Improving ARV Adherence Through Enhancement of HIV Providers' Counseling Skills

描述(申请人提供)：在高效抗逆转录病毒疗法(ART)时代13年后，药物依从性仍然是有效治疗的严重障碍。虽然服药依从性差对所有慢性病的医疗结果都有不利影响，但对艾滋病毒疾病的影响尤其严重，导致免疫功能逐渐衰竭，最终可能导致死亡。提高患者依从性的干预措施很少集中在初级艾滋病毒护理医生身上。迫切需要填补这一空白。艾滋病毒提供者是启动、停止和改变抗逆转录病毒疗法的人；目前，医疗保健系统为频繁的医生就诊买单。正因为如此，艾滋病毒提供者技能的微小改进可以产生巨大的影响。我们的长期目标是开发、测试和传播有效的、以证据为基础的艾滋病毒提供者培训计划，重点是提高患者的服药依从性。R34的总体目标是开发和测试基于动机访谈(MI)原则的强化医生培训干预的可行性、可接受性和初步效果。我们的中心假设是，艾滋病毒提供者对坚持抗逆转录病毒疗法对艾滋病毒患者的重要性了解并有动力，但缺乏在繁忙的办公室实践过程中完成这一咨询所需的技能。我们自己和其他人的研究表明，医生倾向于很少谈论服药依从性，在本质上可以归类为解决问题的谈话不到10%，医生倾向于讲课或给予指示，而不是倾听和试图理解患者的观点、障碍和目标。我们将追求以下具体目标：(1)根据激励性访谈的原则，制定密集的技能发展干预措施，以培训艾滋病毒提供者更有效地提供治疗依从性咨询；(2)进行一项试点研究，比较为期一天的培训课程(简短干预)和为期一天的培训课程加上持续的反馈(强化干预)；以及(3)评估试点研究的可接受性和可行性。我们将在马里兰州巴尔的摩的约翰·霍普金斯艾滋病毒/艾滋病诊所进行研究，该地区受到艾滋病毒/艾滋病疫情的严重影响。在目标1中，我们将对艾滋病毒患者和提供者进行重点小组，咨询专家，并审查我们自己关于抗逆转录病毒药物治疗依从性的实际患者与提供者沟通的录音。为了实现目标2，我们将把10名艾滋病毒提供者随机分配到短期或强化干预组，并在实际患者接触中测量基线(前)和后续(后)沟通行为。在目标3中，我们将评估提供者对干预部分的反应。 公共卫生相关性：在这项申请中，我们将设计和评估一项针对艾滋病毒提供者的沟通技能培训计划的可行性、可接受性和初步效果，重点是关于抗逆转录病毒(ART)用药依从性的咨询。这一点很重要，因为相当大比例的艾滋病毒感染患者不服用药物，而艾滋病毒提供者没有就这一问题提供有效咨询的技能。

DESCRIPTION (provided by applicant): 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. PUBLIC HEALTH RELEVANCE: 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.