HIV management guidelines emphasize primary care

Drug therapy adherence strategies key component

New HIV guidelines address long-term management in the context of a person’s overall life and health — and emphasize the importance of strategies to improve adherence to drug regimens.

The HIV Medicine Association and the Infectious Diseases Society of America, both in Alexandria, VA, developed the guidelines. The guidelines are more about comprehensive general medicine — the primary care of patients, says Judith A. Aberg, MD, an HIV/ADIS care specialist at New York University and lead author of the new guidelines.

"They are not specific therapy recommendations. It’s more about the general care that a patient needs."

The guidelines cover information such as prevention and early diagnosis of chronic conditions that some patients with HIV may have high risk of contracting, including diabetes and heart disease. The guidelines also address HIV transmission, diagnosis, risk screening, and management. There are special sections on caring for women and children with HIV as well.

Strategies to improve drug regimen adherence

Other guidelines may recommend specific therapies but then just brush on drug regimen adherence, Aberg says. "They don’t really spend any detailed amount on it."

Adherence, however, is a critical piece to the HIV guidelines. "That is why we emphasize it, she says. "The primary care provider should educate patients about whether they need to be on therapy. And if they should be, [providers should emphasize] how important it is for them to have appropriate follow-up and monitoring and for them to take their medicines."

Adherence is so important to HIV treatment because the long-term effectiveness of HAART (highly active antiretroviral therapy) is dependent on achieving a maximum and durable suppression of viral replication, the guideline authors say. In some clinical practices, however, as few as 40% to 50% of patients achieve this goal. "The primary reason for failure to achieve maximum suppression of virus load, particularly among patients taking initial regimens, is suboptimal adherence to medications."

HAART regimen characteristics can affect patients’ adherence to their regimen, the authors explain. This includes the complexity of the regimen, side effects, and the "fit" with the patient’s lifestyle and daily routine. Given this, they recommend the following regimen-focused adherence strategies:

  • Prescribe simpler HAART regimens. Focus on constructing regimens that involve fewer pills and fewer doses and that minimize food-dosing restrictions.
  • Individualize HAART regimens. Work with each patient to choose a regimen that is tailored to his or her lifestyle and schedule. Avoid adopting a "one-regimen-fits-all" philosophy. Get the patient involved in choosing and individualizing the regimen.
  • Choose regimens with fewer side effects. Whenever possible, avoid prescribing medications known to frequently cause very unpleasant side effects.
  • Proactively manage side effects. Let patients know what side effects may be experienced and how each side effect will be managed if it occurs.

No matter how simple or complex the regimen is, make sure patients understand exactly how to take their medications, the authors say. "Confusion is an important cause of suboptimal adherence. Providing a dosing schedule with photographs of the medications and helping patients to correctly fill a medication organizer with their new medications are two strategies that will help decrease confusion."

Health care providers can assess patients’ understanding of the regimen by having them repeat back the regimen, the authors say. Providers also should be open to patients’ requests to change their HAART regimen because of side effects.

Measuring adherence to HAART in clinical practice is important, too. "Clinicians should avoid making assumptions about patients’ adherence, because these assumptions are usually incorrect," the authors say. "Ideally, the adherence measurement strategy should be easily incorporated into clinical care, be inexpensive, and be helpful in assessing both baseline adherence and the effectiveness of adherence interventions."

Adherence to HAART can be measured by a variety of methods, they continue. The most commonly used methods in clinical trials are patients reporting their own adherence and electronic medication monitoring devices, such as medication event monitoring systems. Other possible ways to assess adherence include pill counts and checking pharmacy refill records. "No single method has been established as the reference standard for measuring adherence; all have advantages and disadvantages. Once a method has been chosen, it should be used consistently to monitor each patient’s adherence at each visit," the authors say.

The adherence component of these guidelines is particularly important to pharmacists, Aberg says. "One of the great movements in the past few years has been the pharmacist taking part in patient education."

When patients refill their medications, pharmacists can talk with them about the drugs, discuss side effects, and reinforce that it is critical that they take their medicines every day because of the risk of the medications failing, Aberg says. "Then [the patients] can develop resistance and could potentially lose options. If the pharmacist can [emphasize] the need for adherence, it’s very important to the patients’ overall care."

The guidelines were published in the September issue of Clinical Infectious Diseases and are available free on-line at www.journals.uchicago.edu/CID/journal/contents/v39n5.html.