Antiviral Strategies

Page 13 of 18
Adherence to HAART
/0 Discussion Paper "
Highly active antiretroviral therapy (HAART) has brought new hope and new
challenges to people living with HIV. However, if these treatments are not
used properly (i.e., doses are repeatedly skipped, taken at lower than preto HAART scribed dosages, or not taken at scheduled intervals), drug resistance will
almost certainly develop more rapidly and the potential benefits of combination therapy can be lost. Moreover, resistance to one therapy may also result
in decreased effectiveness of other therapies of the same class (cross-resistance). This is particularly true in regard to protease inhibitors. The development of high level resistance to any
one of these drugs almost certainly conveys some degree of resistance to all the other drugs of this type.

Adhering to a treatment regimen is difficult under the best of
circumstances. Studies have shown that even health care providers can find it difficult to take a simple course of antibiotics as
directed. The new triple combinations used with HIV disease typically require that a person take a dozen or more antiviral pills per
day with specific timing and dietary requirements. When a person must also use preventive or maintenance doses of drugs for
opportunistic infections, the total daily pill count soars. Keeping
track of one's medication alone becomes a major activity. It's little
wonder that people have trouble keeping up with the program.
Preliminary data from one clinical trial suggest that as many as
12% of the study population missed one dose in the preceding
day, 11% the day before that. At least two other recent clinical
trials reported that nearly all of the people who failed to achieve
and sustain a viral load below the limit of detection had significantly deviated from their prescribed treatment regimen for a
month or more. There are many possible explanations for failure
to adhere to the treatment regimen. A recent study by the University of California Center for AIDS Prevention Studies (CAPS) showed
that, of those people who admitted missing one or more doses:
40% said they simply forgot
37% slept through a dose
34% were away from home
27% had changed their therapy routine
22% were busy
13% were sick
10% were experiencing side effects
9% were depressed.
There appears to be little debate about the fact that it is difficult
to maintain perfect adherence to today's complex treatment regimens. It is somewhat less clear what degree of non-adherence is
tolerable and how quickly it contributes to drug failure. Most of

all, it is not entirely clear what to do about it, though many useful
strategies are evolving over time.
Initiating Therapy
Engaging in complicated courses of long-term treatment doesn't
feel natural to most people. However, this challenge is not unique
to people with HIV. Millions of people have learned to cope with
diseases requiring complex, long-term management, such as diabetes. Whether or not you feel you are able to commit and adhere
to a treatment regimen may be one factor to consider, along with
lab results and clinical condition, in determining the appropriate
time to begin highly active antiretroviral therapy (HAART). Giving careful thought to what benefits you hope to get from treatment, how you will evaluate the benefit and how you might manage side effects will be helpful. Some people try a "dry run" before
beginning therapy, taking empty gel caps on the prescribed schedule while sticking to the required dietary requirements.
Perhaps the first and most important aspect of adherence lies in
choosing the right therapy in the first place. Drugs differ widely in:
Whether they can be taken with or without food
How many times per day they must be taken
6 What other drugs they can and cannot be used with
Their side effects and how they make a person feel
6 Whether you have access to the facilities need for storage (for
example, refrigeration for supplies of ritonavir [Norvir]).

Similarly, people differ
widely in their personal
habits and needs. A few
examples:

Table of Contents
Initiating Therapy..................... 13
Maintaining Therapy................. 14
Planning................................ 14
Support................................. 14
Commitment.......................... 15
Strategies for Adherence............ 15
Commentary............................. 16

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