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Please refute this article regarding adherence and resistance
Aug 23, 2003

Dr. Young,

Ouch. I though adherence was the key to maintaining the advantage against hiv. But this article points that good patients do worse then problem patients. Ouch, please can you refute this study.

Abigail

Good Pill-Taking Patients -- Not Poor Pill-Takers - Create the Most Resistance to Anti-HIV Drugs

Resistance mutations to anti-HIV medications are more likely to occur in patients who take most of their medications rather than in those who don't, according to AIDS specialists at the University of California, San Francisco (UCSF).

"These findings will make us rethink the argument that life-saving antiretroviral drugs should be denied to some populations because poor pill-taking behavior might accelerate the creation of resistant mutations of the HIV virus," said the study's lead author, David R. Bangsberg, MD, MPH., director of the UCSF Epidemiology and Prevention Interventions (EPI) Center at San Francisco General Hospital Medical Center (SFGHMC).

In a study of patients on antiretroviral drugs, resistance mutations were twice as likely to occur in patients who took 80 percent or more of their antiretroviral medications as they were in patients who took 40 percent or less, according to the researchers.

"Ironically it is the 'good adherers' who developed more resistance, rather than the 'problem patients'," said study co-investigator Andrew Moss, PhD, professor of epidemiology and medicine.

"You need pressure from antiviral medications for resistance to develop. What is surprising is that what we typically take to be excellent pill-taking80 percent of pills or better--leads to more resistance than occasional or inconsistent pill-taking. A caveat--this does not mean patients should take less of their drugs to avoid creating resistance. Good adherence to the antiviral regimens still is the best bet to prevent becoming ill or dying with HIV/AIDS. Many patients with excellent, even perfect, pill-taking are living longer with resistant virus, than those who do not take enough medication to select for resistant virus," said Bangsberg.

The study, appearing in the September 5, 2003, issue of AIDS, looked at 148 participants from the Research on Access to Care in the Homeless (REACH) cohort, a systematic sample of HIV-positive adults recruited from homeless shelters, free meal programs, and low-income single-room-occupancy hotels in San Francisco. The participants, who consented to unannounced pill counts to measure adherence, were all on anti-HIV regimens taking three or more antiretrovirals.

Pill counts were conducted, unannounced, every three to six weeks over a 12-month period at the participant's usual place of residence. Blood was drawn monthly and tested for levels of HIV virus. Blood specimens were also analyzed for drug resistant mutations using genotype tests.

Participants in the top two quintiles of adherence, who took 80 percent or more of their medications, accounted for more than half of all new drug resistance mutations occurring in the study. Those in the next two quintiles, who took between 42 percent and 78 percent of their medications, had 35 percent of the new mutations. Only 12 percent of the new drug resistance mutations were found in the participants in the lowest adherence quintile, those who took less than 41 percent of their medications.

The study was funded by the National Institute of Mental Health, the University-Wide AIDS Research Program of the State of California, the AIDS Clinical Research Center of the University of California, and the UCSF/Gladstone Institute for Virology and Immunology Center for AIDS Research. Bangsberg received additional funding from The Doris Duke Charitable Foundation. Viral load test kits were donated by Roche.

The EPI Center and the Positive Health Programs are programs of the UCSF AIDS Research Institute.

08/15/03

Source UCSF News

Response from Dr. Young

It's not my job to refute published articles, but rather to comment on them.

I'm quite aware of the UCSF study's results and actually agree with the findings-- bear in mind that this study looks at the kind of resistance seen among persons who are failing their treatment, rather than looking at all persons who are taking medications. Simply stated, it means that you have to take medications in order to have resistance selected.

My interpretation of this is that the selection of medications and recognition of the potential of pre-existing resistance become critically important issues for starting HAART therapy, even before the first prescription is written or first pill taken.

The idea that adherence equates with "good" patients bothers me-- the implication is that there are "bad" patients, and the fault of treatment failure lies soley with the person taking the pill. In actuality, the basis of failure are many, poor pill taking for sure, is a large part of it, but poor treatment selection, poor investment in counseling and education and even (yes, Abigail) poor physician eduction play essential parts in the discussion. Understanding how all of these factor into the success or failure of a single individual person is the domain of the doctor-patient relationship. BY



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