Survey: Patients not complying with regimens
Clinicians rely on too few noncompliance indicators
Nearly half of all patients taking anti-HIV drug cocktails are not following directions, while at the same time physicians are relying too strongly on viral load and CD4 count for determining whether patients are complying with their regimens.
That is the disturbing conclusion from a recent national survey sponsored by the DuPont Merck Pharmaceutical Company and published in the May issue of the Journal of the International Association of Physicians in AIDS Care.1
The results indicate that treatment failure may be associated with lack of compliance more than was previously expected, which underscores the need for simpler drug regimens, the authors note.
The telephone survey interviewed 665 HIV-positive people over age 18, of whom 76% were male and 50% white. Nearly half (45%) had had at least 25 months of therapy, and all had been treated with a combination of at least two antiretrovirals.
Although nearly all the patients (93%) knew that proper use of their drug regimen was imperative to improve their lives, one-fourth of them revealed that they had not been taking the prescribed regimen in the previous day, and nearly half (43%) admitted to non-adherence in the previous week.
As part of the study, 100 physicians were interviewed and more than 90% indicated that patient nonadherence with antiretrovirals was a serious problem. They estimated that more than half of their patients missed doses or were otherwise noncompliant in the previous month. Moreover, they estimated that 6% of patients never had their prescriptions filled.
The physicians overwhelmingly (89%) cited lifestyle factors as influencing whether patients comply, with nearly two-thirds listing injection drug use as a factor, followed by lack of education, job demands, indigence, mental problems, and homelessness. The authors note, however, that none of those factors have been shown to predict adherence, and that the only known predictors are past adherence rates and the number of doses required for a daily regimen. The authors also note that few studies have compared adherence rates for multidrug regimens to those for single-dose regimens.
When asked how patient compliance could be improved, 72% said that regimens should be simplified, either by eliminating food requirements or reducing the number of pills and/or doses per day. A total of 28% of the physicians listed once-a-day dosing as the most important measure, followed by having drugs with fewer side effects (15%).
In addition to poor compliance, the study found that "drug holidays" - periods when patients completely stopped taking their prescribed drugs - increased the longer they were on treatment. Nearly one-fourth of all patients reported taking drug holidays, and had done so an average of twice in the past six months, lasting an average of 11 days. Specifically, holidays increased from an average duration of 6.2 days for patients on therapy for two to 12 months to an average duration of 14 days for those on therapy for three years or more.
The survey found no gender differences when it came to compliance. However, females were more likely than males to be satisfied with current therapy regimens, while males were more likely to ask for a specific regimen and to have switched daily regimens.
The income factor
Income alone was not a factor in compliance. However, patients earning $30,000 or more a year were least likely to say they were compliant in the prior day.
Length of therapy translated into differences in compliance with food requirements of antiretroviral regimens. Those patients on therapy two years or longer were more compliant than those with one year or less of therapy, the survey found.
When trying to determine which patients may be noncompliant, physicians relied heavily on increases in viral load (62%), decreases in CD4 count (15%), and increases in symptoms (13%). Although viral load and CD4 changes are not necessarily the result of noncompliance, many physicians depend on them for making treatment decisions related to compliance, with 84% reporting that they limit drugs over concerns about patient compliance, the authors note.
"Relying solely on viral-load measurements is not a strong indicator of compliance," says Ben Cheng, assistant director of the information department at Project Inform in San Francisco. "We need to work with physicians so they can take a more comprehensive approach to assessing patient compliance."
Other findings of the survey include:
· 17% of patients reported having refilled a prescription either late or not at all in the past six months.
· Patients who contracted HIV through injection drug use were more likely to have refilled a prescription late or not at all.
· Patients with less education were more likely to have refilled a prescription late or not at all (17% for high school vs. 12% for college).
· Reasons for not refilling prescriptions included forgetting (18%), had extra pills left over and didn't need to refill on time (10%), and had no means to get to the pharmacy (10%).
· Three-fourths of physicians reported that they consult their patients about which regimen to take.
· Nearly two-thirds of physicians indicate that patients request specific antiretroviral regimens.
Reference
1. Gallant J, Block D. Adherence to antiretroviral regimens in HIV-infected patients: Results of a survey among physicians and patients. J Int Assoc Phys AIDS Care 1998.
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