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Indicators of adherence
Assessments beyond viral load suppression

View transcript below.

Adherence monitoring is an important part of clinical care. Having an accurate assessment of patient adherence can help determine whether additional interventions are needed, to improve adherence or retention in care.

LEANDRO MENA, MD: So, most of as providers, we have to rely on our patients’ self-report of adherence. What do you do to make sure you’re getting a reliable account?

CYNTHIA RIVERA, MD: So, I think trust is really important. And it’s a balance where you want to ensure that the information you’re receiving is accurate, but at the same time, you want to let your patients know that, that what they report to you is being believed. So, so, I just directly ask the patients, on an average, how often do you miss medications—once a week, once a month? Is there an issue where you’re regularly missing doses? Perhaps our patients can remember to bring in their bottles so that we can look at any missing pills left over at the end of the month. So, so, techniques like that. 

DERRICK BUTLER, MD: Yeah, I mean, typically I try to give the patient the benefit of the doubt. I’m now assessing ongoing adherence; I would hope that we have a relationship where they can be honest with me. I try to establish that fact that you should be able to tell me what’s going on, and try to make it nonjudgmental. So, in a sense, I don’t want them to feel bad that if they aren’t taking it, but just say, okay, let’s look at why you can’t—you’re not taking your meds. Let’s try to fix it. So, I don’t make them feel wrong, but make them feel, again—part of that empowerment—make them feel like they can still do this. It’s just now, let’s make sure we can get you there. I usually, I look at their labs and I can—if they’re undetectable, then okay. And if there’s some viremia in the light of a patient saying that they’re taking their medicine every day, then I have to ask them, are you sure? Are you missing some days? Because I can, I really bring it up, I look at their labs. You’re not undetectable, so, I think you’re missing some doses. Can you just tell me how much? And let’s try to figure out how we can improve that.

LEANDRO MENA, MD: It’s about making sure that in no way anything that you say is going to make them feel guilty about it. I think you have to be somehow kind of tempered. If they don’t take their medication, so let’s work at what’s wrong. I always want to kind of be aware what’s happening before. I tend to ask, you know, in the last seven days how many days did you miss any of those? If the answer is none, I say, well, how about last month? And if the answer is no, I say, well, you know, very rarely people take 100% of all their pills. I mean, and that’s okay. This is just so, you know, for us to work together so you can always do a little bit better. I usually ask them too, you know, are you have any problems taking your medication? Are you tolerating them well? Do you develop symptoms? Just to, again, to link it into trying to assess, you know, is this something now that has become a normal part of your life or not? Is there something that could have been avoided with better planning? And once you find that, we have two categories, the things that nothing could have done anything about and is going to happen. But because those things are going to happen, you want to make sure that the things that you can prevent, right, happen less and less frequently just to keep a little bit of cushion for the things that no one can do anything about. 

CYNTHIA RIVERA, MD: Right, and I think if we ask the question every visit and we make a routine out of it, and it’s quick, simple—are you taking the medication every day, do you miss once a week, do you miss once a month?—and the patient realizes that you, as a clinician, are doing your duty and making sure that they’re getting access to their medication, and it’s not about them in specific. It has nothing to do with your perceptions of their adherence but rather you wanting to elicit adherence on all of your patients.