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Sep 16, 1997

Dr. Gallant-- Would you please discuss the issue of compliance? For instance, would you as an AIDS doctor be willing to "police" your patients to make sure they take their medications on time and properly? Or do you rely solely on your patients to do the right thing? The drugs are so expensive that some people are saying that only those who can and will comply should get them. I think this is scary. On the other hand, it is truly difficult to take all the meds we have to take the right way. How are you addressing this with your patients? Thanks for all you do!

Response from Dr. Gallant

Great question, and a tough one.

I don't know of any other disease in which compliance is so important. The degree of compliance required to really maintain a prolonged response to antiretroviral therapy is unprecedented: virtually 100%. Furthermore, the price we pay for noncompliance -- drug resistance -- cannot always be corrected.

Doctors often make decisions about therapy based on compliance. They can do this in one of two ways: the first I call "Prejudicial Paternalism," and is completely inappropriate. The second, "Rational Rationing," makes a lot of sense.

"Prejudicial Paternalism" occurs when a doctor makes an unwarranted assumption about a patient's ability to comply based on factors that have been proven to have nothing to do with compliance: race, educational status, income, former drug use, etc. In fact, study after study has shown that you cannot predict compliance based on anything except past compliance. The one exception might be active drug use, though even that has to be individualized. I have some drug addicts who are quite compliant with ALL of their drug use -- both recreational and prescribed.

"Rational Rationing" occurs when a doctor has legitimate reason to doubt a patient's ability to comply, and postpones using complex regimens until the patient is more likely to benefit from them. Ideally, this decision is made after a frank discussion with the patient. For example, I recently had a patient who asked about "taking the cocktail." This patient was an alcoholic who came to about a quarter of her clinic visits. A one month prescription for d4T usually lasted her for about six months. When I explained the complexity of the "cocktails," and how quickly she would become resistant if she failed to take the medications properly, she quickly admitted that she wasn't ready to start yet.

Obviously, in someone with advanced disease and a very high viral load these considerations are less important. Everyone deserves a crack at these drugs, no matter how unlikely they are to get a prolonged benefit. But I sometimes thing that well-meaning doctors who give these combinations out to all their patients without at least thinking about compliance are doing more harm than good. I've had many patients who "see the light" as their disease progresses, and begin to take their therapy much more seriously. I would have done them no favors had I given them protease inhibitors before they were ready to take them.

kidney disease and combination therapy

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