How PATH works for mentally ill patients with HIV

How PATH works for mentally ill patients with HIV

Nurses provide comprehensive, hands-on help

An intervention called Preventing AIDS Through Health (PATH) is designed to keep mentally ill people infected with HIV from progressing to AIDS.

Still under investigation, the intervention uses a cascade that includes adaptive treatment applied to prevention interventions, says Michael B. Blank, PhD, assistant professor of psychiatry, assistant professor in the School of Nursing, and senior fellow at the Leonard Davis Institute for Health Economics at the University of Pennsylvania in Philadelphia.

The advanced practice nurses also assist patients by helping them with housing and other psychosocial problems, Blank says.

The nurses educate and provide outreach to patients' families, says Nancy P. Hanrahan, PhD, RN, assistant professor for the Center for Health Outcomes and Policy Research at the University of Pennsylvania School of Nursing in Philadelphia.

"The other part of this that is really important is that providers of people with mental illness often do not know their patients have HIV infection," Hanrahan says. "So the nurses do a lot of education among case managers, mental health workers, and providers about the incidence of HIV and what to look for."

The nurses raise the mental health provider community's awareness about the need for HIV testing among any patient who is at risk, Hanrahan adds.

"Nurses bridge the gap between primary care providers and the client," she says. "A lot of their clients are in and out of the hospital, and there is poor communication between the treatment of mental illness and the treatment of health care."

So, the PATH nurses help patients with admission to health care services, they write up reports, talk with providers, and attend clinic visits with patients, Hanrahan says.

"They call providers and, when the patient is discharged, they help them transition into their home environment," Hanrahan adds. "They provide a big link that's helpful in the process."

For mentally ill patients who are HIV positive, the program provides cascading levels of service, including the first cascade of a basic intervention. This consists of a nurse teaching them about their illness, HAART, psychotropic treatment, and the importance of adherence, Blank says.

They are given a watch that can be programmed to beep or vibrate, depending on their preference, at the time they are supposed to take their medications.

They were also given a pill box, and have scheduled nurse visits each week, Blank says.

"So, the intervention provides a psychoeducational program about adherence, as well as a memory aid in the form of the watch and dosing assistance in the form of the pill box," he adds.

Nurses monitor patients' adherence at the weekly visits. They checked the pill box to count pills, elicited a self-report of adherence, and obtained pharmacy reports about the prescriptions being filled, Blank says.

If any of these indicators fell below 80 percent adherence, then the patient was moved to the next cascade level where a social network was engaged, Blank says.

"We ask family members, friends, and significant others to help remind them to take their medications when they should and as they should," Blank says. "The nurse does this by providing the same kind of psychoeducation to family members that is provided to patients themselves."

If the patient remains nonadherent after the second cascade step, then they are given a beeper for the third cascade of the intervention, Blank says.

The beeper is programmed, through a Boston, company's service called E-Pill, to go off when the patient is scheduled to take his or her medication, and an alphanumeric display on its screen will say, for example, "Take the blue pill with food," Blank explains.

The fourth cascade is activated for those patients for whom even the beeper does not work. This intervention involves giving patients a cell phone, and the patient's own family members or other social network members are trained by the nurse to call the patient at the time the patient is scheduled to take medication, Blank says.

"They talk them through taking their medications in real time," he says.

For the patients who still remain less than 80 percent adherent, the fifth and final cascade intervention is having the nurse set up a schedule for directly-observed therapy, Blank says.

The study, which will continue to enroll participants for two more years, has shown in early data some potential for success.

Of 125 patients enrolled, 72.9 percent maintained 80 percent adherence using the basic intervention only.¹

Another 12.4 percent were able to maintain 80 percent adherence with the addition of the second cascade, while 3.7 percent needed the beepers, and 4.3 percent needed the cell phones.¹

Only 1.9 percent needed the directly observed therapy.¹

The patients' adherence is continuously monitored, and once they are above 80 percent, they are moved back to the previous cascade intervention, Blank says.

The intervention and its cascades were designed to be used with a particularly difficult population of HIV patients, he notes.

"That comes from my conviction that most prevention programs are one size fits all and represent a departure from what we do in the rest of clinical medicine, where if something doesn't work, you go a little bit farther," Blank says. "This tailors the intervention to the needs of the individual patients."

The program, if it proves successful in the outcome measures of behavioral risk and biological indicators, including risky sexual behavior and substance use, as well as CD4 cell counts and viral loads, could serve as a model for other clinics, he says.

"We think this could serve as a model for how to provide comprehensive adherence intervention for not only this population, but for others that have trouble following treatment regimens," Blank says.

Reference:

1. Blank M, et al. A Community Health Nursing Approach to HIV Treatment Adherence Among Persons with Comorbid Mental Illnesses. Presented at the XVI International AIDS Conference, held Aug. 13-18, 2006, in Toronto, Canada. Available at www.iasociety.org.