Clinical Manual for Management of the HIV-Infected ... - myCME.com

Adherence
Background
For HIV-infected patients treated with antiretroviral
therapy (ART), adherence to ART is a significant
determinant of survival. Adherence is second only
to the CD4 cell count as a predictor of progression
to AIDS and death. Adherence rates approaching
100% are needed for optimal viral suppression, yet the
average adherence rate to ART in the United States is
approximately 70%. Patients with suboptimal adherence
are at risk not only for HIV progression, but also for the
development of drug resistance (see chapter Resistance
Testing). Studies indicate that health care providers’
assessments of their patients’ adherence often are
inaccurate and limited, so individualized assessment and
planning for adherence are essential for patients to be
successful with ART.
S: Subjective
Adherence assessment is most successful when
conducted in a positive, nonjudgmental atmosphere.
Patients need to know that their provider understands
the difficulties associated with taking an antiretroviral
(ARV) regimen. Within a trusting relationship, a
provider may learn what is actually happening with the
patient’s ARV medication regimen rather than what
the patient thinks the provider wants to hear. Important
questions to ask a patient who is considering ART
may be found in Table 1. Table 2 suggests important
questions for patients who are receiving ART.
Common reasons for nonadherence include the
following: experiencing adverse effects, finding the
regimen too complex, having difficulty with the dosing
schedule (not fitting into the daily routine), forgetting
to take the medications, being too busy with other
things, oversleeping and missing a dose, being away
from home, not understanding the importance of
adherence, and being embarrassed to take medications
in front of family, friends, or coworkers. It is important
to look for these and other potential barriers to
adherence. (See chapter Initial History.)
O: Objective
Evaluate the following:
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CD4 cell count
Section 3—Antiretroviral Therapy | 3–11
HIV viral load (indicating the effectiveness of ART
in suppressing viremia; an indirect indicator of
adherence)
Current drug list (including over-the-counter
medications, vitamins, and herbal remedies); check
for adverse drug interactions with ARV medications
Pharmacy refill records
A: Assessment
Assess adherence at each visit using questions such as
those in Tables 1 and 2, and assessment scales such as
those found in Tables 4, 5, and 6 (Appendix 1). Ask
these questions in a nonjudgmental way and listen
carefully to the patient to invite honesty about issues
that may affect adherence.
Table 1. Important Questions to Ask Patients Considering
Antiretroviral Therapy
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What is your attitude toward antiretroviral therapy?
Do you believe that antiretroviral therapy is effective?
What do you hope these medications will do for you?
Are you ready to take the medication every day,
around the same time each day?
Are you committed and motivated to take the medication
every day for the rest of your life?
Who knows about your HIV status?
What other medications are you taking: prescription,
over-the-counter, herbals?
Are you a morning or afternoon person?
What is your daily routine, including waking and bed times?
How many meals and snacks do you eat per day, and at what times?
Do you use alcohol, marijuana, cocaine, or injectable drugs? If
so, how much do you use and how long have you used them?