Thirteen years into the era of highly active antiretroviral therapy (ART), medication adherence continues to be a serious barrier to effective treatment. While poor medication adherence adversely affects the outcomes of medical care in all chronic conditions, its impact is particularly devastating in HIV disease, leading to the gradual depletion of immune function, which can eventually result in death. Few interventions to improve patient adherence have focused on primary HIV care physicians. There is an urgent need to fill this gap. HIV providers are the ones who start, stop, and change ART;and the health care system currently pays for frequent physician visits. Because of this, small improvements in HIV providers'skills can have a large effect. Our long term goal is to develop, test, and disseminate effective, evidence-based HIV provider training programs that focus on improving patients'medication adherence. The overall objective of this R34 is to develop and test the feasibility, acceptability, and preliminary efficacy of an intensive physician training intervention based on principles of Motivational Interviewing (MI). Our central hypothesis is that HIV providers are knowledgeable and motivated about the importance of ART adherence for their patients with HIV, but lack the skills necessary to accomplish this counseling in the course of busy office practice. Our own and others'research has shown that physicians tend to talk little about medication adherence, that less than 10% of that talk can be categorized as problem solving in nature, and that physicians tend to lecture or give directives rather than listening and trying to understand patients'perspectives, obstacles and goals. We will pursue the following specific aims: (1) develop an intensive skills development intervention, based on principles of motivational interviewing, to train HIV providers to more effectively provide treatment adherence counseling, (2) conduct a pilot study comparing a 1-day training session (brief intervention) with a 1-day training session plus ongoing feedback (intensive intervention), and (3) evaluate the acceptability and feasibility of the pilot study. We will conduct our study at the Johns Hopkins HIV/AIDS clinic in Baltimore, MD, a region that has been greatly affected by the HIV/AIDS epidemic.
In Aim 1, we will conduct focus groups of HIV patients and providers, consult with experts, and review our own audio recordings of actual patient-provider communication regarding ART medication adherence. To accomplish Aim 2, we will randomize 10 HIV providers to the brief or intensive intervention arm, and measure baseline (pre) and follow-up (post) communication behaviors in actual patient encounters.
In Aim 3, we will assess provider response to the intervention components.
In this application, we will design and evaluate the feasibility, acceptability and preliminary efficacy of a communication skills training program aimed at HIV providers focused on counseling regarding antiretroviral (ART) medication adherence. This is important because a substantial proportion of HIV-infected patients do not take medications, and HIV providers do not have the skills to counsel effectively about this issue.
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