Edmonton DOT for HAART: lobbying for sustainable funding as a challenging but critical aspect of effective inner city HIV management

Edmonton DOT for HAART II:
Inner city patient retention, lifestyle stabilization and reduced HIV transmission risk by using a "people first" approach
Wendi Monahan*, Roger Millard*, Peter Akai

DOT for HAART

A growing number of HIV positive individuals live in a world of chaos involving homelessness, crime, addiction and psychosocial instability. These individuals are typically poor candidates for highly active antiretroviral therapy (HAART), due to non-compliance.

Objective: To deliver effective HIV treatment to people living in a chaotic environment.

Method: Compliance with HIV treatment requires responsible behaviour. How can this be achieved in a world of instability? An important premise that emerged was that people living in chaos appeared more chaotic and irrational than they actually were. Choices that may appear unwise actually make sense for those living in a world of chaos. Our approach was therefore to place these people first by adapting our services to their world. The resulting challenge was to emphasise flexibility of service while maintaining the structure necessary to provide that service. Resolution of this challenge was crucial to working effectively with this unconventional population.

Results: Program enrollment steadily increased to 60 by month 33, with only six permanent drop-outs overall. Daily DOT was recorded 86% of the time on average, and additional self-reported (non-DOT) compliance inreased estimated adherence to 90%. Percentage of opiate and cocaine users decreased at all enrollment timepoints (data available up to month 33), as compared to self-reported pre-enrollment usage. The most dramatic change was for opiate usage which was reported as nil by all patients enrolled >9 months. Average risk questionnaire scores decreased steadily with increasing enrollment timepoints, indicating markedly decreasing risk of HIV transmission to others.

Conclusion: Our "people first" approach created a treatment service compatible with the unconventional environment of our participants. In addition to improved health, their increased sense of worth, confidence and capacity to succeed emerged as valued factors in motivating compliance.