Page 167 - HIV/AIDS Guidelines

Limitations to Treatment Safety and Efficacy

Adherence to Antiretroviral Therapy (Last updated March 27, 2012; last reviewed March 27, 2012)
Adherence to antiretroviral therapy (ART) has been correlated strongly with HIV viral suppression, reduced
rates of resistance, an increase in survival, and improved quality of life. 1-2 In the past few years, ART
regimens have been greatly simplified. Although newer regimens include more fixed-dose combination
products and offer once-daily dosing, adherence remains a challenge. Because HIV treatment is a lifelong
endeavor, and because many patients will initiate therapy when they are generally in good health, feel well,
and demonstrate no obvious signs or symptoms of HIV disease, adherence poses a special challenge and
requires commitment from the patient and the health care team.

Adherence remains a challenging and complicated topic. This section provides clinicians with some guidance
in their approaches to assist patients in maintaining adherence.

Factors Associated with Nonadherence
Adherence to ART can be influenced by characteristics of the patient, the regimen, the clinical setting, and
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the provider/patient relationship. To assure adherence, it is critical that the patient receive and understand
information about HIV disease, the goal of therapy, and the specific regimen prescribed. A number of factors
have been associated with poor adherence, including the following:

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• low levels of health literacy or numeracy (ability to understand numerical-related health information); 5
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• certain age-related challenges (e.g., polypharmacy, vision loss, cognitive impairment) ;
• younger age;
• psychosocial issues (e.g., depression, homelessness, low social support, stressful life events, or
psychosis); 7
• nondisclosure of HIV serostatus 8
• neurocognitive issues (e.g., cognitive impairment, dementia)
• active (but not history of) substance abuse, particularly for patients who have experienced recent relapse;

• stigma ;
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• difficulty with taking medication (e.g., trouble swallowing pills, daily schedule issues);
• complex regimens (e.g., high pill burden, high-frequency dosing, food requirements);
• adverse drug effects;
• nonadherence to clinic appointments 10

• cost and insurance coverage issues; and
• treatment fatigue.

Adherence studies conducted in the early era of combination ART with unboosted protease inhibitors (PIs)
found that virologic failure is much less likely to occur in patients who adhere to more than 95% of their
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prescribed doses than in those who are less adherent. More recent adherence studies were conducted using
boosted PIs and non-nucleoside reverse transcriptase inhibitors (NNRTIs). These studies suggest that the
longer half-lives of boosted PIs and efavirenz may make the drugs more forgiving of lapses in adherence. 12-13
Nonetheless, clinicians should encourage patients to adhere as closely as possible to the prescribed doses and
schedules for all ART regimens.

Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents K-1

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