Academy Exchange

  • 1.  Patient compliance?

    Posted 03-29-2021 10:52

    Being a newbie in the HIV treatment around my wanted to ask the community a question regarding treatment compliance.

    I have a number of patients for which I provide primary care, and hopefully in the near future I will be responsible for their HIV treatment as well.  However, these patients are not fully compliant with treatment program for their HIV medications.

    They will often miss appointments, or not get the blood work done.  Our facility does not provide phlebotomy services on site and as a consequence, patients need to go to a local lab for blood testing.

    It has been the practice of our facility to deny them refills of there ART therapy through our Ryan White program until they can comply with adding blood work done or having at least a telemedicine appointment with the provider.

    While I understand the ramifications of not routinely checking blood work including renal function, liver function, routine annual TB testing, viral load and CD4 count.  

    I was recently reprimanded for providing a refill of the patient's Genvoya.  This patient has been routinely undetectable, with stable-ish CD4 count.  He reports 100% compliance with ART therapy, however has been noncompliant with quarterly office visits and lab draws (may be having 2 appointments and to lab draws annually).  I provided the patient a refill of his medication that would carry him through until his next appointment with our office HIV specialist.  The alternative would have been that he had a lapse in treatment for 1-1/2 months.

    In a previous forum post, someone replied they worked in a similar setting, and they will provide an initial medication refill (thread was removed, I forgot the actual durations) something like 30 days, then 14 days, then 7 days.  I found this intriguing, and something I will likely implement.

    I was wondering if anybody had any other solutions/ways of promoting compliance.  And what you have done a similar situation.  Personally, in most areas of medicine, I typically err on the side of providing treatment for the patient.

    I have also been working towards advocating that our clinic provide phlebotomy services for the patients in-house.  (As a former med tech, ER tech and paramedic, I have offered to provide phlebotomy training for our staff, but the powers-that-be have not moved forward with this recommendation).

    --Sean



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    Sean Leonard
    Meadville PA
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  • 2.  RE: Patient compliance?

    Posted 03-30-2021 21:30
    It's quite tricky when dealing with noncompliance with our patients. First thing is for us Providers to understand our patient and then strategize on how to handle them. Personally, I will begin by offering 30days worth of supplies. Secondly, I will involve the Clinic Nurse and the Case Manager and even the Pharmacist to assist with educating and encouraging patients to complete lab test and consultation. 
    Compliance is huge, however, we will continue to work and try as much as we can to meet our patients in their state at each point in time.

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    Lucy Efobi
    Linden NJ
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  • 3.  RE: Patient compliance?

    Posted 03-31-2021 16:51
    Dear Sean,
    Having worked with PLWH since 1982 to present, in many healthcare settings (academic clinics, private practice, and community health center/FQHC in urban areas), I can share with you that punitive healthcare policies rarely result in the kind of outcome that you are seeking with your patients. One of the most important principles that I have learned is that removing or minimizing barriers to seeking and maintaining healthcare is as, if not more, important than the provision of healthcare itself. 
    First and foremost, establish a phlebotomy service in your clinic or have your clinic staff (MAs, LVNs, RNs, MDs) draw, process and send out the blood tests. Ask yourself how you would comply with multiple-stop healthcare. Your patients are often just as busy as you are and have less resources/support to deal with their lives demands.  
    There is much more potential downside to electively stopping a PLWH's ART regimen than simply continuing it especially with our modern second generation integrase inhibitor-based single-tablet regimens (Dovato, Biktarvy, Triumeq) and the one boosted protease inhibitor regimen (Symtuza). The potential harm from the patient trying to "stretch out" their medications and underdose their ARVs with resulting viremia and and viral resistance as well as potential for HIV transmission to others are strongly in favor of continuing prescriptions.
    Prescriber knowledge of and adherence to the DHHS and IAS-USA ART Guidelines for first-line and switch therapy recommendations is important to maximize the efficacy and safety of ART. In other words, boosted integrase inhibitor regimens (Genvoya, Stribild) are no longer recommended due to higher GI intolerance, higher viral failure and viral resistance at the time of failure and many drug-drug interactions due to the cobicistat.
    DHHS guidelines recommends that once a PLWH on ART has has stably suppressed HIV (VL<50 copies/mL for ~ 2 years), Viral load can be checked every 6 to 12 months and CD4+ T cell counts once-yearly as well. If there are other medical concerns, and there often is with our PLWH aging with HIV, more frequent lab tests and visits may be necessary. 
    I have found that meeting PLWH where they are, i.e., connecting with them via telemedicine and virtual clinic visits and placing lab orders at laboratories with extended or weekend hours for the infrequently needed tests goes a long way in ensuring adherence to ARVs.
    Best of luck with your advocacy to convince your clinic administrators to take action to improve and not impede your patients healthcare.

    David Hardy, MD
    HIV/ID Specialist 
    Los Angeles, California
    AAHIVM and HIVMA member


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    W. David Hardy
    Los Angeles CA
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  • 4.  RE: Patient compliance?

    Posted 04-03-2021 21:24

    I am sorry you were reprimanded. As the provider that should be at your discretion, how often to draw labs or have the patient return. If I have a patient who has been positive for 15-20 years undetectable and adherent, I may see them every 5-6 months. I too have about 3 patients on Genvoya. I would love to get them off of that medication, I have never been a fan of boosters. A funny thing I have noticed about Genvoya getting off subject for a second is that almost every West Indie patient I have does not fair well on that drug, interesting. Usually when I have patients that do not make their appointments they are using meth. They will call when they have hit rock bottom and all I can do is welcome them with open arms. In the interim, I refill their ARV because I assume they are sharing needles and I pray I am preventing somehow, transmission, if they are taking their ARV.  I have had other circumstances in which I would make home visits in order to keep patients engaged in care. 

    Amber



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    Amber Siegel
    Crew Health
    Oviedo FL
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  • 5.  RE: Patient compliance?

    Posted 04-05-2021 14:27
    Hello, I appreciate why you would want to give the Rx but as an HIV specilaist, I would not want someone else writing my patients Rx if they are not one of the HIV specialists ( there are 4 at our clinic) .  Some patients are hard to get in and my HIV casemanagers work very hard to get them and there may be a lot of no shows.  Just because someone is undetectable " always" does not mean it will remain like that.  During this pandemic I have seen so much viral breakthrough even in patients who were always undetectable.  If my patient does not have a lab for more than 6 months then I do not refill.  If I have not seen the patient for an exam for over a year, I will not refill.  They eventually do get in or call and I give Refill until there appt.  I do not castigate when they come back, I show them I am happy they came to appt and thank them.  I know there are many factors involved.  I use my casemanagers for this and they are wonderful.  I have been treating HIV since 1988 and still worry about resistance.  I also do the same for my patients with HTN and DM.  
    Once we switched to q 6 months HIV VL testing, I had a few patients that failed and that is when I found out more about their social and behavioral problems.  
    For truly non adherent patients meaning viremic, I still try to get there labs quarterly and do CD4 more often as well and try to get on regimen with high barrier to resistance.
    That one patient that you gave a refill to for 30 days could have been handled differently.  If same clinic, you can let the casemanager know and the HIV PCP.  Or the patient can call the HIV PCP who would most likely give the 30 days and if not has a good reason.  At some point I sometimes have to say, no labs until seen and give enough until appt.

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    Kathy Hernandez
    16th Street Community Health Center
    Milwaukee WI
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  • 6.  RE: Patient compliance?

    Posted 04-05-2021 14:35
    I realize now that you are the HIV provider, I read the post wrong.  In which case I wonder why you were reprimanded.  You did not say how long since last lab or appt.  I know if I have a pt like that, I ask the casemanger to make the appts while I am sending the extra refill.  So sorry you were reprimanded.

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    Kathy Hernandez
    16th Street Community Health Center
    Milwaukee WI
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  • 7.  RE: Patient compliance?

    Posted 04-13-2021 10:03
    To elaborate: I am not his HIV Specialist provider. The HIV Specialist, allows his patients to run out of medications, if they are not compliant with office visits and blood draws. 

    I AM the patient's PCP, and I also recently obtained HIV Specialist certification. 

    I do not want to elaborate on the shortcomings of our program or the current HIV Specialist in a public forum, but let's just say there were a number of reasons, why I became HIV Specialist certified, and they were all patient-centered reasons...

    --Sean

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    Sean Leonard
    Meadville PA
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  • 8.  RE: Patient compliance?

    Posted 04-15-2021 12:04
    Hi Sean.
    just know that you are a great provider...these systems are not perfect and there are always patients that could become non compliant at anytime during the course of their treatment. Sometimes, speaking directly to the patient gives you more insight to the reasons for non compliance. I really hope this information is helpful.

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    Henry Bryant
    Pembroke Pines FL
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  • 9.  RE: Patient compliance?

    Posted 08-09-2021 13:56
    Hello, 
    I also work in an FQHC in urban Milwaukee, and agree with the sentiments already posted.  If our goal is a positive clinical outcome, staying on medications without interruption is far better than being off and on repeatedly.  It reminds me of effective contraception: the goal is to defer pregnancy, thus staying on medications is the goal. Failure to do so because the patient won't come in for labs has a terrible potential effect:  unwanted pregnancy and a 20+ year commitment of child rearing, etc.   

    Lab tests are nice to reinforce the patient's motivation and measure medication effectiveness, potential adverse side effects, etc. But to stop HIV meds if labs are not obtained is inappropriate and has terrible potential personal and economic consequences for both the individual, local health care systems, and society in general, especially since most people seeking care in community health centers are challenged with many disparities in care.  

    Nonadherence and risky behaviors are phenomena of immaturity-- either with youth or those who's early recreational drug use (alcohol, marijuana, cocaine/crack, etc.) has them "stuck" with older bodies mismatched with less mature emotional development.  "Punishing" those who cannot come in to fulfil our need for labs is inappropriate.   Options include monthly refills (RFs) without 3 or 6 month auto-RFs. Text message reminders and phone calls by support staff may also be helpful.  But in order to be effective, we need to be sensitive to what the patient's needs are and to help them achieve their (and our) goals.  

    --Mark P. Behar, PA-C
    Milwaukee, WI

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    Mark Behar
    Milwaukee Health Services
    Milwaukee WI
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