Every HIV patient determines whether or not to adhere to the complex routine of drug taking. How better to learn about the difficulties than from infected individuals? This panel included two presenters, one untreated and the other, highly compliant; both shared their experience and advice. The results from a recent pilot study on hard-to-treat injection drug users (IDUs) offers optimism. Eleven of 13 heroin addicts with AIDS responded and even elected to enter methadone treatment.

D. Barr, JD, Forum for Collaborative HIV Research at the George Washington University Medical Center, Washington, DC, considers communication as the key factor in promoting adherence to therapy. An HIV patient needs to be ready before starting treatment. Regardless of education level, this requires some understanding of viral replication, drug interference of replication, and development of resistance to medication.

The entire healthcare team has opportunity to help answer patients' questions and assist in designing a useful drug-taking strategy. Among such facilitators are the physician, case manager, drug counsellor, pharmacist, nurse, peer educator, and office receptionist.

Predicting who will be adherent to HIV therapy has proven to be difficult. According to Barr, research shows only alcohol and substance abuse to be significant predictors of poor medication adherence. Other factors, such as education level, income status, gender, age, race, and history of using recreational drugs, proved to be poor predictors.

As expected, adherence becomes more difficult as the duration of pill taking increases. Support systems become important in helping the patient cope with changes known to decrease compliance with treatment. Changes in daily routine, depression, lowered self-esteem, and altered beliefs about healthcare and medicine as a consequence of the disease should be considered. Better structure and adherence may be achieved with buzzers, beepers, telephone calls, or multicompartment pill boxes for patients living alone.

For professional correspondence, please contact Mr. Barr by Fax at: (202) 296-0025 or by E-mail at: ihodxb@gwumc.edu.

A.C. Baker, Director of the National Association of People with AIDS (NAPWA), Washington, DC postponed starting HIV therapy mainly because of a hectic work schedule. Clearly, adverse reactions and the ritual of following a complex medication schedule are major considerations. Each infected person determines whether or not to adhere to treatment but needs help from others.

Adherence to a regimen depends in part on the desired outcome. Are there alternative treatment strategies? How does pill taking fit into workday obligations? Both point to the need for open discussion with the physician responsible for HIV therapy. The selected intervention(s) ought to convey respect, realism, and hope. This requires knowledge of the patient as a person by the physician to help avoid real impediments to treatment.

According to Baker, important impediments to adherence are:

• fear that taking medications in the workplace will result in losing one's job,
• interruptions in therapy due to arrest and need to stop treatment in jail,
• poor family attitude toward medicine, and
• society at large (including public health, medicine, and nursing) focused mainly on personal wants or making money rather than on human survival and what a patient really needs.

Our healthcare system must remove these impediments to assure optimal use of currently available highly active antiretroviral (HAART) drugs.

For professional correspondendence, please contact Mr. Baker by Fax at: (202) 898-0435 or E-mail at: cbaker@NAPWA.org.

Researchers at the Yale University School of Medicine, New Haven, Conn, link the increased incidence of AIDS in IDUs with (1) decreased access to health services, (2) fewer administrations of HAART, especially protease inhibitors, and (3) high levels of physician mistrust. New Haven and other communities use needle or syringe exchange and drug treatment programs to facilitate patient access to health care. Pilot results from the Yale AIDS Program directed by G.H. Friedland, MD appear promising.

Thirteen HIV positive IDUs participated. All took daily heroin in a single occupancy building but none received HAART or participated in a methadone treatment program. A mobile health clinic furnished clean needles and user-preferred HAART plus heroin. Medical services were provided weekly.

The results at 9 months included:

• 10/13 (77%) participants achieved viral loads of <300 copies of HIV-RNA/mL plus increased levels of CD+4 T cells and elected to enter methadone treatment.
• 3/13 (23%) showed 1,000 to 2,000 copies of HIV-RNA/mL; one patient experienced repeated incarcerations and discontinued HAART while two others were noncompliant because of alcohol abuse.

Overall efficacy in this study approximated that seen in well-controlled trials with triple combination antiretroviral therapy, according to the investigators. Perhaps stabilizing such basic needs as food, safety, and shelter represent the first step in managing HIV/AIDS in IDUs. Then, the patient can turn to seeking healthcare followed by adherence to treatment.

Barr cited several recent reports published in June 1998, by the Forum for Collaborative HIV Research (FCHR):

• HIV Anti-Retroviral Treatment Failure: A Review of Current Clinical Research
• Dissemination and Evaluation of Clinical Practice Guidelines for HIV Disease
• Metabolic Consequences of HIV Disease and Treatment

These and other FCHR reports can be downloaded from the website at: www.gwumc.edu.

B. Lubin, PhD, Hektoen Institute, Chicago, Ill, presented the paper entitled "The Midwest AIDS Training and Education Partners Adherence Initiative: Identification of Effective Intervention Models from Research and Best Clinical Practices." The text is available at: www.matep.org as a virtual monograph based on two symposia held in November 1997 and January 1998.