Examining Adherence Barriers in Pediatric and Adolescent HIV Patients

Examining Adherence Barriers in Pediatric and Adolescent HIV Patients

Summary of Baseline Information for PACT Clinic Patients

27 patients at PACT Clinic

Children’s Hospital of Buffalo

Student Names:Melannie Cummings, Pharm.D. Student

Desiree Tomilo, Pharm.D. Student

University at Buffalo

Department of Pharmacy Practice

Primary Contact: Linda Catanzaro, Pharm.D., Clinical Assistant Professor

University at Buffalo, Department of Pharmacy Practice

Consultants:Lori Esch, Pharm.D., Clinical Assistant Professor

Judianne Slish, Pharm.D., Clinical Assistant Professor

Gene Morse, Pharm.D., FCCP, BCPS

Associate Dean, Clinical Education and Research

Professor and Chairman, Department of Pharmacy Practice University at Buffalo

PACT CLINC

Women and Children Hospital of Buffalo, New York

Babette Sullivan, RN

Dawn Melancon, RN

Robert Welliver, MD

Funding for this research project was provided by NYS Office of Children and Family Services, Contract year 2002: Project 1029136, Award: 27267; Contract year 2003: HIV/AIDS 01, Project: 1037132, Award: 31192; CC02, Project: 1037122, Award: 31183 through the Center for Development of Human Services, College Relations Group, Research Foundation of SUNY at Buffalo State College.

Summary of Baseline Information for PACT Clinic Patients

CD4+ T Cell Percentage

No Suppression (>25%) / Moderate Suppression (15-24%) / Severe Suppression (<15%) /

Unknown

<12 months / 0 / 0 / 0 / 0
1–5 years old / 2 / 2 / 0 / 0
6–12 years old / 7 / 2 / 1 / 0
>12 years old / 5 / 2 / 2 / 1
Total / 14 / 6 / 3 / 1

CD4+ T cell percentage is an indicator of the immune status. A CD4+ T Cell percentage of >25% is desirable because it means that the patient does not have any immune suppression and thus is better able to fight off infection.

This table shows that 14 of the 24 patients have no immune suppression, 6 patients have moderate suppression, 3 have severe suppression and 1 patient’s CD4+ T cell percentage is unknown.

This can be further broken down by age. Of the four patients who are 1-5 years old, 2 have no immune suppression and 2 have moderate suppression. Of the 11 patients who are 6-12 years old, 7 have no immune suppression, 3 have moderate suppression and 1 has severe suppression. Of the 10 patients who are greater then 12 years old, 5 have no immune suppression, 2 have moderate suppression, 2 have severe suppression and 1 is unknown.

History of Depression in Patients and Caregivers

History of Depression

Total Number

Child

/ 8

Caregiver

/ 4

Both

/ 3

No history

/ 8

Unknown - 1

This table shows that of the 24 patients, 8 have a documented history of depression. Four of the caregivers of patients have a history of depression. Three patients personally have a history of depression and their caregiver also have depression. One patient is unknown and the other eight patients have no history of depression

It is significant to know the history of depression in the patients and caregivers because this could have an effect on medication adherence.

History of Substance Abuse in Patient and Caregivers

Substance Abuse

Total Number

Child

/ 2

Caregiver

/ 10

Both

/ 0
Neither / 11

Unknown – 1

This table shows that 2 of the patients have a history of substance abuse and 10 of the patient’s caregivers have a history of substance abuse. There are no patients where both the patient and the caregiver have a history of substance abuse. Eleven of the patients have no history of substance abuse personally or in their caregiver.

It is significant to know the history of substance abuse in the patients and caregivers because this could have an effect on medication adherence.

Medication Administration

< 12 months / 1 - 5 years old / 6 - 12 years old / > 12 years old / Total

Patient

/ 0 / 0 / 0 / 3 / 3

Caregiver

/ 0 / 4 / 4 / 0 / 8

Both

/ 0 / 0 / 4 / 5 / 9

No ART

/ 0 / 0 / 2 / 0 / 2

Unknown

/ 0 / 0 / 0 / 2 / 2

ART = Antiretroviral Therapy

This table is reporting who is primarily in charge of medication administration in this patient population. When looking at the entire population, only 3 of the patients are solely in charge of their own medication administration. With 8 of the patients, the caregiver is totally in charge of administration. In 9 of the patients, both the patient and the caregiver are involved in medication administration. Two patients are not on any antiretroviral therapy and in 2 situations is it unknown who is in charge of medication administration.

When looking by age group, all children ages 1-5 years old are given their medications by a caregiver. In patients 6-12 years old, 4 are given medications by their caregiver, 4 are involved but still get help from their caregiver and 2 are not on any therapy. In patients greater than 12 years old, 3 patients take care of their medications by themselves, 5 are involved with help from caregiver and 2 are unknown.

Patient Reported Adherence vs. Medication Administration

Good (0 – 2 doses missed/month)

/ Fair (3 – 5 doses missed/month) / Poor (>5 doses missed/month)

Patient

/ 2 / 0 / 1

Caregiver

/ 4 / 0 / 0

Both

/ 6 / 1 / 1
Total / 12 / 1 / 2

No ART – 3

Unknown – 6

This table is comparing patient reported adherence to who is in charge of medication administration. A total of 12 patients have reported good adherence (which means that they reported missing only 0-2 doses in the last month). Of these12 patients, 2 patients take care of their medication alone, 4 are given medications by their caregiver and 6 are involved along with their caregiver. One patient is reported to have fair adherence (which means that they reported missing 3-5 doses in the past month. This patient is involved with medication administration along with a caregiver. Two patients have poor adherence (which means they reported missing greater than 5 doses in the past month). One of these patients is totally in charge of their medication administration and one is involved with the help of a caregiver. Three patients are not on any antiretroviral therapy and 6 patients have unknown adherence.

Age vs. Patient Reported Medication Adherence

Good Adherence (0-2 missed doses/month / Fair Adherence (3-5 missed doses/month / Poor Adherence (>5 missed doses/month) / No ART / Unknown
< 12 months / 0 / 0 / 0 / 0 / 0
1-5 years old / 1 / 0 / 0 / 1 / 1
6-12 years old / 5 / 0 / 1 / 2 / 3
>12 years old / 6 / 1 / 1 / 0 / 2
Total / 12 / 1 / 2 / 3 / 6

This table compares the age of the patient to patient reported adherence. There are no patients that are less than 12 months of age. There are 3 patients that are 1-5 years old. One of these patients has good adherence, one of these patients is not on antiretroviral therapy and one patient is unknown. There are 12 patients that are 6-12 years old. Five of these patients have good adherence, 1 has poor adherence, 2 are not on antiretroviral therapy and 3 are unknown. There are 10 patients that are greater than 12 years old. Six of there patients have good adherence, one has fair adherence and one has poor adherence and 2 are unknown.

Reasons for Missed Doses

Total

Away from Home

/ 4

Fell Asleep

/ 3

Side Effects

/ 2

Ran Out

/ 1

Confidentiality

/ 1

Substance Use

/ 1

Forgot

/ 0

Pill Burden

/ 0

Other

/ 2 (no reason, sick of
taking medications)

Zero Missed Doses = 7

No ART = 3

Unknown = 2

This table is showing that the most common reason that a patient reports for missing a dose is that they were away from home. The next common cause is that they fell asleep. Next are side effects and then running out of medication, confidentiality and substance abuse. Forgetting and pill burden were not reported by any of the patients. One patient reported that they were sick of taking their medications and one patient gave no reason.

Subject 6 = Fair Adherence (3-5 missed doses/month)

Subject 6:

Patient - clinically diagnosed depression (sees a counselor), no history of

substance abuse

Caregiver - no history of depression or substance abuse

Subjects 8 and 9 = Poor Adherence (>5 missed doses/month)

Subject 8:

Patient – clinically diagnosed depression (saw a counselor in the past),

history of substance abuse (opiates and alcohol)

Caregiver – legal guardian - no history of depression or substance abuse

Subject 9:

Patient – signs/symptoms of depression (goes to group counseling),

No history of substance abuse

Caregiver – clinically diagnosed depression (was suicidal), on

antidepressants, History of substance abuse (alcohol, cocaine, heroin) clean since 1993

It was seen that in the three patients with the poorest adherence all three of the patient’s had depression while only one had a history of substance abuse. One of the caregivers had a history of depression and substance abuse while the other two caregivers did not have a history of either.