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Adherence is a decisive factor in the success of HIV treatment: high levels of adherence can achieve durable virologic suppression1,2 while suboptimal adherence can increase the risk of developing resistance to ART and HIV transmission.3 Therefore, good strategies for maximising ART adherence are essential.

 

Information gathered from viral load monitoring is important to guide tailored interventions by identifying adherence issues before they have impact on the person living with HIV.3 Assessment of self-reported adherence is recommended every 3–6 months by the European AIDS Clinical Society.4

 

While virologic suppression is typically associated with treatment adherence, non-adherence can take many different forms but not all of them are down to individual choice.3 The COVID-19 pandemic has presented challenges for people living with HIV to access timely care and antiretroviral therapy (ART).5

 

To help establish and maintain adherence, a multifaceted approach may be required. This can include actively involving people living with HIV in their own healthcare decisions, tailoring ART to the individual and providing appropriate support services.5,6

 

 

What are the main challenges to adherence?

Advances in ART now allow dosing simplification and reduction of pill burden for a majority of people living with HIV.2,3,6

 

Factors that impact might adherence to ART include:

 

Personal circumstances – life events, family emergencies or sudden routine upheavals can add stress to an already stressful diagnosis.6,7

 

Comorbidities – management of other conditions that people living with HIV might be living with, can be challenging.6

 

Complex ART regimens – ART adherence has become easier over time with newer and simpler formulations. Specifically, once-daily regimens have shown improved adherence rates compared with multi-dose regimens, particularly in treatment-naïve people living with HIV or those who have experienced virologic failure.8

 

ART tolerability - adverse events related to ART can be a barrier to adherence in people living with HIV and therefore should be considered when managing treatment.9

 

Mental health – while depression is among the most significant predictors of nonadherence, hopelessness, negative feelings and treatment fatigue can reduce motivation to care for oneself and may also impact a person’s ability to follow instructions.7,10-12

 

Denial - the psychological mechanism of denial often results in a repression of the desire to follow prescribed treatment.13,14

 

Awareness of social conditions, suitability of regimen to lifestyle, availability and nature of social support structures provides an opportunity to enhance adherence to treatment. Similarly, attention to mental illness, as well as alcohol and substance abuse allows for the incorporation of intervention strategies that are tailored to the individual’s needs.

 

In all cases, it is essential that people living with HIV understand the importance of adherence and the serious consequences of non-adherence (i.e. treatment failure, or in some cases, disease progression, and drug resistance).

 

 

What strategies can improve adherence?

Where adherence can be improved for simple reasons of forgetfulness or a busy schedule, there are several strategies to assist people living with HIV to take their medication:

 

Reminders - individuals can set daily reminders to ensure they take their medication. A smartphone, personal organiser app or simply a mark on the calendar at home can help with this. Texting dosing reminders, including two-way SMS, have also been linked to improved adherence.3,6,15

 

Routines - routines associated with taking medication have been shown to improve adherence.16 Associating medications with daily activities can help, for example, morning rituals such as brushing teeth or reading the newspaper.17

 

Facilitation - Multidisciplinary teams involving pharmacists, nurses, social workers and psychiatric consultations can improve linkage to care, retention in care, and adherence to medication for people living with HIV.6,15 Some healthcare professionals might not have access to multidisciplinary support, but broad support can be provided by mobilising community-based organisations, educating on the use of medicines for people living with HIV and enlisting the support of family members and significant others to assist with treatment adherence.3,6

 

Self-reporting – self-reporting might overestimate adherence compared to pharmacy-based refill measures, but self-reported non-adherence has a high predictive value for virologic failure.3,6,18,19 Self-reporting allows people living with HIV to also measure their own commitment to treatment. It can also provide information about why non-adherence may be occurring. Selective questioning can help to assess the accuracy of self-reports and maximise the benefits of the information provided:6

 

  • Ask the individual to confirm how often they miss medications, to clarify when and why they might be regularly missing doses (consider factors such as finances and drug/alcohol use)
  • Employ a structured format that normalises or assumes less-than-perfect adherence and minimises socially desirable responses
  • Give individuals the benefit of the doubt to foster trust and honesty
  • Provide encouragement rather than guilt for missing doses

 

Reasons for treatment non-adherence in people living with HIV can be complex but by promptly identifying and addressing challenges to adherence, virologic suppression can be maintained and risk of transmission reduced.

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References:

  1. Viswanathan S, Detels R, Mehta SH et al. Level of adherence and HIV RNA suppression in the current era of highly active antiretroviral therapy (HAART). AIDS Behav 2015;19(4):601–11.
  2. Cihlar T and Fordyce M. Current status and prospects of HIV treatment. Curr Opin Virol 2016;18:50–6.
  3. World Health Organisation. Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: Recommendations for a public health approach – Second edition, 2016. Available at: https://apps.who.int/iris/handle/10665/208825.Accessed October 2023.
  4. European AIDS Clinical Society. EACS Guidelines v10.1. 2020. Available at:https://eacs.sanfordguide.com/. Accessed October 2023.
  5. Jiang H, Zhou Y and Tang W. Maintaining HIV care during the COVID-19 pandemic. Lancet HIV. 2020 May;7(5):e308-e309. doi: 10.1016/S2352-3018(20)30105-3.
  6. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents with HIV. 2021. Available at:https://clinicalinfo.hiv.gov/en/guidelines/adult-and-adolescent-arv/whats-new-guidelines. Accessed October 2023.
  7. Corless IB, Hoyt AJ, Tyer-Viola L et al. 90-90-90-Plus: Maintaining Adherence to Antiretroviral Therapies. AIDS Patient Care STDS. 2017 May;31(5):227-236.
  8. Nachega JB, Parienti JJ, Uthman OA et al. Lower pill burden and once-daily antiretroviral treatment regimens for HIV infection: A meta-analysis of randomized controlled trials. Clin Infect Dis. 2014 May;58(9):1297-307.
  9. Shubber Z, Mills EJ, Nachega JB et al. Patient-Reported Barriers to Adherence to Antiretroviral Therapy: A Systematic Review and Meta-Analysis. PLoS Med. 2016 Nov 29;13(11):e1002183.
  10. Gonzalez JS, Batchelder AW, Psaros C et al. Depression and HIV/AIDS treatment nonadherence: a review and meta-analysis. J Acquir Immune Defic Syndr. 2011 Oct 1;58(2):181-7.
  11. Claborn KR, Meier E, Miller MB, et al. A systematic review of treatment fatigue among HIVinfected patients prescribed antiretroviral therapy. Psychol Health Med. 2015;20(3):255-65.
  12. Beer L, Heffelfinger J, Frazier E et al. Use of and Adherence to Antiretroviral Therapy in a Large U.S. Sample of HIV-infected Adults in Care, 2007-2008. Open AIDS J. 2012;6:213-23.
  13. Laws MB. Explanatory Models and Illness Experience of People Living with HIV. AIDS Behav. 2016 Sep;20(9):2119-29.
  14. Laws MB, Rose GS, Bezreh T et al. Treatment acceptance and adherence in HIV disease: patient identity and the perceived impact of physician-patient communication. Patient Prefer Adherence. 2012;6:893-903.
  15. International Advisory Panel on HIV Care Continuum Optimization. IAPAC Guidelines for Optimizing the HIV Care Continuum for Adults and Adolescents. J Int Assoc Provid AIDS Care. 2015 Nov-Dec;14 Suppl 1:S3-S34.
  16. Ryan GW and Wagner GJ. Pill taking 'routinization': a critical factor to understanding episodic medication adherence. AIDS Care. 2003 Dec;15(6):795-806.
  17. Catz SL, Kelly JA, Bogart LM et al. Patterns, correlates, and barriers to medication adherence among persons prescribed new treatments for HIV disease. Health Psychol. 2000 Mar;19(2):124-33.
  18. Sangeda RZ, Mosha F, Prosperi M et al. Pharmacy refill adherence outperforms self-reported methods in predicting HIV therapy outcome in resource-limited settings. BMC Public Health. 2014 Oct 4;14:1035.
  19. Glass TR, Sterne JA, Schneider MP et al. Self-reported nonadherence to antiretroviral therapy as a predictor of viral failure and mortality. AIDS. 2015 Oct 23;29(16):2195-200.

UK-BVY-0705 Date of preparation October 2023