Adherence to HIV combination therapy

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Abstract

The emergence of drug-resistant strains of HIV virus and treatment failure can result from non-adherence to antiretroviral therapy. While non-adherence to therapy is not a new issue or specific to HIV/AIDS, it has received renewed attention because of the complicated combination treatment regimens being prescribed. This paper reviews the relevant background literature on the contributions of social and behavioural science to non-adherence to HIV medications. Data indicating problems with adherence prior to combination therapy are reported. Despite limitations, even self-report assessments have already succeeded in showing that adherence to combination therapy is significantly related to HIV viral load. Recent research data are discussed. Implications of findings for counselling patients to increase their adherence are presented.

Section snippets

Background to adherence or compliance: A social and behavioural science perspective

Biomedical scientists involved in clinical trial research and health care providers charged with treating persons living with HIV are turning to social and behavioural scientists for assistance with adherence. In particular, there is interest in understanding the factors that account for patients’ difficulties in adhering to care. While some social and behavioural scientists have become very involved in developing measures of adherence, studying explanatory factors and developing programs to

Adherence and emergence of drug resistant virus

All recently published treatment guidelines (Carpenter et al., 1997, Dormont, 1997, Dormont, 1998) have a twofold orientation: positive recommendations and warnings. On the positive side, they confirm the prognostic value of viral load and CD4+ level. The guidelines clearly indicate that one criterion and operational objective for evaluating drug effectiveness is the lowering of viral load, optimally to below a detectable level. The other goal is to rebuild the immune system, which is

The challenge of non-adherence

The new focus on adherence begs two questions. First, what are the levels of adherence that have been seen? Second, how much adherence is necessary to prevent treatment failure? Even the most casual awareness of the factors associated with non-adherence to other conditions should have sent out an alert as the full extent of the medications involved in combination therapy became apparent. Research on adherence over recent decades, independent of HIV/AIDS indicated that adherence decreased as the

Non-adherence — assessment

Determining the level of non-adherence among patients living with HIV/AIDS is complicated by the general methodological difficulties of adherence assessment. There is no “gold standard” of adherence assessment. Self-reported measures of medication adherence are subject to social desirability and recall bias. Despite these weaknesses, this approach has been shown to give satisfactory concurrent and predictive validity when used in a controlled design and multimethod approach (Brooks et al., 1996

Non-adherence — scope of the problem

The existing surveys of adherence to combination therapy indicate that adherence is likely to be a significant problem. Two such preliminary surveys were reported on at the European Conference. Both of these used a self-report instrument designed specifically to assess the extent and reasons for non-adherence. The first of these was a study conducted at San Francisco General Hospital (Hecht et al., 1998a, Hecht et al., 1998b). AIDS outpatients seen during January and February 1997 were given

Social and behavioural factors in non-adherence

Interest in developing strategies to address non-adherence has led to investigations of its correlates. Sociodemographic factors are among the earliest variables to be examined. As is common throughout the adherence literature, non-adherence to HIV therapy is not consistently associated with demographic characteristics (Eldred et al., 1997, Morin and Moatti, 1996, Singh et al., 1996). For example, male gender seemed in some studies associated with decreased adherence, especially when associated

Intervention

As research to identify factors associated with adherence proceeds, and given the urgency of patients on these medications, there is pressure on social and behavioural scientists to provide assistance in modifying this behaviour. Numerous programs incorporating these ideas were presented at the 12th World AIDS Conference in Geneva. These programs are available for the patient and the team consisting of the clinician, nurse and nurse practitioner, pharmacist, social worker/psychologist, and

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