Antiviral Strategies

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Adherence to HAART
Discussion Paper
Some people are bound to rigid schedules defined by their
employment, such as hourly workers.
Some people have loose and constantly changing schedules
or routinely move in and out of different time zones, such as
many airline workers.
Some people are unable to work and their schedules are dictated by a seemingly endless string of medical appointments.
Some also have children, parents, or partners to care for.
Some have people around them all the time to help remind
of their medication schedules, while others are alone and must
rely on timers, pill boxes and other devices.
Some people suffer from wasting syndrome which makes eating difficult and critical; others have no dietary problems but
don't eat on a regular schedule.
4 Finally, some people have to deal with other challenging life
issues such as substance abuse or homelessness.
To find a treatment regimen you can live with, it is necessary to
reconcile the two sets of requirements: yours and the drug's. People
who lead busy, but largely unstructured lives might prefer drugs
that can be taken easily with or without food and thus more easily
fit in with their changing daily routines. Others whose time is
tightly structured by job requirements might find it easier to accept more demanding drug schedules and therefore can select a
regimen purely on the basis of its expected potency. People who
have trouble eating or who are struggling with weight loss might
wish to avoid drugs which can't be taken with foods. People who
must take a large number of other drugs for treatment or prevention of opportunistic infections might avoid antivirals that have
the highest number of drug interactions or require the greatest
number of pills per day.
The goal is to select a regimen you believe you can live with, one
that fits with who you are and how you live. There are, of course,
no perfect choices in this regard. Some people may seek a regimen that most easily fits their lifestyle, while others may be willing to adapt their lifestyle in hopes of getting the most potent
possible treatment. Also, the more HIV medications you have used
previously, often the fewer choices you have about what to use
next. Thus, often in more advanced disease, prior history with the
drugs tends to dictate what can and can't be done.
Maintaining Therapy
Once a regimen has been selected, sticking to it requires planning, support and commitment.
Planning
Stable access to drugs is a critical requirement for effective use.
People cannot adhere to a regimen if they do not have continu
ous access to the drugs. While it may sound obvious, many or

even most people taking HIV medications sometimes find themselves running short of one or another treatment. This is almost
always a consequence of poor planning. Skipping doses when you
run out of a drug temporarily is still skipping doses, with all the
consequences. Thus, it is best to try to plan to never have less
than a week's supply of your entire medication needs on hand.
Remember also that some drugs require much different storage
than others, so part of your planning must address the storage
requirements. Once storage is addressed, it is often helpful to put
aside an entire week's supply the first time the drugs are delivered, and then use only the remaining supply. This will also create an "emergency stash" should unforeseen circumstances cause
your basic supply to run short. The "stash" should be rotated or
replaced once a month to keep it fresh.
Keeping a steady supply of your prescriptions requires close coordination with your doctor and your pharmacist. When using
sources like the AIDS Drug Assistance Programs or patient assistance programs sponsored by pharmaceutical companies, which
are potential sources of drug access, more of the burden falls on
you to make sure you order supplies as the program requires. But
the main point is always to stay at least a week ahead of your needs.
Your care provider should work closely with you to ensure access.
People with varying lifestyles may differ in their ability to adhere
to a treatment regimen. People dealing with major life problems
such as active drug use or homelessness face the most difficult
challenges adhering to a treatment regimen. But that doesn't mean
that adherence is impossible. Studies have shown that people with
depression are also more likely to have difficulty taking their treatments consistently. If you suffer from depression and are considering treatment, consult a mental health professional as well as
your regular provider. Outside of depression, there are very few
reliable predictors of non-adherence. In reality, only you can make
the decision as to whether you are ready and committed enough
to maintain a steady course of treatment. If you are not ready or
in a position to make a serious attempt at adherence, you might
be better off to delay treatment. This option doesn't jeopardize
your ability to use treatment effectively some time later in the
future. In contrast, the misuse of treatment, through inconsistency or poor adherence, can indeed jeopardize future options by
encouraging development of drug resistance that affects entire
classes of anti-HIV therapy.
Support
Establishing a good working relationship with your provider is
critical for maintaining adherence to a treatment regimen. A provider should be knowledgeable in the current standards of care
for treating HIV and should be willing to spend time to thoroughly
explain the benefits and challenges of treatment.

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