Adherence & Retention

Dear Jean,

I'm not surprised about the results. To my opinion DOT is usefull in highly nonadherent patients who lack a structure in their lives which they can use to guide their medication intake. Using DOT in the whole HIV population is expensive and not feasible.

Ann Deschamps

Thanks Ann. I agree with your comment. For clinical/public health practice, it is important that we have now hard data from both developed & developing countries which sheds lights on this controversial issue in support of earlier expert opinions.
Best Wishes for the New Year!
Jean

Ann's comments here are really important. While we are all interested in finding a strategy that works, finding one that works for everyone equally well may be an oversimplification. What works, for whom, when is likely the better question. We need the meta work and the large trials to provide empirical guidance. Research of this kind helps to answer- What is likely or unlikely to work well, globally (in general and in comparison to something). We have far less guidance on how the intervention worked for what types of people with what kinds of challenges. It is critical that we NOT lose the point that no behavioral intervention is likely to work for everyone. Personally, I look forward to advances in research on efficacy analyses or efficacy subset analyses, in RCTs or demonstration trials, as one way to start generating answers to 'what seems to work best for whom when'. The other thing to keep in mind is that the intervention trials formally evaluated are always in comparison to something. Recent meta work by deBruin et al. suggest that there are many active ingredients in the comparison groups (control arms) used in ARV adherence intervention trials- multiple strategies levied ...

Ann's comments here are really important. While we are all interested in finding a strategy that works, finding one that works for everyone equally well may be an oversimplification. What works, for whom, when is likely the better question. We need the meta work and the large trials to provide empirical guidance. Research of this kind helps to answer- What is likely or unlikely to work well, globally (in general and in comparison to something). We have far less guidance on how the intervention worked for what types of people with what kinds of challenges. It is critical that we NOT lose the point that no behavioral intervention is likely to work for everyone. Personally, I look forward to advances in research on efficacy analyses or efficacy subset analyses, in RCTs or demonstration trials, as one way to start generating answers to 'what seems to work best for whom when'. The other thing to keep in mind is that the intervention trials formally evaluated are always in comparison to something. Recent meta work by deBruin et al. suggest that there are many active ingredients in the comparison groups (control arms) used in ARV adherence intervention trials- multiple strategies levied at the patient and clinic level to provide adherence support-- and we need to keep all that in mind when we see a null result (the intervention did not 'work' over and above what??). When reviews indicate that a strategy was not effective over multiple trials, on average, I do think we need to have some degree of concern over its potential impact in practice, but I don't think we are at a point in our research to conclude that it would not be effective for some.

Dear Rivet, dear Jean,

wouldn't this be a topic for a workshop at the next IAPAC NIMH conference?
Ann Deschamps

Dear Ann:
Certainly! A workshop at the 5th NIH/NIMH-IAPAC International HIV Treatment Adherence Meeting (Miami, May 23-25, 2010) seems an ideal opportunity. I will make the suggestion to my colleagues on the Program Committee. While providing important and useful information, the recent Lancet paper (Ford et al. 2009) is not the final answer to all questions related to this debate. In meantime, we continue to encourage reactions of GHD members for a healthy and instructive debate.
Best, Jean

Dear all

in reply of Rivet's comments (what really works for whom and when) I suggest that we focus a workshop on connecting the needs of the practice with the knowledge of the research. Mostly, we do a review, find the ‘gap’ in research and design a study, without considering the lived experience in the clinical field.
I'm now doing research on diabetes type 2 management (call it adherence, self management, it all comes to the same thing: helping patients to deal with their disease, their health and optimize their clinical outcome and quality of life).
We hypothesized that the implementation of e-communication would improve the care for and the communication with the patients and the health care workers.
We first started with going to the literature, and there is already some evidence that supports this. Then we started talking with key persons in the clinical field and discovered that very recently the government changed the organization of the care for diabetes patients into a 'care path' with a central role for the general physician, the patient, the specialized doctor in endocrinology, the community nurse and nutritionists who educate the patient. All those partners work with different ICT ...

Dear all

in reply of Rivet's comments (what really works for whom and when) I suggest that we focus a workshop on connecting the needs of the practice with the knowledge of the research. Mostly, we do a review, find the ‘gap’ in research and design a study, without considering the lived experience in the clinical field.
I'm now doing research on diabetes type 2 management (call it adherence, self management, it all comes to the same thing: helping patients to deal with their disease, their health and optimize their clinical outcome and quality of life).
We hypothesized that the implementation of e-communication would improve the care for and the communication with the patients and the health care workers.
We first started with going to the literature, and there is already some evidence that supports this. Then we started talking with key persons in the clinical field and discovered that very recently the government changed the organization of the care for diabetes patients into a 'care path' with a central role for the general physician, the patient, the specialized doctor in endocrinology, the community nurse and nutritionists who educate the patient. All those partners work with different ICT programs, making communication between each other difficult and time consuming (writing things on paper, mailing them because you cannot use e-mail to send patient data and so on..)
This exploration of the field took about 3 months, but now we know what they need and what they all want together: we will therefore develop the e-tool based on their needs, with research results as backup.
Could this be a topic for the IAPAC/NIMH workshop (it is not HIV, but it is just an example)?

Dear all,

I just became member of this website because I saw this communication about adherence support in relation to HIV (and learning from other fields such as Diabetes). I am the de Bruin et al. person Rivet refered to. Rivet and I have had contact about our work and future plans a couple of times, following from our meta-analyses.

Below the abstracts of 2 meta-analyses I recently published on these topics (last one this monday), which may be interesting in relation to this discussion.

Best wishes,
Marijn de Bruin

http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=2009-20990-003&CFID=60...

http://archinte.ama-assn.org/cgi/content/short/170/3/240?rss=1

Dear Marijn:

Welcome to GHD!

Are you planning to attend the 5th NIMH-IAPAC International HIV Adherence Meeting to be held in Miami (May 23-25)? If yes, it will be great to see you there. We did submit a workshop proposal to discuss the current evidences related to the effectiveness of directly observed therapy in different settings, share experiences/perspectives and the way forward.

We anticipate the participation of patients, clinicians, pharmacists, nurses, social scientists, community workers, funders, policymakers, graduate students etc. Once the workshop is approved, we will post the full program on the GHD online forum.

In meantime, here is the conference's official website:https://www.confmanager.com/main.cfm?cid=2027

Best regards,

Jean

Dear Jean,

thank you. Yes, I was afraid I missed the deadline for abstract submission, but Dr. Jane Simoni forwarded me that the deadline were extended to February 28. So I plan to submit an abstract myself as well (randomized controlled trials to support HIV adherence- or perhaps practical implications following from the meta's). Please note that our meta's specifically did not focus on DOT, but on programs that target fully "autonomous" patient behavior.

Best wishes,
Marijn

Dear Marijn,

welcome to GDH!
I'm pleased to hear that you will send in an abstract for the IAPAC/NIMH conference. I'm looking forward to meet you there.
Ann Deschamps
Researcher in nursing
Anchor lector internationalisation
University College of Leuven
Department Health and Technology

Ann

Dear all:

I am pleased to confirm that our workshop proposal:
"Promises and Pitfalls of Directly Observed/Administered Antiretroviral Therapy in Treatment Naive and Experienced-HIV Infected Adults in Developed and Developing Countries" has been approved by the program committee to be presented at the 5th International Conference on HIV Treatment Adherence.

Please find the detailed program below.

We look forward to see you there and let us know if you have any question(s) or comment(s).

Best Wishes,

Jean

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DOT/DAART-ART Workshop- 5th International HIV Treatment Adherence Conference, May 23, 2010, 12:00 noon-2pm, Eden Roc Renaissance Hotel, Miami Beach, in Miami Beach Florida. Room TBA

•Title of Workshop: Promises and Pitfalls of Directly Observed/Administered Antiretroviral Therapy in Treatment Naïve and Experienced-HIV Infected Adults in Developed and Developing Countries

•Chairs Information: Jean B. Nachega, MD, PhD, Johns Hopkins University, Baltimore, MD, USA & Stellenbosch University, Cape Town, South Africa; ; David R. Bangsberg, MD, MPH, Harvard University, Boston, MA, USA ...

Dear all:

I am pleased to confirm that our workshop proposal:
"Promises and Pitfalls of Directly Observed/Administered Antiretroviral Therapy in Treatment Naive and Experienced-HIV Infected Adults in Developed and Developing Countries" has been approved by the program committee to be presented at the 5th International Conference on HIV Treatment Adherence.

Please find the detailed program below.

We look forward to see you there and let us know if you have any question(s) or comment(s).

Best Wishes,

Jean

-----------------------------------------------------
DOT/DAART-ART Workshop- 5th International HIV Treatment Adherence Conference, May 23, 2010, 12:00 noon-2pm, Eden Roc Renaissance Hotel, Miami Beach, in Miami Beach Florida. Room TBA

•Title of Workshop: Promises and Pitfalls of Directly Observed/Administered Antiretroviral Therapy in Treatment Naïve and Experienced-HIV Infected Adults in Developed and Developing Countries

•Chairs Information: Jean B. Nachega, MD, PhD, Johns Hopkins University, Baltimore, MD, USA & Stellenbosch University, Cape Town, South Africa; ; David R. Bangsberg, MD, MPH, Harvard University, Boston, MA, USA & University of Mbarara, Mbarara, Uganda;

•Sponsors: IAPAC, NIH/NIMH, NIH/NIDA

•Purpose/objectives: Critical review and discussion of recent evidences for the effectiveness of Directly Observed/administered ART in developed and developing countries as well as in various patients populations (Homeless, IVDU, Prisoners, Adolescents, etc.) and concluding recommendations for the scientific agenda and the way forward for HIV/AIDS providers

•Topics and Speakers:

1.Welcome and Introduction: Jean B. Nachega, MD, PhD (3min)

2.“Modified DOT-ART Compared with Self-Administered Therapy in Treatment-Naïve HIV-1 Infected Patients: A Multicenter Randomized Trial. Robert Gross, MD, MSc, Univ of Pennsylvania, PA (10min + 5 min for Qs)

3.Randomized Controlled Trial of Trained Patient-Nominated Treatment Supporters Providing Partial DOT-ART. Jean B Nachega, MD, PhD, Johns Hopkins University, Baltimore, Md, USA (10min + 5 min for Qs)

4.DOT-ART Experience of Partners In Health in Boston, Haiti, Rwanda and Peru. Heidi Behforouz, MD, Harvard University, Boston, MA, USA (10min + 5 min for Qs)

5.Directly Administered Antiretroviral Therapy (DAART) Among Vulnerable Populations (IVDU, Prisoners) Frederick Altice, MD, Yale University, CT, USA (10min + 5 min for Qs)

6.Systematic Review and Meta-Analyze of DOT-ART To Date: Critical Look at the Qualitative and Quantitative Evidences. Ed Mills, PhD, MSc, University of Ottawa, Canada (15min + 5 min for Qs)

7.Summary and The Way Forward. David Bangsberg, MD, MPH. (5 min) followed by Q & A to Include Patients and Providers Perspectives/Experiences (35 min).

•Interactive Elements: Patients and Providers Sharing Experiences/Perspectives @ Q&A
•Audience: HIV Patients, HIV Clinicians, Pharmacists, Nurses, Social Scientists, Funders, Community Outreach HIV Workers, Graduate Students (Masters, PhDs, Post-Docs, media professionals, etc.)
•Audience Size Expected: Medium to large
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Thank you for all your comment. I have time to give you more details for challenges in ARV treatment and TB detection and treatment in DRC.
By now you have to know that many people infected by HIV in DRC don't have access to treatment, also the cure rate for TB in Goma city increased in 2009 from 85%-52% but no MDR-TB was been diagnised. I think that in these cases which didn't positively respond to the treatment, there are some MDR-TB cases but we have to confirm this.

Thank you,
Dr Mateus K. Sahani.

Thanks all for the discussion. The centre for Infectious DIsease Research in Zambia is also starting to examine current practice / thoughts about adherence. One area that interests us is thinking about the relative role of clinicians/counselors in the clinics, in a)stressing adherence b) identifying behaviours / behavioural risk factors in poor adherence and being able to flag them. In the context of a discussion of self-management this becomes even more appropriate since the guidance and opinions of key medical staff (clinicians or lay health staff )may well be considered even more critical.
Unfortunately I can't attend IAPAC but look forward to discussing mroe on this forum.
Steph Topp, ART Integration Coord, CIDRZ, Zambia.