Addressing Adherence

Transcript: Janelle's Adherence Counseling

As the video begins, the patient enters the clinic. The following text shows on screen:

• Patient: Janelle
• 17-year-old African American female
• Perinatally infected with HIV. Mother is deceased, grandmother is guardian.
• Reason for visit: ARV adherence counseling

Dr. Rollins: Hi, Janelle. Good to see you.

Janelle: Hi, Dr. Rollins.

Dr. Rollins: Now, Janelle, I want to talk to you today about your HIV medications, and the results from some of the tests that we took. I was concerned at your last visit because your viral load has been going up.

Janelle: I know. I don't understand that. I've been taking my medicine every day.

Dr. Rollins: Well, Janelle. There's several reasons why your viral load could have come back so strongly. But what your lab results show me is that you haven't been taking your medications. It looks like you've developed a mild resistance to one of the drugs that we prescribed for you. If you keep missing doses, then these drugs aren't going to be able to help you. Now, every time you come in for a visit, you tell me you're taking your drugs all the time, but I don't think that's what's happening. Now it's important for me to know how often you're missing your medications and what might be getting in the way of you taking them.

Janelle: I guess I've been missing a lot of doses.

Dr. Rollins: Do you want to be on the ARVs?

Janelle: Yes, I do. I know I need them to live. Just had a lot going on lately.

Dr. Rollins: OK. Let's talk about that. What's going on that's causing you to miss your medications?

Janelle: When I'm out late with friends, sometimes I forget to take the pills when I come home late. Or sometimes I forget when I sleep past breakfast. So then sometimes I don't take them until night. Or, not until the next day.

Dr. Rollins: Now are you drinking or partying when you go out with your friends at night? Janelle, you've known me for a long time. Now I won't ever share what we talk about with your grandmother unless you give me your permission. OK?

Janelle: Yes. I drink a little sometimes.

Dr. Rollins: How often are you drinking?

Janelle: I never have more than one drink a night, really.

Dr. Rollins: What about party drugs?

Janelle: I smoke weed every now and then, but I'm not a pothead.

Dr. Rollins: How often are you going out with your friends?

Janelle: Almost every night, I guess.

Dr. Rollins: Do you think that partying and drinking may be getting in the way of your medications?

Janelle: Yes.

Dr. Rollins: Why do you think that you party and drink so much?

Janelle: I've been really stressed out lately. My grandmother and sister are always getting on my case. They keep bugging me about school, my medication, the staying out. I just want to be normal and be with my friends like everyone else.

Dr. Rollins: Do you feel like you might be sad or depressed?

Janelle: I don't know. Maybe.

Dr. Rollins: That's OK, Janelle. I know some really good people who can help you work through and deal with whatever it is that's making you feel that way. Before you leave, we can go down and make an appointment and you can come back and talk to one of them. OK?

Janelle: OK.

Dr. Rollins: We're going to get back to these medications, now. All right? I really need to know if you want to keep taking these medicines now.

Janelle: Yes, I do. I really do. I know it helps me. It's just hard to be perfect.

Dr. Rollins: Good. I'm glad that you and I agree on the fact that you need to take these medicines so that you can stay healthy. And I understand that it's really hard to remember to take them regularly all the time, but we can work on some tricks that will help you get better at that. OK? Now I really need to know, honestly, how many doses do you think that you're missing every week?

Janelle: About half.

Dr. Rollins: Do you miss more in the morning? Or the evening dose?

Janelle: I don't miss one more than the other. I'm kind of bad at taking them both.

Dr. Rollins: We need to work out a better system for you to take your medications regularly; otherwise the HIV will become resistant to your medications. You remember what resistance is?

Janelle: Yes. If I start with a drug and don't take it all the time, the virus can change in my body so that the drug doesn't work for me anymore.

Dr. Rollins: That's right. And there's only a few drugs that we can use, so we have to be very careful. Now is there anything that you can think of that might help you take your medications more regularly?

Janelle: Just wish it was easier.

Dr. Rollins: Would it help you if you took your medications just once a day?

Janelle: Yes.

Dr. Rollins: We can try that, but it's really important that you take them every day. Now, would it help you if we had an alarm to take your medications?

Janelle: What kind of alarm?

Dr. Rollins: Well we could program your cell phone or your pager. It will go off at a certain time every day to remind you to take your pill.

Janelle: Yeah. That sounds cool.

Dr. Rollins: Before we can switch you to the new medication, we need to make sure that you can get into the habit of taking the pill every day. So we're going to put you on some practice meds for a couple of weeks. What that means is you're going to take a vitamin once a day for a couple of weeks. We'll have your cell phone remind you when to take it. And if that works, then we'll switch you over to the new HIV pill. What time of day do you think that you'd like to take your pill?

Janelle: I usually eat lunch when I get home from school around 3:00. Can I take them then?

Dr. Rollins: We'll program your cell phone to ring or vibrate at 3:00 p.m. and then you can take your pill with your lunch. OK. So we're going to take you to the nurse. She's going to set you up with the practice meds, and then we'll see how that's going to work out with this new system once you talk to your counselor. If it all works, then we can restart you on the new once-daily 3-pill regimen. OK?

[End of Video]

[Text on screen]

• Nonadherence is a common cause of virologic failure among patients taking ARVs.
• Be certain that patients want to be on ARV treatment.
• Emphasize the danger of nonadherence, including the development of drug resistance.
• Explore psychosocial factors associated with nonadherence, such as depression, alcohol use, and substance use.
• Discuss lifestyle issues that may be either obstacles to or opportunities for adherence.
• Once-daily ARV regimens can make adherence easier to achieve.
• Programmed cell phone alerts can remind patients to take their medications.
• Practice regimens with vitamins can help in identifying barriers to adherence before patients begin their ARV treatment.

See the Resources tab for more resources on strategies for improving adherence.

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