Treatment adherence in HIV disease is a complex clinical, cultural, and social problem. It has been estimated that an adherence rate of 95% is required to achieve adequate viral suppression.1 Demanding this near-perfect rate is difficult. However, coupling the issues with the need for lifetime therapy and toxic side effects make adherence a true clinical challenge. In addition to these common barriers to adherence, living with increased stress and mental illness can further complicate this already complicated issue.
Post-traumatic stress can affect many people living with HIV infection. Certainly, after the terrorist attacks there was an increase in stress throughout the country. However, traumatic stress can result from many causes such as homelessness, sexual abuse, drug addiction, and numerous other factors. Stress can impact people living with HIV and affect their ability to adhere to therapy. There are many different signs and symptoms of post-traumatic stress:
" Feelings may become intense and unpredictable. Patients may be irritable and moody, and may experience increased anxiety or nervousness. Depression is common.
" Patients may have repeated memories of the stressful event. These may be intensified if the patient is on certain medications, such as efavirenz (SustivaĻ), which has vivid dreaming as one of its major side effects. Also, flashbacks can occur for no apparent reason and may lead to physical reactions such as rapid heart rate or sweating.
" Anniversaries of the stressful event can re-trigger symptoms.
" Relationships with others may suffer. Greater conflict, such as more frequent arguments with family members and coworkers, is a frequent occurrence. The patient might become withdrawn and isolated and avoid usual pleasurable activities.
Physical symptoms may accompany the extreme stress that patients are feeling. Stress can lower the immune system and lead to a variety of illnesses.
Severe mental illness, substance abuse, and homelessness are frequent co-factors in many people living with HIV disease. Developing a treatment adherence program for this population can be a daunting challenge.
Severe mental illness refers to those individuals with psychiatric disorders that include schizophrenia, schizoaffective disorder, major depression, and bipolar disorder. These disorders can result in significant functional impairment and disruption of activities of daily living, as well as homelessness, periods of hospitalization, and disruption of medication adherence.2
The first symptoms of persistent mental illness frequently develop when patients are in their teenage years or in their early twenties. Illness during these periods of life can dramatically impact on education and on career and training opportunities, leading to substance abuse and homelessness.2 Homeless people suffer higher rates of many diseases, including HIV, than the general population.3
In developing a treatment adherence program there are five basic issues that should be considered.4 These include:
Care provider-patient trust
Is there faith and trust between the primary care provider and the patient? The only acceptable answer is "YES!" If there is any hesitancy, then the negative potential impact on treatment adherence appears high.
Commitment to life-long therapy
Can the patient commit to a potentially life-long therapy? Well, the real answer to this one is: "Who can?" That aside, the reality is that taking antiretroviral medications is presently a life-long affair. Treatment interruption and other studies are being done, but they are not reality yet.
Committing to life-long therapy is a frightening prospect. It may be more useful to help patients view therapy over the long haul. However, the patient and the clinician need to be honest about this and not abandon therapy after a few weeks because drug resistance can develop rapidly. A side effect-management program should be developed before therapy begins.
It might make sense to "rehearse" the patient prior to starting therapy. Use a pillbox and put in candy in the amount that would be needed if they were pills; have the patient follow any food or fluid requirements that would be necessary. See how the patient does after several weeks, and assess where support may be needed.
Lifestyle
Does the regimen fit into the patient's lifestyle? Can the medications be taken on time? Are the patient's job, children, or other responsibilities going to interfere? Is there a refrigerator available if needed? Drug regimens have to be practical to be successful. Don't set up a regimen that requires the organizational skills of a NASA launch. It has to fit the lifestyle of the patient.
Short-term side effects
What side effects is the patient willing to tolerate for the short term? Examine the different drug combinations and have patients decide what they can live with for a little while. Joint aches, nausea, and nightmares are just a few possible side effects. Some can be moderated by using some simple over-the-counter treatments. It is important for the patient and the clinician to talk about any fears and concerns.
Cultural meaning
Does the regimen have meaning for the patient? Does it fit into the patient's culture and beliefs? If a regimen is culturally unacceptable to the patient, it will more than likely fail.
Adhering to a treatment plan can be hard but it can be done. What is critical in developing an adherence program, especially in times of high stress, is for both the patient and clinician to approach it from a calm and rational prospective with honesty. It is essential that a realistic regimen with adequate support and side effect management be developed before the first pill is even taken.
Please see Dr. Ferri's bio on page 85.
References
1. Paterson DL, Swindells S, Mohr J, Brester M, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Int Med. 2000;133(1).
2. Bangsberg D, Tulsky JP, Hecht FM, et al. Protease inhibitors in the homeless. JAMA. 1997;278:63-65.
3. Draine J, Solomon P. Explaining attitudes toward medication compliance among a seriously mentally ill population. J Nervous Mental Dis. 1994;182:50-54.
4. Prochaska JO, Redding CA, Harlow LL, Rossi JS, Velicer WF. Transtheoretical model of change and HIV prevention: a review. Health Education Quarterly. 1994;21:471-86.