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Table 2 Core elements of life steps and anticipated modifications

From: Adherence intervention for HIV-infected persons who use drugs: adaptation, open trial, and pilot randomized hybrid type 1 trial protocol

Module Description Anticipated modifications to life steps
Existing life steps protocol
Step 1: Education and introduction Information about how medication adherence plays in successful treatment is provided. The aim is to increase knowledge and self-efficacy to influence treatment success and introduce problem-solving for medication adherence Information regarding the physiological and psychosocial impact drug use has in PLWH, address impact on ART medications and increased HIV transmission
Step 2: Transportation to appointments Problem-solving strategies, brief cognitive restructuring, and rehearsal techniques are provided to address transportation issues to prevent missed appointments with health care providers No anticipated modifications
Step 3: Obtaining medications Develop a plan for continues access to medications. Address concerns about patient’s privacy and confidentiality during interactions with the pharmacist No anticipated modifications
Step 4: Communicating with health care providers Brief cognitive techniques are suggested for irrational fears about asking questions Address concerns about drug use stigma; teach strategies for improving patient-provider relationship
Step 5: Coping with side effects Learn to (a) pick a regimen with their doctor to minimize side effects; (b) re-interpret side effects as signs that medications are in their bloodstream and working; and (c) increase the salience of benefits of adherence No anticipated modifications
Step 6: Formulating daily medication schedule Patients complete a detailed map of an average day of pill-taking, specifying environmental and other cues for pill-taking throughout the day Address challenges to maintaining the daily medication schedule during periods of intoxication
Step 7: Storing medications Problem-solving techniques for storing medications when not at home No anticipated modifications
Step 8: Cues for pill-taking Taught how to use cues to remember to take pills (e.g., setting alarms, reminder system). Adaptive cognitions for adherence are rehearsed No anticipated modifications
Step 9: Response to slips in adherence Patients are taught how to handle slips and to avoid all-or-nothing thoughts. Cognitive techniques to cope with a lapse are discussed Address how drug use may result in slips on adherence and how to minimize negative health outcomes
Step 10: Review Review previous steps and address concerns No anticipated modifications
Anticipated additional adherence-related modules to the life steps protocol (based on the syndemics model by Singer [1])
 Interpersonal factors
  Increasing social support and relationship stability Brief training in interpersonal skills and strategies to help increase support networks and build healthy relationships
 Individual factors
  Psychiatric comorbidities Participants will receive a list of local mental health and substance abuse treatment options
  HIV-related beliefs Address interaction toxicity beliefs in regards to taking ARTs while using drugs and alcohol
 Environmental factors
  Stigma Cognitive techniques will be provided to help participants cope with stigma related to HIV and drug use
  Access to services Participants will receive a list of local resources to assist with housing, transportation, and food insecurity
Anticipated additional drug use modules to the life steps protocol (based on the FRAMES approach by Miller and Sanchez [23])
Personalized assessment and feedback Participants will complete a baseline assessment of their drug use ad risk behaviors. Individualized feedback regarding personal risk or impairment will be given following assessment
Changing risk behaviors Use of MI techniques to address drug use and other risk behaviors. Techniques include assessing stage of change, use of decisional balance, address discrepancies between personal goals and behavior, and emphasize that autonomy and responsibility for change is explicitly on the participant
Advice about changing Advice about reducing or stopping drug use will be given to the participant in a nonjudgmental manner
Treatment options A menu of self-directed change options and treatment alternatives will be offered to the participant
Empathic counseling The clinician will show warmth, respect, and understanding towards the participant
Self-efficacy for change Self-efficacy to change drug use will be engendered in the participant to encourage change