HIV and Adherence

Adherence is of paramount significance in obtaining success with HAART

What do we know? HIV Treatment in 2001:

  • Many regimens (PI and non-PI combinations) are theoretically able to suppress HIV to below limits of detection in "naïve" individuals.
  • Decreased adherence =>viral replication and resistance
  • Need for long term high level adherence in HIV is complicated by this threat of resistance and newly emerging toxicities and side effects
  • Failure carries a high price on an individual, financial and public health
  • Finding the reasons for decreased adherence and preventing failure are therefore critical

ARV in the "Real" World

  • Many studies show suppression in >80% of subjects
  • BUT, studies in a multitude of clinical settings have shown only 50% success rates with multiple-drug therapy at 1-2 years
  • WHY?
  • While baseline resistance and poor prescribing contribute, poor adherence accounts for many of these failures

Improving long-term adherence is complex and required continuos support and monitoring

Adherence and HIV

  • Adherence correlates with viral suppression and clinical outcome
 
Level of adherence
% with undetectable viral load
 
>95%
81%
 
90-95%
64%
 
80-90%
50%
 
<80%
6%
  • Taking between 60 and 90% is associated with increased risk development of resistance
  • Decreased adherence is associated with increased morbidity and mortality
  • In a bid regimen, less than 1 dose/week can be missed

Adherence

  • Multiple barriers to adherence exist for individuals with HIV
    • Medication-related
    • Patient-related
    • System-related
  • Reasons for missing doses changes over time and adherence wanes over time
  • Adherence enhancement can focus on one aspect or address multiple barriers in a multidisciplinary holistic approach

Where do we stand?

  • Adherence is a challenge for all chronic diseases
  • The implications of nonadherence in HIV are complicated by development of resistance on a personal and global scale
  • Predicting, measuring and improving adherence is very much a work in progress, but this work is critical to assist clinicians and patients maximize chances for success
  • The challenge of adherence in very resource-poor settings in the developing world is enormous with significant public health as well as individuals implications
  • Adherence support will likely be multidisciplinary, change for each individuals and over time, but must be constant and integrated into every aspect of care and daily life

 

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