Globally, HIV is one of the
most critical healthcare issues, resulting in more than 35 million deaths thus
far (WHO, 2017). Approximately 37 million people were living with the virus at
the end of 2016 (World Health Organization,
2017). Left untreated, it triggers weakening of the immune system (AIDS),
causing infection, disease and eventually death (Weiss, 1993). Nonetheless, the
use of antiretroviral therapy (ART) to diminish the viral load has allowed HIV
to be considered a controllable disease, with death rates declining
considerably as a result of the medicines (Barry
et al., 2002). It is estimated that 700,000 lives were saved by ART in just
2010 (Fauci and Folkers, 2012). Presently, 54% of adults with HIV are receiving
ART treatment. (WHO, 2017).


Nevertheless, the success of
ART has been blunted by suboptimal adherence to the prescribed treatment. (Bartlett,
2002) This occurs through the interruption of part or all of the treatment, and
can be voluntary or involuntary. The standard level of adherence is approximately
70%, which is problematic, as long-term viral suppression necessitates full
adherence (Paterson et al., 2000). Nonadherence leads to drug resistant HIV
strains, low quality of life, and fewer treatment options (Bangsberg et al.,
2001). This results in more healthcare resources being required, and ultimately
upsurges the cost of care.

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Clearly, a public health issue
is evident when it comes to adherence to ART. This essay will aim explore
reasons why medications and not adhered to, the complications this causes to
suggest interventions that could be made to try and increase adherence.

Some Reasons for Nonadherence

Involuntary nonadherence occurs
when patients agree with the value of treatment, but experience obstacles that inhibits
them from taking medication. It is reasonably common; in one study 45% of
patients stated that they forgot to take dosages of their medication, and 40% attributed
their lack of adherence to the fact that they were away from home (Gifford et
al., 2000). Forgetting to take medication is frequent when a patient has a condition,
such as an opportunistic infection, caused by the HIV virus. (Gimeno-Gracia et
al., 2015). This is because such a patient would require a convoluted drug
regimen. Thus, even those prepared to sustain a rigorous programme could miss


Furthermore, there are
lifestyle factors that could lead to a subconscious decrease in adherence to
ART. For example, issues such as substance abuse can result in a lack of adherence,
with it reaching approximately 60% in one study (Hinkin et al., 2006). The lack
of adherence is particularly stark when certain drugs are taken: in one
particular report, patients who were supplementing other drugs with cocaine had
much lower adherence that those who were not consuming cocaine (Arnsten et al.,
2002). Other lifestyle issues include homelessness and lack of education. Less
economically developed countries suffer from these issues to a greater extent,
and hence the reported rate of nonadherence is predominantly higher in
developing world (Orrell, 2005).


Additionally, there are
concerns regarding adherence in HIV-infected children. This is as HIV-positive children
are reliant on caregivers to administer treatment. This is a concern for some,
as the stigma around HIV (Visser and Forsyth, 2009) could mean the caregiver
could try to hide the condition.  This
could result in them sending their kids to school without medication to hide
their HIV-positive status, for example. Moreover, therapies are difficult to
administer to new-borns who need formula feeding due to food requirements (Barry
et al., 2002) linked to ART. However, contrary to these concerns, recent
studies seem to challenge this and show high adherence in children, with it
reaching as high as 95% in one report. (Arage et al., 2014)


Voluntary non-adherence, when
a patient chooses to ignore the recommended treatment, can also occur. It happens
due to various reasons, such as apprehension of stigma associated with HIV, rebuffing
the diagnosis, lack of trust in the healthcare system or the belief that their
medication is not working.


Unfortunately, the
aforementioned stigma causes people to avoid their treatment. This particularly
affects teenagers, sex workers, and men who have sex with men (MSM). One trial showed
that there was a large variability in adherence within teenagers, ranging from
50% to 80%. (Kim et al., 2014) This is significant that this group represents a
large proportion of new HIV infections (Rotheram-Borus, 2008). In different
studies conducted, adherence for sex workers was as low as around 30%, and only
45% of mem adhered to ART (Liu et al., 2014; Mountain et al., 2014). Undoubtedly,
this absence of adherence will not be exclusively due to stigma, there could be
an alternate explanation; nevertheless, it cannot be overlooked that the stigma
still connected to HIV must have played a part in their decision to avoid ART.


Lastly, there are many side-effects
of ART, which could deter patients from following their medication program.

This is evident by the fact that approximately 90% of HIV patients experience
side-effects due to medication (Koochak et al., 2017). One example of a side-effect
is lipodystrophy, which is experienced by around 80% of patients This can lead
to change in body shape, self-confidence issues, therefore inhibits adherence. (Moyle
and Sutinen, 2004). ART can also lead to increased risk of pancreatitis, osteoporosis
or myocardial infarction. (Carrieri et al., 2010; Lugassy et al., 2010). All
these side-effects could lead to patients discontinuing their treatment.


Public Health Issues Caused by

Nonadherence, whilst causing issues such as weight loss, fevers and
increased likelihood of opportunistic infections (Weiss, 1993) for the individual, also results
in public health concerns; a HIV-positive patient presents a superior risk of
spreading the virus to others if their viral load has not been minimised by ART
(Grulich, 2006). Additionally, nonadherence leads to financial burdens: it
results in the growth of drug resistance, imposing the use of more complexed
ART regimes, which encapsulate many more medicines (Bangsberg et al., 2001).  Furthermore,
nonadherence results in more hospitalisation and lengthier hospital stays (Paterson et al., 2000). Consequently, there is an issue of increased healthcare


Some Interventions to Improve Adherence

Adherence can be improved by guaranteeing
contact to a welcoming, trustworthy and open-minded multidisciplinary team.

(Acri, 2007) Such a team can use a patient’s input (considering schedules, pill
numbers and food requirements etc.) to specifically tailor a medication schedule
which the patient can follow. The process by which a patient needs to recollect
their medication should also be described. This not only ensures a higher chance
of adherence through minimising the risk of involuntary adherence, but also
improves the doctor-patient relationship through open communication; shown to
be beneficial for voluntary adherence. (Acri, 2007)


Additionally, healthcare
professionals should evaluate a patient’s knowledge regarding HIV, and the
treatment. This could include topics such as the goals of ART, history of HIV,
and the consequences of not adhering etc. If a lack of knowledge is found, the
healthcare professional should endeavour to inform the patient as soon as
possible. This minimises the chance of unexpected changes for the patient
whilst they are undergoing treatment, which could have decreased adherence.

Furthermore, potential barriers to adherence for the patient must be evaluated.

This can be done by assessing the competence of the patient, and discussing any
issues they could face (stigma, depression, substance abuse etc.) It has been
proven that the earlier a barrier to adherence is found, the earlier it can be
eliminated, ensuring maximum adherence to ART. (Selin et al., 2007)


Directly observed therapy (DOT), when staff watch a patient take their
medication (Tyndall et al., 2007) can be used to increase adherence. The
efficacy of this is debatable however, as there have been negative and positive
reports in trials assessing DOT.  (Ford
et al., 2009; Macalino et al., 2007) Nonetheless, this intervention was to be
successful when followed by drug users, increasing viral suppression rates in a
trial (Tyndall et al., 2007). It can be argued that DOT is a nuisance to
practise, as it requires patients having to come in to healthcare settings often.

However, it was found in a study in Africa that around 90% of patients using
DOT found regular communication with healthcare professionals worthwhile (Pearson
et al., 2006).


In today’s world, technology can also have a massive impact on
adherence. For example, technological reminders could be used, via text
messaging and alarms/reminders. In a study conducted testing the efficacy of such
reminders, adherence was at least 90% (Chesney, 2000). However, there are
concerns about the permanency of such a system, as there were glitches with the
system that caused some concerns. Nonetheless, it can be said that there are
more advantages to such technological reminders. This is because they could
also be particularly useful for individuals with impaired memory.


Lastly, depression could be targeted in HIV patients. This is because
around 50% of HIV patients suffer from depression, which is an enormous barrier
to adherence. (Yun et al., 2005) Therefore, the use of antidepressants
alongside ART could improve the really improve adherence. However, it must be
acknowledged that there have not been any studies on this particular
intervention, and therefore they must be carried out before it is used.



To conclude, HIV is a global
issue, but through recent ART treatment it has become manageable. Nevertheless,
nonadherence has stunted this. There are many reasons for nonadherence such as
side-effects, stigma, education, etc. Ideally these barriers must be amended promptly
by clinicians. Having a good patient-doctor relationship is the most
significant way to increase adherence, as it allows a tailor-made medication
regimen to be made for patient. There is no universal solution for nonadherence,
as HIV affects different individuals in different ways; hence each patient should
be targeted with specific interventions. Moving forward, research could be
conducted to simplify ART medication programs e.g. drugs could be made with
longer half-lives to reduce pill counts. This could mean simpler regimens, and
reduce nonadherence.








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