AIDS patients are daunted by medication regimens

Eminent behavioral scientist calls for help in boosting patients? adherence to AIDS drug therapies.

By Sara Martin
Monitor staff

As part of their work to help inner-city AIDS patients, health-care workers often go right into patients? homes to assess whether they are taking their medications properly. The first time a San Francisco health-care team made such a visit, they were shocked by what they saw.

'These patients had so many unopened bottles of medicine, they could have opened a pharmacy,' said Margaret Chesney, PhD, a researcher at the University of California at San Francisco. 'They just keep receiving drugs from their mail-order pharmacies, physicians, clinical trials. Many of these patients were overwhelm-ed, not clear about which drugs to take, when or how much.'

Even though most AIDS patients know that protease inhibitors and other drug therapies have dramatically increased survival rates for people with the disease, they aren?t taking the medications as prescribed, said Chesney. And, she added, the reasons behind their nonadherence have been little studied and even misunderstood by the medical community.

As experts in human behavior, she said, psychologists are needed to investigate this critical problem and to design strategies to solve it. At the APA Annual Convention session 'AIDS therapy?a state of the science overview,' Chesney told a room packed with researchers, clinicians and even people from the community living with AIDS that more research is needed on why patients fail to take medications correctly. She also discussed what is known so far about noncompliance.

'The only way we can keep from capsizing all of HIV care is by enhancing adherence, and the buck stops right here,' she said. 'As Surgeon General C. Everett Koop said, ?Drugs don?t work if people don?t take them.?'

Preventing ?breakthrough?

When patients don?t take their AIDS medications as prescribed, they enable what researchers call 'breakthrough'?the state when there?s not enough drug in a patient?s body to stave off the virus? ability to replicate and take a stronger hold over the immune system. Breakthrough may not take long. In fact, said Chesney, it may even happen when a patient misses just one dose over a two-day period.

How many patients are at risk for breakthrough? Little research has been done to assess the problem, but Chesney provided some insights by presenting results of a telephone survey of 665 patients on HIV-therapy. The study found that 26 percent of patients admitted that they did not take a drug as prescribed in the last day?they either took the medication at the wrong time, missed a dose or didn?t take their medications with food, as instructed.

'These and other data indicate that numerous patients are at serious risk of developing resistance to these life-saving drugs,' Chesney said. 'Moreover, patients who have developed resistance can transmit drug-resistant strains of HIV to others, which then limits the treatment options for the newly infected person.'

Physicians vs. patients

A first step in preventing breakthrough is identifying the reasons patients fail to take their medications correctly. But physicians and patients disagree on those reasons, according to results of the same telephone survey, she said.

The study found that most physicians (59 percent)

believed that patients didn?t take their medication as prescribed because of the high 'number of doses and pills.' They named 'side effects of the medications' as the second most likely cause of patient nonadherence (28 percent).

But patients? answers differed dramatically. Only 16 percent cited the 'high number of doses and pills,' and 13 percent named 'side effects' as significant factors behind their nonadherence. In fact, the leading reason patients cited wasn?t even on the questionnaire: 26 percent listed 'other reasons.'

Further study of patients? attitudes has identified the 'other' reasons. Patients reported that they:

? Just forgot (43 percent).

? Were asleep (36 percent).

? Were away from home (32 percent).

? Were too busy (22 percent).

? Felt sick (11 percent).

? Were depressed (9 percent).

? Changed their routines (27 percent).

(Results don?t equal 100 percent because some patients reported more than one reason.)

What psychology can do

To boost adherence, Chesney urged psychologists to conduct basic qualitative and quantitative research to better understand the reasons for nonadherence and to pinpoint the amount of drug needed to prevent breakthrough.

Based on what psychologists know now, she also called for psychologists to:

? Motivate patients by better explaining the importance of the drugs in preventing breakthrough. Chesney suggests that psychologists help patients form partnerships with pharmacists, nurses or others who can help them stick to their regimens.

? Help design clear medication instructions that simplify drug taking.

? Tailor medication regimens to patient lifestyles. To help one woman stick to her drug regimen, Chesney designed a program around the woman?s primary reason for living: her young daughter.

? Treat stress and depression, two areas psychologists are highly equipped to address.

? Work with other disciplines to address the issue. Psychologists could work with physicians to help them unravel the events behind a patient?s noncompliance.

Chesney emphasized that psychologists must also conduct controlled, clinical studies to evaluate these suggestions whenever possible. 'These are based on what we know now, but it?s clear that we need to better understand nonadherence and to find more innovative solutions.'