Hundreds of medical researchers at the XIV International AIDS Conference testified to something most reasonable people already know: The more a healthcare professional helps HIV-positive people who miss their doses of antiretroviral medications, the more likely these people are to stop missing doses.

Though it may seem to be a no-brainer, the main finding on adherence reported at Barcelona was that HIV support services need to be linked with a person's regular medical care. We're not talking about just any HIV support services -- not simply a doctor in a white coat offering a smile and a pat on the back. What quite a few studies have shown is that direct intervention is key: a mix of adherence advice, one-on-one counseling and group support, organized by trained professionals and geared toward a patient's specific needs.

Direct intervention, researchers have found, seems to work for everyone. Whether patients are happy or depressed; whether they have low self-esteem or huge egos; whether they're white, black or Hispanic; young or old; addicted to drugs, alcohol or nothing at all -- everyone can benefit from having a healthcare provider who does more than measure CD4+ count and dispense medication.

The ways in which this direct intervention can be carried out are many and varied. The most common is a variation on the system set up by The New York State AIDS Institute, which funded so-called "adherence services" that provide support and education at the same site where patients get their regular HIV medical care. Researchers found that this step alone made people more than twice as likely to perfectly adhere to their regimens (MoPeB3284).

Other creative (and successful) ideas for improving adherence abound. In Brazil, a program called "Therapeutic Friends" (ThPeF8176) trained volunteers and relatives of HIV-positive people to visit people with HIV in their homes. These volunteers provided direct counseling and a caring ear, helping to break down the barriers of stigma and isolation -- especially prevalent in developing nations -- that so often result in low adherence to drug regimens.

And a group of researchers from Harlem Hospital/Columbia University organized an eight-week "participatory theatre" program that featured skits, presentations, talk sessions and support groups (MoPeF3963). HIV-positive people who enrolled in the program discussed their obstacles to adherence (among them, issues of disclosure, stigma and sociocultural problems unique to specific minority groups) -- and, in the process, they established closer bonds with other attendees. Though before-and-after adherence statistics were not made available in this presentation, researchers concluded that the result of the program was the creation of a new community support system that kept those involved happier -- and thus more likely to stick to their meds.

The Harlem participatory theatre program highlights what many studies found to be the most important factor in encouraging adherence: directly addressing problems that are unique to specific groups of people. Women, some studies found, are more likely than men to have lower adherence due to depression or anxiety (WePeB5854), often brought on by societal pressures and caretaker responsibilities (MoPeE3828). Drug and alcohol use have a major negative impact on adherence, other researchers found, and require their own brand of intervention targeting that specific characteristic (ThPpB2138 and MoPeB3300, among others). The same goes for being a child (TuPeG5673, WePeB5822, WePeF6877 and others), a prisoner (MoPeB3259), living in rural areas (MoPeC3527, ThPpE2151), having a mental disorder (C10844) and even not being in a relationship (B10453). Though most of these studies didn't necessarily offer solutions, they do point to the necessity of customizing adherence programs for different populations.

The bottom line here, many studies show, is that for most HIV-positive people missing meds isn't only a matter of dreading side effects, loathing the idea of taking so many pills or simply forgetting (B10451). There are complicated psychosocial factors at work for almost every single person, and those factors require a lot more attention than many people -- healthcare providers, politicians and patients alike -- are willing to acknowledge. Study after study has shown that special intervention programs located in the same place where people get their HIV care is a major step. The hope is that, ultimately, people will be able to simultaneously receive help for not only the physical effects of their HIV infection, but the equally devastating emotional effects as well.

In Other News: Non-Psychosocial Factors in Adherence

Although the bulk of the adherence-related research presented in Barcelona found that tackling a person's emotional problems can improve his or her propensity to take meds on time, several studies focused on more clinical ways to improve adherence. Once-a-day drugs received a good amount of attention. For instance, a small Spanish study (WePeB5815) and a smaller U.S. study (WePeB5855) found that a new once-a-day formulation of didanosine (VidexEC), known to cause fewer side effects than its twice-a-day counterpart, was better adhered to by patients, resulting in somewhat higher mean CD4+ counts and lower HIV RNA levels. Similar results were found in a study comparing the once-a-day saquinavir soft-gel capsule/ritonavir combo to a twice-a-day NRTI combination (WePeB5869).

The saquinavir study was notable in that it found a protease inhibitor combination to be better tolerated by people with HIV than an NRTI combination. In general, study results have found much the opposite; many studies at the International AIDS Conference highlighted the adverse effects of PI-containing drug regimens (see, for instance, Dr. Pablo Tebas' coverage on PIs versus NNRTIs in naive patients, or Dr. Mark Holodniy's coverage on coronary heart disease). One rather ironic, if morbid, survey of highly HAART-experienced Italian patients found that the better those patients adhered to their meds, the more likely they were to develop lipodystrophy (WePeB5824). Though the researchers in this study were unable to analyze the specific antiretrovirals their subjects had taken, lipodystrophy is more closely associated with protease inhibitors than NRTIs or NNRTIs. Another international group of researchers noted that because of lipodystrophy, other side effects more common in protease inhibitors than other classes of drugs, and PIs' comparatively high pill burden, NRTI- and NNRTI-containing regimens are much easier to adhere to (WePeB5852).

Ultimately, though, the breadth of research presented at this year's International AIDS Conference revealed that a more holistic approach to HIV medical care is needed. It's not enough to dish out prescriptions and monitor for resistance; the more personal attention and counseling a patient gets, the greater role the patient is allowed to play in his or her treatment, the better trained an HIV specialist is to handle non-clinical situations, the more his or her patient will thrive, and the more likely that person will be to take the meds that will keep him or her healthy for a long time to come. It's a shame we need studies to prove this -- but, hopefully, if this information continues to appear in the context of scientific conferences, more healthcare professionals will incorporate it into their medical practices.