Rethinking Nonadherence: Historical Perspectives on Triple-Drug Therapy for HIV Disease

Abstract

The advent of triple-drug therapy for HIV disease has raised the concern that disadvantaged patients with multiple social problems may be nonadherent to treatment. Fearing that partial adherence will lead to drug resistance, some clinicians are withholding these powerful new drugs from such patients. The historical record demonstrates that labeling patients as nonadherent may be both stigmatizing and inaccurate. Since 1900, such adjectives as ignorant, vicious, and recalcitrant have been used to describe patients who do not follow medical advice. Less judgmental terms, such as nonadherent and noncompliant, are now used, but these terms still imply that patients should obey physician-imposed regimens. Studies of nonadherence have consistently shown that the problem is widespread among all persons and cannot reliably be predicted on the basis of patient characteristics. This paper argues that physicians should deemphasize the standard approach of predicting and correcting nonadherent behavior in certain patients. Rather, clinicians should encourage all HIV-positive patients to devise individualized treatment plans that can facilitate reliable ingestion of medication. Although the potential development of resistance to triple-drug therapy remains an important public health issue, concern about this possibility must be balanced with respect for patients' rights. Encouraging the active participation of HIV-positive persons in their own treatment will help avoid judgmental and inaccurate assessments of patient behavior and may help patients take medications more successfully.

Treating depression in HIV-positive patients affects adherence

“…The tendency to ascribe low adherence to often-deprived social groups is a well-established trend; 68 however, as experience with antibiotics has demonstrated, low adherence is widespread and unpredictable rather than restricted to certain social classes. 69 Moreover, adherence rates have been shown to vary between individuals and within the same individual over time. 59 Adherence is therefore best thought of as a variable behaviour rather than a stable characteristic of an individual, and most people will exhibit low adherence some of the time.…”

Correlation between Health-Related Quality of Life and Various Therapeutic Monitoring Parameters of Ivorian HIV-Infected Patients

“…For patients who start out with at least some deficits in physical functioning, the net effect of ART on physical function should be positive because the indirect positive effects with elevated CD4 cells counts and undetectable viral load outweigh the negative direct toxic effects of ART [30]. Not only the complexity of ARV regimens affects the quality of life of a patient, but it has become a major obstacle for adherence, which is one of the main determinants for successful ART, as that has been shown in many studies [37][38][39][40][41][42]. In the study of Fumaz et al, HRQOL increased in group patients treated with efavirenz-based regimens during the follow-up compared to the HRQOL at baseline.…”

A new paradigm for HIV care: ethical and clinical considerations

“…Workable treatment plans are not standard issue.They require individualized crafting and the ongoing concerned attention of all parties. 18 This holistic approach should be incorporated into planning by funding agencies and organizations.…”

“…Since effective treatment involves personal responsibility as well as professional skill, the workgroup suggested using the term "treatment maintenance." 17(pp6,9), 18 It was the view of the workgroup that denying patients access to information about HAART or to the therapies themselves without making a diligent effort to enable patients to use these therapies constitutes an ethically unacceptable standard of care. Specifically, presumptive judgments about the likelihood of treatment maintenance should not be used to restrict access to HIV treatment education or therapies.…”