Patients who do not think they need antiretroviral therapy have poorer adherence to such treatment, Dutch investigators report in the December 1st edition of the Journal of Acquired Immune Deficiency Syndromes. The investigators also found that a higher CD4 cell count was associated with a lower perceived necessity to start HIV treatment and theycomment “this finding…is relevant for the debate regarding the possibility of starting earlier with [antiretroviral therapy], that is, at a CD4 cell count of 500 cells per microliter.”
HIV treatment can mean a longer and healthier life, but a very high level of adherence is needed for this treatment to keep viral load at undetectable levels. It is therefore important to understand the factors influencing adherence.
Investigators from the Dutch ATHENA cohort wished to establish whether the perceived need to start antiretroviral therapy and concerns about the side-effects of such treatment had an impact on adherence.
They therefore designed a cross-sectional (or 'snap-shot') study involving 341 patients who were receiving HIV treatment at 21 HIV clinics across the Netherlands.
The study was conducted between 2002 and 2004. The patients completed questionnaires and provided demographic details, HIV treatment history, and their level of adherence to antiretroviral therapy. They were also asked to answer a series of questions to assess their perceived need for antiretroviral therapy and concerns about side-effects.
Most of the patients (90%) were taking HIV treatment and the mean duration of treatment with combination antiretroviral therapy was five years. Just under a quarter of patients (23%) had a detectable viral load (above 50 copies/ml).
The overwhelming majority (90%) of patients agreed or strongly agreed with statements about their need to take antiretroviral treatment. For example, 95% of individuals agreed with the statement “these medicines keep my HIV under control”, 88% agreed with the statement “my health, at present, depends on these medicines”, and 87% agreed with the statement “my future health will depend on these medicines”.
As regards statements designed to assess concerns about side-effects, 72% agreed with the statement “I sometimes worry about long-term effects of these medicines” and 52% agreed with the statement “I am likely to get a bad side-effect from this medication in the next month”.
A quarter of patients (86 individuals) reported non-adherence in the previous month and 26 (30%) of these individuals had a detectable viral load compared to 18% of those who reported 100% adherence. This meant that self-reported non-adherence was associated with a near doubling in the risk of having a detectable viral load (odds ratio: 2.0, 95% CI: 1.1-3.4).
Patients with a lower perceived need to take HIV treatment were significantly more likely to be non-adherent (OR = 1.6, 95% CI: 1.1-2.4) and to have a detectable viral load (OR = 1.9, 95% CI: 1.1-3.4).
However, concerns about side-effects were not associated with poorer adherence or a detectable viral load.
“In conclusion”, write the investigators, “patients with lower beliefs about the necessity of [antiretroviral therapy] were more likely to be nonadherent and to have a detectable viral load.” They add, “studies should investigate whether discussing the patients’ view about their personal need for [antiretroviral therapy] will lead to increased adherence.”
De Boer-van der Kolk M et al. Lower perceived necessity of HAART predicts lower treatment adherence and worse virological response in the ATHENA cohort. J Acquir Immune Defic Syndr 49: 460-62, 2008.