SummaryA nurse-led program designed to improve adherence to antiretroviral medication regimens for patients with human immunodeficiency virus/acquired immunodeficiency syndrome who are homeless or live in marginal housing used standard clinical classifications to identify client needs and then develop and deliver a set of interventions tailored to those needs. A randomized controlled trial found that the program had no meaningful impact on adherence with medication regimens.
Developing OrganizationsColumbia University Department of Biomedical Informatics, New York; Columbia University School of Nursing, New York; University of California, San Francisco, School of Nursing; University of Texas School of Public Health, Houston
Date First Implemented2001
Patient PopulationThe study also included transgendered individuals.Vulnerable Populations > Homeless
Problem AddressedPromoting adherence to antiretroviral medication regimens among human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) patients is difficult, with the degree of adherence varying based on patient characteristics, complexity of the treatment regimen, the client–provider relationship, the clinical setting, and illness severity.
- Near-perfect adherence needed: In contrast to those with other chronic diseases, HIV/AIDS patients require nearly perfect (at least 95 percent) adherence to maintain their health. High levels of adherence are needed to decrease viral loads (ideally to nondetectable levels), reduce the risk of HIV viral mutations that may confer resistance to the medications,1 and increase immune system capability.2
- Limited patient knowledge: Many HIV/AIDS patients, particularly those who are homeless or live in marginal housing, have knowledge, skill, and resource deficits related to medication adherence and the management of side effects.
Description of the Innovative ActivityThis nurse-led program was designed to improve adherence to medication regimens for patients with HIV/AIDS by first assessing client needs using a structured tool and then developing a set of interventions tailored to meet those needs. Key elements of the program are described below:
- Patient recruitment: Participants were recruited from a public HIV/AIDS clinic in Houston, TX. Recruitment signs were posted in waiting areas within the clinic. Potential participants contacted the study nurse to express their interest in participating in the trial. Eligible participants were consented and received $20 for each of the four visits they attended, plus $10 for a supplemental literacy survey. From this sample of 243 participants, 75.3 percent reported that they were unemployed, and 53.1 percent had no health insurance.
- Initial visit to assess client needs: Nurses used a method known as client adherence profiling to help identify client needs that can be met through nursing interventions.3 Client adherence profiling assesses the following client characteristics: (a) medication-taking knowledge, (b) reasons for missing medications, (c) self-rated adherence, (d) perceived medication side effects, (e) medication troubles (e.g., getting prescriptions filled), and (f) ways used to remember to take medications. Client adherence profiling also assesses four aspects of the client–provider relationship: (a) client perceptions of provider’s technical skill, (b) affective tone of relationship, (c) communication, and (d) overall satisfaction.
- Development of tailored interventions: Based on the client adherence profiling scores, the nurse assigns diagnoses (i.e., client problems) from the Clinical Care Classification System (formerly called the Home Health Care Classification).4 The nurse then develops and delivers a tailored set of interventions (a process known as intervention tailoring) designed to address the needs and problems identified in the client adherence profiling. The most common of these interventions are (1) education on medication compliance (received by 98.3 percent of clients), (2) self-care management of perceived side effects (72 percent), and (3) education about memory devices (slightly more than half). Additional interventions focus on coping support, stress control, education on energy conservation, and arranging for meals and other needed services. Overall, just over one-half (51.3 percent) of clients receive at least one intervention. The nurse documents all interventions on a client adherence profiling–intervention tailoring form for evaluation purposes during subsequent visits.
ResultsA randomized controlled trial comparing an intervention to a control group found that the program resulted in no significant change in client adherence to medication regimens.
- No difference in medication adherence: Multiple methods were used to assess adherence, including self-reporting on two different measures, electronic monitoring of pill bottle opening, pill counts, and pharmacy refill records. The data consistently show no significant difference in adherence between the intervention and control groups.5
- Little association between measures: There was little correlation across the five different methods for measuring medication adherence, which suggests that the adherence instruments are measuring different behaviors. The lack of congruence among adherence measures has been reported in other studies.6-8
|There are a number of potential reasons for the lack of significant differences in medication adherence between the intervention and control groups, including the following:
- Knowledge and skills alone are insufficient for behavior change; motivation is also a key component. This program did not incorporate any specific behavioral theory in assessing and developing interventions for patients.
- The frequency and time of the tailored interventions may not have been sufficient for some participants.
- It is unclear whether the participants intended to change their adherence behaviors. In addition, the extent to which financial remuneration played a role in recruiting participants who may have lacked motivation to improve medication adherence is not known.
- Although the client adherence profiling–intervention tailoring form was designed to ease the documentation burden, it is possible that insufficient detail was available to adequately assess whether the intensity of the intervention was sufficient to change medication adherence among many participants.
Contact the InnovatorWilliam L. Holzemer, RN, PhD, FAAN
Dean and Professor
College of Nursing–Newark & New Brunswick
Rutgers, The State University of New Jersey
180 University Way
Newark, NJ 07102
Innovator DisclosuresDr. Holzemer has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.
References/Related ArticlesHolzemer WL, Bakken S, Portillo CJ, et al. Testing a nurse-tailored HIV medication adherence intervention. Nurs Res. 2006;55(3):189-97. [PubMed]
Bakken S, Holzemer WL, Portillo CJ, et al. Utility of a standardized nursing terminology to evaluate dosage and tailoring of an HIV/AIDS adherence intervention. J Nurs Scholarsh. 2005;37(3):251-7. [PubMed]
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. [PubMed]
Bangsberg DR, Perry S, Charlebois ED, et al. Non-adherence to highly active antiretroviral therapy predicts progression to AIDS. AIDS. 2001;15:1181-3. [PubMed]
Holzemer WL, Henry SB, Portillo CJ, et al. The Client Adherence Profiling-Intervention Tailoring (CAP-IT) intervention for enhancing adherence to HIV/AIDS medications: a pilot study. J Assoc Nurses AIDS Care. 2000;11(1):36-44. [PubMed]
4 Saba VK. Clinical care classification (CCC) system manual: a guide to nursing documentation. New York: Springer Publishing Company; 2007. Available at: http://www.sabacare.com
Holzemer WL, Bakken S, Portillo CJ, et al. Testing a nurse-tailored HIV medication adherence intervention. Nurs Res. 2006;55(3):189-97. [PubMed]
Fletcher CV, Testa MA, Brundage RC, et al. Four measures of antiretroviral medication adherence and virologic response in AIDS clinical trials group study 359. J Acquir Immune Defic Syndr. 2005;40(3):301-6. [PubMed]
Liu H, Golin CE, Milller LG, et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Ann Intern Med. 2001;134(10):968-77. [PubMed]
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Original publication: April 25, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: April 03, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: March 27, 2013.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.