CD Connelly, VA San Diego and the VA Center for Health Care Provider Behavior; Children's Hospital and Health Center; AL Gifford, VA San Diego and the VA Center for Health Care Provider Behavior

Objectives: To examine the variation in structure of antiretroviral medication care across 4 VA-affiliated HIV specialty clinics, in order to enhance intervention strategies to improve patient adherence to antiretroviral medications.

Methods: Interviews were conducted with physicians, pharmacists, nurses, physician assistants and other key staff involved in patient care, at two large (>400 patients) and two small (<200 patients) VA HIV specialty clinics. Interviews focused on the process of antiretroviral prescription, delivery, and adherence issues. Interviews were guided by an interview protocol, were audiotaped and transcribed. Content analyses of interview transcripts were performed to identify recurrent themes.

Results: therapy, (5) usually monitors adherence by evaluating pharmacy profiles and laboratory data, (6) encourages patients to call the clinic in-between office visits with questions or concerns, therefore patient management is telephone intensive, (7) reports clinic flow is negatively impacted by patient failure to call in refills in a timely manner and (8) has a perception of grave time shortage, in particular on the part of the pharmacists. Differences among the four sites were in the following areas. Smaller sites seem more streamlined and integrated; physicians are more central and support staff friendlier, yet more overextended than at the larger clinics. Smaller sites also offer more "personalized attention", including Based on key-informant reports, the four sites were comparable in many areas. Each site (1) places high value on working as a team and being a central place for the patient where almost all medical needs are met, (2) has a designated "point person" to serve as a facilitator/problem-solver for patients, (3) attempts to "buffer" their patients from the rest of the VA system, (4) has no absolute exclusion criteria for antiretroviral staff visits and phone calls to patients at home. Overall, adjunct medical and social support varies from clinic to clinic. Each site differs in how the decision to begin antiretroviral therapy is made, and with respect to who primarily discusses the importance of adherence. The definition of "good adherence" varies between and within sites. In general, adherence barriers fall into four major categories: pharmaceutical, psychosocial, mental illness/substance abuse, and structural, with a vast array of adherence promoting measures currently in place, ranging from the "maternal mothering" to Direct Observational Therapy.

Conclusions: Understanding the current operational style and milieu of clinics involved in intervention studies is an important first step in the research process. In general, interventions that contribute to positive change are more likely to continue to exert a positive influence after the intervention has ended. Although there were many commonalties across the four sites, important differences were identified. These differences may confound research outcomes and must be considered in intervention design, implementation, and evaluation.

Impact: Exploring current clinic operational style and milieu, facilitates the evaluation of whether an intervention has achieved the desired goal or whether a similar mechanism, was in place prior to the implementation of the intervention. Such evaluation is necessary to foster evidence based practice.