Strategies for Improving Adherence

Providers can improve adolescent adherence by:

In the REACH study, only 41% of youth claimed good adherence and 18% admitted that they had never taken their prescribed ARV drugs.13
Adopt proven tactics that help patients adhere:
- Select the best regimen for each patient's lifestyle
- Assess patients' ability to adhere to regimens by using practice "pills" such as vitamins or candies
- Evaluate patients' willingness to have family members or friends provide reminders
- Use dosing cues such as meals or toothbrushing, and have patients place medications where they see them during regular activities
- Provide pillboxes or unit dosing packaging, which helps if patients need to take their medications with them when they are away from home
- Remind patients to take medications via alarms on cell phones or pagers

Help establish a solid therapeutic alliance between the patient and clinic staff based on respect, trust, and honesty. Clinicians working with the Adolescent AIDS Program at Montefiore facilitate patient adherence to HIV regimens by "using their EARS" (see Toolbox).
Utilize the lessons learned from Project TREAT to identify each patient's stage on the Stages of Change and their medication adherence (see Toolbox).14
Address mental health issues:
- Nonadherent patients should be given a brief depression screening with a tool (see Toolbox) and should be referred for psychiatric or psychological evaluation and treatment when appropriate.
- Substance-using patients should be referred for treatment services and may need detoxification and residential treatment before initiation or reinitiation of ART.
- Patients with poor self-efficacy or low outcome expectancy may benefit from referral for cognitive behavioral counseling or motivation interviewing treatment before initiation of ART.

Pill burden affects adherence. Pill burden includes the number, size (some youth have a particularly hard time with large capsules), and taste of the medications.
For ease of dosing, consider once-daily regimens with low potential for side effects. Many clinicians recommend that all youth initiate a once-daily, boosted protease inhibitor (PI) with two nucleoside reverse transcriptase inhibitors (NRTIs) as backbone. Boosted PIs have low probability for development of resistance, even when adherence is poor.
Avoid medications with food requirements if possible. Youth may not have reliable sources of food, or may fail to eat at regular times.
Make the ARV dosing schedule friendly to the individual. ARV doses should be taken at times that fit an adolescent's schedule. For example, it is often inconvenient to take medications during school hours or at work. Also, some youth have trouble with adherence to efavirenz, because it should be taken at bedtime, and doses may be missed when youth stay out late.
Efavirenz is not recommended for women who may become pregnant, because it may cause birth defects. It also may cause failure of oral contraceptives.
Nevirapine can cause severe liver impairment; this occurs more frequently in women.