- It is problematic when any patient doesn’t take a life-saving medication, but it is downright scary when more than two-thirds of HIV positive Medicaid patients have low medication adherence, according to Keith Dunn, PharmD, BCPS, AAHIVE.
Dunn is the associate medical director for Janssen Infectious Diseases, and recently completed research about medication adherence in the Medicaid HIV-positive population. The study showed that over two-thirds of Medicaid beneficiaries who are HIV positive have at least suboptimal medication adherence, which has many adverse side effects.
Patients who don’t take their HIV medications, which prominently include antiretroviral (ARV) treatments, run the risk of delaying viral suppression and building a resistance to other HIV treatments.
With some 1.2 million individuals living with HIV across the country, achieving full viral suppression is key to controlling the virus and preventing further outbreaks, Dunn explained in an interview with PatientEngagementHIT.com.
When patients miss doses of their ARV treatments – or don’t take them at all – the virus has the opportunity to replicate, leaving patients liable to HIV drug resistance and limited future treatment options.
There are also significant financial implications, Dunn said. Patients who don’t consistently take their ARV drugs experience an increased number of days spent in the hospital and have more long-term care admissions. This leads to higher medical costs and hurts the financial bottom lines for payers and hospitals alike.
The healthcare industry is aware of these risks, and has done extensive research into medication adherence trends among patients with HIV, Dunn acknowledged.
However, most of this research looks at patients with private healthcare coverage. A significant gap in research surrounds patients receiving Medicaid benefits. With Medicaid being the largest insurer of patients with HIV, Dunn asserted it critical he look into this subpopulation.
By getting a more holistic view of medication adherence in HIV positive patients, Dunn said insurers, clinicians, and drug developers can develop strategies to improve adherence. Taking into consideration the habits of Medicaid patients is a part of making all-inclusive changes.
“Understanding the rates and reasons and consequences of non-adherence in this population is important when healthcare providers and formulary committee members select regimens to help improve adherence such as fix those combinations, single tablet regimens or those regimens that might help prevent the development of HIV drug resistance,” Dunn said.
Dunn and his research team looked at Medicaid claims data from between 2012 and 2015. Data from Iowa, Kansas, New Jersey, Missouri, Mississippi, and Wisconsin helped Dunn attain a full glimpse into spending patterns for patients with HIV as well as proportion of days covered (PDC), a key medication adherence measure.
Dunn and his team specifically split patients into three adherence groups: those with optimal adherence (PDC at greater than 95 percent), those with suboptimal adherence (PDC between 80 and 95 percent), and those with poor adherence (PDC lower than 80 percent).
More than two-thirds of the test patients had suboptimal or poor medication adherence, Dunn found. Medication adherence was better for older patients over the age of 50 than for patients aged between 18 and 29, an alarming figure, Dunn said.
“The increased risk of non-adherence in the younger population is concerning as nearly 50 percent of new HIV infections in 2015 occurred in patients ages 18-29 years,” he pointed out.
The study did not investigate the individual trends among patients with suboptimal of poor medication adherence, Dunn noted, but he and his team did draw a few anecdotal conclusions.
“The [Department of Health & Human Services] guidelines do site potential reasons for non-adherence in the adolescent population,” he said. “These may include denial and fear of their HIV infection, unstructured or chaotic lifestyles, mood disorders or other mental illnesses, lack of familial support or social support, and lack of or inconsistent access to healthcare or insurance.”
Additionally, patients might have health literacy or other barriers keeping them from taking their ARV treatments. The social determinants of health – specifically socioeconomic status, environment, and education level – can have an impact on medication adherence.
The prescribed regimen, patient-provider relationships, and clinical condition can all also have an effect on medication adherence, Dunn pointed out.
For example, patients who are newly diagnosed as HIV positive are more likely to have lower medication adherence than patients who have had their diagnosis for longer.
“Patients who are naïve to treatment or not yet demonstrating HIV symptoms may not yet be fully aware about the goals of treatment, the importance of adherence, and the risk of developing resistance, which could limit future treatment options,” Dunn posited.
Patients might also be having difficulties navigating insurance coverage and coordinating copayments, Medicaid benefits, and other associated costs.
Clinicians can work with individual patients to reduce pill burden through dosage combinations or work to identify effective single tablet regimens, Dunn suggested. Healthcare professionals should also look into an ARV regimen that can prevent growing drug resistance in the face of poor medication adherence.
“Overall, healthcare providers and decision makers need to recognize that a very high proportion of patients in this population demonstrates some form of suboptimal adherence,” Dunn said. “Healthcare providers who recognize risk factors of non-adherence make better target interventions to improve adherence through targeted efforts like adherence counseling.”
While it is critical for healthcare professionals to work with patients to uncover the barriers and challenges they face in remaining adherent to patient treatments, Dunn explained that stakeholders must also collaborate with one another.
“Improving the outcomes of those living with HIV should be a team effort,” he added.
Dunn suggested that all stakeholders – clinicians, drug makers, payers, and policymakers – should all work together to develop solutions.
“As the largest source of coverage for those living with HIV, healthcare providers and Medicaid decision makers should work together to facilitate access and use of antiretroviral regimens that may improve adherence and decrease the development of resistance,” Dunn concluded.