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
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.