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.3 Because of the great importance of adherence to ART, good strategies for maximising adherence are essential.

Regular monitoring of viral load will show whether ART is being taken as directed.4 However, information-gathering approaches can: a) assist to identify potential adherence issues before they have impact on a person’s viral load and, b) help guide tailored regimens to maximise adherence.

Non-adherence can take many different forms – and not all of them are down to individual choice.

A multifaceted approach to improve adherence is most likely to be beneficial, particularly a combination of actively involving people living with HIV (PLHIV) in their own health care decisions, individually tailoring the treatment regimen and providing appropriate support services.5, 6

What are the main challenges to adherence?

Advances in ART now allow simplification of dosing schedules and reduction of pill burden for a majority of PLHIV while maintaining excellent viral suppression. Additional risk factors for non-adherence include:

Other medical issues

Comorbid conditions and concomitant medications.

Changes to the personal circumstances

A stressful event such as a family emergency or sudden routine upheaval can affect willingness to continue treatment.7

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.8, 9

Mental health

Depression is among the most significant predictors of adherence. Hopelessness, negative feelings and treatment fatigue can reduce motivation to care for oneself and may also influence a person’s ability to follow instructions.10, 11

Denial

The psychological mechanism of denial often results in a repression of the desire to follow prescribed treatment.12-14

Awareness of social and living conditions, suitability of regimen to lifestyle, availability and nature of social support structures provides an opportunity to enhance adherence to treatment. Similarly, attention to mental illness, as well as to abuse of alcohol and other drugs allows for the incorporation of intervention strategies that are tailored to the individual’s needs.

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).

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.3 Texting dosing reminders from the clinic with telephone follow-up for those requesting it has also been suggested.15

Routine methods

The principle of associating medications with daily activities can assist with adherence.16 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 socio-economic, psychosocial, behavioural and/or cultural barriers, a multidisciplinary team approach may assist with adherence to therapy.

How can a multidisciplinary team approach help improve adherence?

The involvement of pharmacists, nurses, social workers and psychiatric consultations as part of a multidisciplinary team can improve linkage-to-care, retention in care, and adherence to medication for PLHIV.14, 15 

Of course, not all healthcare professionals (HCPs) will have access to multidisciplinary support, but the idea that the individual has a team supporting them can be provided by mobilising community-based organisations, education on the use of medicines for PLHIV with low levels of literacy and enlisting the support of family members and ‘significant others’ to assist with treatment adherence.3

 

 

How do I work with self-reporting?

Self-reported adherence should be routinely obtained in all PLHIV.14 Although self-reporting commonly overestimates adherence compared to pharmacy-based refill measures,17 self-reported non-adherence has a high predictive value18 and allows PLHIV to measure their own commitment to treatment.

Self-reporting can also provide information about whether PLHIV are selectively adherent to counter side effects, or if there is another issue responsible for non-adherence. Selective questioning can help to assess the accuracy of self-reports and maximise the benefits of the information provided:

  • Ask 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).
  • Employ a structured format that normalises or assumes less-than-perfect adherence and minimises socially desirable or ‘white coat adherence’ responses.
  • Give individuals the benefit of the doubt, as this will foster trust and honesty.
  • Provide encouragement rather than guilt for missing doses.