Antiviral Strategies

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Adherence to HAART
Discussion Paper

Evaluating your treatment regimen about two weeks after
you start. It may take a few weeks of experimenting to figure
out how to best schedule both your medications and other
events in your life. For this reason it may be useful to start a
'dry run' of therapy, allowing time to adjust routines prior to
actually taking the drugs.
Planning ahead for weekends and vacations. People often miss doses when they are away from home. For most
people, weekends are different from their normal weekday
routine so it is important to plan ahead. Take into account
the changed environment. Will you feel comfortable with your
normal routine or will you need other strategies?
Keeping all your medications with you when traveling.
Baggage containing medication can be lost or delayed.
Planning ahead for privacy if you need to hide the fact that
you are taking medication. If you are not able to take your
medication openly, try to find at least one person with a similar problem with whom you can discuss strategy. Some examples might be adjusting your lunch or break schedule to
ensure privacy or keeping water in your bedroom at all times.
Keeping a diary - include whatever is important to you: when
you took treatment, reason for missed dose, how you feel,
etc. Keeping a record like this serves as a reminder of how
well, or poorly, you are doing with adherence.
Using your support network to remind you of your medication requirements. Some people select a "treatment buddy"
who can make daily reminder phone calls.
Setting up a support network for your emotional needs.
It's hard to take treatment and also deal with daily stress, whether
it be taking care of children, working or dealing with illness.
These strategies may not work for all individuals. Because of cultural, gender and socio-economic differences, some suggestions
are more appropriate for some people than others. Different issues are more important in some settings than others. For example, in the Latino community, many individuals reported that
people they knew might not be able to reveal their HIV status or
their use of medications. This places much greater emphasis on
planning ahead for moments of privacy each day. For people struggling with lack of housing, active drug use or untreated mental
health conditions, the strategies for successful treatment will often go beyond what we cover here. Still, even under the most
challenging situations, people have daily routines which can be
used as triggers for the use of medications.
Adherence strategies can and must vary from person to person
and group to group. However the most effective method of ensuring success is motivation and commitment to a treatment regi
men, along with the recognition that it is possible to accommodate the need for long-term treatment. It may take several attempts before you find the approach that works best for you, but
people with other life-threatening chronic illnesses have long demonstrated that it can be done. As an elderly woman with diabetes
said at a recent Project Inform Town Meeting, "if you want to live,
you'll find a way to do it."
Commentary
Perhaps the greatest way in which adherence to HIV treatments
differs from adherence in other chronic illnesses is the lack of
immediate symptoms or consequences when adherence fails. In
diabetes, for example, failure to adhere can quickly result in insulin shock or even death. In HIV disease, the effects of non-adherence are slow to appear, but nonetheless deadly. This lack of a
rapid feedback or response places more of the burden for adherence on the intellect and a bit less on the immediate reaction of
the body. A person with HIV infection must take a long-term view
in order to have a long-term future.
Adherence is also a challenge to the many of the support systems
for people with HIV. Managed care and other economic changes
in the medical field have left providers with less time to spend
educating patients. Moreover, most health care providers have little
or no training in the self-adherence tools that might help people
who are undertaking a new treatment regimen. Training will be
needed both in HIV treatments and tools of self-compliance. Some
pharmaceutical companies already offer "adherence training" programs which have been developed for other illnesses. They are
just now beginning to pilot test their use in HIV disease.
There are few structures in the HIV care and service industry to
support people taking treatment effectively, such as treatment
support groups and treatment-knowledgeable case managers.
Many working in the HIV service field have been operating from a
model of disability and death. The shift to supporting people who
are living longer with complex treatments and social needs will require planning and shifts, not only in programs, but in paradigms.
The best long-term solutions must ultimately go beyond helping
the individual adhere to the schedules demanded by the drugs.
Instead, they must begin to focus on making better therapies and
longer-lasting formulations that are easier to use, more easily
absorbed, have fewer side effects and drug interactions, and maintain more consistent drug levels in blood. This work is already
well underway with studies beginning this month for treatments
which may require only once per day dosing. The final solution,
of course, is an outright cure to the disease, one which not only
results in eradication of HIV and immune restoration, but no further need for medication. The prospects for this kind of solution
are, unfortunately, less certain. 4

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