Addressing a key issue in the HIV/AIDS epidemic, the International Association of Physicians in AIDS Care (IAPAC) has released “Guidelines for Improving Entry Into and Retention in Care and Antiretroviral Adherence for Persons With HIV: Evidence-Based Recommendations.” The recommendations were published March 5 ahead of print in the Annals of Internal Medicine.

While it is well established that entering care immediately after an HIV diagnosis, staying in care and adhering to antiretroviral (ARV) therapy are necessary steps on the road to successfully controlling the virus, figuring out how to ensure that people living with the virus take these steps has turned out to be a challenge. The Centers for Disease Control and Prevention (CDC) estimates that only half of people living with HIV in the United States are receiving regular medical care, and far fewer have their virus under control with ARVs. Numerous studies have been undertaken to address this challenge. Until now, they have not been compiled and assessed based on their results.

“Over the last 15 years, we have made astounding progress in HIV treatment, resulting in longer and healthier lives for people living with HIV,” Melanie A. Thompson, MD, co-chair of the IAPAC panel said in a press release accompanying the guidelines. “Yet many people are unable to optimally benefit from these advances.” The guidelines, Thompson continued, are geared to address the problems that interfere with ARV access and adherence, leading to viral resistance and possibly treatment failure. Successful retention in care and ARV adherence have been shown to reduce the transmission of HIV. They also help solve the issues of viral resistance and treatment failure—in addition to improving the lives of HIV-positive people.

The guidelines, compiled by a group of 20 health care professionals including Tim Horn, editor-in-chief of AIDSmeds.com, list and discuss 37 recommendations along with several suggestions for future research. The list, accumulated from 325 evidence-based studies, includes a review of successful interventions to monitor adherence to care and medication doses and improve adherence among special populations (including homeless people, pregnant women, incarcerated people and children and adolescents).

Among the key recommendations:

  • Self-reported adherence should be routinely obtained from all patients.
  • Once-daily ARV regimens and fixed-dose combinations should be used where possible.
  • Adherence tools such as interactive reminder devices should be accompanied by one-on-one adherence education.
  • The practice of directly observing people take their medications (Directly Administered Antiretroviral Therapy, or DAART) should not be used generally, but should be considered for special groups such as IV-drug users and currently or recently incarcerated people.
  • Case management should be provided to assist HIV-positive people who experience food or housing insecurity or transportation needs, and for children and adolescents.
In their recommendations for future research, the authors suggest investigating the success of using HIV biomarkers (measuring blood levels of ARVs) as part of adherence monitoring, and analyzing the cost effectiveness of various interventions.

“These guidelines are the foundation of an evolving blueprint that practitioners and health systems can use as a resource to improve entry into and retention in HIV care as well as adherence to HIV treatments,” Thompson said. To follow up on the recommendations, IAPAC plans to create a continuing education program to educate providers about the recommendations in the new guidelines.

To read the IAPAC recommendations, click here.