When prescribing antiretroviral medications, many clinicians find themselves in the position of downplaying the role of unwanted side effects. Familiar words such as: "The possible side effects are nausea, vomiting, diarrhea, neutropenia, thrombocytopenia, and rash" seem to slip out with ease. This is related to the fact that many people have few or no side effects, and for most patients, side effects resolve spontaneously within a week or two after starting therapy. However, some patients do experience moderate to severe side effects that do not resolve and that ultimately interfere with their lifestyle.

Patients can become overwhelmed with the possibilities of side effects and may even decline treatment to avoid having to experience them.1 Finding a balance between being informative and frightening individuals away from treatment should be the goal.

Unwanted side effects can have a significant impact on medication adherence. In a recent study, 3.6% to 30% of respondents reported not taking HAART medications regularly because of unwanted side effects.2 This is very important information because nonadherence can lead to viral resistance and treatment failure. An adherence rate of less than 95% has been reported to result in a greater likelihood of having a detectable viral load and eventual viral resistance.3 For the first few weeks, education and close follow up with new patients, or new medication regimens with experienced patients, can dramatically increase the possibility of a positive outcome.

Patients who are told in advance what to expect at their initial visit do better overall. They experience less stress and anxiety, feel more in control, and have the opportunity to prepare for potential side effects by adjusting their schedules and developing a management program in advance. For example, it may be helpful to let a patient know that experiencing nausea, vomiting or diarrhea for the first week or so while their body "adjusts" to the new medication is normal. And a very clear message is sent if patients are told that if an overall body rash appears, the medication should be stopped immediately and their provider should be called sends a clear message. Patients may choose not to start a new medication on the day before an important event and should be encouraged to plan in advance to start at a time when they can manage any adverse situations.

Close follow up is an essential element of successful treatment. Roberts conducted a qualitative study to examine factors that were facilitators and barriers to adherence.4 Respondents identified social and professional support among the top five facilitators. Medication side effects were listed among the top five barriers. The author concluded that professional and lay support, along with alarm reminding devices, can increase the likelihood of adherence. Having someone with HIV/AIDS expertise readily available to discuss unexpected or moderate to severe side effects can be reassuring and can decrease the likelihood of a medication being skipped or stopped altogether.

In some cases, vague reports of side effects can make patients hesitate to use whole classes of medications, limiting treatment choices. For example, a patient may call to say he had a rash over the weekend and has stopped his new medication. By the time he reports the incident, all signs of the rash are gone, and he may or may not be able to describe it clearly or remember whether it was a total body rash or centralized only on his trunk. Then, after some consideration, he may think it resembled a rash he had at another time that may have been due to a change in laundry detergent. But when patients understand the importance of early reporting and the monitoring of side effects, they can provide more accurate data than one gets with week-old self reports and this will ultimately result in better-informed decision making.

Common complaints such as nausea, vomiting, and diarrhea can usually be handled over the telephone. In many cases, taking a medication with food can decrease symptoms. More serious episodes may require medical follow up such as hydration, stool tests, antidiarrheal medications, and nutritional counseling. Rashes should be evaluated in person, and other possible, non-medication-related etiologies should be explored with the patient.

Side effects such as vivid dreams, nightmares, and other CNS symptoms usually resolve in four to six weeks. Prescribing a sleeping agent can be helpful for the first few weeks, and the dosing time can be arbitrarily adjusted with some success. In addition, complementary therapies such as herbal teas, relaxation techniques, and aromatherapy may be helpful.

Patients must be carefully monitored for blood dyscrasias including (most commonly) neutropenia, thrombocytopenia, elevated liver function tests, and anemia. In severe cases medications may need to be changed.

Fat loss or redistribution can negatively effect adherence to treatment and is now considered to have a significant impact on the lives of those affected.5 Previously considered to be more of a cosmetic or body image problem, newer studies indicate that an increase in truncal fat may lead to hypertension or heart disease as well as bodily shape changes.6

Side effects continue to be a major cause of non-adherence and ultimate treatment failure for patients on antiretroviral therapy. Providing education, support, and a system for close monitoring remain the most important interventions to improve the likelihood of uninterrupted therapy and positive health outcomes.

See Judy K. Shaw's bio on page 92.

References

     1.   Chesney M, Ickovics J, Chambers D, et al. Self reported adherence to antiretroviral medication among participants in HIV clinical trials: the AACTG adherence instruments. AIDS Care. 2000;12;.

     2.   Ammassari A, Murri R Pezzotti P, et al. Self-reported symptoms and medication side effects influence adherence to highly active antiretroviral therapy in persons with HIV infection. J Acquired Immune Deficiency Syndromes. 2001;28(5):.

     3.   Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Annals Internal Med. 2000;1:21-30.

     4.   Roberts K. Barriers to and facilitators of HIV-positive patients' adherence to antiretroviral treatment regimes. AIDS Patient Care and STDs. 2000;14(3):.

     5.   Shevitz A, Wanke C, Falutz J, Kotler D. Clinical perspectives on HIV-associated lipodystrophy syndrome: an update. AIDS. 2001;15:.

     6.   Sattler F, Qian D, Johnson D, Briggs W, DeQuattro V, Dube M. Elevated blood pressure in subjects with lipodystrophy. AIDS. 2001;15:.