should be routinely screened for mental health problems. Counselling and cognitive behavioural therapy can improve adherence in the context of depression and other mental health disorders.

Incarceration

• Directly observed HIV therapy is recommended for patients during incarcerated and following their release.

Homeless patients and individuals in marginal housing

• Patients with no or unstable housing should be provided with case management which focuses on the multiple barriers to adherence which they face.

• All homeless patients should be provided with pillboxes.

Children and adolescents

• Individualised case management can improve entry into care and retention and is recommended for all younger patients.

• Pill swallowing training is recommended for children.

• Directly observed therapy can improve adherence in the short term and may be appropriate in some circumstances.

Recommendations for future research

• The impact of co-infections on adherence.

• Factors affecting adherence to antiretroviral therapy when used for the purposes of prevention.

“As the global economy contracts, the identification and implementation of evidence-based strategies to maximize the individuals and societal benefits of HIV treatment will become increasingly important,” conclude the investigators. “With proper research and resources, the tools are at hand for substantially decreasing – and perhaps ending – the global HIV epidemic.”