Understanding your patients’ barriers to care
Taking a comprehensive treatment approach can help address patients' needs1
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You encounter different patients in your practice every day.
Explore three different scenarios and practical considerations below.
Scenario #1: Restart treatment for Doug
How do you typically make an informed treatment decision in patients with a similar profile?
AETC recommends considering key factors when reinitiating HIV therapy in ART-experienced patients.2
Insurance status is a common barrier to adherence. Consider asking if your patient is facing other barriers before assessing restarting ART.1
It's important to take a comprehensive approach to regimen selection and consider each of your patient's needs related to treatment administration.1
How do you help your patient fully understand the process of restarting treatment?
Many patients may stop ART or fall out of care for periods of time. It is important to reengage these patients in care at the earliest opportunity and support them in restarting ART. A key goal of HIV care is to help patients achieve continuous viral suppression on ART.2
Replication of the HIV-1 virus is error prone, resulting in millions of mutations each day. When mutations occur in virus proteins that are targets of antiretroviral drugs, drug resistance can occur. These resistance mutations can jeopardize future treatment options. Choosing a regimen with a high barrier to resistance can help maintain the regimen's efficacy in the presence of mutations. Consider prior and current drug resistance test results and a regimen's barrier to resistance to inform treatment strategy.1,3-6
Adherence to therapy is closely linked with viral suppression, which can help decrease a multitude of HIV-associated complications. Patients are more likely to be adherent to their prescribed regimen when convenience is a key factor.1
Scenario #2: Treatment optimization for Emily
How do you typically make an informed treatment optimization decision in older patients?
DHHS guidelines ask you to consider key factors when optimizing HIV therapy.1
The landscape of HIV treatment continues to rapidly shift, with the most up-to-date guidance emerging from the DHHS.1
Simple administration may help patients address adherence challenges.1
Your patient is concerned about maintaining viral suppression during treatment optimization. How would you address their worries?
DHHS guidelines include common considerations to optimize treatment while maintaining viral suppression.1
Switching therapy may enhance tolerability, eliminate food or fluid requirements, and more.1
Rigorously evaluated regimens have data that can support more conversations about how the regimen might work for your patient.1,7
Your patient has concerns about how their new treatment will interact with their other medications. How would you address this worry?
DHHS guidelines recommend closely monitoring the potential for drug-drug interaction when switching antiretrovirals in older patients.1
Scenario #3: Help with adherence for Liam
What strategy would you use to help improve medication adherence?
DHHS guidelines can help reinforce the importance of staying in care, including behavioral modification techniques to help them establish good habits.1
Addressing the potential barriers in care can help promote adherence to prescribed ART, which may help achieve and maintain an undetectable viral load.1
According to DHHS guidelines, suppressing the HIV viral load to <200 copies/mL with ART prevents sexual transmission of HIV, which is also called “Undetectable equals Untransmittable,” or “U=U.” If a patient achieves and maintains an undetectable viral load for at least 6 months, sexual transmission of HIV to the patient’s partner can be prevented.1
How would you help your patient understand the risks of suboptimal adherence?
Retention in care is a vital aspect of treatment adherence and may lead to better outcomes in patients, linkage to care, initiation of effective ART, and adherence to treatment as prescribed.1
Optimal adherence as prescribed results in reducing the risk of developing resistance, better health, improved viral suppression, and more.1
Drug resistance can develop in the presence of suboptimal or inconsistent levels of ARVs. Resistance mutations may jeopardize future treatment options. With the lifelong complications that your patients with HIV may face because of resistance, this should be a major consideration during treatment selection. Successful adherence to prescribed HIV medication may help reduce the risk of drug resistance, particularly when the regimen has a high barrier to resistance.1,6
Social determinants of health (SDOH) create common barriers to adherence
Many conditions in your patients’ environments can impact health and quality of life. It is important to consider these SDOH when engaging patients in HIV care.8,9
- Inconsistent access to medications
- Depression and other mental illnesses
- Neurocognitive impairment
- Low levels of social support
- Low health literacy
- Stressful life events
- Alcohol/substance use
- Homelessness, poverty
- Nondisclosure of HIV serostatus/denial
- Stigma
- Financial/insurance status
- Treatment fatigue
AETC, AIDS Education and Training Centers; ART, antiretroviral therapy; ARV, antiretroviral; DHHS, US Department of Health and Human Services; MSM, men who have sex with men; MSW/M, men who have sex with women and men; WSW, women who have sex with women.
References:
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. US Department of Health and Human Services. Updated September 12, 2024. Accessed January 8, 2025. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/adult-adolescent-arv/guidelines-adult-adolescent-arv.pdf
- Coffey S, Bacon O. Immediate ART Initiation & Restart: Guide for Clinicians. AETC National Coordinating Resource Center. March 17, 2023. Accessed February 28, 2025. https://aidsetc.org/sites/default/files/media/document/2023-06/ncrc-rapid-art-full.pdf
- Soriano V, Perelson AS, Zoulim F. Why are there different dynamics in the selection of drug resistance in HIV and hepatitis B and C viruses? J Antimicrob Chemother. 2008;62(1):1-4.
- Cromer D, Schlub TE, Smyth RP, et al. HIV-1 mutation and recombination rates are different in macrophages and T-cells. Viruses. 2016;8(4):118-132.
- Tang MW, Shafer RW. HIV-1 antiretroviral resistance: scientific principles and clinical applications. Drugs. 2012;72(9):e1-e25.
- Gardner EM, Burman WJ, Steiner JF, Anderson PL, Bangsberg DR. Antiretroviral medication adherence and the development of class-specific antiretroviral resistance. AIDS. 2009;23(9):1035-1046.
- World Health Organization. Guidance for best practices for clinical trials. Updated September 2024. Accessed February 25, 2025. https://www.who.int/publications/i/item/9789240097711
- Healthy People 2030. US Department of Health and Human Services, Office of Disease Prevention and Health Promotion. Accessed March 31, 2025. https://health.gov/healthypeople/priority-areas/social-determinants-health
- Menza TW, Hixson LK, Lipira L, Drach L. Social determinants of health and care outcomes among people living with HIV in the United States. Open Forum Infect Dis. 2021;8(7). https://doi.org/10.1093/ofid/ofab330