The importance of adherence strategies

Adherence is a decisive factor in the success of HIV treatment. Unlike other chronic diseases, the rapid replication and mutation rate of HIV means that high levels of adherence are required to achieve durable suppression of viral load.1,2  

Suboptimal adherence also increases the risk of developing resistance to antiretroviral therapy (ART) and the transmission of HIV.1,3 Because of the great importance of adherence to ART, good strategies for maximising adherence are essential.

Monitoring adherence

Regular monitoring of viral load will show whether ART is being taken as directed.4 However, information-gathering before initiating therapy can:

  • help identify potential adherence issues before they have impact on a person’s viral load,5 and;
  • help guide tailored regimens to maximise adherence.6

Non-adherence can take many different forms – some of which are unintentional. It is therefore essential to identify each individual’s barriers to adherence in order to tailor their treatment regimen and provide appropriate support services.5,6

The main challenges to adherence

Although advances in ART now allow simplification of dosing schedules and reduction of pill burden for a majority of PLHIV, non-adherence can still occur.

 

Additional risk factors for non-adherence include, but are not limited to:

Comorbidities and concomitant medications

Many PLHIV use concomitant medications to manage comorbidities or ART side effects. Polypharmacy can make non-adherence more likely by increasing the complexity of medicine schedules, as well as the risk of drug-drug interactions.7

Changes to personal circumstances

A stressful event such as a change in relationship, family emergency or sudden routine upheaval can increase the likelihood of missing HIV medication. Addressing these issues and providing referrals where appropriate can be an important step in managing adherence.8

Complex ART regimens

Complex treatment regimens can be challenging for many individuals. However, adherence to ART has become easier over time with newer and simpler formulations. Several studies have reported increased ease of adherence to once-daily regimens compared to multi-dose regimens.9-11

Mental health

Depression is among the most significant risk factors for non-adherence, and depressive symptoms may be highly disruptive to self-management strategies.10,12

Treatment fatigue can also reduce motivation to care for oneself and may also influence a person’s ability to follow instructions.13

Denial

HIV-positive individuals who do not openly disclose their seropositive status are also less likely to be adherent to treatment.14-16

Understanding the individual’s needs

Awareness of the individual’s social and living conditions, suitability of regimen to lifestyle, and the availability and nature of social support structures provides an opportunity to enhance adherence to treatment.10

Similarly, attention to mental illness, as well as alcohol and other drug use allows for the incorporation of intervention strategies that are tailored to the individual’s needs.10

In all cases it is essential that PLHIV understand the importance of adherence and the serious consequences of non-adherence (i.e. treatment failure, or in some cases, disease progression, and drug-resistance).16

Adherence strategies

Where adherence can be improved for simple reasons of forgetfulness or a busy schedule, there are several strategies to assist PLHIV to take their medication:

Reminder methods

Individuals can set themselves daily reminders to ensure they take their medication. A smartphone, personal organiser app or simply a mark on the calendar at home can help with this.17

Texting dosing reminders from the clinic with telephone follow-up for those requesting it has also been suggested.4,17

Routine methods

Associating medications with daily activities can assist with adherence.18 For example, the medication can be associated with morning rituals such as brushing teeth or reading the newspaper.

Facilitating adherence

In situations where non-adherence is due to complex issues – including socio-economic, psychosocial, behavioural and/or cultural barriers – a multidisciplinary team approach may assist with adherence to therapy.16,17

Resources that may need to be considered to facilitate uninterrupted access to ART include16:

  • Allowing for flexible appointment scheduling
  • Assisting with transportation
  • Financial assistance with treatment costs

Working with self-reporting

Self-reported adherence is a useful tool, should be routinely obtained in all PLHIV.10,16 Although self-reporting commonly overestimates adherence compared to pharmacy-based refill measures,19 self-reported non-adherence has a high positive predictive value20 and allows PLHIV to measure their own commitment to treatment.

The reliability of patient self-reporting often depends on how the information is obtained. Some recommendations for improving the reliability of self-reports of adherence include16:

  • Asking the individual to confirm how often they miss medications; to clarify when and why they might be regularly missing doses (consider factors such as finances, drug and alcohol use).
  • Using a simple, consistent and non-judgemental format that normalises or assumes less-than-perfect adherence and minimises socially desirable or ‘white-coat adherence’ responses.
  • Providing reassurance to patients in order to alleviate guilt for missing doses.
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