Direct to Consumer: HIV and Adherence

It may seem unimaginable that patients with a condition as serious as HIV would fail to comply with their treatment regimens. Yet, according to a 2002 study led by Stephen Becker of the Pacific Horizons Medical Group, adherence to HIV treatments appears to be just as abysmal as it is for other conditions (around 50 percent).

Jeffrey E. Glor, PhD,

The implications of a failed treatment regimen for HIV patients, however, are particularly disturbing. Adherence rates of 80-90 percent—considered adequate in many other therapeutic areas—are associated with a 50 percent failure rate for HIV therapy (according to a 1999 study led by D.L. Patterson of the Veteran's Administration Medical Center). Poor adherence also leads to less durable antiretroviral (ARV) therapy and an increase in the incidence of opportunistic infections.

Perhaps even more troubling is the indirect consequence of medication-resistant HIV. Partially adherent patients who become resistant can transmit the resistant virus to others: Robert Grant of the Gladstone Institute of Virology and Immunology documented that, in 2001, 27 percent of newly infected patients in San Francisco had a virus that already showed resistance to at least one ARV.

Transmission of a resistant virus means that future HIV patients will have to face their disease with less effective drugs. And for pharma companies, poor adherence can accelerate product lifecycles, create inaccurate perceptions of drug efficacy, and, according to a 2004 Datamonitor report, reduce revenues by as much as $30 billion a year across all treatment areas.

Carter L. Smith, PhD

Barriers to Overcome

Complicated treatment regimens and side effects make adherence difficult for HIV patients. And because regimens typically become increasingly demanding as the disease advances, long-term therapy—the goal in HIV—tends to be associated with diminishing adherence, according to a 2003 study led by Amanda Mocroft of the Royal Free and University College Medical School.

External obstacles to adherence can be even harder to overcome. Psychosocial factors such as fear paralyze many patients. Language and literacy barriers can also be a hurdle, as can transportation or reimbursement constraints.

A New Approach

To date, most efforts to improve adherence to HIV therapy have focused on patient information. This reflects a fundamental myth within the healthcare industry—that if HIV patients are sufficiently informed about health consequences, they will achieve perfect adherence. This model, however, has not produced adequate adherence among HIV patients. Clearly, pieces of the puzzle are still missing.

Relationship of Adherence to Treatment Failure

Perhaps the flaw lies not in a lack of information, but rather in the way patients process the information they receive. Psychologists have observed that showing people the likely outcomes of their decisions does not necessarily lead to sensible choices. That's because when humans are bombarded with extensive, complex information, we reflexively sift through it using simple rules of thumb that strongly influence the decision-making process. It follows, then, that the next logical step in improving HIV patient adherence is to accommodate the way people naturally process information.

In the book Adaptive Thinking, psychologist Gerd Gigerenzer recounts the story of seven Florida blood donors who committed suicide after receiving positive results on an HIV test. Gigerenzer suggests that those patients may have reconsidered their choice if they had understood that their real chances of HIV infection were as low as 1 in 4 (when taking into account both the sensitivity of the tests and the incidence of HIV in most populations).

The Role of Information Processing

The problem is that medical professionals too often communicate health risks in terms of percentages. Rather, Gigerenzer explains that people have an easier time relating to data in the form of frequencies. For instance, a patient might be confused when his doctor says, "Fifty percent of patients fail their HIV therapy when they take only 80 percent of their doses, whereas 100 percent adherence leads to a 10 percent failure rate." But the same patient may grasp the risks associated with noncompliance if the doctor says, "One out of two people who take their medication only eight out of ten times will fail treatment. On the other hand, only one out of ten fails when all doses are taken." This simplistic example suggests that simply adjusting HIV patient materials so that numbers read in the form of frequencies rather than percentages may have a dramatic effect on how patients make decisions.

Another problem with most HIV patient information is that it tries to "sell" the benefits of adherence, such as staying healthy or living longer. But the reality is that patients must face the downsides of therapy long before they see those benefits, if they ever do. In his work on decision making, Nobel Laureate Daniel Kahneman found that people will go out of their way to avoid losses, even if it means passing up opportunities. So framing compliance in terms of loss instead of gain capitalizes on a natural bias in information processing. In other words, citing the consequences of nonadherence, such as the compromise of immune function, packs a bigger punch than touting the potential health improvements associated with perfect adherence.

As far back as 1977, research by Irving Janis and Leon Mann also demonstrated that the amount of information processing required can also influence adherence. In practice, many physicians assess likely adherence to HIV therapy while discussing the possible outcomes with patients. But the list of outcomes they present is often incomplete, and patients' comprehension of such verbal information is uncertain. Janis and Mann suggest that a more formalized, thorough, and straightforward "balance sheet" of all outcomes—good and bad—associated with any regimen will allow patients to form more concrete attitudes toward starting therapy. That, in turn, would also help doctors make more accurate predictions of their likely adherence.

Admittedly, changing HIV treatment materials is no panacea. But it may constitute an incremental advance—one more piece in the adherence puzzle.

Launches

MedZine

launched HealthStart, a new division headed by former Bates exec

John Garett

, which creates "patient starter kits" that include Rx medicines and relevant consumer products such as healthy foods, services, and educational materials for doctors to give to their patients adjusting their lifestyles to manage illness.

People

Richard Nordstrom

joined McCann Healthcare Worldwide as global CEO. He had been executive vice-president, COO, and president of Corbett Accel New York. Meanwhile, two other former Corbett Accel executives have teamed up on a new venture.

Charlene Prounis

, who had been executive vice-president and chief marketing officer, and

Risa Bernstein

, former Accel chairwoman, will head an agency that will focus on direct-to-patient initiatives.

Awards

Jeffrey E. Glor, PhD, is a team executive for Biovid and is focused on HIV/AIDS market research.jglor@biovid.com

Carter L. Smith, PhD, is an associate team executive for Biovid and an expert in patient adherence.csmith@biovid.com