Adherence to Antiretroviral Therapy:Ready or Not?

by Diana Antoniskis, M.D.

The importance of adhering to antiretroviral (ARV) therapies has been widely publicized and accepted as a critical element in the success of highly active ARV therapy. Treatment failure, which can reduce future options for treating HIV, is often linked to the patient’s inability to take medications as prescribed. Estimates of successful adherence range from 41% to 69% for long-term treatment trials, and 33% to 94% for long-term prevention studies (Besch CL. Compliance in Clinical Trials, AIDS 1995;9:1-10). A number of factors have been identified that influence adherence rates (see table).

Predictors of poor adherence may include current, active drug addiction, alcoholism, psychological stress and depression. It is interesting to note that gender, HIV disease stage and history of substance abuse have not been shown predictive of adherence. Furthermore, in many studies, clinicians have been found to be inaccurate in predicting which patients will adhere to antiretroviral therapy. Another important factor that influences a patient’s ability to successfully take medications is the "readiness" of the patient to begin therapy. Various guidelines have been published regarding initiation of antiretroviral therapy. Criteria on which to base the decision usually include: HIV viral load, CD4 count, clinical symptoms and "if the patient is ready." However, there are no standardized assessment tools, no simple questionnaire, and no real method of deciding when the individual is ready, other than asking the question, "Are you ready to start treatment for your HIV infection?" From the patient’s point of view, answering that question can be tough. Many people (particularly with early stage HIV disease) have little or no experience taking chronic medications. They really don’t know the impact on their lives of taking medications several times a day, every day. Secondly, the multiple side effects from these drugs are difficult for individuals to understand until they have actually experienced them. Also, many patients want to please their doctor and be a "good patient." If the physician or health care provider poses the question, the patient may assumes that the answer must be "yes," even if personal nagging doubts remain.

Patient Characteristics Treatment Regimen Patient-Provider Relationship Knowledge Social Support Beliefs Trust in provider Number of medications Frequency of dosing Complexity of dosing Duration of treatment Side effects Degree of behavioral change required Knowledge Trust Consistency Level of supervision Similar demographic characteristics

Adapted from Friedland GH. Adherence: the Achilles’ heel of highly active antiretroviral therapy. HIV InSite 1997;5:13-15.

What can physicians and health care providers do to help both the patient and the physician or provider honestly evaluate the readiness of the patient for ARV therapy? The following are suggested starting points.

Establish trust. Take the time to build a relationship between the patient and physician or provider so that dialogue will be as open and honest as possible. Some patients with HIV have been alienated by health care systems in the past, and learn to distrust health care providers. Physicians and health care providers need to recognize that actively engaging patients in treatment decisions helps establish this relationship. Don’t rush into things. A simple recommendation is to see the patient at least twice before starting therapy---questions or problems often surface after patients have had time to re-think information. Written handouts are also valuable to send home with people (since it’s easy to get overwhelmed with long verbal information at one sitting). If the clinical time allows, use more time for education, treatment of underlying problems (e.g. substance abuse or depression) and to establish a closer relationship between provider and patient. Involve other members of the health care team. Nurses can do HIV education, pharmacists can discuss medication dosages/timing/side effects, mental health professionals can initiate treatment for depression or substance abuse, and social workers can help stabilize disorganized living circumstances. It’s best to try to troubleshoot problems before getting the medication started, if possible. Follow-up is important. Don’t send patients out with a handful of prescriptions without an appointment for a timely return, usually within a month. Also, telephone calls from office staff to check for side effects, adherence difficulties and to offer support or more frequent medical appointments can be invaluable in those first weeks of a new medication regimen. Even under ideal circumstances, no one can predict exactly how well a medication regimen will fit for any given patient. However, investing time prior to initiation of therapy hopefully will help patients and providers be "as ready as they’ll ever be" for successful antiretroviral therapy.

Many of the clinical answers valued by HIV physicians and health care providers can only be answered truly by long term research. Please consider referring patients to The R&E Group CPCRA trial studying the impact of interventions on adherence on therapy. Call R&E staff at (503) 229-8428 or 1 (800) 875-8428 and ask about the CPCRA adherence study 062.