By Dan Leaderman

Special to The Sentinel

Part two of a two-part series.

Taking HIV medications on strict daily routines poses the greatest challenge for HIV patients and their doctors, according to area medical professionals. Adherence to a drug regimen is essential to controlling the amount of HIV in a patient's blood, called the viral load.

"It's not like with blood pressure medicine, where if you skip the meds, your blood pressure will go up, but will usually go down when you start taking them again," said Kim Lehrfeld, a clinical pharmacist with Chase Brexton Health Services in Baltimore who works exclusively with HIV patients. "With HIV, if you're not adherent to the medication schedule, [the virus] will become resistant to the medication."

If a patient becomes resistant to one type of antiretroviral medication, doctors may be able to substitute another drug. But with a limited number of ATRs to use, patients have few chances for the treatment to take hold.

According to Lehrfeld, the goal for HIV patients is usually 95 percent adherence, the minimum needed to keep the virus from building resistance to the drugs, but for some patients that level of adherence is "next to impossible."

HIV treatments are usually complex, involving several pills that need to be taken at different times of day. Some must be taken on an empty stomach, some after a meal, some after one medication but before another. Side effects from one medication, such as fatigue or extreme nausea, will often interfere with the taking of others.

Many ATRs must be combined and do not work alone.

"If a patient takes a cocktail of three medications, but stops taking one due to side effects, the patient will become resistant to the other two because all three need to work together," said Eva Hersh, Chief Medical Officer of Chase Brexton.

One such combination of three medications is now available in a single pill and Hersh is optimistic about the future of such techniques.

"Simple treatment promotes adherence. Psychologically, it's much easier to take one pill than to take three. People see three pills and think 'I'm really sick.'"

The adherence problem is aggravated by substance abuse and mental illness, often cited as the two biggest obstacles for HIV patients because they may prevent the patient from following a strict routine.

Hersh stressed the need to address addiction, mental illness and homelessness before antiretroviral treatment begins. "We assess readiness before starting treatment. [Patients] need to show willingness and ability to maintain medication, because once you start treatment, it's very dangerous to ever stop."

Any number of socio-economic factors can inhibit a patient's ability to get and maintain treatment.

"The main complaint I hear is housing," said Henry Bishop, HIV Program Chief for the Prince George's County Health Department. "If a patient's housing situation is unstable, adherence becomes more and more difficult."

The recent mortgage crisis has intensified housing concerns, but the fundamental problems have been in place for a long time, according to Bishop.

"These socio-economic conditions undermine people's ability to stay in care. All other issues can be addressed."

Many financial obstacles getting HIV medication can be dealt with through the Maryland AIDS Drug Assistance Program, or MADAP, a state initiative to help low and middle income HIV patients pay for treatment, Bishop said.

Bishop, Hersh and Lehrfield agree that having a good case manager — often a nurse or social worker who works with the health care provider—is crucial to an HIV patient's adherence.

"Case managers are responsible for care coordination," Bishop said. "They can help you with MADAP forms, social services, provide transportation vouchers and food vouchers." Bishop emphasized that effective HIV treatment comes from a web of care providers, such as nutritionists and mental health professionals.

"Case managers connect the dots and bring the various disciplines together."

Case managers are also the ones who work with patients to solve problems such as addiction and mental illness before ATR treatment can begin, said Hersh. Lehrfeld emphasized the importance of measures such as pillbox support, where once a week HIV patients have their pillboxes filled so that the right dose of each drug can be taken at the right time.

Chase Brexton works with the Greater Baden Medical Services to provide HIV care and case management services in Prince George's. The Prince George's Health Department has nine nurses providing free case management services at the county's Cheverly Health Center and the results have been positive.

"Most of our [patients] are undetectable," Bishop said, meaning that the viral load of HIV in their blood is below detectable levels. This does not mean the patients are HIV-free, but such a low viral load indicates a high adherence to the medication regimen.

Many HIV patients who do achieve a high adherence rate aren't able to maintain it, according to Justin Goforth, R.N., Director of Medical Adherence for the Whitman-Walker Clinic in the District of Columbia.

"In the western world, you can get people virally suppressed, having an undetectable level of HIV, but only 60 percent will still be undetectable after one year. In Africa, despite a lot of talk about people not having watches, or lacking the infrastructure for [HIV] treatment, the overall adherence rate for HIV patients is 75 percent," Goforth said.

Part of the problem in the U.S., Goforth said, is the low rate of adherence for prescription drugs in general, not just HIV treatments.

"When a doctor prescribes medicine, only 88 percent of people will fill the prescription, only 76 percent will start taking it and only 47 percent will continue."

If all forms of medical non-adherence were grouped in a single category, it would be the fourth-leading cause of death in the U.S. and the leading cause of accidental death, ahead of motor vehicle accidents, Goforth said.

Levels of HIV-specific non-adherence are difficult to quantify because "adherence data is difficult to collect," according to William Honablew, Jr. of the state-run Maryland AIDS Administration.

"Often times, you can only tell if patient have picked up their prescriptions, not whether they are being taken on time."

Researchers are working to fill this information gap. Adherence to HIV treatment is one of the issues being examined by an ongoing national research project initiated by the U.S. Centers for Disease Control and Prevention and implemented in Maryland by the Maryland AIDS Administration.

The Medical Monitoring Project, introduced in 2007, conducts interviews with patients drawn from HIV care facilities statewide. In addition to treatment adherence, the project is collecting data regarding demographics, access to health care, insurance, sexual behavior, drug use behavior and mental illness among Maryland HIV patients, according to a summary of the project provided by Honablew.

The project's first reports are expected to be published in the spring of 2009.