Starting Your Patient on an Antiretroviral Regimen

The abbreviated case history of John L. offers us little information about John's own preferences and beliefs. In my own practice, I find it essential to explore each patient's experience with, and attitudes about, HIV treatment, both personal and vicarious. Working with a patient who says "I want to do everything I can to fight the virus" is very different from working with a patient who expresses reservations about "putting strong chemicals into my body."

In any event I almost never start an antiretroviral regimen, either two-drug or three-drug, on the day I discuss that regimen with my patient. I encourage a patient to go home and talk about treatment choices to half a dozen people whose opinions the patient values. For this discussion I use patient-education materials, and sketches that I've drawn, as visual aids. I particularly emphasize the importance of talking to people who are skeptical about, or critical of, the use of antiretroviral agents. I spend a lot of time talking about the potential side effects of therapy, and whenever I am prescribing a protease inhibitor I actually draw a time-line of the patient's day -- discussing with the patient when he would take the protease inhibitor, when he would take his other medications, and when he would eat.

All antiretroviral regimens have a common goal. That goal is to attain, and then to maintain, serum concentrations of the chosen drugs at levels high enough to suppress viral activity -- ideally to undetectably low levels -- and prevent the development of drug-resistant viral strains. Viral burden is likely to rise, and resistance to develop, when this siege line is breached -- either because the chosen doses are not high enough to prevent replication and resistance or because the patient has failed to take his medications as prescribed.

Most antiretroviral agents must be taken twice-daily, and several, notably ZDV and the protease inhibitors saquinavir and indinavir, must be taken three times a day. A standard dose can range from one tablet twice a day (3TC) to three capsules three times a day (saquinavir). These variables compound the issue of compliance, and the fact that two of the most commonly prescribed agents, ddI and indinavir, must be taken on an empty stomach -- whereas another agent, saquinavir, must be taken after a full meal -- imposes a considerable burden on even the best-motivated and most compliant patients.

Every patient is different, but all antiretroviral-naïve patients have concerns about initiating therapy. What are the actual benefits? What are the possible adverse effects? What constraints will a complex, multidrug regimen impose? Clinicians who confront these questions may find it helpful to incorporate the sample time-line below into their discussions with new patients -- to show those patients that compliance can be achieved, even with triple-drug combinations, in ways that do not disrupt the patient's daily life or restrict his normal activities.

I have had much better luck keeping patients on their chosen drug regimen when they have come back to me saying that they have considered the likely side effects, have thought about the criticisms offered by skeptics, and have decided that they want to begin antiretroviral therapy after contemplating all of these factors.

Molly Cooke, M.D., is Professor of Medicine, UCSF Medical School, San Francisco, CA.