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*249. Strategies, Skills, and Social Contexts that Enhance or Disrupt Adherence to HAART

MJ Mohler, Southern Arizona VA Health Care System; K Kroesen, Southern Arizona VA Health Care System; CS Wendel, Southern Arizona VA Health Care System; NM Ampel, Southern Arizona VA Health Care System; J Bormann, VA San Diego Health Care System; P Reid Duffy, Western AIDS ETC- AZ, University of Arizona; AL Gifford, VA San Diego Health Care System

Objectives: The rates of opportunistic infection, AIDS, and death have significantly decreased since the initiation of highly active anti-retroviral treatment (HAART). However, many patients for whom appropriate treatment is prescribed fail to achieve and/or sustain full benefit due to non-adherence to treatment. We performed Qualitative Inquiry, nested within a descriptive study (n=71) of HAART adherence, to explore patient perspectives concerning predictors associated with strategies, skills, and social contexts that enhance or disrupt adherence.

Methods: Subjects were selected from the HIV Clinic of a single academically affiliated VA hospital in the Southwestern U.S. based upon their Medication Event Monitoring System adherence (MEMS-ADH) levels. A panel of nine highly adherent "experts" (above 90%) provided qualitative focus group data to develop a theory of "successful adherence". Questions were posed regarding practical and ideological issues including individual, provider, and health care system adherence-related behaviors. Personal adherence strategies were reviewed and ranked as to effectiveness. We sought participant input in predicting those at highest risk of poor adherence, in addition to effective interventive strategies to improve adherence.

Nine of the fifteen lowest adherers (below 77%) consented to two-hour semi-structured in-home interviews. Interviews were chosen, in lieu of a panel, in order to assure optimal subject comfort in discussing sub-optimal adherence behavior. Content consisted of several semi-structured questions developed from the descriptive study and expert panel findings.

Expert focus group audio-recordings were played and topics were marked and grouped to reflect patterns and themes, and used to construct a "successful adherence" theory. Low adherer Interview audio-recordings were played, marked and grouped to reflect patterns and themes. These were then pattern matched to the "successful adherence" theory.

Results: A "successful adherence" theory was constructed of six adherence-enhancing categories: 1) perceived self-efficacy; 2) perceived treatment-efficacy; 3) HIV and HAART knowledge; 4) social support, 5) patient adherence skills; and 6) health care provider/ system interaction. A single disruptive category -disordered daily life- was identified. Low adherer responses showed poorer perceived self-efficacy, perceived treatment-efficacy, social support and adherence skills (organizing and preparing strategies) when compared to the "successful adherence" theory. In addition, chaotic work schedules contributed to disordered daily life.

Conclusions: HAART adherence interventions, utilizing a problem-oriented approach to identify and implement adaptive adherence strategies, should be offered to all patients on HAART regimens. These programs may improve adherence through the mediation of improved self-efficacy, problem solving and organizing and preparing skills. A panoply of scheduling cues and tools, personal adherence tracking, and organizing tools should be routinely offered to support patients who are initiating or changing HAART regimens. Routine assessment and appropriate social support referral for depression, substance abuse, and psychological counseling is required to minimize adherence-disruptive factors.

Impact: Application of these findings to adherence intervention may enable individual HIV+ veterans to delay clinical progression, resulting in decreased utilization of services and related costs, increased quality of life and functional status. In addition, the model we have developed may be transferable to the development of adherence interventions that are widely applicable in other chronic disease conditions.