Antiretroviral therapy (ART) is recommended for all people living with HIV, regardless of CD4 cell count, to consistently suppress viral load, maintain high CD4 cell counts, prevent AIDS, prolong survival, and reduce risk of transmitting HIV to others.1, 2, 3 Research demonstrates that the success of ART, however, depends on the extent to which a patient takes his or her treatment according to the prescribed doses, dosing intervals, and other medication instructions. 4, 5 Several studies have shown that health care providers can positively impact medication-taking behaviors among HIV-infected patients by engaging in regular, ongoing discussions at every office visit that describe the benefits of ART adherence; track clinical measures that are influenced by adherence, such as a viral load; identify barriers to adherence; offer adherence support services; and provide information on other interventions that can improve adherence and reduce the risk of HIV transmission to others.1, 2, 3, 4, 5, 6
Establishing ongoing brief conversations with patients in a supportive and nonjudgmental way encourages trust and facilitates opportunities to identify teachable moments in which HIV care providers can better help patients achieve sustained viral suppression. For example, HIV care providers can communicate the benefits of adherence by explaining that with ART medications, patients can now expect to live longer lives if they adhere to their ART regimen exactly as prescribed. Patients entering care should also understand the potential negative consequences of nonadherence such as increased mortality and morbidity, drug resistance, and risk of transmitting HIV to others.3, 6
Recent findings show that assessing a patient’s ART readiness is the first step to successful ART adherence. 6 Patients starting ART should be willing and able to commit to treatment and understand the benefits and risks of therapy and the importance of adherence.
Before patients begin ART, health care providers can evaluate patient readiness to help identify predictors of suboptimal adherence 5, 6 HIV care providers can enhance communication with patients by asking several open-ended questions—questions that cannot be answered with a simple yes or no. 6 Following are some examples of questions probing ART readiness:
- “What have you heard about HIV medicines?”
- “What are the most important results you hope to gain from treatment?”
- “What are your concerns about HIV medicines?”
Objectivity and a nonjudgmental attitude are important. Health care providers can make it clear that even if they do not share patients’ views, they respect them. By understanding and respecting patients’ views, HIV care providers have the opportunity to improve the patient-health care provider relationship and make the patient more likely to be open and adherent.
Barriers to ART adherence may arise from a patient’s personal or cultural beliefs, cognitive abilities, or health status, including comorbidities. 3, 4, 5 A patient’s capacity for treatment competence or regimen-specific barriers also may impact adherence, as well as psychosocial or structural issues such as poor mental health, drug use, or even lack of housing or health insurance. 3, 4, 5
Brief conversations with patients can help HIV care providers identify and utilize teachable moments. Numerous studies show that through open discussion, HIV care providers and patients can uncover barriers, identify strategies, and set behavioral goals to improve adherence. 2, 3, 4, 5 Following are some suggestions for how HIV care providers may address barriers to ART adherence as they arise:
When discussing patient beliefs and behaviors:
- Explain the importance of consistent ART adherence even when viral load is undetectable.
When addressing cognitive barriers:
- Offer advice about and tools for adherence, such as weekly pill boxes, linking dosing to daily events/activities, and dose reminder alarms.
- Use a feedback strategy (such as “tell me what you just heard”) to help patients avoid confusion about new medicines and/or changed regimen.
To assist with competence issues:
- Involve patients in decision making, including selection of the ART regimen if options exist.
- Ensure patients understand the treatment plan, including drug regimen, dosing schedule, and dietary restrictions. Prepare patients for situations or changes in routine that could trigger nonadherence or short-term interruption, such as side effects, substance use, or running out of HIV medicines. Remind patients to contact their HIV care provider or pharmacist immediately if they are experiencing side effects or need to refill medication prescriptions. Encourage patients to discuss their challenges with substance use and offer information or referrals for treatment options and support services.
When addressing comorbid conditions:
- Regularly review total treatment plan, and simplify regimen, if possible, with consideration for patients’ lifestyles and comorbidities.
- Anticipate (and plan to manage) possible drug-drug interactions.
When discussing regimen-related barriers:
- Offer ART regimens that are highly effective; prescribe once daily or other simple regimens that reduce pill burden, dosing frequency, and dietary restrictions as much as possible.
- Explain that treatment is well tolerated.
- Prepare patients for the possibility of ART side effects and regularly evaluate and manage side effects should they arise.
- Encourage patients to recruit friends and/or family members to help with adherence.
To assist with psychosocial barriers:
- Offer referrals to and/or information about mental health, substance use, and other support resources (e.g., psychologists, addiction specialists, support groups, adherence counselors, and case managers).
- Remind patients not to share their ART with anyone.
To help mitigate structural barriers:
- When possible, refer patients to case management and wraparound services for help with issues such as lack of transportation, housing, child care, and access to insurance.
Adherence to ART over the long term can be challenging, even for the most motivated patients. As recent research demonstrates, brief discussions about ART adherence at every follow-up visit can help improve patient success.6 Following are a few questions probing ongoing adherence:
- “How has it been going taking your medicines?”
- “How many doses have you missed?”
- “What was going on when you missed that dose you told me about?”
- “What seems to get in the way of taking your medicines?”