The importance of adherence strategies

Adherence is a decisive factor in the success of HIV treatment: 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 ART and the transmission of HIV.3 Because of the importance of adherence to ART, good strategies for maximising adherence are essential.

Viral load monitoring is an important method of assessing adherence.3 Information-gathering approaches can guide tailored interventions to maximise adherence by helping to identify adherence issues before they have impact on a person’s viral load. Assessment of self-reported adherence is recommended every 3–6 months.4

Non-adherence can take many different forms – and not all of them are down to individual choice.3 The COVID-19 pandemic in particular has presented challenges for people living with HIV (PLHIV) to access timely care and antiretroviral therapy (ART).5

To help maintain adherence, a multifaceted approach may be required. This can include actively involving PLHIV in their own healthcare decisions, individually tailoring ART and providing appropriate support services.5,6

What are the main challenges to adherence?

Advances in ART now allow dosing simplification and reduction of pill burden for a majority of PLHIV.2,3,6 Some key factors for non-adherence currently include:

 

Other medical issues

Comorbid conditions and concomitant medications.6

 

Changes to personal circumstances

A stressful event such as a family emergency or sudden routine upheaval.6,7

 

Complex ART regimens

Adherence to ART has become easier over time with newer and simpler formulations. Once-daily regimens have shown improved adherence rates compared with multi-dose regimens, particularly in treatment-naïve PLHIV or PLHIV with virological failure.8

 

Tolerability of ART regimen

Adverse events related to ART are reported as a barrier to ART adherence in PLHIV.9

 

Mental health

Depression is among the most significant predictors of non-adherence. Hopelessness, negative feelings and treatment fatigue can reduce motivation to care for oneself and may also impact a person’s ability to follow instructions.7,10–12

 

Denial

The psychological mechanism of denial often results in a repression of the desire to follow prescribed treatment.13,14

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 (ie. 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 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.3,6,15 Texting dosing reminders, including two-way SMS, have also been linked to improved adherence.3,6,15

 

Routine methods

Routines associated with taking medication have been shown to improve adherence.16 Associating medications with daily activities can help.17 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.6

 

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.6,15

Not all healthcare professionals will have access to multidisciplinary support, but broad support 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.3,6

 

How can self-reported adherence measures support the care of PLHIV?

Self-reported adherence should be routinely obtained in all PLHIV.3,6,15 Self-reporting commonly overestimates adherence compared to pharmacy-based refill measures,3,18 but self-reported non-adherence has a high predictive value for virological failure. 6,19 Self-reporting allows PLHIV to also measure their own commitment to treatment.

Self-reporting can also provide information about whether PLHIV are selectively adherent to reduce side effects, or if there is another issue. Selective questioning can help to assess the accuracy of self-reports and maximise the benefits of the information provided:6

  • 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 and drug/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 to foster trust and honesty
  • Provide encouragement rather than guilt for missing doses