1. Improvement in adherence to HAART:
Best practices in adherence education by
three model programs
Myriam Hamdallah, MS, MPH
Center on AIDS & Community Health
FHI 360

2. Session Objectives
– Provide a background/context of the study
– Describe the three agencies and their adherence
education interventions
– Describe the study methodology
– Share findings
– Discuss implications and recommendations

3. Study Context – the ConnectHIV initiative
• ConnectHIV was a national initiative supported by
the Pfizer Foundation through $7.5million in grants,
technical assistance and networking resources over
three years (2007-2010) to 20 mid-sized AIDS Service
Organizations (ASOs) in the10 states with highest
AIDS prevalence in the United States.

4. ConnectHIV Funding Categories
The 20 organizations differed in populations served &
interventions implemented –
from prevention of infections among high-risk, HIV-
negative persons, to promotion of adherence and
delay of disease progression among persons living
with HIV

5. Agency Characteristics
Characteristics ASO A ASO B ASO C
Agency funds for HIV
$2.17M $3.96M $2.80M
services
FTE staff in agency 47 36 24
FTE staff dedicated to
2 1 4
program
PT staff dedicated to
5 2 3
program
Volunteers dedicated to
12 0 20
program

6. Agency Characteristics
Characteristics ASO A ASO B ASO C
Staff to client ratio for
1:26 1:26 1:21
AE intervention
HIV/AIDS services
13 5 6
delivered in-house
% Clients substance
abuse/addiction co- 30 66 75
morbidity
% Clients - psychiatric
65 30 70
co-morbidity

7. Characteristics of populations served
100%
ASO A
90%
ASO B
80%
ASO C
70%
60%
50%
40%
30%
20%
10%
0%
Female Male Sex w persons of Sex w persons of
the opposite sex the same sex

8. Age of the populations served
50%
ASO A
45%
ASO B
40%
ASO C
35%
30%
25%
20%
15%
10%
5%
0%
<= 19 20 - 29 30 - 39 40 - 49 50+

9. Intervention Characteristics
ASO A ASO B ASO C
To mobilize family, peer To help clients needing To equip clients w. knowledge,
& social support as key additional assistance for skills to understand science
Objectives
elements in successful stability in both housing behind HIV, care & treatment;
adherence. and medical adherence. prevent 2˚ infection; focus on
compliance and adherence;
become advocates
● Individual counseling ● Individual level ● 18-hour peer-led training
● 8-session women’s intervention. (offered as a 3-day or a 6-day
wellness HIV support ● Peers met with course) that includes 8 content
Structure
groups clients once a week for specific education modules
● Peers met 1X week, & 12 weeks or about 3
face to face at intervals months.
for one year
● MEMS cap –2 weeks

10. Intervention Characteristics
ASO A ASO B ASO C
Individual health Individual meeting with Counseling is provided in
counseling with HIV Peers; review medication house as needed but is not
Counseling
medication adherence regimen; create I-MAPs; part of the intervention.
specialist problem solve barriers to
adherence; provide HIV med
education & adherence
counseling.
Adherence education - Personalized medication Fundamentals of HIV biology
Help clients understand education; Review of med development, resistance,
Education
illness; provide medication regimen; doc/patient relation, advocacy,
information on meds & Individual Medication nutrition, compliance &
regimen. Adherence Plans (I-MAPs), adherence to HIV in special
are completed. popn, clin trials, co-infections

11. Intervention Characteristics
ASO A ASO B ASO C
Clients are assigned a Peers conduct the Peers lead the
Peer Piece
treatment adherence intervention with training.
buddy; they can attend supervisory support.
support groups.
One-hour training session, Peers received 2 month 18-hour peer-led
paid $40 to attend. training serve as Peer training (offered as a
Training
Coordinator or Peer 3-day or a 6-day
Interns. course).
$20 for treatment $200/week $20 at conclusion of
Incentive
adherence buddy; $10 for training; bus passes,
joint coffee meeting. meals.

12. Study Methods
• survey/interview designed in collaboration with the
grantees and an Evaluation Advisory Committee
• IRB approval obtained
• 30 min individual interview with client
• baseline and two follow-up measures
– 2-6 months from baseline for the second measure
– 6-12 months from baseline for the third measure

13. Variables
• HIV disease management knowledge
• Overall experience taking HIV medications
• Viral load
• CD4 count
• Perceived health score

14. Variables and Measures
• HIV disease management knowledge score
1. What happens when someone with HIV infection has a high
CD4 count?
2. What indicates that HIV infection has progressed to AIDS?
3. Typically, how often should a person with HIV have their viral
load and CD4+ counts assessed?
4. In order for HIV medications to be effective, they should be
taken…
5. If someone with HIV misses or skips taking some of their anti-
HIV medications…
6. Anti-HIV medications can cause some health issues called
"side-effects."

15. Variables and Measures
• Overall experience taking HIV medication
• Over the last 30 days, which of the following best
describes your general experience taking your HIV
medications?
– 1. I never take my pills
– 2. I take my pills less than 50% of the time
– 3. I take my pills between 50 and 90% of the time
– 4. I take my pills at least 90% of the time
– 5. I take them exactly as prescribed, never missing a
dose.

16. Variables and Measures
• Viral load
• Categorical variable developed from actual viral load
data or self-reported viral load data (if clinical data
was not available) with the following Likert-style
categories:
– 1. Undetectable (<400 or <40 depending on test)
– 2. Detectable, but less than 1,000
– 3. Between 1,000 and 9,999
– 4. Between 10,000 and 55,000
– 5. More than 55,000

17. Variables and Measures
• CD4 count
– What was your most recent CD-4 or T-cell count?’ A
continuous variable was developed from the actual
CD4 data or self-reported CD4 data (if clinical data was
not available).
• Perceived health score
– On a scale from 1 to 100, how would you rate your
overall health?
– Worst Health = 1; Perfect Health = 100

18. Data Analysis
• Generalized Estimated Equations (GEE) models were
created to determine change over time (taking into
account repeated measures over individuals –
measures at baseline, post and follow-up)
• N=386
• The models controlled for client level confounders -
age and gender
• Significance was reported at a < 0.05 level.

19. Findings
Change Across Mean Scores of Client Outcomes from Baseline to 1st
to 2nd Follow-up
Mean Scores Level of Significance
Outcome Baseline Baseline 1st FU vs.
Baseline 1st FU 2nd FU vs. 1st FU vs. 2nd FU 2nd FU
Knowledge of HIV 11.36 11.98 12.14 <.001 <.001 NS
disease management
(1-14) (N=386)
Overall experience 4.36 4.52 4.58 <.001 <.001 NS
taking HIV medication
(1-5) (N=356)
Viral load (1-5) (N=374) 1.82 1.54 1.48 <.001 <.001 NS
CD4 count (N=367) 517 543 554 <.05 <.01 NS
Perceived health score 76 81 83 <.001 <.001 NS
(1-100) (N=384)

20. Findings
Overall Health Score by Period
100
"How would you rate your health (1-100)?"
ASO A
95 ASO B
Average Health Score (1-100)
ASO C
90 88
85 84
80 77 80 79
79
75 75 77
73
70
Baseline Post Followup

21. Interactions
• Gender was significantly (p<.01) associated with
knowledge of HIV disease management; males
tended to score higher than females
• Gender was significantly (p<0.01) associated with
HIV medication experience; men took their
medications more consistently than women
• Age was significantly associated with viral load;
clients 50 years and older had significantly lower viral
load compared to those younger than 30 (p <0.05)

22. Interactions
• Gender significantly associated with overall health
score, with males scoring higher than females
(P<0.001)
• Age significantly associated with overall health score,
with persons under 30 years of age scoring
significantly higher than older persons (p<.001)

23. Discussion
• Significant positive change from baseline to post, &
baseline to follow-up across all client outcomes
• All 3 interventions accomplished goal of improving
adherence to HIV medications
• Two ASOs (A and B) reviewed individual regimens; B
developed IMAPs (Individual Medication Adherence
Plans); C’s intense training focused on adherence

24. Discussion
• Peers were key element in ASO B’s & C’s and a
component of ASO A’s intervention
– Rationale for peer support/peer-led interventions
• Social support theory (positive relations; emotional &
other support)
• Experiential knowledge (practical experience)
• Social learning theory (learning in social context & role
modeling)
– CDC’s compendium/adherence chapter includes two
interventions with peer components

25. Discussion
• Knowledge of disease mgmt – Men scored higher
than women; & Adherence – Men had higher
adherence than women (stigma; child care; adverse
drug effects reported)
• Viral load – older had lower VL than younger
(increased virologic suppression in older adults
reported in literature)
• Health score – Men scored higher than women

26. Implications & Recommendations
• Patient education, imparting knowledge on HIV
management & importance of adherence; review of
regimens; problem solving to reduce barriers
• Strong, well supported peer components with
structured training and incentives
• Consider competing priorities for women, in addition
to managing potential adverse drug effects and
stigma

27. Unpublished Manuscript and Acknowledgements
Authors:
• Myriam Hamdallah
• Stacey Little • Derek Worley
• Dave Nimmons • Caitlin Corcoran
• Lisa Rizzano • Susan J. Rogers
• Acknowledgements:
The authors would like to thank Evany Turk and Warren Reich as well as
other staff from the ConnectHIV grantee agencies and their clients for
their contribution to the manuscript and to Atiya Ali Weiss at the Pfizer
Foundation, David Holtgrave at Johns Hopkins University and to Sally
Munemitsu and Janice Brown at TCC.

28. Contact Information & Thank you!
• Myriam Hamdallah
• mhamdall@fhi360.org
• 202 884 8858