Routine
Daily schedules that are erratic or chaotic in nature can make it more difficult to establish routines for remembering to take medications. For this reason, the ability to plan ahead becomes very important. Research indicates that chaotic lifestyles and difficulty in planning ahead are barriers to adherence for many people. Common issues impeding medication adherence include leaving home without pills, forgetting to take doses, and sleeping through dose times. Furthermore, there is a direct association between complexity of medication regimens and interference with daily schedules and adherence (Chesney et al, 2000; Mills et al, 2006). A recent study by Gross and colleagues (2013) suggests that an intervention based on a theory of problem solving, Managed Problem Solving (MAPS), improved medication adherence and increased the odds of an undetectable viral load compared to usual care. MAPS consist of a 5-step process to address barriers that may affect medication adherence: problem identification, brainstorming possible solutions, selection of the best possible solution, implementing a solution, and feedback. Benefits from MAPS were sustained for 2 years. Clearly, effective intervention programs need to foster the development of skills for establishing daily routines, planning ahead for unexpected daily life situations, and making appropriate adjustments to daily schedules to incorporate taking medications correctly.
Social Support
Research indicates that having a healthy network of interpersonal support through friends, family, significant others, and health care providers can have a positive impact on treatment adherence (Halkitis, 1999). On the other hand, lack of social support and complex, negative personal relationships can decrease adherence (Kemppainen, 2001). For example, relationships with conflict have been shown to have a negative impact on medication behaviors.
Societal Stigma
Social relationships play an integral role in medication adherence. Some people are unwilling to take medications in public for fear others will find out about their illness (Mills et al, 2006). This raises the issue of finding safe places to take medications in order to keep illness hidden, which is not always available, especially when away from home and even at home, if members of the household are not aware of the illness. Balancing caregiving of children and taking medications may also present barriers to adherence, especially when illness has not been disclosed to the children.
Personal Beliefs and Motivation
Beliefs play an integral role in medication-taking behaviors. Brook et al (2001) found that lack of motivation and general ambivalence to treatment were main reasons for a lack of adherence. Suspicions of pill efficacy deter some people from taking their medications. For some, taking pills every day serves as unpleasant reminders of illness (Roberts & Mann, 2000). There are others who believe that feeling healthy means medication is not needed. On the other hand, there are those whose beliefs have a positive effect on adherence. For example, religiosity, strong faith, hopeful attitudes, and having intentions and motivation to adhere provide the foundation of encouragement and support for many people to continue to take their medications (Sankar, 2002).
Relationship with Health Care Provider
Having a good relationship with the physician is an important factor related to adherence in that it allows clients to open up and disclose information and feel safe doing so. Good communication opens doors for safe disclosure of personal information with knowledge that information is being considered seriously. Bakken et al (2000) found that clients having a personal relationship with their health care providers reported better treatment adherence and were more satisfied with care. Clients who are not accustomed to sharing personal problems with their clinicians as well as those who lacked trust with the prescribing physicians were more likely non-adherent to medications (Spire et al, 2002). In light of the research stating the importance of good communication between client and practitioner, Brook et al (2001) found that 40% of the 89 patients in the study reported having inadequate discussion about drug side effects, consequences of missing doses, potential drug interactions, and alternative drug regimens with their health care practitioners, even though physicians felt they were the most important source of information regarding medication. It is not uncommon for people to leave the doctor's office with conflicting or confusing instructions on how to take medications and not questioning when the doctor says something different than the prescription bottle. Good communication is a two-way street, with clients needing to be open to sharing and receiving advice and practitioners taking time to answer questions and offer adequate information about medications and side effects.
Emotional and Psychological Issues
In a study of 72 respondents investigating the relationship of disease severity, health beliefs and medication adherence, 55.7% perceived dealing with side effects as stressful. Fears of changing body weight and fatty deposits on the stomach also contribute to non-adherence (Roberts and Mann, 2000). Research has also indicated a strong link between depression and poor self-esteem as negatively affecting treatment adherence. Negative moods such as anger and frustration impact medication-taking behaviors (Halkitis & Kirton, 1999).
Medication Characteristics and Side Effects
Difficulty following special instructions, including food and water requirements; need for refrigeration of certain medications; and unpleasant-smelling, tasting, and shaped medications emerged as barriers to adherence (Murphy, 2000; Roberts & Mann, 2000). Harsh side effects, including severe nausea, diarrhea, vomiting, and sleepiness, as well as the need to take many doses multiple times per day has been identified as a source of inconvenience for many people with HIV/AIDS, leading to inappropriate use and disuse of medications.
Individual Characteristics
Demographic factors such as age, gender, ethnicity, and length of time known to be HIV+ have not been shown to consistently influence treatment adherence (Bakken, 2000; Chesney, 2000). However, other risk factors can negatively impact medication-taking behaviors. Given the complex medication regimen and the need for many to take up to as many as 30 pills a day, many people simply forget to take their pills. This issue is further complicated by the presence of mental illness, homelessness, or recreational drug use (Spire, 2002; Chesney, 2000). Some people self-medicate with over-the-counter or illegal drugs to offset the severe side effects.
Recreational Alcohol and Drug Use
Alcohol consumption is common among people with HIV and the rate of hazardous use is two-times greater than the general population (Galvan et al, 2002). Alcohol consumption exacerbates the comorbid conditions of people with HIV, such as the hepatitis C and B virus. Besides secondary behavior risks that arise from alcohol, such as unprotected sex or injected drug use, it has also been associated with the poorest outcomes of HIV treatment, and death (Chandler et al, 2006; DeLorenze et al, 2011).
Special consideration should be given to clients who engage in recreational drug use on a consistent basis. Studies have found that people who regularly participated in recreational drug use had lower levels of adherence (Gordillo et al, 1999; Mills et al, 2006). According to Bakken et al (2000), 41% of 707 people in the sample reported past or current drug use and less engagement with their health care providers, were more likely to miss appointments, and were more likely non-adherent.
System Barriers
The overall health care delivery system can be at fault for treatment adherence-related problems. Some have expressed difficulty in obtaining refills because pharmacies are short of medications (Murphy, 2000). Prescription medications are also expensive, which poses barriers to access for economically disadvantaged and uninsured clients.
Developing Interventions
Recommendations for intervention drawn from current research indicates need for a more patient-centered approach to bridging treatment adherence dilemmas faced by people with HIV/AIDS. Spire (2002) calls for a more "empathic" and "dynamic" approach to treatment adherence intervention that emphasizes sensitivity to internal and external factors affecting adherence, as well as active participation of the patient in treatment design to motivate patients to take control of their illness and empower them to successfully adhere. Sankar (2002) similarly recommends a patient-centered approach that incorporates the patient's own ideas toward his or her illness and treatment as well as the cultural and social context in which treatment adherence occurs. Kalichman (2001) suggests practicing skills-building experiences, problem-solving potential barriers threatening adherence, and developing strategies for integrating medication into daily routine and reminder systems to increase adherence self-efficacy. Sorenson (1998) highlights the importance of matching appropriate strategies with individual patients, since each person is presented with different obstacles to adherence.
In light of recommendations for effective interventions drawn from current research, promoting health of people with HIV/AIDS taking antiretroviral treatment involves placing the client's needs at the center of interventions. Given the complex nature of factors influencing adherence, continuous appraisal and appreciation for unique life situations of each person must be considered to even begin to address the issues of medication treatment adherence. The MAPS intervention conducted by Gross et al (2013) is a great example of an innovative approach that focuses on clients’ needs and their adherence to medication. However, there is still urgency of addressing the issue of treatment adherence is great considering the potentially damaging effects of non-adherence, including ineffective suppression of viral load, increased susceptibility to opportunistic infections, potential mutation of the virus that is resistant to drugs, and, ultimately, decreased health and productivity in activities of daily living.