Since the introduction of antiretroviral therapy more than a decade ago, morbidity and mortality among patients infected with HIV has decreased considerably thanks to improved access to care, prophylaxis against opportunistic infections, and medications. In the September 1, 2009 issue of Clinical Infectious Diseases, guidelines were released to assist clinicians managing this infection. They provide information on patient management as well as medication adherence, and can assist clinicians in all stages of HIV management.
Judith A. Aberg, MD, who was on the guideline panel that was created by the HIV Medicine Association of the Infectious Diseases Society of America, says “once therapy has been initiated, the response to therapy should be monitored 4 to 8 weeks later with a repeated virus load determination.” CD4 cell counts should be followed both for assessment of antiretroviral efficacy and to determine the need for prophylaxis against opportunistic infections.
A Multipronged Approach to Adherence
In the December 8, 2009 Journal of the American College of Cardiology, my colleagues and I conducted a study in which we compared outcomes in 2,868 patients who underwent PCI for ACS just prior to enrollment in the PROVE IT–TIMI 22 (Pravastatin or Atorvastatin Evaluation and Infection Therapy–Thrombolysis In Myocardial Infarction 22) trial. The PROVE IT–TIMI 22 randomized ACS patients to either 80 mg atorvastatin or 40 mg pravastatin daily. Of the original cohort, 69% had undergone PCI just prior to randomization. The incidence of the primary composite end point of all-cause mortality, myocardial infarction, unstable angina leading to hospitalization, and revascularization after 30 days and stroke was evaluated. We also assessed the incidence of TVR and non-TVR during follow-up.
“It’s essential that clinicians be knowledgeable about how to assist patients with optimizing their adherence to drug regimens.”
“Once antiretroviral therapy is initiated, adherence is important to treatment success,” says Dr. Aberg. “As such, it’s essential that clinicians be knowledgeable about how to assist patients with optimizing their adherence to drug regimens. Clinicians should think about using multipronged strategies to improve adherence.” Several patient factors have been found to consistently predict lower adherence to antiretroviral therapy, such as heavy alcohol use, active injection or other illicit drug use, depression, a lack of believing in the benefits of medications, and low health literacy. In addition, social situations can have an impact on patients’ ability to consistently adhere to medications. “People who have chaotic, unstable lives and those who have poor social support will find adherence to be more challenging,” adds Dr. Aberg. Strategies to overcome some of these challenges may include screening patients for depression prior to initiating antiretroviral therapy and regularly screening patients for substance abuse.”
Guidelines note that clinicians should be mindful of reading skills and the primary language of patients when providing educational materials. When possible, clinicians should provide dosing schedules that maximize the use of pictures, especially photographs of the medications. Structured individualized or group educational sessions about antiretrovirals, how they work, the importance of adherence, and strategies for adherence are also impactful, and the sessions may be administered by other staff members in one-on-one or group settings. To enhance social support, family members, friends, or partners should be identified as those who will assist with and help take responsibility for ensuring adherence.
In addition to patient-focused strategies, the guidelines in Clinical Infectious Diseases also recommend regimen-focused strategies (Figure 1). Antiretroviral regimen characteristics—including the complexity of the regimen, side effects, and how regimens fit within lifestyles and daily routines—can affect adherence to drug regimens. Regardless of the simplicity or complexity of the regimen, clinicians are advised to make sure that patients understand exactly how to take their medications. “Confusion is an important cause of suboptimal adherence,” Dr. Aberg says. The guidelines recommend helping patients to correctly fill drug organizers with new medications to help decrease confusion. Having patients recite their regimen back to clinicians can help assess patient understanding of the regimen. Clinicians should also be open to patient requests to change their antiretroviral regimens because of side effects. A key message in the guidelines is for clinicians to make efforts to prescribe simpler antiretroviral regimens, with the goals of using fewer pills and doses and minimizing food-dosing restrictions. “It’s important to avoid using a one-size-fits-all antiretroviral regimen because each person living with HIV is different,” says Dr. Aberg. The guidelines also recommend selecting regimens with fewer side effects whenever possible and being proactive about the management of side effects.
Considering the Patient-Provider Relationship
The quality of the patient-provider relationship has been found to influence adherence to antiretroviral therapies. Studies suggest that patients who are cared for by more experienced HIV providers are more likely to adhere to their regimens. Strategies that are geared to maximize the patient-provider relationship can further improve adherence (Figure 2). Clinicians are recommended to develop adherence-focused activities that are geared towards education on adherence, the use of tools to enhance adherence, and identifying potential problems with adherence before they begin. It is recommended that patients undergo intensive and frequent visits during the first month after antiretroviral therapy is initiated. Furthermore, a multidisciplinary team should be utilized to increase the likelihood of adherence. Dr. Aberg says “patients must be empowered with information about the importance of good adherence. By taking individualized and flexible approaches, clinicians can maximize their role in managing adherence issues in HIV.”
Aberg JA, Gallant JE, Anderson J, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis. 2009;49:651-681. Available at: http://www.journals.uchicago.edu/doi/pdf/10.1086/423390.
Romanelli F, Matheny SC. HIV infection: the role of primary care. Am Fam Physician. 2009;80:946-52.
Cohen DE, Mayer KH. Primary care issues for HIV-infected patients. Infect Dis Clin North Am. 2007;21:49-70, viii.
Mofenson LM, Brady MT, Danner SP, et al; Centers for Disease Control and Prevention; National Institutes of Health; HIV Medicine Association of the Infectious Diseases Society of America; Pediatric Infectious Diseases Society; American Academy of Pediatrics. Guidelines for the Prevention and Treatment of Opportunistic Infections among HIV-exposed and HIV-infected children: recommendations from CDC, the National Institutes of Health, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. MMWR Recomm Rep. 2009;58(RR-11):1-166.
Walensky RP, Wolf LL, Wood R, et al; CEPAC (Cost-Effectiveness of Preventing AIDS Complications)-International Investigators. When to start antiretroviral therapy in resource-limited settings. Ann Intern Med. 2009 Aug 4;151:157-166.
Hoang T, Goetz MB, Yano EM, et al. The impact of integrated HIV care on patient health outcomes. Med Care. 2009;47:560-567.