Adherence tips included in IDSA care blueprint
Guidelines for primary care of HIV patients
The first guidelines written explicitly for the primary care of HIV patients include two pages about antiretroviral adherence, demonstrating how management of HIV disease increasingly is incorporating behavioral factors with medical practice.
According to the guidelines — Primary Care Guidelines for the Management of Persons Infected with Human Immunodeficiency Virus: Recommendations of the HIV Medicine Association [HIVMA] of the Infectious Diseases Society of America [IDSA] — research has shown that a greater than 95% adherence is necessary to achieve nondetectable virus load in most HIV patients taking antiretroviral medications.
However, only about half of HIV patients in some clinical practices are able to achieve a maximum suppression of HIV, indicating that most HIV patients are not achieving the optimal adherence, the guidelines state.1
"The guidelines’ section on adherence is the section that maybe gets taken for granted," says Joel Gallant, MD, MPH, associate professor of medicine and epidemiology at Johns Hopkins School of Medicine in Baltimore. Gallant is one of the authors of the HIVMA/IDSA guidelines.
"People forget they have to keep discussing adherence on an ongoing basis," he says. "This section on adherence is very helpful and reminds physicians how important it is to keep emphasizing it."
The guidelines advise clinicians to avoid making assumptions about patients’ adherence because they’re usually incorrect. Instead, clinicians should find a specific method for measuring antiretroviral adherence.1 Examples of methods for measuring adherence include patient self-report, electronic medication monitoring devices, pill counts, and checking pharmacy refill records.1
The guidelines discuss factors that negatively impact adherence, including depression, alcohol and drug use, lack of education about HIV, frequency of dosing, etc.1
Adherence strategies are divided into patient-focused, regimen-focused, and provider-focused strategies. The advice varies depending on the strategy. For example, with patient-focused strategies, the first advice is to screen all patients for depression before initiating antiretroviral drug therapy. For regimen-focused strategies, clinicians are advised to prescribe simpler antiretroviral regimens; and for provider-focused strategies, the guidance says they should develop a set of adherence-focused activities that are provided for each patient, including an assessment of readiness for antiretroviral therapy.1
The HIVMA/IDSA guidelines also pull together information about the metabolic complications of highly active antiretroviral therapy (HAART), including serum lipid abnormalities, morphological changes, dysregulation of glucose metabolism, lactic acidemia, and reduced bone mineral density.1
"We have guidelines on metabolics because we felt it was important to focus on this area," says Judith Aberg, MD, an associate professor of medicine at New York University and director of HIV at Bellevue Hospital Center, New York University AIDS Clinical Trials Unit, both in New York City. Aberg is the first author of the new HIVMA/IDSA guidelines on HIV primary care.
"HIV specialists watch HIV treatment and follow T cells and viral loads, but they are not comfortable with complications like lipodystrophy, bone disease, etc.," she says. "And primary care providers have to be aware of this — they’re looking at the routine management of health issues."
While primary care physicians might be comfortable managing a general population’s metabolic disorders, they may be less experienced in dealing with metabolic problems related to complications from HIV antiretroviral medications, Aberg notes.
"Whether it’s from HIV itself or the drug therapies or a host of risk factors, we’re not still sure, but there is an increase in lipid abnormalities and bone disorders among HIV patients, and we want to alert physicians to incorporate screening for these into the patient’s primary care," she says.
For example, the IDSA guidelines discuss premature osteopenia, osteoporosis, and osteonecrosis with avascular necrosis of the hips, which all have been found in HIV-infected patients. The guidelines advise clinicians to consider having patients who take antiretroviral drugs and who have other risk factors for premature bone loss to undergo bone densitometry at baseline and to prescribe to these patients calcium and vitamin D supplements, as well as prescribing exercise and the cessation of cigarette smoking.1
The guidelines also provide HIV experts strategies for better managing their patients’ primary care issues, Gallant says. "People are getting older and living longer with HIV, so issues like blood pressure and blood sugar need to be managed. Pre-HAART physicians forgot about those issues because they were so trivial, and now we need to refresh their memories."
The HIV Medicine Association of IDSA created the guidelines as an acknowledgement of how HIV medicine is evolving into treatment of a chronic disease, requiring more attention to primary care of patients, Aberg notes.
"Since the guidelines have come out, I’ve gotten interesting e-mails from HIV specialists and primary care physicians, saying, Thanks for putting those out because I realize there were things I was missing,’" she says. "We’ve had a very good response."
1. Aberg JA, Gallant JE, Anderson J, et al. Primary care guidelines for the management of persons infected with human immunodeficiency virus: Recommendations of the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2004; 39:609-629.