Antiretroviral therapy (ART) has been shown to effectively control the HIV disease process and extend survival when taken with a high level of adherence. “Even current medications—which are less toxic and more forgiving than older drugs—require sustained adherence in order to be effective,” says Seth C. Kalichman, PhD. “However, patients with HIV often have difficulties remaining adherent with ART for a variety of reasons, including a history of substance abuse, poor access to care, and low socioeconomic status. The development of interventions to improve adherence is a priority because poor adherence impedes progress toward controlling the HIV epidemic.”


A New Approach

For a study published in the Journal of Acquired Immune Deficiency Syndrome, Dr. Kalichman and colleagues tested the independent and interactive effects of five sessions of telephone-delivered, brief, self-regulation counseling and daily text message medication reminders on HIV adherence and HIV viral suppression.  Participants included 600 adult men and women who were receiving ART and self-reported less than 95% adherence to their medication regimens in the previous month. Patients were randomly assigned to receive telephone counseling or not and to receive text messages or not. They were then followed for 1 year.

Those who underwent phone counseling first had a 45-minute, in-office visit in which information was offered on how HIV impacts the immune system and how ART slows HIV progression. The group also collaborated with researchers to develop a personalized adherence plan that included strategies for overcoming barriers to taking medications. Four subsequent, biweekly counseling sessions were then given by phone. As a whole, the intervention was framed around corrective feedback and delivered by an adherence counselor. Each session started with a pill count, followed by the counselor calculating adherence and delivering immediate corrective feedback.

Participants who were 95% adherent to ART or better were reinforced and aided in establishing plans for continued adherence. Those with lower adherence rates worked with counselors on problem solving to overcome barriers to adherence. Whether or not solutions helped overcome these barriers was addressed during subsequent sessions. Matched controls underwent counseling with the same structure and frequency. However, this counseling concentrated on improving general health and well-being in relation to living with HIV/AIDS.

Patients in the study who were randomized to receive text message reminders received them for up to two daily medication times. Messages were sent by an automated system and signaled a light flashing, sound, and vibration upon delivery. Participants were instructed on how to respond to these messages.


Phone Counseling Worked, Texts Did Not

“The five sessions of phone counseling demonstrated very clear effects in improving medication adherence and clinical outcomes at low cost when compared with control counseling,” says Dr. Kalichman (Table). Differences between the self-regulation adherence counseling group and control group in achieving 90% ART adherence were significant, particularly during the first 6 months of follow-up. “When patients drop below 90% adherence on ART, they’re in danger of not having enough medication in their system for it to be effective,” Dr. Kalichman notes. “This can lead to antiviral resistance. To that end, phone counseling displayed effects in helping improve viral suppression as well.”

Although the effects of phone counseling remained significant in sensitivity analyses conducted at 85% and 95% adherence, the overall percentages of patients reaching that level of adherence were lower than desired. “The five sessions of counseling were effective for some of these patients but not for all,” says Dr. Kalichman. “We’re currently conducting further analyses to determine if we should develop a more intensive intervention for these individuals or if five sessions will suffice.”

The use of daily text messages did not improve upon the ART adherence rates achieved with counseling alone, according to the study. The findings suggest text message reminders may actuallyresult in adverse effects on adherence self-efficacy. “Studies published while we were conducting ours also showed that daily text messages don’t help improve medication adherence,” Dr. Kalichman adds. “However, more intermittent text messages—for example, weekly and on varying days of the week—do appear to help improve adherence.”

According to Dr. Kalichman, daily text messages sent around medication dose time were ultimately ignored. “Patients habituated to them,” he says. “While it’s not prudent to completely give up on text messaging as a strategy to improve adherence, it may make sense to slow our continued pursuit of using daily dose-linked reminders until other investigations suggest otherwise.”


A Low-Tech Solution

Access to transportation to and from physicians’ offices and clinics has been well-documented as a major issue for many people with HIV. “Considering this important issue, doctor’s offices should be taking better advantage of telemedicine,” says Dr. Kalichman. “In our research, we assessed a simple, low-tech, highly accessible approach. Those who provide adherence counseling in the office should recognize that they can deliver this care just as effectively on the telephone but at lower cost and with the added benefit of easier patient monitoring. Such approaches may also be more convenient for patients.”