• New York State Department of Health. Adherence to antiretroviral therapy among HIV-infected patients with mental health disorders. New York (NY): New York State Department of Health; 2006 Sep. 20 p. [21 references]

This is the current release of the guideline.

• Human immunodeficiency virus (HIV) infection
• Mental health disorders

Counseling
Management

Allergy and Immunology
Family Practice
Infectious Diseases
Internal Medicine
Psychiatry

Advanced Practice Nurses
Health Care Providers
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Public Health Departments

To provide recommendations for adherence to antiretroviral therapy among human immunodeficiency virus (HIV)-infected patients with mental health disorders

Human immunodeficiency virus (HIV)-infected patients with mental health disorders

1. Stabilizing patient's mental health including consultation with a psychiatrist or referring the patient to a licensed mental health provider
2. Identifying and addressing potential barriers to adherence before initiating highly active antiretroviral therapy (HAART)
3. Assessing adherence at every monitoring visit using the following methods or a combination:
   • Self-report
   • Pill counts
   • Pharmacy records
   • Electronic pill bottle monitors
   • Therapeutic drug monitoring
   • Computer-assisted self-interview (CASI) assessment
4. Improving adherence using the following strategies
   • Patient-provider interaction
   • Health education
   • Motivational strategies
   • Cognitive-behavioral strategies
   • Directly observed therapy

• Predictors of and barriers to adherence to antiretroviral therapy
• The advantages and disadvantages of adherence measures

Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases

Not stated

Not stated

Expert Consensus (Committee)

Not applicable

Review

Not stated

Expert Consensus

The Human Immunodeficiency Virus (HIV) Guidelines Program works directly with committees composed of HIV specialists to develop clinical practice guidelines. These specialists represent different disciplines associated with HIV care, including infectious diseases, family medicine, obstetrics and gynecology, among others. Generally, committees meet in person 3 to 4 times per year, and otherwise conduct business through monthly conference calls.

Committees meet to determine priorities of content, review literature, and weigh evidence for a given topic. These discussions are followed by careful deliberation to craft recommendations that can guide HIV primary care practitioners in the delivery of HIV care. Decision making occurs by consensus. When sufficient evidence is unavailable to support a specific recommendation that addresses an important component of HIV care, the group relies on their collective best practice experience to develop the final statement. The text is then drafted by one member, reviewed and modified by the committee, edited by medical writers, and then submitted for peer review.

Not applicable

A formal cost analysis was not performed and published cost analyses were not reviewed.

Peer Review

Not stated

Introduction

Patients with mental health disorders should be considered candidates for highly active antiretroviral therapy (HAART) if they meet the medical eligibility criteria for HAART and demonstrate readiness to begin therapy. Clinicians should determine treatment readiness on a case-by-case basis, weighing such factors as whether the patient attends the majority of his/her appointments and whether he/she expresses an interest in receiving antiretroviral (ARV) therapy.

Key Point:

The most effective means of promoting adherence in patients with mental health disorders is through adequate stabilization of their mental health and integration of mental health treatment into the comprehensive treatment plan.

Coordination of Care

Primary care clinicians should refer patients to licensed mental health providers when:

• Initial mental health treatment by the primary care clinician is ineffective
• Complex mental status evaluations become necessary or a patient's behavior jeopardizes effective treatment
• The patient has co-occurring mental health and substance use disorders

Primary care clinicians and mental health care providers should collaborate to develop a step-by-step treatment plan. The treatment plan should delineate the frequency of follow-up visits with both providers as well as the frequency of team meetings to reevaluate effectiveness of the overall medical and mental health treatment.

Primary care clinicians should initially consult with a psychiatrist when managing patients with mental health disorders who refuse mental health care. Throughout the patient's care, the clinician should communicate with a psychiatrist or a licensed mental health professional who can provide consultation.

Primary care clinicians should notify the mental health care provider when there is a change in medical or mental health treatment.

Predictors of and Barriers to Adherence

Key Point:

Patients with mental health disorders may have learned skills related to adherence to psychiatric medications that they can use to help them adhere to HIV treatment.

See the original guideline document for lists of predictors of and barriers to adherence.

Identifying and Addressing Potential Barriers to Adherence before Initiating HAART

Clinicians should carefully assess each patient to evaluate his/her ability to adhere to HAART.

Clinicians should identify and address potential barriers to adherence before initiating HAART. If clinicians elect to defer HAART while addressing potentially modifiable barriers to adherence, they should discuss this decision with the patient and document it in the medical record.

Clinicians should discuss the following with patients before initiating HAART:

• Clinician and patient treatment goals
• Patient's concerns about treatment and ability to adhere
• Potential side effects of ARV therapy and potential interactions with psychotropic and other medications, as well as how the side effects and interactions will be managed should they occur

Clinicians should use translator or sign language services when language barriers exist.

Primary care clinicians should refer patients with mental health disorders to specialized adherence services when adherence barriers cannot be resolved, particularly if the patient has acquired immunodeficiency syndrome (AIDS) or is at risk for advanced progression of HIV.

Refer to Table 1 in the original guideline document, "Assessment and Approaches to Potential Barriers to Adherence".

Initiating, Measuring, and Monitoring Adherence to ART Therapy

Clinicians should assess adherence at every routine monitoring visit by verifying that patients are taking the correct medications, correct number of pills per dose, and correct number of doses per day.

Clinicians should use finite time intervals when inquiring about and quantifying the patient's self-report. Clinicians should calculate an average response rate based on information obtained at multiple visits to determine a more accurate estimate of adherence.

Clinicians should reassess potential barriers to adherence at least every 3 to 4 months and whenever adherence problems are identified.

When clinicians find it necessary to speak with the patient's friends or family to assess adherence, permission should be obtained from the patient and the patient should be involved in these discussions.

Strategies to Improve Adherence

Patient-Provider Interaction Strategies

Clinicians should encourage patients to state in their own words what they understand about treatment instructions and to ask questions when additional information is needed.

Clinicians should encourage patients to be honest by responding in a nonjudgmental, supportive manner when patients report non-adherence.

Key Point:

A strong patient-provider relationship, including trust and engagement with the provider, has been associated with improved ARV adherence.

Health Education Strategies

Clinicians should provide adherence information in an organized manner, both orally and in written form, with easy-to-understand brief statements.

Motivational Strategies

Table. Key Components of Motivational Interviewing

See the original guideline document for information on cognitive-behavioral strategies and directly observed therapy.

None provided

The type of supporting evidence is not specifically stated for each recommendation.

• Improved adherence to antiretroviral therapy among human immunodeficiency virus (HIV)-infected patients with mental health disorders
• Refer to Appendix B in the original guideline document for information on advantages of adherence measures.

Refer to Appendix B in the original guideline document for information on disadvantages of adherence measures.

Following the development and dissemination of guidelines, the next crucial steps are adoption and implementation. Once practitioners become familiar with the content of guidelines, they can then consider how to change the ways in which they take care of their patients. This may involve changing systems that are part of the office or clinic in which they practice. Changes may be implemented rapidly, especially when clear outcomes have been demonstrated to result from the new practice such as prescribing new medication regimens. In other cases, such as diagnostic screening, or oral health delivery, however, barriers emerge which prevent effective implementation. Strategies to promote implementation, such as through quality of care monitoring or dissemination of best practices, are listed and illustrated in the companion document to the original guideline (HIV clinical practice guidelines, New York State Department of Health; 2003), which portrays New York's HIV Guidelines Program. The general implementation strategy is outlined below.

• Statement of purpose and goal to encourage adoption and implementation of guidelines into clinical practice by target audience.
• Define target audience (providers, consumers, support service providers).
  • Are there groups within this audience that need to be identified and approached with different strategies (e.g., HIV Specialists, family practitioners, minority providers, professional groups, rural-based providers)?
• Define implementation methods.
  • What are the best methods to reach these specific groups (e.g., performance measurement consumer materials, media, conferences)?
• Determine appropriate implementation processes.
  • What steps need to be taken to make these activities happen?
  • What necessary processes are internal to the organization (e.g., coordination with colleagues, monitoring of activities)?
  • What necessary processes are external to the organization (e.g., meetings with external groups, conferences)?
  • Are there opinion leaders that can be identified from the target audience that can champion the topic and influence opinion?
• Monitor progress.
  • What is the flow of activities associated with the implementation process and which can be tracked to monitor the process?
• Evaluate.
  • Did the processes and strategies work?
  • Were the guidelines implemented?
  • What could be improved in future endeavors?

Living with Illness

Effectiveness
Patient-centeredness

• New York State Department of Health. Adherence to antiretroviral therapy among HIV-infected patients with mental health disorders. New York (NY): New York State Department of Health; 2006 Sep. 20 p. [21 references]

Not applicable: The guideline was not adapted from another source.

2006 Sep

New York State Department of Health - State/Local Government Agency [U.S.]

New York State Department of Health

Not stated

Not stated

Not stated

This is the current release of the guideline.

None available

This NGC summary was completed by ECRI on November 20, 2006.