An HIV
infected person
can possibly live a
normal lifespan today, provided she or he takes
highly active antiretroviral therapy (HAART)
and takes it regularly.
The widespread uptake of highly active antiretroviral
therapy since mid-1996 has resulted in a dramatic
decline in the number of AIDS-related deaths.
High levels of adherence to antiretroviral
drugs are a prerequisite for a successful and
durable virological and immunological response.
Nurses play a vital role in initiation and monitoring
of adherence of the patient on antiretroviral.
The use of HAART since 1996 has substantially
changed the evolution of HIV infection, with
a dramatic reduction in morbidity and death
rate.
These advantages have to be counterbalanced
by important limitations such as the complexity
of regimens and considerable short and long
term toxicity. The lack of adherence is considered
the main cause of virological failure.
Factors Governing
Adherence
Patient factors include assessing patient’s
motivation, commitment to and understanding of
taking therapy, behavioural skills and ability.
The author works as a Lecturer
at College of Nursing, AIIMS, New Delhi. |
to adhere to therapy, the role of environmental
and social factors in influencing adherence,
and the patient’s overall mental health.
Provider factors include ensuring a multidisciplinary,
multiintervention approach, providing support
to patients both when starting and changing
therapy, providing medication alerts and appropriate
containers and ensuring continued professional
development and skill based training.
Regimen factors relate to issues around the
drugs, such as dosing frequency, pill burden,
drug interactions and side effects and the extent
to which lifestyle factors, such as sleeping,
eating and working may impede adherence to the
proposed regimen.
The guidelines acknowledge that adherence is
a process, not a single event, and that adherence
support must be integrated into clinical follow-up
for all patients who have been prescribed HAART.
Pre-requisites
Treatment decisions for an individual patient
is based on three factors: HIV RNA(viral load);
CD4 T cells and clinical condition of the patient.
In general, treatment should
be offered to individuals with T-cell count of
less than 350 or plasma HIV RNA levels |
exceeding
55,000 copies/mL (Panel, 2000).
Steps for ART Initiation
Establishing patient
medical history and understanding of HAART : The
aim of these sessions is to give enough information
to enable patients to make an informed decision
about whether to start/change/interrupt therapy
and how best to do this.
The patients’ medical history,
their knowledge of HIV and HAART and their expectations
of therapy in general is taken.
Lifestyle and psychosocial
assessment : In order to establish
the regimen options best suited to the patient,
all advisors carry out a lifestyle and psychosocial
assessment.
This includes a discussion of
the behavioural determinants of adherence, such
as daily routine, e.g. eating, sleeping and working
patterns; recreational activities (e.g. recreational
drug use); familial/social relationships; and
travel plans.
It sometimes involves a discussion
of social factors relevant to adherence, such
as relationship status and accommodation issues,
and it establishes the presence of any psychological
issues, such as depression or anxiety.
For example, the observations
reveal that some people work in shift duties |
rather than from 09:00 hours to 17:00 hours.
This often means that eating habits are erratic
and set meal times problematic.
It is crucial that these individuals have a
regimen best suited to this way of life, rather
than one that requires food at set time intervals.
All patients need to have a regimen tailored
to fit in around their lifestyle very beneficial.
Depression and severe anxiety are variables
that predict non-adherence.
Most people with HIV, at some time in the course
of their illness, experience a psychiatric disorder
(Buhrich & Judd, 1997) and depression and/or
anxiety which are reported in up to 70% of patients
with symptomatic
HIV-disease (Hayman & Buhrich, 1994). Poor
social relationships, living alone and lack
of support have been associated with an increase
in non-adherence( Besch, 1995; Williams &
Friedland, 1997) and social isolation is predictive
of non-adherence (Besch, 1995; Williams &
Friedland, 1997).
Not living alone, having a partner, social or
family support, peer interaction, and better
physical interactions and relationships are
characteristics of adherent patients. Active
drug use or alcoholism has been associated with
poor adherence (Chesney, 1997).
A drug picture chart and real pills are used
to demonstrate the options available to each
patient, and they find this interactive and
practical aspect of the session particularly
beneficial. Side effects are to be discussed
in detail. The most important factor is to help
patient know the side effect and how to cope
with it.
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Follow-up
Visits : In the first two weeks
of initiating therapy, some patients are asked
to call the advisor or the advisor contact the
patient at regular intervals to check progress,
and patients find this initial telephone support
invaluable.
The perceived benefits are that
it removes feelings of isolation for those who
do not have support from partners, and provide
adherence support and reassurance about side effects.
Being a good listener is really
good because it’s a stressful time and necessary
support is to be given to the patient while experiencing
side effects.
Improving Adherence
Our understanding of the barriers, facilitators
and adherence is low. In terms of HIV, interventions
which have led to improvements in adherence include
providing information and education about
HIV and treatment along side
skill building and counselling and more practical
adherence tools and aids, such as reminder alarms,
beeper boxes, telephone reminders.
In practice, many HIV drug adherence
programmes combine various elements of different
interventions and both clinicians and patients
share the burden of taking steps to enhance and
maintain adherence.
The advisors addressed adherence |
indirectly through establishing simple regimens
tailored to patients’ lifestyles, and
directly through providing adherence tools,
such as daily and weekly pill boxes and adherence
counselling.
Patients found that knowing what to expect
and knowing that most side effects subsided
helped them to cope better with adhering to
their medication.
Rates Of Adherence
Non-adherence to treatment regimen is not unique
to people living with HIV/AIDS (PLWHA).
From the literature it is clear
that non-adherence is ubiquitous. Estimated rates
of non-adherence in the non-HIV population range
from 10% - 92% with an average of 50% (Eraker,
Kirscht & Becker, 1984).
In people with HIV-infection,
reports of adherence (usually defined as taking
80% or more of the prescribed regimen) range from
25% - 85% (Chesney, 1997;Singh, et al., 1996;
Bachiller, Arrando, Liceago, Iribarren & Olloquiegui,
1998).
In recently published data on
924 PLWHA in Australia 87.4% had not missed a
dose from their HAART regimen in the two days
prior to completing the survey .
In HIV-infected patients on
HAART, 80% - 90% adherence has been associated
with failure to achieve complete viral suppression
in 50% of patients (Paterson, et al., 1999).
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Nurses’ Role
It is clear that adherence to HAART is a multidimensional
phenomenon comprising multiple interrelated
factors and as such requires a multi-disciplinary
approach.
Adherence (or the lack of) to treatment is
an interaction between the patient, the regimen,
the providers of therapy, and the environment
in which this occurs.
This interaction is the context in which adherence
does or does not occur. The issue of adherence
is one that requires expertise, collaboration,
and coordination of services within primary
care, specialist care, social service settings
and the broad multidisciplinary team.
Most (if not all) of the variables that impact
upon a patient’s ability to adhere are
amenable to meaningful intervention.
It is abundantly clear from the literature that
adherence is an equal partnership between the
patient and his or her health care provider’s
adherence. Apart from adherence, nurse also
plays a major role in monitoring the toxic side
effects of these drugs.
Side effects include peripheral neuropathy,
myopathy, cardiomyopathy, lactic acidosis, pancreatitis,
osteopenia and osteoporosis.
Nurses are called upon to provide physical
and emotional support to patients and families
with HIV. Counseling regarding healthy life
style practices, safe sexual behaviour, partner
testing are inevitable part of HIV care.
Conclusion
High levels of adherence to |
antiretroviral drugs is a prerequisite for
a successful and durable virological and immunological
response to HIV.
Treatment guidelines acknowledge that adherence
is a process, not a single event, and that adherence
support must be integrated into clinical follow-up
for all patients receiving these drugs.
References
Bachiller, P., Arrando, F. R., Liceago, G., Iribarren,
J. A. & Olloquiegui, E. (1998). Drug compliance
in patients starting saquinavir. 12th World AIDS
Conference, Geneva, abstract 32392.
Broers, B., Morabia, A., Hirschel, B. (1994).
A Cohort study of drug users compliance with zidovudine
treatment. Archives of Internal Medicine, 154,
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Chesney, M.A. (1997). New HAART therapies: adherence
challenges and strategies. Evolving HIV treatments:
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Detels, R., Munoz, A., McFarlane, G., Kingsley,
L.A., Margolick J.B., Giorgi, J., Schrager, L.K.
& Phair, J.P. (1998). Effectiveness of potent
HAART therapy on time to AIDS and death in men
with knownHIV infection duration. Journal of the
American Medical Association, 280 (17), 1497–1503.
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Eraker, S.A., Kirscht, J.P. & Becker M.H.
(1984). Understanding and improving compliance.
Annals of Internal Medicine, 100, 258–268.
Hayman, J. & Buhrich, N. (1994). Psychiatric
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How much adherence is enough?A prospective study
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Nguyen, H. & Yu, V.L. (1996). Determinants
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