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Pattern of Nonrational Use of Antiretroviral Drug
Treatment and Use of Personalized Treatment
Regimens to Optimize Compliance
Vilai Chinveschakitvanich
Drug Dependence Research Center WHOCCR,
Institute of Health Research, Chulalongkorn University,
Bangkok, Thailand. E-mail: [email protected]
Title:
Pattern of Nonrational Use of Antiretroviral Drug Treatment and
Use of Personalized Treatment Regimens to Optimize Compliance
Authors: Vilai Chinveschakitvanich
Abstract:
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Problem Statement: Following the emergence of the HIV/AIDS epidemic in Thailand in the 1990s, antiretroviral (ARV) drugs
were consistently promoted as the best treatment option. Blind belief in the lifesaving efficacy of ARVs by people living with
HIV/AIDS (PLWHAs) led to extensive nonrational use of ARVs despite the high cost of the drugs. In view of the current
policy of implementing a large subsidy for ARV treatment, there is an immediate need to seek an appropriate approach to
encourage compliance with rational use.
Objectives: To demonstrate the noncompliance pattern of ARV treatment in order to more efficiently implement personalized
ARV treatment regimens for optimal compliance.
Design: Longitudinal, qualitative, in-depth study.
Setting and Study Population: A cohort of 12 PLWHAs receiving ARV treatment were recruited and have been followed
since 2000. Informal relationships were developed with counseling companions and health care facilitators. Information and
data were gathered by observation and by informal and formal interviews. Data gathered included social and sexual history,
current lifestyle, prospective lifestyle, HIV exposure, health problems, self-care, and treatment.
Results: All patients clearly understood the need to take the ARVs for the rest of their lives, the costs entailed, the probability
that complications would develop, and the daily treatment regimen. However, not a single patient was able to adhere to the
treatment regimen over the study period of three years. A few major constraints led to noncompliance, including physical
discomfort, such as fatigue, nausea, and dizziness, following each dose. Another constraint was patients’ forgetting to carry
the drugs along during the day, which sometimes caused patients to take the ARVs of other PLWHAs. Daily life activities
and/or fear of social rejection also led to skipped doses and regimen modification. One person discontinued taking ARVs
because each dose reminded him strongly of his HIV status and created stress. After he stopped taking the drugs, he reported
relief from stress and was able to forget his HIV status. Many reasons for noncompliance could possibly be dealt with
through good understanding of the constraints. Alternative regimens could be worked out systematically without deleterious
outcome. Effective two way communication is an essential component of case management.
Conclusions: Noncompliance to the strict ARV regimen is common for many reasons related to drug side effects and to
specific daily lifestyle. The negative consequences are most likely preventable with additional attention to each PLWHA’s
needs and with a collaborative effort to find the most suitable drug regimen for each PLWHA.
Background
Antiretroviral (ARV) drugs have been consistently
promoted as the best treatment option, life saving
efficacy. Most patients clearly understood that a good
result derived from strictly compliance to the drug
prescription. However, what the ARV users found
difficult were that its lifetime taken, its costs entailed, the
probability of developing complications and the daily
treatment regimen. These were the influential factors for
their discontinuing the treatment. Patients tried to find
other practical ways to ensure the adherence to
antiretroviral therapy.
Objectives:
To demonstrate the noncompliance pattern of ARV
treatment in order to more efficiently implement
personalized ARV treatment regimens for optimal
compliance.
Method:
This study was a longitudinal, in-depth interview of 77
PLWHAs. Some attended to have HIV therapy at the
hospitals and some were the members of HIV-Self
Help Group. Data were gathered from current and
prospective lifestyle, HIV exposure, health problems
and treatment.
PLWHAs’ Characteristics
On - ARVs
Sex
Non – ARVs
(%)
Paid (%)
Free (%)
Male
Female
60.0
40.0
76.5
23.5
64.4
35.6
Total
100.0
100.0
100.0
N
15
17
45
Age
Non – ARVs
(%)
Paid (%)
Free (%)
<30
30-39
40-49
50-59
6.7
73.3
13.3
6.7
5.9
58.8
35.3
-
24.4
42.2
24.4
8.9
Total
100.0
100.0
99.9
N
15
17
45
On - ARVs
PLWHAs’ Characteristics
Infected time
Average infected time (yrs)
Range
Total
Non – ARVs
On - ARVs
Paid
Free
3.8  3.2
(1-12)
5.7 2.9
(1-10)
5.7  3.7
(1-16)
15
17
45
On - ARVs
Non – ARVs
(%)
Paid (%)
Free (%)
Primary
Secondary
High/Vocational
Graduate
20.0
6.7
26.7
46.7
35.3
23.5
41.2
31.1
20.0
26.7
22.2
Total
100.1
100.0
100.0
15
17
45
Education
N
Occupation Classified by ARV-Use
50
46.7
45
Non ARV (N=15)
40
35.3
On ARVs - Paid (N=17)
35.3
%
35
On ARVs - Free (N=45)
30
26.7
26.7
25
20
20
20
15.6
15
11.1
10
6.7
5.9
11.1
6.7
6.7
5.9
5
11.8
5.9
2.2
0
0
0
0
owner
business
Business
workers
* HIV-Self Help Group Volunteer
Employee
Civil servant Aqriculturer
Volunteer*
Unemployed
Income Classified by ARV-Use
60
53.3
50
45.9
40
Non ARV (N=15)
On ARVs - Paid (N=16)
37.5
%
On ARVs - Free (N=37)
30
25
24.3
20
18.8
20
13.3
10.8
10
13.3
12.5
6.2
10.8
5.4
2.7
0
0
0
0
<3,000
3,000-6,000
6,001-9,000
9,001-12,000
12,001-15,000
>15,000
Making Decision in Taking ARVs
Reasons of Taking ARVs
%
Having AIDS-related symptoms
59.7
Free of charge
46.8
Drug Pro’s
38.7
Prescribed by doctor
29.0
Persuated by family, friends
22.6
No choice
14.5
N
Reasons of Non-Taking ARVs
62
%
Financial problem
53.3
Still healthy
40.0
Alternative therapy
26.7
Having another health problem
13.3
Afraid of drug resistance
6.7
N
15
Nonrational Use: Reasons of starting ARV use
Case #1
• female, 29 yrs old
• infected for 4 yrs.
Case #2
• male, 30 yrs old
• infected for 2 yrs.
Treatment : Sep 2003-present
: Saquinavir, Ritronavir, Combid
“I started using ARVs even though I was healthy
and didn’t have any HIV-related symptom because I
couldn’t resist my friend persistence”.
Treatment: Aug 2002-present
: AZT, 3TC, EFV
“I was very glad to have the chance to take the
ARV regimen at no cost. The doctor said it was
an expensive one. I have to comply with
the treatment as long as I can”.
Nonrational Use: Reasons of stopping Drug use - Financial Problem
Case #3
• male, 38 yrs old
• infected for 7 yrs.
Treatment: Aug 1999-Mar 2002 : d4T, ddI
“I stopped taking the first regimen because the trial
ended. If I want to continue the treatment I will have
to pay by myself. I couldn’t afford it”.
Treatment: Apr 2003-present : GPO-vir
“For enrolling the ATC program, I had to lie that
I never take any ARVs”.
“I strictly adhered to it, I’m afraid of drug resistance”.
Case #4
• female, 40 yrs old
Treatment: end of 2000-end of 2001
: 3TC, d4T, EFV
• infected for 8 yrs.
“I couldn’t continue the ARV treatment after the
trial ended because I had no enough money to
pay”.
Nonrational Use: Reasons of stopping Drug use - Adverse Effects
Case #5 • male, 35 yrs old
• infected for 3 yrs.
Treatment: Oct 2001-Apr 2002 : d4T, ddI, EFV
“I did not feel well whenever I had to take ddI because of its smell, taste and
adverse effect-diarrhoea. Therefore, some days I took the pills once instead of
twice a day. EFV also caused me a headache so I had to skip 3-4 times per
month”.
“Finally, I quitted the regimen because of its adverse effects and I changed the
hospital”.
Treatment: Apr 2002-Apr 2003 : 3TC, d4T, NVP
“The cost was lower and easier to take”.
“Anyway, I quit again as I got lipodystrophy, my face became thinner”.
Treatment: May 2003-Oct 2003 : Combid, NVP
“I went back to take ARVs again because my CD4 had fallen and I felt worse”.
Treatment: Oct 2003-present : Saquinavir, Ritronavir, 3TC
“The doctor told me to change the regimen because I got anemia and low
blood platelet”.
Nonrational Use: Reasons of stopping Drug use - A constant Remind
Case #6 • male, 38 yrs old
• infected for 6 yrs.
Treatment: end of 1998- Jan 2001
: AZT, ddI
“The doctor told me that I should take ARVs otherwise I could be
worse. I believed him and followed his instruction. But from my
experience, I learn that exercise made me healthier than taking ARVs.
I was still sick. I had fever and often got a cold. The main factor that
made me discontinue taking ARVs was that each dose reminded me
strongly of my HIV status and created stress”.
“You know after I stopped taking drugs I felt relieved from stress and
able to forget my HIV status”.
Nonrational Use: Adjusted themselves for Adherence
Case #7 • male, 37 yrs old
• infected for 10 yrs.
Treatment: Feb 1996- Oct 1996 : AZT, ddI
Oct 1996- present : AZT, ddI, Ritronavir
“When I knew there is a new strong ARV (PI), I wanted to take it
although it is very expensive. I believe it can save my life”.
“I skip every 3-4 days a dose otherwise I can’t work due to its adverse
effects; i.e. blurred vision; numbness on lip, tongue, fingers, feet;
dizziness and fatigue. Then I start the next dose sooner. This practice
make me can comply to the treatment until present”.
Nonrational Use: Adjusted themselves for Adherence
Case #7 • male, 37 yrs old
• infected for 10 yrs.
Treatment: Feb 1996- Oct 1996 : AZT, ddI
Oct 1996- present : AZT, ddI, Ritronavir
“When I knew there is a new strong ARV (PI), I wanted to take it
although it is very expensive. I believe it can save my life”.
“I skip every 3-4 days a dose otherwise I can’t work due to its adverse
effects; i.e. blurred vision; numbness on lip, tongue, fingers, feet;
dizziness and fatigue. Then I start the next dose sooner. This practice
make me can comply to the treatment until present”.
Conclusions:
Noncompliance to the strict ARV regimen is
common for many reasons related to drug side
effects and to specific daily lifestyle. The
negative consequences are most likely
preventable with additional attention to each
PLWHA’s needs and with a collaborative effort
to find the most suitable drug regimen for each
PLWHA.