Antiretroviral Therapy

Antiretroviral Therapy: Adherence, Drug Interactions, and Safety Among Women
Presentation by: Melissa D. Johnson, PharmD, MHS

Objectives
* Identify adherence barriers and motivators specific to women
* Discuss several drug-drug interactions of particular interest among women with HIV
* Describe mechanisms of gender differences antiretroviral pharmacokinetics and the potential implications of this on toxicity

Factors contributing to poor adherence among women
HIV-infected women have higher incidence of:
o Depression
o Emotional stress
o Fatigue and anxiety
o Physical and sexual abuse
o Stigma, rejection, and isolation
o Hiding diagnosis

Barriers to adherence among HIV-infected women
Factors influencing adherence
* Treatment experiences
* Support from provider and others
* Health care environment and material factors
* Informational resources

Factors influencing adherence
Beliefs, attitudes and behaviors regarding adherence among women
Motivators of adherence
o Physician
o Quasi-scientific rationale
o Belief that the drugs work
o Religiosity and faith (support from God)
o Family members (mom)
o Secular popular cultural prescription
o Television talk shows
o The body instinct (my body tells me when I need it)
o Friends
o Self (I know when I need it)
o The belief in the power of positive thinking
o Individual responsibility

African-American women in an inner city clinic, cited sources encouraging adherence:
Approaches to improve adherence
* Motivational interviewing/group workshops
* Positive life skills programs
* Modified directly observed therapy
* Cognitive-behavioral therapy for substance abuse
* Customized telephone calls
* Buddies/peer support

Approaches to improve adherence
KHARMA project
Motivational Interviewing principles:
* Expressing empathy and building rapport, through reflective listening and acceptance
* Highlighting the discrepancy between current behavior and it’s effect on the patient’s life goals
* Avoiding conflict by using a positive approach and avoiding negating and direct confrontation
* Assisting patients in exploring options, as a means of overcoming ambivalence or resistance to change
* Supporting self-efficacy and encouraging patients to consider and choose personal options, and to develop belief in their own power to make changes

Schema of KHARMA Workshops
Summary & Termination: Putting it all Together with Goals and Values
Disclosure of HIV Status: To tell or Not to Tell
Risk Reduction behavior: Balance & Negotiation
Risk Reduction behavior: Knowledge & Skills
Sharing successes & ART Strategies
ART Adherence: Change & Exploring Goals
ART Awareness: The Good Things and the Not so Good Things
Introduction, Group Guidelines, Exploration of Lifestyles

Resources
* United Nations
o UNIFEM Gender and HIV/AIDS Web Portal
http://www.genderandaids.org/index.php
* South Africa HIV and AIDS Information Dissemination Service
o Women’s treatment literacy toolkit:
http://www.safaids.org.zw/viewpublications.cfm?linkid=47
* DHHS
o HIV/AIDS Bureau
http://hab.hrsa.gov/publications/womencare05/WG05chap2.htm
http://hab.hrsa.gov/publications/womencare05/WG05chap5.htm

Approved Antiretroviral Agents 1987-2008

Non-nucleoside RTI
Protease Inhibitor
Fusion Inhibitor
Nucleoside RTI
Common Drug Interactions
Drug Interactions: Methadone
Decrease Methadone levels
NNRTIs
* Efavirenz
* Nevirapine
PIs
* Amprenavir/fosamprenavir
* Nelfinavir
* Ritonavir
* Lopinavir/ritonavir
* Saquinavir/ritonavir

Methadone effects on other agents:
Drug Interactions: OCs
Recommendations
Interaction
At risk for pregnancy
Mechanisms of differential PK
Lower hepatic p-glycoprotein in women
CNS effects
Toxicity
Concentrations in Women vs. Men
Toxicity in Studies of PIs
HAART including at least one PI
Toxicity in women vs. men
Focusing on Safety
Summary

Antiretroviral Therapy.ppt