What is the best approach to assess and improve antiretroviral therapy (ART) adherence in a patient with Human Immunodeficiency Virus (HIV)?

HIV ART Adherence Assessment and Improvement

Assessment Methods

Self-reported adherence should be obtained routinely from all HIV patients at every clinical visit, as it remains the most practical and recommended method for monitoring adherence in clinical practice. 1

Recommended Assessment Approaches

• Self-report measures: Use validated questionnaires at each visit to assess adherence patterns, barriers, and missed doses 2
• Pharmacy refill data: Track prescription refill records as an objective measure of adherence, which correlates well with viral suppression 2, 1
• Viral load monitoring: Measure HIV RNA every 3 months until suppressed for at least one year, then every 6 months if adherence is consistent 1

Assessment Methods NOT Recommended for Routine Clinical Use

• Pill counts: Not routinely recommended due to susceptibility to "pill dumping," personnel burden, and inconsistent correlation with biological outcomes 2
• Drug concentration testing: Not routinely recommended due to inconsistent results, assay limitations, and short medication half-lives 2
• Electronic drug monitors (EDMs): Despite being most closely associated with HIV RNA levels in research settings, EDMs are not recommended for routine clinical use because they are burdensome to patients and incompatible with adherence-promoting strategies like pill organizers 2

Interventions to Improve Adherence

Medication Regimen Optimization

Switch treatment-experienced patients on complex or poorly tolerated regimens to once-daily regimens with equivalent efficacy. 2

• Fixed-dose combinations: Use single-tablet regimens to decrease pill burden when regimens have equal efficacy and safety 2, 1
• Once-daily dosing: Simplify to once-daily regimens for both treatment-naive and treatment-experienced patients with suppressed virus 2, 1

Important caveat: When switching regimens for treatment-experienced patients, carefully consider treatment history and prior ART resistance patterns 2

Technology-Based Interventions

Reminder devices and interactive communication technologies are strongly recommended to improve adherence. 2, 1, 3

• Interactive text messaging: Use SMS reminders with expected patient replies, which are superior to one-way reminders 2
• Dose-time alarms: Implement reminder alarms on phones or other devices to prompt medication taking 2
• Personal telephone reminders: Provide calls before scheduled doses and within 24-48 hours after missed doses 1, 3

Education and Counseling

Individual one-on-one ART education combined with adherence-specific tools is recommended for all patients. 2

• Enhanced adherence counseling: Provide intensive counseling for patients with difficulty maintaining their ART schedule 3
• Tool-based education: Combine pillboxes, dose planners, or reminder devices with structured counseling about their use 2
• Behavioral interventions: Target cognitive, behavioral, emotional, and social barriers to adherence through comprehensive counseling 4

Critical point: Adherence tools are most successful when offered as part of a comprehensive support package rather than in isolation 2

Adherence Thresholds and Clinical Implications

Recent evidence challenges the traditional 95% adherence benchmark:

• Minimum adherence threshold: Adherence levels of 80-85% may be sufficient for viral suppression with modern ART regimens 5, 6
• Regimen-specific thresholds: Integrase inhibitor-based regimens achieve 90% viral suppression with adherence levels as low as 75%, while NNRTI-based regimens require approximately 78% 6
• Clinical recommendation: Despite lower thresholds being potentially effective, aim for ≥90% adherence to maximize viral suppression and prevent resistance 5, 6

Important nuance: While newer regimens may be more "forgiving" of missed doses, this should not be communicated as permission for poor adherence, but rather as reassurance for patients who occasionally miss doses 5, 6

Managing Missed Doses

• 1-2 day delays: Resume normal dosing schedule immediately without doubling doses 3
• Pattern recognition: Focus on preventing patterns of missed doses rather than isolated incidents 3
• Provider communication: Encourage honest self-reporting of adherence challenges to develop appropriate support strategies 3

Systematic Monitoring Framework

Systematic monitoring of ART adherence is essential for successful treatment outcomes. 2, 1

• Baseline assessment: Evaluate adherence barriers including housing stability, food security, psychiatric disorders, and medication adverse effects 1
• Ongoing monitoring: Assess adherence at every clinical visit using multiple methods (self-report, pharmacy refills, viral load) 2, 1
• Multidisciplinary approach: Utilize specialized nurses for behavioral intervention, counseling on substance abuse, motivational interviewing, and social workers for healthcare system navigation 7

Special Populations

• Substance use disorders: Integrate directly observed ART in treatment programs and consider opioid substitution therapy 1
• Unstable housing: Provide intensive case management and address structural barriers to medication access 1, 5
• Mental health conditions: Screen for and treat psychiatric comorbidities that may interfere with adherence 1, 5

Common pitfall: Avoid focusing solely on patient-level factors; address structural barriers including medication costs, transportation, and healthcare access 7