|nurse from UK working in HIV
Feb 23, 2002
Is there an established correlation between poor adherence and resistance? If so, should I be encouraging my patients (regardless of whether they are showing symptoms) to consider starting a combination if I suspect their adherence will be poor?
Response from Dr. Little
There is a very clear association between poor treatment adherence and virologic failure - which then leads to the selection of drug resistant variants over time as treatment is continued in a suboptimal fashion. The decision to use potent combination therapy in a patient who is likely to be non-adherent, yet who has symptomatic HIV disease/AIDS - is a very difficult one. There are several studies to show that treatment - even non-supressive treatment - prolongs life and reduces disease morbidity. Alternatively, non-adherence in these patients will almost certainly lead to the development of drug resistance and limited treatment options in the future. There is also the risk of secondary transmission of drug resistant variants if your patient is both non-adherent and engaged in high risk practices. So - what would I do - I always try to offer patients the chance to receive potent therapy with as much education and peer education as necessary to promote the best possible chance of treatment adherence. In the end - if you have patients on combination treatment regimens who are non-adherent with no plans to become adherent, then this is really a personal choice on your part. I will not deny anyone access to treatment, yet, it is very hard to feel good about treating someone who is not invested in their own care and may contribute to the spread of drug resistant virus. I wish I had a better solution for these patients, but I do not. Good luck.
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