Directly observed antiretroviral therapy improves adherence and viral load in drug users attending methadone maintenance clinics: A randomized controlled trial

Abstract

Objective-To determine if directly observed antiretroviral therapy (DOT) is more efficacious than self-administered therapy for improving adherence and reducing HIV viral load (VL) among methadone-maintained opioid users. Design-Two-group randomized trial.Setting-Twelve methadone maintenance clinics with on-site HIV care in the Bronx, New York. Participants-HIV-infected adults prescribed combination antiretroviral therapy. Intervention-24 weeks of DOT.Main outcomes measures-Between group differences at 4 assessment points from baseline to week 24 in: (1) antiretroviral adherence measured by pill count, (2) VL, and (3) proportion with undetectable VL (< 75 copies/ml). Results-BetweenJune 2004 and August 2007, we enrolled 77 participants. Adherence in the DOT group was higher than in the control group at all post-baseline assessment points; by week 24 mean DOT adherence was 86% compared to 56% in the control group (p<0.0001). Group differences in mean adherence remained significant after stratifying by baseline VL (detectable versus undetectable). In addition, during the 24-week intervention, the proportion of DOT participants with undetectable VL increased from 51% to 71%.Conclusions-Among HIV-infected opioid users, antiretroviral DOT administered in methadone clinics was efficacious for improving adherence and decreasing VL, and these improvements were maintained over a 24-week period. DOT should be more widely available to methadone patients.

Integrating HIV services with other health services to improve care, retention and adherence

“…For example, two studies assess the effect of directly administered medication versus self-administered medication among substance abuse populations (integration of HIV services with substance abuse services) (Berg et al 2011;Macalino et al 2007). This impact evaluation compares directly administered medication, not the integration of HIV services with substance abuse services versus not integrating those services.…”

The Health Promotion Model in HIV Care

“…Berg and colleagues conducted a randomized trial using DOT to explore adherence behavior. The study indicated DOT enabled patients to maintain low viral loads and found they were more accepting of future medical evaluations and more likely to maintain ART adherence (17).…”

“…One of the suggested intervention models that can be implemented easily by healthcare providers is a personal telephone call or a short reminder message sent a few days before a scheduled medical appointment. This kind of direct, personal communication reminds the patient of the importance of the pending medical appointment (17). Computerized reminders also are highly cost-effective and can motivate higher levels of adherence among HIV patients.…”

“…As patients are made aware of their current viral load, this information may motivate them to take control of managing their health (16). Other interventions such as providing groceries, meal tickets, and other tangible bonuses as part of attendance rewards have been shown to improve adherence in routine HIV medical care (17,18). Directly observed therapy (DOT) is another strategy that also could improve medication adherence.…”

“…This is considered a non-intentional factor. Forgetfulness can be challenged and even improved as providers implement various reminder strategies such as cellular phone messages, alarms, emails, telephone reminders, and direct mail letters (17). Engaging the assistance of HIV patient caregivers establishes another route to removing non-adherence as a barrier to a medical regimen (34).…”