Recent Data on Anti-Retroviral Therapy Adherence Barriers

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Moti Ramgopal, MD, FACP, FIDSA, CPI: When we look at antiretroviral therapy [ART] and its effectiveness, over time we’ve seen that the medication becomes quite effective. However, we are still seeing patients not taking their medications and there are still adherence issues. What are these adherence issues? What are these barriers to patients taking their medications?

There are many of these barriers, including inconvenient drug dosing, inconvenient schedule of medications, adverse events, and swallowing difficulties. What is also very important are the physical, emotional, and psychological challenges patients with HIV face, the stigma related to this. Adherence issues can be quite challenging and are influenced by, as mentioned, [adverse] effects, stigma, impairment of day-to-day life, daily medication, stress, anxiety. There is this suboptimal feeling that overall their health is not as good.

The study that we are looking at analyzed 2389 adults with HIV on antiretroviral therapy; 67% were male, 70% were younger than 50 years, and 74.1% had virologic suppression. The study revealed that 58% of patients were cueing bad memories; 57% were disguising HIV pills, that’s what people do when they don’t want others to know that they’re taking HIV medication; 33% reported stress; and difficulty swallowing pills was still quite high at 33%. These all led to treatment dissatisfaction and suboptimal overall health.

There’s also that feeling of being limited by antiretroviral therapy. Because these people who reported this feeling, they also reported higher odds of suboptimal overall health. Difficulty swallowing, privacy concerns, these were [adverse] effects that also were associated with suboptimal overall health. It is noted that only 52% of these patients were comfortable discussing the ART, related to privacy concerns. And 29% of participants missed more than 1 dose in the past month. Seeing that medications now are simpler, medications are given once a day, have fewer [adverse] effects and are more tolerable, still 29% of participants in this large study of 2389 adults show that they were still missing a dose. This is a result of privacy concern and many other factors.

What was interesting is 12.6% of participants shared their HIV status only with the HIV provider, and 6.8% always share their HIV status. You would think that a lot of those patients would share their status because they’re more comfortable with the disease. This study showed that this was not so. Also, 54.7% prefer a nondaily regimen. Now we’ve moved from a regimen of multiple pills a day, 2 or 3 times a day, and even though we’ve given patients a once-a-day regimen, 54.7% prefer a nondaily regimen. I think this is a surprising number, and I was quite impressed with the data. Now 72.3% are still open to ART with fewer therapies. This opens up a lot of different opportunities for new strategies of treatment care.

As a result of these findings, this study identified several challenges with ART among people with HIV and underscored the need for increased flexibility of our delivery and to meet diverse patient needs. Addressing these needs may improve the overall health, the outcomes for these patients.

Then the question is, what implications for needs in ART therapy need to change to meet these diverse patient needs? The most important thing this study suggests is patients may benefit from alternative treatment that’s not once a day anymore; long-term delivery of medications, possibly long-term injectable strategies, nondaily medication treatment strategies. This can lead to improved outcomes in these patients who are struggling with this. Treatment strategy to assist in addressing psychosocial as well as stigma and emotional challenges is very important. Medications that contribute to the role of depression and social anxiety are also going to be important strategies in the future.