Adherence & Retention

Promises and Pitfalls of DOT-ART/DAART: Feedback From the 5th International Conference on HIV Treatment Adherence-Miami, FL, May 23-25, 2010

Started by Jean Nachega, MD, PhD on 24 Jun 2010
Last edited by Sophie Beauvais on 27 Oct 2010

Dear Colleagues:

For those who were not able to participate, below is a summary of the DOT-ART/DAART workshop which took place at 5th International Conference on HIV Treatment Adherence, Miami Beach, May 23-25, 2010 and sponsored by the IAPAC, NIMH and NIDA.

Is DOT-ART/DAART an effective adherence intervention strategy?
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No, when implemented in all HIV+ patients initiating ART (ART-naïve) in both resource-limited and rich settings (as demonstrated by meta-analysis by Ford et al. Lancet 2009; Gross et al. Arch Intern Med 2009; Nachega et al. AIDS 2010).

Yes, in specific HIV+ patients populations with documented history of struggle to adhere or to stay on ART (See recently published meta-analysis by Hart, Behforouz & Shin, JAIDS 2010)

1.Active IV drug users (Altice et al. Clin Infect Dis 2007)

2.Heavy Alcohol Abusers

3.Mentally- ill patients

4.Homeless patients (especially, if high prevalence of drug use)

5.Possibly long-term ART-experienced patients (e.g. due to treatment fatigue)

How DOT-ART/DAART Works?
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1.By increasing ART adherence in the above patient populations

2.Possibly through ancillary benefits in a setting where DOT/DAART is performed by community treatment supporters/buddies (friends, family etc.) by increasing social capital/support, likelihood of access to care…and hence improves patient survival (Ware et al. PlosMed 2009; Nachega et al. AIDS 2010). Of note, these ancillary benefits are likely to be easily detected in resource-limited settings where the median CD4 count at start of ART is about 100.

The Way Forward or The Research Agenda
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1.DOT-ART/DAART works in vulnerable populations mentioned above. However, as soon as the intervention is discontinued, non-adherence becomes a recurring problem (Maru & Altice, JAIDS 2009)

2.The Key question is how to proactively detect non-adherence behavior and implement an intervention before patients experience virologic failure?

3.Technological advances will increase feasibility of real-time adherence monitoring allowing us to target our adherence intervention(s) to patient(s) who need it and when they need it and therefore prevent virologic failure/disease progression, drug resistance and the need for ART regimen change (Bangsberg et al. JID 2008).

4.The cost-effectiveness of DOT-ART/DAART and other proven ART adherence interventions is badly needed in both resource-limited and rich settings (Nachega et al. Ann Intern Med.2010)

We welcome any comment(s)/question(s) on the above.

All the best,

Jean Nachega

Keywords: Clinical Guidelines  Publications & Research