University Of Washington SealExtremely active antiretroviral therapy seems to have increased the longevity and quality of life for people living with human immunodeficiency virus (HIV). However it involves severe adherence in taking the medicine, something that could be extremely difficult for many individuals to do.

Two novel University of Washington studies demonstrate plainly how hard it is to make sure people take their HIV medicine. One study was believed to have examined the effects of drinking alcohol on adherence.The second study was noted to have evaluated interventions with the help of peers, electronic pagers or both. The findings of the first study showed that the possibility for non-adherence seems to have doubled among drinkers in contrast to abstainers. Whereas, the findings of the second study showed that these tools may have promoted no lasting improvements in adherence rates.

“HIV is unique in the adherence levels needed to be effective,” says Jane Simoni.

“Typical adherence for people taking medication is 50 percent. But 50 or 60 percent adherence isn’t going to work for HIV medications and will lead to resistance to the drugs. Taking drugs for HIV is a lifetime commitment; you are married to the pills,” continues lead author of the pager-peer paper and a co-author of the alcohol study, Jane Simoni, a University of Washington psychology professor who specializes in studying adherence.

The alcohol study was believed to have examined data from nearly 40 previous studies involving more than 25,000 people. Apparently, it established that drinking does have a consistent effect on adherence across studies.

“Drinking quantity, more than frequency of drinking, is associated with non-adherence,” says Christian Hendershot.

Since various studies appeared to have different criteria for drinking, the study experts seemed to have made use of meta-analysis in order to examine three categories namely any drinking, moderate drinking and problem drinking. Apparently, the latter was defined as meeting the National Institute on Alcohol Abuse and Alcoholism criteria for at-risk drinking or meeting criteria for an alcohol use disorder. For example, consuming 14 drinks a week or more than 4 in a day for men.

Christian Hendershot, lead author of the alcohol study and a postdoctoral researcher at the University of New Mexico said that, “In general, people who drank alcohol had nearly twice the risk of non-adherence. But the risk of non-adherence went up as the level of drinking went up. At problem levels of drinking we see a higher probability of non-adherence.”

However, he appears to have cautioned that these findings don’t essentially hold for all people on HIV medicine and who drink.

“Alcohol may have a causal effect, but there also may be other factors affecting both alcohol and adherence that partly explain the association. We need to treat people individually,” he continues.

For the peer-pager study, study authors were observed to have recruited approximately 224 patients who were being treated at a Seattle clinic. Patients were randomly assigned to one of four treatment groups namely pager, peer, combined peer-pager and treatment as usual for about three months.

During the study, patients with peer support attended twice-monthly meetings with other participants and trained HIV-positive peers who provided medicine-related social support. Also, peers further called participants weekly in order to provide more one-on-one feedback.

It was observed that participants in the pager group were asked to carry a customized device when they were awake. Supposedly, the two-way pagers came with messages that were timed to each participant’s daily medication schedule. The pagers seem to have sent educational, humorous and adherence assessment text messages.

Participants in all four groups also received standard care at the clinic including an educational program that provided information about the medicine and adherence in a series of three meetings with a pharmacist, nutritionist and case manager.

The participants were believed to have completed self reports on their adherence two weeks after the study began and once more at three, six and nine months. An electronic pill cap and bottle also was noted to have been used in order to check the consumption of medicine.

Moreover, every three months they had blood drawn in order to measure the levels of HIV and white blood cells in their system. For this study, adherence was defined as taking medicine 100 percent of the time over the past seven days. It was observed that a standard patient on the highly active antiretroviral therapy consumes one or two pills once or twice a day.

Simoni claimed that patients who had peer support in the beginning showed some increased adherence levels. However, this appears to have not persisted once the support ended. More so, the pagers were unable to successfully promote adherence at any point.

She further said that, “We can change adherence a little, but it disappears when the intervention is taken away. Even though you are capable of doing something that doesn’t mean you are motivated to do it all the time. Just ask anyone, ‘Did you exercise yesterday?’ ‘Floss your teeth?’ ‘Avoid sweets?’”

“Add to this the complication that a person has to take these meds every day for a life-threatening disease. There is a lot of emotional baggage surrounding the disease and the pills, and the medications have severe side effects,” explains Simoni.

So what is required for the promotion of improved adherence?

“I wish I knew. We looked for less intensive solutions. But they didn’t work. What we need are very individualized comprehensive programs. And to sustain adherence, the intervention must be as dynamic as the changes in people’s lives,” concludes Simoni.

The studies may perhaps have broader societal implications. Also, Simoni is of the opinion that adherence could possibly be a major problem in future.