Australians find that money problems lead to poorer adherence to HIV therapy

Difficulties meeting pharmacy costs and those incurred travelling for clinic appointments are associated with interrupting or stopping HIV therapy, Australian investigators report in HIV Medicine.

Overall, 14% of patients reported that they had interrupted treatment and 9% that they had stopped their HIV treatment because of pharmacy costs.

“Both delaying and stopping were significantly associated with meeting pharmacy costs and difficulty meeting travel costs,” write the authors.

Antiretroviral therapy requires high levels of adherence. Research conducted in some resource-limited countries has shown that an inability to meet pharmacy costs or those associated with travel to medical facilities are associated with poorer adherence to therapy.

Little is known about the association between financial pressures and adherence in richer countries.

Australia provides government subsidised antiretroviral treatment to all its citizens as well as those with the right to permanent residence. However, patients are required to pay a contribution towards the cost of their medication. This co-payment amount to 17% of the cost of medication. It is capped at AUS$336 per year for pensioners and individuals with a right to concessions and AUS$1317 for all others.

Doctors from St Vincent’s Hospital, Sydney, wanted to see if the cost of obtaining medication was associated with the interruption or cessation of antiretroviral treatment.

Between November 2010 and May 2011, patients attending the hospital’s HIV out-patient clinic were asked to complete a questionnaire enquiring about these issues.

The questionnaire was completed by 335 HIV-positive patients, and 10% were co-infected with hepatitis C. The patients had a mean age of 52 years and 76% attended the clinic every three to six months.

In all 19% of patients stated that it was difficult  (16%) or very difficult (3%) to afford pharmacy dispensing costs. In addition, 6% reported that they had problems paying for travel to the hospital for their follow-up appointments.

Some 14% of patients reported that they had delayed obtaining medication because of pharmacy costs and 9% said they had stopped their HIV therapy because of these costs.

Therapy was stopped by 29% of patients who found it difficult to pay for their medication. However, only 4% of individuals who were not experiencing financial stress ceased taking their antiretrovirals.

The investigators found that difficulties paying pharmacy costs were associated with interrupting and ceasing therapy (both p < 0.001). In addition, patients with problems paying for travel to the clinic were also significantly more likely to interrupt (p < 0.001) or stop (p = 0.05) their treatment.

Most of the patients participating in the study reported that questions about adherence formed part of their routine clinic appointments. Sixty percent said they were usually asked if they had missed any doses and 54% said that they were asked if their medication caused side-effects.

In contrast, only 5% of patients were asked if they were experiencing problems paying for their treatment.

“Increased direct questioning about financial stress is appropriate and might help identify patients at greater risk of poor adherence,” suggest the authors. “The data also suggest that patients reporting financial stress, including those in a wealthy country such as Australia…might have better ART [antiretroviral therapy] adherence with a greater degree of financial assistance.”

Indeed, the investigators believe that Australia is unlikely to be the only richer country where patients are having difficulty paying their contribution towards the cost of HIV medication. Co-payment is also required in the USA, Canada and Switzerland.

“Our data suggest that financial stress and its relationship to ART adherence should be ascertained in all patients receiving ART,” conclude the investigators. “The relationship between financial stress and treatment failure (loss to follow-up, virological failure, cessation of ART, and cessation of other medications, especially those used for the prevention of comorbid disease) should be formally evaluated in a prospective study.”

McAllister J et al. Financial stress is associated with reduced treatment adherence in HIV-infected adults in a resource-rich setting. HIV Med, online edition. DOI: 10. 1111/j.1468-1293.2012.01034.x, 2012.