My next patient is a young man in his 20s. He’s healthy, except that he has HIV/AIDS. Diagnosed about a decade ago, he has consistently been noncompliant with several antiretroviral regimens, mostly because he reports adverse side effects. Yet most of them do not appear to be related to the medications.
Besides not taking his antiretrovirals, his history is marked by sometimes taking medications at different doses than recommended. For example, he told me one pill made him feel like he was gaining weight and so he decided the dose was too high. He cut the pill in half and took it every other day. With a virus known for its ability to develop resistance, this is playing with fire. He has also chronically missed appointments in our clinic, making the process of caring for him difficult. Given all of this, it is not surprising that his most recent HIV genotype is resistant to most of the medications we have available to us.
A couple of months ago, he called the clinic urgently after a spate of no-shows (seven in a two-month period), reporting severe shortness of breath. We saw him urgently in clinic and began a work-up. What followed were several intense visits, an Emergency Department evaluation and gradual improvement. Then, a couple weeks later, an outbreak of shingles. Over this period, and with these intervening illnesses, the reality of his disease seems to have finally sunk in.
Today he tells me that he has decided he does want to treat his HIV and that he will take his medications as prescribed. And he will contact us prior to making any changes to his regimen so we can discuss the potential side effects, working with him to minimize the chance of developing further resistance. I’m skeptical, but I encourage him, and we make a plan for a specific start date two weeks from now. On that day, he will bring in all his medications and meet with one of our nurses to set up his pill box and go over the regimen, major side effects, and other issues. Then he will meet with either me or a nurse in the clinic at two-week intervals as we monitor his progress on the regimen.
Noncompliance with medication is very common throughout medicine, and well-documented in the case of HIV. Gifford et al. (Journal of Acquired Immune Deficiency Syndromes, 2000) found that only 50 percent of study participants were 100 percent adherent to their antiretroviral regimens. About a third of patients were taking less than 80 percent of the appropriate therapy daily. Lack of adherence was associated with higher viral loads, or “virological failure.” Recently, researchers have found that lower adherence has specific effects on different classes of antiretrovirals. Gardner et al. (AIDS, 2010) showed that in two classes, NNRTIs and NRTIs, resistance occurred with lower levels of adherence, which contrasted with protease inhibitors, for which they found no association between adherence and virological failure. These responses are likely secondary to the pharmacokinetics of the various classes of drugs.
Will my patient succeed in adhering to this regimen? It’s too soon to tell. One ominous sign is that he cancelled his appointment for the start date we had set several weeks ago. To his credit, though, he actually called to cancel and then rescheduled right away. That’s a big step since in the past he would often just not show up and be lost to follow-up for months at a time. I hope that he can pull things together this time and commit to treatment—his life depends on it.
Erica Seiguer Shenoy, MD–PhD ’07, is a fellow in infectious disease at Massachusetts General Hospital and Brigham and Women’s Hospital.
The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions or Harvard University.
