Achieving and maintaining viral suppression can help decrease HIV-associated complications and prevent transmission.1 Regimens with simple administration, including low pill burden and no food requirement, help improve treatment adherence.1-4 Additionally, single-tablet regimens (STRs) minimize the possibility of selective noncompliance and the risk of patients taking an incomplete regimen.3,5,6

Patients need to take their medication every day as prescribed to achieve virologic suppression.1 Side effects of patients’ treatment can lead to discontinuation or altering of therapy. Management strategies must be individualized for each patient.1

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COMMON BARRIERS TO ADHERENCE

Despite prescribing a simple regimen and other efforts to maintain patients on the HIV continuum of care, a multitude of patient-related factors can pose barriers to adherence1,7:

  • Inconsistent access to medications1

  • Depression and other mental illnesses1

  • Neurocognitive impairment1

  • Low levels of social support1,8

  • Low health literacy1

  • Stressful life events1,8

  • Alcohol/substance abuse1,8

  • Homelessness, poverty1

  • Nondisclosure of HIV serostatus/denial1,8-10

  • Stigma1,9

  • Financial/insurance status1,7

  • Treatment fatigue1,7

People who are not adherent risk becoming resistant to medications and they have fewer regimen options.1 Despite being on a regimen with simple administration, common barriers to adherence can prevent patients from maintaining virologic control.1,11

Methods to help improve patient adherence

Consistently assess adherence1
The DHHS Panel’s recommendations on adherence to the continuum of care include assessing (and reassessing) the patient’s linkage to care and adherence to antiretroviral therapy (ART) and clinic appointments; approaching patients about adherence problems in a constructive, collaborative, nonjudgmental way; and tailoring the approach to each patient’s needs or barriers to care.

Measuring retention in care should be done consistently1
Consistency measures that can be used for clinic quality assurance:

  • Minimum of 2 visits at least 90 days apart over a period of 1 year

  • At least 1 visit every 6 months over a period of 2 years

Reminder & routine methods1,12

  • Medication reminders

  • Alarm clock

  • Calendar

  • Mobile apps

  • Pill organizers

  • Linking medication to daily activities

Access videos, discussion guides, and tools to help your patients understand HIV treatment.

Benefits of simple administration

Characteristics of a regimen can affect adherence differently.1,13 Higher levels of adherence are associated with the following attributes1,14,15:

  • Once-daily dosing

  • Lower pill size/burden

  • Fewer side effects

  • No food requirement

When selecting a regimen for your patients, components and configuration are important.1 Simple administration, reducing side effects, finding assistance with co-pays or out-of-pocket costs, and maintaining an uninterrupted supply of ART medication can help patients overcome adherence barriers.1 Prescribing an STR can help minimize the risk of resistance by promoting adherence through a lower pill burden and by eliminating the need to refill multiple prescriptions to provide a complete HIV treatment.1-3,5,6

Potential benefits of dosing simplification1,5,14,16

Low pill
burden

Lower dose frequency

Decreased healthcare costs

Fewer
co-pays

Fewer prescriptions needed

Simplified administration could help improve virologic suppression5

A simplified treatment such as an STR can help provide sustained viral suppression, allowing for improved immune function. While data that support or refute the superiority of an STR versus a once-daily multiple-tablet regimen (MTR) are limited, the study below suggests that an STR may offer advantages.1

In a clinical study5:

Virologic suppression (<50 copies/mL) was greater in patients using an STR (~84%) compared to an MTR (~78%)

View Study Design

It’s important to note that this study is not representative of all studies and that individual results can vary.

Regimen selection can affect retention in care5

Treatment adherence includes retention in care, which is defined as regularly attending appointments, and remaining in medical care.1

In the same study5:

One year after starting ART, ~81% of patients on an STR were retained in care versus ~73% of patients on an MTR

View Study Design

Additional endpoints were reported as part of this study.

Treatment persistence can be improved by
selecting a regimen with simplified dosing4

Persistence is the duration of treatment from initiation to discontinuation. This can be measured by the number of consecutive days medication is taken without exceeding permissible intervals of therapy.4

  • STR

    MTR

  • Bangsberg et al2

    STRs demonstrated greater pill count, which is a measure of adherence

    View Study
    Design

    ~86% of patients remained adherent

    ~73% of patients remained adherent

  • Yager et al3

    More prescription refills were seen in the STR group

    View Study
    Design

    ~81% of treatment-naive patients refilled prescriptions

    ~66% of treatment-naive patients refilled prescriptions

  • Juday et al4

    Significantly longer time on treatment (average) was seen in patients taking STRs

    View Study
    Design

    370 days on treatment

    295 days on treatment

Watch a panel of HIV specialists discuss setting and achieving treatment goals.

REFERENCES:

  1. US Department of Health and Human Services. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents living with HIV. https://aidsinfo.nih.gov/contentfiles/adultandadolescentgl.pdf. Updated May 30, 2018. Accessed June 4, 2018.
  2. Bangsberg DR, Ragland K, Monk A, Deeks SG. A single tablet regimen is associated with higher adherence and viral suppression than multiple tablet regimens in HIV+ homeless and marginally housed people. AIDS. 2010;24(18):2835-2840.
  3. Yager J, Faragon J, McGuey L, et al. Relationship between single tablet antiretroviral regimen and adherence to antiretroviral and non-antiretroviral medications among Veterans’ Affairs patients with human immunodeficiency virus. AIDS Patient Care STDs. 2017;31(9):370-376.
  4. Juday T, Grimm K, Zoe-Powers A, Willig J, Kim E. A retrospective study of HIV antiretroviral treatment persistence in a commercially insured population in the United States. AIDS Care. 2011;23(9):1154-1162.
  5. Hemmige V, Flash CA, Carter J, Giordano TP, Zerai T. Single tablet HIV regimens facilitate virologic suppression and retention in care among treatment naïve patients. AIDS Care. 2018;30(8):1017-1024.
  6. Thompson MA, Mugavero MJ, Amico KR, et al. Guidelines for improving entry into and retention in care and antiretroviral adherence for persons with HIV: evidence-based recommendations from an International Association of Physicians in AIDS Care panel. Ann Intern Med. 2012;156(11):817-833.
  7. Burgess MJ, Zeuli JD, Kasten MJ. Management of HIV/AIDS in older patients—drug/drug interactions and adherence to antiretroviral therapy. HIV AIDS (Auckl). 2015;7:251-264.
  8. Halkitis PN, Shrem MT, Zade DD, Wilton L. The physical, emotional and interpersonal impact of HAART: exploring the realities of HIV seropositive individuals on combination therapy. J Health Psychol. 2005;10(3):345-358.
  9. Carr RL, Gramling LF. Stigma: a health barrier for women with HIV/AIDS. J Assoc Nurses AIDS Care. 2004;15(5):30-39.
  10. Stirratt MJ, Remien RH, Smith A, et al. The role of HIV serostatus disclosure in antiretroviral medication adherence. AIDS Behav. 2006;10(5):483-493.
  11. Centers for Disease Control and Prevention. HIV continuum of care, U.S., 2014, overall and by age, race/ethnicity, transmission route and sex. https://www.cdc.gov/nchhstp/newsroom/2017/hiv-continuum-of-care.html. Accessed April 30, 2018.
  12. Fisher JD, Fisher WA, Amico KR, Harman JJ. An information-motivation-behavioral skills model of adherence to antiretroviral therapy. Health Psychol. 2006;25(4):462-473.
  13. Parienti JJ, Bangsberg DR, Verdon R, Gardner EM. Better adherence with once-daily antiretroviral regimens: a meta-analysis. Clin Infect Dis. 2009;48(4):484-488.
  14. Nachega JB, Parienti JJ, Uthman OA, et al. Lower pill burden and once-daily antiretroviral treatment regimens for HIV infection: a meta-analysis of randomized controlled trials. Clin Infect Dis. 2014;58(9):1297-1307.
  15. Raboud J, Li M, Walmsley S, et al. Once daily dosing improves adherence to antiretroviral therapy. AIDS Behav. 2011;15(7):1397-1409.
  16. Vitoria M, Ford N, Doherty M, Flexner C. Simplification of antiretroviral therapy: a necessary step in the public health response to HIV/AIDS in resource-limited settings. Antivir Ther. 2014;19(suppl 3):31-37.