Factors affecting adherence and nursing interventions used to promote adherence

Factors influencing antiretroviral adherence are multifactorial. They can be internal - pertaining to the person, and external - pertaining to those providing the care and to the medicines themselves.^{^[12]} External factors affecting an individual’s adherence can also be structural and systemic.

Nursing interventions depend on the setting and the patient population. There is no single guideline or recommendation that will prove beneficial for all patient groups, therefore, a variety of strategies may need to be trialled until one or more are successfully adopted by the patient.

Nursing strategies to encourage, improve and maintain adherence include discussing potential antiretroviral regimes with consideration to lifestyle, comorbidities, family history, evidence surrounding early treatment and continuing therapy once commenced.^{^[13]} ^{^[14] ^[15]} Table 8 summarises internal or individual factors affecting adherence and nursing interventions.

Table 9 summarises external factors relating to the medication affecting adherence and nursing interventions and Table 10 summarises external factors relating to health-care providers and the broader system.

Table 8: Individual factors affecting adherence and nursing interventions ^{^[16]}

Individual -related factors influencing adherence	Comments and evidence	Nursing interventions
Younger age at HIV diagnosis	Shown to predict poorer antiretroviral adherence^{^[17]}	Empower the client by including her or him in all decision-making processes Link with age-appropriate counselling and support services Involve friends and family members where appropriate
Ambivalence around commitment to life-long treatment	Regardless of age, starting a medication that requires life-long commitment can be daunting	Explore the person’s reasons behind ambivalence Provide pragmatic suggestions such as planning the best time of day to take medication or a practice run with a multivitamin before commencing antiretroviral therapy Allow the person to select his or her own start date Provide adherence aids such as dosette box or suggest a phone app as a reminder Provide evidence-based literature and information about the long-term effects of the regime
Alternative or poorly informed health beliefs	There are many myths surrounding both HIV and antiretroviral therapy. These may contribute to an individual’s reluctance to start and adhere to therapy ^{^[18] ^[19] ^[20]}	Explore health beliefs and provide education with non-biased evidence-based information specific to needs and level of understanding Use a non-judgmental, non-coercive approach to foster engagement, taking into account the choices made by the person living with HIV and acknowledging the beliefs behind his or her decision Linking the person to an HIV specialist who will listen and will nurture a respectful relationship Providing non-didactic education and health promotion about HIV and related health issues. For example, encouraging vaccination, teaching people to recognise signs and symptoms of disease progression and assisting them to access medical care when needed Support and encouragement in health maintenance. For example, encouraging the person to agree to take prophylaxis to prevent opportunistic infections, despite choosing not to take antiretroviral therapy Health monitoring and crisis intervention including specialist referral if the client becomes unwell Linking with mental health services, community-based support and other HIV-specific services such as housing and counseling
Stigma related to taking antiretroviral therapy	HIV-related stigma can affect a person’s willingness to start and adhere to antiretroviral therapy ^{^[21]}	Identify specific concerns around stigma Counteract myths around taking antiretroviral therapy and living with HIV Suggest counselling Refer to peer support group and networks Assist the person to develop strategies to minimise unwanted disclosure e.g. locked medication cabinet Explore multiple levels of influence – intrapersonal, interpersonal, structural^{^[22]}
Occupational	Shift work or regular travel may make daily adherence to medication difficult.	Suggest the client switches or simplifies regimes Consider dosing requirements and pill burden Devise a back-up plan with the client to manage a missed or delayed dose Assist client to manage side-effects if changing regimes is not possible
Lack of support network and poor engagement in health care	Social isolation and poor engagement in health care have been identified as a predictor of poor medication adherence	Ensure clinical support is adequate to meet the client’s needs Consider a team care approach involving pharmacist, social worker, community nursing service and GP Encourage client to attend peer support group Consider case conferences at structured intervals
Financial barriers	Despite universal health care and subsidised antiretroviral therapy in Australia, evidence shows that 3% of Australians cease antiretroviral therapy each year ^{^[23]}	For eligible Indigenous clients with chronic illness, antiretroviral therapy and all medicines are available free of charge through the Closing the Gap Pharmaceutical Benefits Scheme (PBS) Co-payment measure^{^[24]} Ensure financial support is provided in other areas of life where possible such as a subsidised taxi card if eligible, access to free or subsidised food Simplify antiretroviral therapy regime to reduce pharmacy dispensing fee Refer for financial counselling
Mental illness	Depression and mental illness are predictors of poor adherence ^{^[25] ^[26] ^[27]}	Engage the client’s mental health-care team. Adopt a team care approach Explore adherence aids Develop a plan of care with the client, and a plan of action in the event of an exacerbation of his or her mental illness
Psychosocial factors	Family violence, unstable housing, food insecurity contribute to suboptimal adherence	Explore the client’s priorities which may be different from assumed priorities Engage social work and other allied-health support. Assess support to access and maintain stable housing Provide dietary education and linkage to community agencies that provide subsidised or free food and meals
Alcohol and other drug use	The use of amphetamine-type stimulants (ATS: such as crystal meth and speed) has been identified as playing an important role in difficulties with adherence to antiretroviral therapy. ATS use has been described as a barrier to adherence among gay and bisexual men. This may be both planned or unplanned non-adherence^{^[28]}	With client’s consent, engage with pharmacotherapy provider and pharmacist to provide additional support Consider a planned treatment break with increased health monitoring in consultation with the client’s physician as this may reduce the risk of developing a medication resistance if unable to maintain adherence and all other avenues of support have been exhausted
Cognitive impairment and ageing	As Australia’s population ages, so too are people with HIV, many of whom are in their fifth or sixth decade of life and may have been living with HIV in the pre- antiretroviral therapy era^{^[29]}	Referral and assessment for HAND and other organic causes of cognitive impairment. Suggest changing antiretroviral therapy regime to one with a higher degree of CNS penetrability. Use of reminders i.e. use the smart phone calendar, set an alarm clock, leave notes in a visible place, involve carer or significant others to remind the person or to administer if required Refer to a community-based nursing service to support and promote adherence, to coordinate medication management and administer medication regularly if required
Level of health literacy	Poor health literacy is a strong predictor of poor health and negative treatment outcomes, and as such needs to be explored with the client and accounted for during adherence counselling sessions.^{^[30] ^[31]} It is important to help the person understand the need to continue taking treatment when he or she feels well, and to understand health jargon terminology and meaning e.g. undetectable viral load does not mean the virus has gone^{^[32]}	Ensure education is appropriate to the client’s level of comprehension Engage pharmacist, other clinical or allied health-care providers involved in client’s care to provide a team care approach Introduce supportive strategies such aseeping a diary of dosing and any questions for the next appointment with the physician or nurse
Ethnicity and cultural influences	People from different cultures hold varying beliefs around ill health and medication and may influence a person’s acceptance of his or her HIV diagnosis and willingness to accept treatment	Explore cultural beliefs around health, illness, and medication and incorporate into adherence counselling sessions Engage community members or elders if appropriate Ensure CALD resources are available Use an interpreter service ensuring appropriate confidentiality provisions are in place beforehand

CALD: culturally and linguistically diverse; CNS: central nervous system; HAND: HIV-associated neurocognitive disorder

Table 9: Medication-related factors affecting adherence and nursing interventions

Medication-related factors	Comments and evidence	Nursing interventions
Pill burden	As the HIV population ages, concomitant medication use accumulates and can lead to suboptimal antiretroviral therapy adherence	Introduce a dosette box or other dosage administration device Engage the pharmacist and a team care approach Arrange Home Medicine Review through client’s GP Simplify antiretroviral therapy regime where possible
Adverse effects	Undesirable effects can have a negative effect on the capacity of the individual to cope with daily activities Poorly managed symptoms can lead to poorer adherence and influence people’s decisions to seek and remain engaged in care^{^[33]}	Support through initial side-effects post- antiretroviral therapy commencement by providing anti-emetic, antidiarrhoeal and temporary dietary restrictions as required Ask the client to keep a diary of adverse effects, noting pattern, frequency, any relieving or exacerbating factors, and if any were present before commencing antiretroviral therapy Consider changing regimes or the time of dosing i.e. before bed if sedating side-effects are being experienced
Drug-drug interactions	Actual or potential drug-drug interactions can introduce complexity affecting adherence	Liaise with all members of the care team to stay abreast of medication changes Educate client about drug-drug interactions with an emphasis on over-the-counter remedies such as antacids and herbal medicine Suggest Liverpool website phone app
Food requirements	The food requirements associated with some antiretroviral therapy regimes may act as a barrier to optimal adherence	Client education about food, vitamin and supplement interactions with antiretroviral therapy Review drug regimen, change antiretroviral therapy or time of dosing Dietitian referral Ensure the client has access to food and basic amenities

Table 10: Provider, health system and socio-political factors affecting adherence and nursing interventions

Provider, health system and socio-political factors

Comments and evidence

Nursing interventions

Service access

Access to health services may provide a barrier for clients living in remote and rural regions

Physical access to a service may also pose a barrier for an individual living with a disability

Specific settings such as prison, immigration detention or other institutional settings may thwart or support adherence ^{^[34]}

Consider referral to a local provider or telehealth conferences
Consider using the local pharmacy for medication collection
Ensure the health services the client is accessing are aware of specific needs
Outreach of HIV specialist teams to custodial settings

Cost

See Financial barriers

Provider attitude

Institutionalised stigma may prevent people with HIV engaging in their care ^{^[35]}

Educate and dispel myths about HIV among clinicians
Ethical consciousness-raising ^{^[36] ^[37]}

Incorrect prescribing, dispensing or administration^{^[38]}

Prescriber errors can contribute to suboptimal adherence as can incorrect dispensing from pharmacy

Dosing errors and drug interactions ^{^[39]}

Consequences can include:

o Drug resistance

o Treatment failure

o Toxicities

o Loss of trust

o Increased costs

o Legal implications^{^[40]}

Enhanced medication reconciliation upon admission or discharge from hospital or other transitions or settings (respite, aged care) ^{^[41]}
Nursing consultation with HIV specialist pharmacists
HIV nurses supporting, educating and mentoring general nursing staff
Improved data collection, analysis of medication errors
Attention to factors contributing to errors: interruptions, communication, lack of adequate medication reconciliation processes and procedures^{^[42]}

Fragmented or uncoordinated care

Poor continuity of care may contribute to poor adherence

Referral to community nursing services with expertise in HIV can be an important early intervention for those identified as at risk of poor adherence
Involvement of community sector (e.g. HIV organisations, local services) to provide supports such as transport
Professional and industrial nursing advocacy for appropriate staffing levels, skill mix

Other psychosocial and socio-political factors

Examples:

Family dysfunction
Criminalisation of drug use
Homelessness
Poverty
Cost shifting

Refer for social work and counselling
Support in accessing legal, housing and financial services
Structural advocacy