A comprehensive approach can Help optimize therapy for each patient
Tens of thousands of individuals are diagnosed with HIV each year in the US. Each has a unique history and reality. The baseline evaluation is a chance to learn more about your patients and foster open communication. And frank, effective communication can help foster a trusting patient-provider relationship.
CYNTHIA RIVERA, MD: When an HIV-infected patient comes into your office for the first time, what components of that initial evaluation are you including in that visit?
LEANDRO MENA, MD: Like any patient you will see, you want to start with a thorough and complete medical history. You want to make sure you get information about any medications the patient is taking, any past medical problems, family history, and so on. But also if the patient is someone who has been on HIV treatment before coming to you, you want to get a complete history of prior antiretrovirals. You want to order, you know, laboratories for initial assessment.
DERRICK BUTLER, MD: Another area that I found to be useful and critical in terms of my practice is also assessing the emotional state of the patient really around HIV and the diagnosis itself. Some patients are coming in, you know, still in denial, or shock, or even devastated, again sometimes basing their – the information that they've retained from decades ago about HIV or from what they’ve felt from their own communities that have kind of influenced their opinions on HIV themselves. And I think also important is that social history. The idea of where they are in terms of, you know, their status, in terms of homelessness, if there are any issues with substance abuse that you need to be aware of.
LEANDRO MENA, MD: One thing related to that, the social history, is actually even asking if the patient happens to be in a relationship. What’s the HIV status of their partners? Because that may be important when you come to talking to the patient about the benefits of treatment and how they’re, you know, taking treatment and keeping a suppressed viral load. It may also to–to reduce the risk they could transmit HIV to their unaffected partner.
CYNTHIA RIVERA, MD: Right and it's a great segue into the importance of STD screening. We are talking about HIV, and it's a great way to have that conversation about screening for other sexually transmitted diseases that they or their partners may be affected with.
DERRICK BUTLER, MD: And also it’s their sexual orientation, their sexual history because you really need to know if they say they are you know gay, if they've disclosed that status. In the area where I work, there's a quite a bit of homophobia stigma around just being homosexual, and that can come into play in terms of, you know, the diagnosis of HIV and then them also being successful in treatment.
Stigma and low levels of social support are two of the psychosocial, behavioral, and structural barriers that can impact patient adherence, which, when not maintained, can be a major cause of therapeutic failure.
LEANDRO MENA, MD: One of the things that I like to do, because again – because sometimes you give information. You're not really sure if they’re getting information in, at some point stop and ask, well, tell me now: what do you understand? In your own words, meaning how do you–what do you understand for the things that I told you about?
DERRICK BUTLER, MD: Really how much do they know and understand about HIV itself, you know, what it is, how it’s transmitted, and that really helps you kind of tailor your education with them and how you're gonna actually can tailor your approach to keeping them adherent to their medications and choosing that regimen that will work with that. I always ask them, have you told anyone? Have you told anyone in your family? Because I know from just anecdotally from my own practice, patients who have close relatives or someone close to them who knows their diagnosis actually do a little better, because they have that support, and they’re advocates for them. Many times, they're the ones that actually making the patient take their medicine or encouraging them at the same time, and then, then you avoid the issue where patients are trying to hide the diagnosis or hide their medicine. So I put that in part of my initial assessment also and try to kind of dissuade those feelings and help that patient build confidence. And again, the word we use in this industry is, it’s empowerment. Empower them, overcoming those barriers that could be existing there.
When optimizing HIV care, keep long-term treatment success in mind
Long-term treatment success can be affected by many aspects of HIV care. One of the most important factors to consider is a comprehensive approach to treatment, which can help address several optimization considerations.1
Common concerns your patients may have with HIV care
|Patient has difficulty taking multiple pills a day|
ART regimens can vary in pill burden and should be tailored for an individual patient’s medical situation. Tailoring an ART regimen can enhance adherence and support long-term treatment success.1
Administration issues, such as a high pill burden, may be a reason patients want to discuss optimization.1
|Patient is experiencing intolerable side effects from their current ART regimen|
|Treatment with ART may result in a multitude of adverse reactions, and patients may be experiencing intolerable side effects with their current regimen.1|
|Patient is having difficulty adhering to their medication|
|According to the DHHS guidelines, the failure to understand dosing instructions, the complexity of a regimen, and more can be reasons for poor adherence.1|
|Patient misses doses due to an eating/drinking requirement with their current treatment|
|According to the DHHS guidelines, food or fluid requirements are not necessary for several ART regimens.1|
|Patient is having adherence issues due to internalized stigma|
|Adherence to ART may be influenced by many factors, including the patient’s social situation and HIV-related stigma.1|
|Patient is nervous about their current pregnancy or future pregnancy|
|Regularly check in with patients as they consider family planning.1|
|Patient has difficulties refilling their medication due to cost|
|There may be financial assistance programs available for patients worried about access or cost of medication.1|
Clinical considerations when optimizing therapy
Before selecting a new ART regimen for your patients, it’s important to consider1:
- A patient’s full ARV history
- Past virologic responses
- Past ARV-associated toxicities and intolerances
- Cumulative resistance test results
Maintaining viral suppression is a primary goal when switching therapies1
A comprehensive approach to treatment may help maintain or reestablish viral suppression without jeopardizing future treatment options. It’s important to select a treatment that:
- Is proven to achieve and maintain viral suppression
- Has as well-established safety and tolerability profile that is appropriate for your patient
It’s imperative to consistently evaluate your patient’s current treatment regimen to understand whether optimization is necessary.1
ART, antiretroviral therapy; ARV, antiretroviral; DHHS, US Department of Human and Health Services; HAART, highly active antiretroviral therapy.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in adults and adolescents with HIV. Department of Health and Human Services. Updated January 20, 2022. Accessed January 31, 2022. https://clinicalinfo.hiv.gov/sites/default/files/guidelines/documents/guidelines-adult-adolescent-arv.pdf