Addressing Adherence

Top 4 Barriers to ART Adherence

1. Patient Characteristics

Patient characteristics are the most common and complex factors affecting adherence.

• A diagnosis of depression is commonly associated with nonadherence and has been documented in 49% of HIV-infected youth.10 Other common psychiatric diagnoses, such as bipolar disorder and schizophrenia, also are likely to affect adherence. Substance abuse is another factor that often contributes to nonadherence. Recent unpublished research on adolescent adherence to ART indicates that greater self-efficacy and, to a lesser extent, better outcome expectancy were associated with improved adherence.11
• Though yet to be evaluated in research, adolescent developmental factors are believed to affect adherence. Younger and more impulsive patients are more likely to forget or not prioritize taking their medications. Adolescent patients may be more easily distracted by issues of daily life.
• Some adolescents are extremely concerned that taking medications might inadvertently reveal their HIV status, and this can have profound impact on their adherence.
• Many adolescents have limited social support. In some cases, cultural or other factors may hinder youth from disclosing to their families, and some youth may be estranged from their families as a result of a variety of issues.
• One common phenomenon seen with perinatally infected children is that adherence starts waning during adolescence.
• Health care providers speculate that the normative adolescent tasks of separation and individuation lead adolescents to use control over medication adherence as a method of self-assertion. Clinicians can combat this surge in nonadherence by establishing better communication with the adolescent, exploring healthy ways for youth to express their independence, gradually handing responsibility for medication use from parents to teens, and being vigilant in recognizing parent-youth conflict over medication use and intervening early in the process.

2. Adverse Regimen Characteristics

Negative characteristics of particular medication regimens are common barriers to adherence. Youth who feel healthy before starting ARVs will be very unlikely to accept having significant side effects, especially if they last more than a week or two. Side effects such as diarrhea, rashes, or jaundice may be particularly troublesome because youth frequently worry that friends and contacts may assume they have HIV. Suggesting and rehearsing responses that patients can give to their friends if they experience side effects may help (eg, "I got this rash from a medication my doctor gave me for an infection.").

3. Health Care System

Ensure that the health care system works for each patient. Help prevent lapses in patients' insurance coverage. Loss of coverage may be prevented by assigning case managers to monitor insurance status closely. Additionally, as mix-ups and delays of prescription deliveries are common, unplanned lapses in a patient's supply of medications can be avoided by establishing a regular delivery schedule with a pharmacy that is good at notifying the clinic when there is a potential problem.

4. Patient-Provider Relationship

Research has demonstrated that adherence can be facilitated when a patient-provider relationship incorporates trust, good communication, adequate education about medications, and an overall perception of caring, including a culturally and linguistically appropriate approach to the relationship.12

References

10. Murphy, DA, Durako SJ, Moscicki AB, et al. Adolescent Medicine HIV/AIDS Research Network. No change in health risk behaviors over time among HIV infected adolescents in care: role of psychological distress. J Adolesc Health. 2001 Sep;29(3 Suppl):57-63.
11. Personal communication with Bret J. Rudy, MD, Associate Division Chief, Craig Dalsimer Division of Adolescent Medicine, Children's Hospital of Philadelphia.
12. Sbarbaro JA. The patient-physician relationship: compliance revisited. Ann Allergy. 1990 Apr;64(4):325-31.