The most common cause of viral resistance, reduced effectiveness, and therapeutic failure with antiretroviral therapy (ART) is nonadherence to the recommended drug regimen.1 Full adherence to most medications requires that patients take 95% of their dose at the recommended times. Yet studies find various rates of nonadherence or suboptimal use ranging from 17% to as high as 95%. In HIV treatment, adherence rates as low as 50% contribute to viral resistance and reduce the protective effects of treatment on transmission.1
There are numerous reasons for nonadherence, all of which fall into one of five categories:
• Health system factors, including the quality of the patient/provider relationship, reimbursement, and availability and knowledge of providers
• Patient-related factors, including forgetfulness, alcohol and drug abuse, and inconvenience of the drug regimen
• Health-related factors, including symptom severity and disability
• Therapy-related factors, including side effects and pill burden
• Social and economic factors, including stress, homelessness, stigma, and economic issues
“We’ve looked at a lot of different barriers to medication adherence,” said adherence researcher Seth C. Kalichman, PhD, who works in the department of psychology at the University of Connecticut-Storrs, “and found a wide range. But the really robust thing that gets in the way is substance abuse,” predominantly alcohol. Patients on ART with a history of alcohol use—regardless of the extent—have higher viral loads and lower CD4 counts than those who do not drink.2 One study of 881 HIV-infected veterans found that approximately a third were binge drinkers, with the majority demonstrating disease progression and signs of liver damage.3
Studies find that the cognitive effects of intoxication, which leads to forgetfulness and missed pills or medication taken off schedule, are a common reason for alcohol-related nonadherence. In addition, Kalichman said, hung-over patients often don’t take their medication.
Now Kalichman and his colleagues have confirmed the relevance of an underappreciated and often unexplored factor: patients who believe that alcohol plus ART is a toxic mix, and who deliberately stop taking their medication so that they can drink.
Kalichman became intrigued with the impact of patient beliefs about drinking and ART after reading a qualitative study on alcohol and nonadherence. Other studies had found that drug users who believed that drugs and ART were a toxic combination skipped doses, with a third saying they would not take their medication on a day they planned to get high.4
The qualitative study found the same for alcohol and ART. Half of the 82 patients interviewed said they would not take their medication if they had been drinking (64% of light drinkers, 55% of moderate drinkers, and 29% of heavy drinkers). Again, these patients had a misplaced belief that combining ART and alcohol was toxic, so they deliberately skipped their medication when they planned to drink.
In reality, said Kalichman, although drinking is never a good idea while taking any medication, it is only medically harmful in HIV-infected patients who are co-infected with hepatitis C virus (HCV), or who have other liver-related problems.
|Moderate drinker: ‘‘I don’t take my medications if I’m going to consume alcohol. Taking those two things together and not knowing what kind of interaction they’re going to have on each other is not a good thing.’’|
Heavy drinker: ‘‘You might as well not even take the medication. You know that you’re not supposed to take different drugs or alcohol with your medicine. I wouldn’t go to the club knowing that I have to take my meds at 12 and start drinking at 12; the medicine’s not going to work.’’
--- Sankar A, Wunderlich T, Neufeld S, et al. Sero-positive African Americans' beliefs about alcohol and their impact on anti-retroviral adherence. AIDS Behav. 2007;11(2):195-203
Kalichman and his colleagues set out to examine the validity of the finding in a prospective trial. They enrolled 178 HIV-positive patients who were on ART and had admitted alcohol use. About half believed that they could not safely mix ART and alcohol. These patients were less adherent, had higher viral levels, and were more likely to have low CD4 counts (<200/cc3) than those who drank but did not have this belief.
All of which presents a conundrum to clinicians caring for HIV-infected patients who drink: If you tell patients that alcohol and ART are not a toxic brew, do you encourage drinking?
That’s exactly what Kalichman says should not happen. Providers need to ask their patients about their drinking habits in “a nonjudgmental, open way that will lead to a honest discussion about drinking,” he said. If providers learn that patients are drinking, they should ask about ART adherence. If they learn that patients deliberately stop taking their medication when drinking, clinicians should educate patients about the risks of drinking and ART, but clarify that, unless the patient has HCV or other liver conditions, they can take their medication when drinking.
“We don’t want to say you can mix drinking and ART and not worry about it,” he said. “And we don’t want people who stopped drinking when they started ART to drink again.” Even patients who understand that alcohol and ART are not toxic together still demonstrate reduced adherence, he stressed.
Regardless of patient beliefs about drinking and ART, clinicians should always provide evidence-based counseling regarding alcohol use. “There is really strong evidence for the benefits of brief counseling interventions in clinical settings, including inpatient units,” Kalichman said.5,6 In general, such discussions should use motivational interviewing, a form of communication that includes open-ended questions designed to learn why patients engage in unhealthy behaviors and what steps they think might be effective at behavior change.
Clinicians also need to understand where patients fall along the Stages of Change continuum: precontemplation, contemplation, preparation, action, maintenance, and relapse.7
This all starts, of course, with the discussion about drinking. Yet in Kalichman’s study, while 80% of providers told patients not to mix alcohol and ART, and 65% said their provider specifically discussed their alcohol use, they all still drank. “Which begs the question,” he said. “What is happening in those conversations?”