Improve bedside manner, affect patient adherence
Communication makes a difference
(Editor’s note: As clinicians, researchers, and public health officials become increasingly concerned about the development of multidrug resistant HIV, it’s clear that more research and interventions need to be designed to improve adherence to antiretroviral treatment regimens.
Beginning in this issue of AIDS Alert, there will be a regular feature in which adherence news and strategies are described. The first adherence strategy profiled, below, involves research showing how providers have a powerful opportunity to influence patient adherence by adopting a warmer and more open relationship with their HIV patients.)
Physicians through their doctor-patient relationship and communication skills have far greater influence over their HIV patients’ adherence than they might imagine, a researcher says.
Many physicians don’t realize the impact their bedside manner may have on HIV patients’ adherence, says Lydia Temoshok, PHD, professor of medicine at the University of Maryland, School of Medicine, Institute of Human Virology in Baltimore.
"So much of the medical field is focused on technical solutions, like pill burden," she says. "So now we’re back to bedside manner and whether patients feel their doctors care about them."
Temoshok’s research has shown that physician trust is a significant independent predictor of adherence among HIV patients, who attended an inner-city HIV clinic.
Adherence was based on patients’ self-reporting, and the analysis controlled for depression and patient life stressors.1
"We found a very strong correlation and predictive relationship between good provider-patient communication and adherence; it was the strongest of all the factors," she says.
"That is very important to recognize, because a lot of times, providers have been doing this such a long time, and they’re very busy and are thinking about complex medical situations," Temoshok explains.
"So they’ll get kind of annoyed when some patients don’t show up for appointments or are not adhering or don’t understand," she notes.
To many physicians adherence is a black or white issue: "Either take the medications and live or don’t take them and die," Temoshok says.
"So doctors think this is logical and straight-forward, but from a patient’s point of view, it is not," she adds. "There are all these additional factors, like side effects, and many patients will stop taking their medication because they have syndromes, like the buffalo humps we’ve seen in a few patients."
Investigators analyzed adherence issues among 70 patients of a southeastern HIV clinic serving a disadvantaged, mostly African American, inner-city population that was 36% female.1
More than half of the participants had been infected via intravenous drug use (IDU), followed by heterosexual sex, and men who have sex with men (MSM).1
The study found that depressive symptoms, social instability, and life stressors were significantly correlated with missed doses, but patients’ trust and confidence in their medical providers was one of the strongest predictors of missed doses.1
Also, if the patients demonstrated satisfaction with their physical health, they reported a significantly lower number of missed doses in the previous week.1
Providers may improve patient adherence by ensuring patients’ health concerns are answered, the study concludes.
Some of the side effects to highly active antiretroviral therapy (HAART) have created a reintroduction of stigma because the effects are physically noticeable, Temoshok notes.
While HIV-infected individuals earlier were stigmatized when their appearance suggested Kaposi’s sarcoma, AIDS wasting, and other symptoms of infection, now some individuals have lipodystrophy and buffalo humps, which also suggest HIV infection.
"It’s bad enough someone looks bad and feels bad about how their body looks, but now they have the HAART look, and people know they’re on medications, and that has its own repercussions," she says.
The way to address this issue is to take patients’ concerns seriously, Temoshok says.
"Say, There are things we can do for the side effects,’ or We can switch you to another regimen,’" she explains. "Those are the patients who adhere because their doctors are concerned about the whole of them and not just the viral load."
Ask questions
Sometimes the concerns patients have defy all medical logic and require a particularly astute provider or a psychological consult to resolve.
For example, some patients continue to believe the urban legends about HAART, believing that a friend with HIV who died after initiating AZT treatment had died because of the drugs not the disease, Temoshok says.
"I’ve had patients who have their own ideas about what it means to be detectable and undetectable — that phrase is a problem phrase," she notes.
One patient was particularly unadherent. She’d do well for a while and then stop showing up for appointments, and when she finally did show up, she was resistant to the last drug she’d taken, Temoshok recalls.
"I finally talked to her because it seemed we were missing something," says Temoshok, who is a health psychologist. "I said, You were doing so well; you were down to undetectable, and your virus is back up — you missed some doses.’"
The woman’s response was surprising: "She said, Well if it’s undetectable, you’re not going to see it — I want to see the little nonadherent,’" adds Temoshok. "She’d titrate her doses to see’ the virus."
She explained to the patient how it’s always a good thing to have the virus so low that the instruments can’t detect it, but that the virus always will be there even if it’s suppressed to the point that it won’t start replicating.
Then Temoshok explained the patient’s ideas to her doctor who had never understood why the woman was not adherent. Once the health care team fully understood the woman’s concerns and addressed them, her adherence improved, she adds.
Doctorate-level behavioral medicine specialists interview HIV patients before they begin therapy at Temoshok’s clinic, she says.
The specialists are knowledgeable about HIV and HAART and interview patients to assess potential barriers to adherence, as well as possible adherence support, Temoshok notes.
"We see if stress is an issue or if other cognitive problems might prevent the person from understanding directions, because these regimens are very complicated," she explains.
For instance, the specialists will note whether the patient plans to disclose his or her HIV status to family and close friends.
"If the people around them don’t know they’re HIV-positive, then they have to hide their drugs, and they’re less likely to take them on time," says Temoshok. "Can they get a ride to the doctor if they’re not feeling well?"
Also, specialists assess the patient’s cognitive functioning, coping skills, and whether the patient is depressed or a potential suicide risk, she adds.
"If a person says, Why bother — I’m going to die from HIV,’ then they’re not a very good risk for adhering," Temoshok says. "They need to have good contact with a provider who explains how optimistic their outlook is in 2005 if they take their medications right."
Since HIV patients need to achieve 95% adherence, health care providers must understand the person’s ability to take every single pill on schedule, she adds.
The behavioral medicine specialists make recommendations about new patients’ readiness to adhere to HAART, and they suggest what might be done to make sure adherence is as optimal as possible, Temoshok says.
For instance, the specialists might suggest the physician hold off on prescribing HAART to see if the patient will return to a follow-up visit first. Or maybe the patient is being prescribed drugs for pneumonia, then that provides an opportunity to see if the patient adheres well to that simpler regimen, she says.
"After that assessment and in conjunction with people looking at their needs for social and medical services, we refer back to the physician and enter into the chart a summary of recommendations," Temoshok says. "And if there are some real concerns that need more elaboration, then we talk directly to the physician."
Physicians like this process because it easily identifies adherence obstacles and gives them strategies for providing adherence support to patients, she notes.
Another strategy to improve adherence would be to have physicians involved in a patient’s care from the time of diagnosis, Temoshok suggests.
"Diagnosis is a medical process, and if you start early on, you will build that up," she says.
Newly diagnosed HIV patients might be missing the provider connection because the diagnosis is done at a testing center, Temoshok says.
The provider connection probably is important to HIV patients, particularly those from disadvantaged backgrounds, because they often have pasts that include drug use stemming from low self-esteem, she hypothesizes.
"They may have been brought up in a household where no one cared if they lived or died, and they suffered a lot of abuse — both sexual and physical," she says. "So it’s important that someone cares that they are taking their medicines."
Support from health care providers can be very empowering to HIV patients, Temoshok adds.
"It’s a very positive cycle, and they think, If someone cares about me then I think I’m worth caring about, and therefore I’m going to do everything I can to live,’" she says. "When you have a powerful person as a health care provider who communicates that, then that will help you take your medicine."
Reference
- Wald RL, Temoshok LR. Subjective beliefs about health care predict adherence to anti-retroviral medications in a U.S. clinic. Presented at the XV International AIDS Conference. Bangkok, Thailand; July 2004. E710S4098:257-260.
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