Research has shown that the level of adherence in resource-limited countries is at least as good as in resource-rich settings and that rates of virologic suppression are equivalent or better. Lack of access to a consistent supply of ARV medications, including financial barriers that may cause interruptions in treatment, appears to be the primary obstacle to adherence in resource-limited settings.
Patient Education
• Educate patients about the importance of adherence and the need to take their ARV medications exactly as prescribed and to take every dose, every day.
• Advise patients that, if they miss an ARV dose on a rare occasion, that usually will not result in failure of the regimen. On the other hand, if they frequently miss or skip doses of their ARV medications, the regimen may become ineffective, and the HIV may develop resistance to ARVs.
• Tell patients to notify the clinic if they miss doses of the ARV medications.
• Work with patients to devise ways to
improve their adherence, and reinforce good adherence behavior.
• Advise patients in advance that some people have adverse effects from the medications, and tell them to notify the clinic if they develop adverse effects. Discuss ways to reduce these effects.
Sec
tion 4: HIV
Tr
eatment
Appendix
Table 4. Visual Analog Scale Used in a Research Study to Assess Adherence to HIV Medication Regimens
Script for Interviewing Patients About Adherence
Interviewer Now I’m going to ask some questions about your HIV medications.
Most people with HIV have many pills or other medications to take at different times during the
day. Many people find it hard to always remember to take their pills or medicines. For example:
• Some people get busy and forget to carry their pills with them.
• Some people find it hard to take their pills according to all the instructions, such as “with
food” or “on an empty stomach,” “every 8 hours,” or “with plenty of fluids.”
• Some people decide to skip taking pills to avoid adverse effects or to just not take pills that day.
We need to understand what people with HIV are really doing with their pills or medicines. Please tell us what you are actually doing. Don’t worry about telling us you don’t take all your pills or medicines. We need to know what is really happening, not what you think we “want to hear.” Which antiretroviral medications have you been prescribed to take within the last 30 days?
INTERVIEWER: LIST CODES FOR ALL ANTIRETROVIRALS THAT SUBJECT WAS PRESCRIBED TO TAKE IN LAST 30 DAYS. IDENTIFY UP TO 4 DRUGS.
DRUG A: DRUG C:
DRUG B: DRUG D:
Interviewer Now, I am going to ask you some questions about these drugs. Please put an “X” on the line below at the point showing your best guess about how much (DRUGS A-D) you have taken in the last 3-4 weeks. We would be surprised if this were 100% for most people.
HAND INSTRUMENT AND PEN TO RESPONDENT Interviewer • 0% means you have taken no (DRUG A)
• 50% means you have taken half your (DRUG A)
• 100% means you have taken every single dose of (DRUG A)
Adherence Self-Assessment Instrument Instructions
for Patient: Put an “X” on the line below at the point showing your best guess about how much of each drug you have taken in the last 3 to 4 weeks. • 0% means you have taken none of the drug
• 50% means you have taken half of the drug
• 100% means you have taken every single dose of the drug
DRUG A: 0 1 2 3 4 5 6 7 8 9 10
DRUG B: 0 1 2 3 4 5 6 7 8 9 10
DRUG C: 0 1 2 3 4 5 6 7 8 9 10
DRUG D: 0 1 2 3 4 5 6 7 8 9 10
Adapted from Machtinger EL, Bangsberg DR. Adherence to HIV Antiretroviral Therapy. In: Coffey S, Volberding PA, eds. HIV InSite
Knowledge Base [textbook online]; San Francicsco: UCSF Center for HIV Information; May 2005. Available at hivinsite.ucsf.edu/ InSite?page=kb-03-02-09. Accessed December 1, 2013.
Sec
tion 4: HIV
Treatment
Table 5. Morisky Scale to Assess Adherence to HIV Medications: Dichotomous Response Options
Subjects were asked: “Thinking about the medications PRESCRIBED to
you by your doctor(s), please answer the following questions.” NO YES
Do you ever forget to take your medications?
Are you careless at times about taking your medications?
When you feel better, do you sometimes stop taking your medications?
Sometimes, if you feel worse when you take your medications, do you stop taking them?
Adapted from Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence.
Med Care 1986;24:67-74.
Table 6. Morisky Scale to Assess Adherence to HIV Medications: 5-Point Response Options
Subjects were asked:
“Thinking of the medications PRESCRIBED to you by your doctor(s), please answer the following questions.” Response options: never = 0; rarely = 1; sometimes = 2; often = 3; always = 4 0 1 2 3 4
Do you ever forget to take your medications?
Are you careless at times about taking your medications?
When you feel better, do you sometimes stop taking your medications?
Sometimes, if you feel worse when you take your medications, do you stop taking them?
Adapted from Morisky DE, Green LW, Levine DM. Concurrent and predictive validity of a self-reported measure of medication adherence.
Med Care 1986;24: 67-74.
References
• Bangsberg DR, Moss AR, Deeks SG. Paradoxes of adherence and drug resistance to HIV antiretroviral therapy. J Antimicro Chemother 2004: 53: 696-99.
• Gaithe J Jr. Adherence and potency with antiretroviral therapy: a combination for success. J Acquir Immune Defic Syndr. 2003 Oct 1;34 Suppl 2:S118-22.
• Golin CE, Smith SR, Reif S. Adherence counseling practices of generalist and specialist physicians caring for people living with HIV/AIDS in North Carolina. J Gen Intern Med. 2004 Jan;19(1):16-27.
• Machtinger EL, Bangsberg DR. Adherence to HIV Antiretroviral Therapy. In: Coffey S, Volberding PA, eds. HIV InSite Knowledge Base [textbook online]; San Francisco: UCSF Center for HIV Information; May 2005. Available at hivinsite.ucsf.edu/ InSite?page=kb-00&doc=kb-03-02-09. Accessed December 1, 2013.
• Malcolm SE, Ng JJ, Rosen RK, et al. An examination of HIV/AIDS patients who have excellent adherence to HAART. AIDS Care. 2003 Apr;15(2):251-61.
• Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at aidsinfo.nih. gov/guidelines. Accessed December 1, 2013. • Protopopescu C, Raffi F, Roux P, et al.; ANRS
CO8 APROCO-COPILOTE Study Group. Factors associated with non-adherence to long-term highly active antiretroviral therapy: a 10 year follow-up analysis with correction for the bias induced by missing data. J Antimicrob Chemother. 2009 Sep;64(3):599- 606.
• Stone VE, Smith KY. Improving adherence to HAART. J Natl Med Assoc. 2004 Feb;96(2 Suppl):27S-29S.