If you think taking anti-HIV medications is as easy as popping a daily vitamin, think again. Combination treatments for HIV are among the most demanding, inflexible, and “unforgiving” of oral medications. Because of limited bioavailability (the ability of a drug to be absorbed by the body) and short half-life (the period during which a drug remains effective), combination therapies must be taken at fixed intervals, either with meals or on an empty stomach (depending upon the drug). Making things even more difficult, antiviral drugs require different dosing schedules, and the number of pills ranges up to 20 or more per day.
Many people on combination therapy must also take additional medications, making the process of scheduling even more complicated. People with HIV may also be struggling with weight loss (not form dieting, from wasting) or disrupted sleep patterns, making it more difficult to maintain a medical regimen that places further restrictions on eating and sleeping. Finally, some patients experience a range of side effects from their medications and may skip doses to avoid these effects.
All in all, HIV treatment regimens can be extremely challenging and at times debilitating. There has been speculation that the misconceptions about HIV treatment regimens being easy have caused some complacency concerning safer sex. Reading this article should dispel some of those misconceptions.
THE CHALLENGE OF ADHERENCE
Medication adherence, also known as “compliance,” is of key importance in fending off drug resistance. In other words, taking HIV meds as prescribed is necessary to the success of the drugs. And while it may seem like no big deal to stick to treatment plans, taking medications as prescribed has long been recognized as problematic.
Adherence is generally at its most challenging when the regimen is complex, intrusive, and of long duration. These are the exact characteristics of anti-HIV therapies. Adherence is also difficult when the treatment is for chronic conditions, which are often asymptomatic, as opposed to acute, symptomatic conditions, again, the case for many people with HIV. In such cases, side effects are more apparent than the medication’s hidden benefits, which are fighting the disease’s underlying infection. Consistent long-term adherence to a complex regimen of combination therapy is very challenging. If an individual cannot adhere to the strict dosing schedule and food requirements, the therapy is destined to fail because of the growth of insufficiently suppressed viral strains.
The good news is that people living with HIV/AIDS are now able to benefit from a knowledge base of four years of clinical life experiences with combination therapies, including optimal dosing schedules, remedies for common side effects, and strategies for maximizing absorption and adherence. Continuing research has also been conducted, with some success, on ways to simplify medication regimens, such as reducing the number of doses daily or the number of pills per dose.
Most promising of all has been research into “structured intermittent therapy” in which patients under the careful watch and supervision of their physician are able to stop taking medications entirely. If done properly, such interruptions may not only ease the burden of adherence, eliminate side effects and minimize the long term toxic effects of medications, but may actually help to train the immune system to better battle HIV in the future.
ATTITUDES TOWARDS COMBINATION THERAPY
In order to achieve a better understanding of protease inhibitor (one class of anti-HIV medications) use among clients, Gay Men’s Health Crisis (GMHC), conducted pilot studies, which sought to assess the extent of, reasons for, and predictions of, non-adherence to combination therapy.
Approximately three-quarters of the participants in the focus group segment reported missing doses of their protease inhibitor in the previous six months, and nearly one-third had missed a dose in the past week. The following were the mostly widely reported reasons for non-adherence.
- Being away from home without the medications
- Forgetting to take a dose due to timing
- Conflict with eating
- Running out of medication
Gay men, often, cited stress, anxiety, and depression as reasons for missing doses. While practical considerations seem to be paramount, for gay men, mental health issues such as underlying depression, anxiety or other emotional problems exacerbates adherence challenges. For HIV positive gay men who have difficulty taking anti-HIV drugs exactly as prescribed it may be beneficial to seek out an evaluation of their mental and emotional condition in an effort to reduce obstacles to medication adherence. For some adherence becomes harder to maintain over time. Since many gay men living with HIV have been infected for a very long time, they have an even greater likelihood of suffering from “adherence fatigue.”
The GMHC study found the following factors improved a person’s ability to adhere to the treatment schedule: believing in the effectiveness of treatment; evidence that the regimen was working; success in minimizing side effects; and support from family and friends. Another key factor was the level of trust in the health provider. Although all the participants in the GMHC study reported having discussed combination treatment with their doctors, almost a quarter felt their doctors did not clearly explain drug interactions, and almost one-fifth felt that their doctors had not clearly explained side effects or the consequences of non-adherence. Complex treatment decisions that can help lead to the strict adherence necessary in order to achieve long-term viral suppression and durable clinical effectiveness, must be driven by personal preference, common sense, rapidly accumulating data, changes in community prescribing patterns, and perhaps most important, a comfort with uncertainty. In addition, people with HIV can maximize adherence by identifying cues that help remind them to take medications, and anticipating changes in daily patterns that will pose a difficulty to taking the medications as prescribed.
WHAT YOUR DOCTOR OR PROVIDER CAN DO
Cassy Workman, an Australian primary care physician, suggests that a member of the health care team intervene at three critical points in the process, to increase the likelihood that people will adhere to treatment schedules. These points are: before treatment is initiated; immediately after treatment has begun and at regular points during the therapy. She suggests that a counselor or medical provider needs to make certain that the patient understands three things: why he or she needs to begin this treatment; that he or she can take the medication as prescribed; and strategies to insure that they can take the medications as prescribed.
TIPS FOR ADHERENCE
Always have a medication supply with you where ever you go
- Set alarms and timers to remind you of doses
- Call the pharmacy and make arrangements for refills before your medication is about to run out
- Find a doctor you can trust and discuss problems (including side effects) you may be experiencing
Category: AIDS/HIV Articles