UB AIDS Adherence Clinic Gets Patients to Stick to Their Drug Regimens

CINCINNATI -- After receiving the devastating news that they have AIDS, HIV patients have to go through a second shock: The knowledge that their lives now will be governed by pills, sometimes as many as 40 or more per day, many of which carry unpleasant side effects.

Right from the start, the way that patients respond to that prospect makes a real difference in their clinical outcomes.

To maximize the chances that patients will do well with such complex, medication regimens, the University at Buffalo School of Pharmacy has developed the world's first HIV Medication Adherence Clinic.

The clinic was described during a presentation today (Sunday, Nov. 8) by Lori Esch, Pharm.D., UB assistant professor of pharmacy practice, at the meeting of the American College of Clinical Pharmacists.

Based in the Immunodeficiency Services Clinic in the Erie County Medical Center in Buffalo, the HIV Medication Adherence Clinic is designed to provide patients with intensive education and support about their medications, often before they take their first pill.

Staff members have counseled more than 200 HIV patients since the clinic opened in September 1997. It is funded primarily by the UB School of Pharmacy.

"Adherence is crucial to the success of anti-HIV drugs," said Esch, who operates the clinic.

It was founded by Esch and colleagues in the School of Pharmacy's Department of Pharmacy Practice, under the supervision of Gene Morse, professor and department chair.

"We now know that the first shot we get at drug therapy with patients is the one that either makes or breaks it," Esch said. "If therapy is interrupted for any reason, the second-line drugs will never work as well as the first one. The purpose of our clinic is to try to spend time with the patient before he or she even starts their medication, to get them to understand the importance of taking their medications properly so that they have the best chance of working properly."

At first, said Esch, patients were skeptical, wondering why they had to make yet another appointment with another health-care provider. But after their first consultations, she said, most became very enthusiastic.

Follow-up is intensive, generally occurring after the first day of medication, then once every one or two weeks for several months.

Esch said that the purpose of the clinic is to take a comprehensive approach to ensuring that patients stick to their medication regimen.

That could involve something as simple as a pill organizer, medication beeper or other reminder aids, or the development with the patient of a reasonable strategy for fitting the medications into his or her lifestyle.

"The difference between compliance and adherence is the difference between 'do as I say' and 'do as we agreed'," she explained.

Each patient has different barriers that need to be addressed.

"One of the biggest ones is that patients who are working find it difficult to take complex regimens of pills," she said. "Other patients don't have stable home lives; either they are homeless or are in and out of short-term rentals. We work with each patient to find a way to work the medications into their schedules."

The adherence clinic makes recommendations to physicians on what drugs might be prescribed for a particular patient. It also helps patients manage side effects of drugs, or drug interactions with food, alcohol or other drugs, sometimes recommending that a drug be changed.

"We may assist a physician in selecting specific drugs for a patient at the outset," said Esch. "We may know, for example, that one drug works a little better than another one but that its side effects are extremely difficult to deal with."

After the regimen has been selected, Esch will discuss it with her patients in lay terms.

"This is what pharmacists have been trained to do," she said.

A key clinic emphasis is providing patients with information about how the drugs will make them feel before they start therapy.

"We prepare them for therapy by telling them, 'look, you are probably going to feel worse than you do now when you start taking the medicine, but this is a transient thing, it will pass.’"

This is critical information because the most dangerous thing a patient can do is interrupt therapy once it has begun.

"Before they start therapy, their virus is very stupid, so the minute we give them medication, we are usually guaranteed to knock it down," said Esch, "but it also gives the virus an opportunity to begin fighting back, or mutating. So when we start therapy, we want to make sure patients are ready for it, that they understand it and are committed to sticking with it."