Author(s): Paterson DL, Swindells S, Mohr J, Brester M, Vergis EN,
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Abstract BACKGROUND: Combination antiretroviral therapy with protease inhibitors has transformed HIV infection from a terminal condition into one that is manageable. However, the complexity of regimens makes adherence to therapy difficult. OBJECTIVE: To assess the effects of different levels of adherence to therapy on virologic, immunologic, and clinical outcome; to determine modifiable conditions associated with suboptimal adherence; and to determine how well clinicians predict patient adherence. DESIGN: Prospective, observational study. SETTING: HIV clinics in a Veterans Affairs medical center and a university medical center. PATIENTS: 99 HIV-infected patients who were prescribed a protease inhibitor and who neither used a medication organizer nor received their medications in an observed setting (such as a jail or nursing home). MEASUREMENTS: Adherence was measured by using a microelectronic monitoring system. The adherence rate was calculated as the number of doses taken divided by the number prescribed. Patients were followed for a median of 6 months (range, 3 to 15 months). RESULTS: During the study period, 45,397 doses of protease inhibitor were monitored in 81 evaluable patients. Adherence was significantly associated with successful virologic outcome (P < 0.001) and increase in CD4 lymphocyte count (P = 0.006). Virologic failure was documented in 22\% of patients with adherence of 95\% or greater, 61\% of those with 80\% to 94.9\% adherence, and 80\% of those with less than 80\% adherence. Patients with adherence of 95\% or greater had fewer days in the hospital (2.6 days per 1000 days of follow-up) than those with less than 95\% adherence (12.9 days per 1000 days of follow-up; P = 0.001). No opportunistic infections or deaths occurred in patients with 95\% or greater adherence. Active psychiatric illness was an independent risk factor for adherence less than 95\% (P = 0.04). Physicians predicted adherence incorrectly for 41\% of patients, and clinic nurses predicted it incorrectly for 30\% of patients. CONCLUSIONS: Adherence to protease inhibitor therapy of 95\% or greater optimized virologic outcome for patients with HIV infection. Diagnosis and treatment of psychiatric illness should be further investigated as a means to improve adherence to therapy.
This article was published in Ann Intern Med
and referenced in Journal of AIDS & Clinical Research