Helping HIV patients stick to tough drug regimens
|Olga Klibanov counsels patients on the 28 different medications currently available to treat HIV.
|(Photo by Ryan S. Brandenberg / University Photography)
The devastation of AIDS in the United States that marked the middle to late 1980s has significantly decreased, mostly due to advances in HIV treatment.
So much so, that HIV can now be a chronic rather than a terminal disease. Still, to prevent disease progression and drug resistance, patients must strictly adhere to their medication regimen: a difficult prescription, given the complicated rules for taking the drugs and their potentially troubling side effects.
With other chronic diseases — hypertension for example — sticking to the drug regimen 80 percent of the time is sufficient to stabilize the condition.
“Unfortunately, with that level of adherence in HIV infection, many patients will experience treatment failure,” said Olga Klibanov, Pharm.D., clinical assistant professor at Temple University School of Pharmacy and a member of the healthcare team at the Temple University Comprehensive HIV Program. “In fact, a 95 percent adherence rate is necessary for HIV drug treatment to work optimally.”
Because drug adherence is so difficult, Klibanov works closely with patients who are referred to her, helping them manage complex medication schedules, multiple drug-drug and drug-food interactions, and potential side effects — primarily gastrointestinal problems, but also fatigue and headache. New patients undergo extensive counseling with Klibanov, who explains how the virus spreads, how the disease progresses, their medication schedule and how to minimize possible side effects.
Klibanov joined the Temple HIV program, directed by professor of medicine Ellen Tedaldi, M.D., in 2003. It’s increasingly common for HIV programs to employ a pharmacist, given the complexities and rapidly changing field of HIV treatment.
“What we do today is not the same as what we’ll do tomorrow,” said Klibanov, who stays abreast of new developments by constantly monitoring scientific and professional meetings, journals and announcements. With the physicians, Klibanov customizes drug cocktails, a combination of at least three medications active against the virus, according to each patient’s medical condition and individual preferences. She also adjusts medications when a patient builds resistance to a drug or experiences unacceptable side effects. The main goals are decreasing HIV virus replication and improving a patient’s immune system, as well as his or her quality of life.
Patients can also choose to take part in experimental drug studies at either Temple or other medical centers.
So far, 28 drugs for HIV have been approved, and many more are on the horizon. Each medication falls into one of several different “classes” of drugs that fight a particular aspect of HIV. Combining different drug classes has helped in both preventing and overcoming drug resistance, which happens when the virus mutates and adapts to a drug, rendering it ineffective — a significant risk among HIV patients.
One advance expected to ease the burden of HIV patients’ multiple tablets or capsules is the recent FDA approval of a once-a-day dosage form. Experts hope that the combination of the three most common HIV drugs into a single delivery system will be easier for patients who have trouble forgetting or missing doses.
While HIV drugs are effective, experts worry about their toxicity over time. The drugs are extremely potent and often taken for several decades.
Besides the toxicity and complexity, other issues affect drug therapy adherence — although according to several studies, patient age, race, sex, education level, socioeconomic status and history of substance abuse are not significant factors. Rather, the reasons are more commonly related to mental illness, especially depression, homelessness, active substance abuse and major life problems.
Additionally, new patients sometimes don’t understand the disease or have difficulty accepting their diagnosis, Klibanov explains. They also might be reluctant to share their diagnosis with family and have to hide medications, said Tedaldi, who considers patient readiness and empowerment as essential to HIV treatment. Patients might stop taking HIV medicine because of side effects, food restrictions, or the difficulty of taking multiple drugs at different times of day.
“Taking medicine correctly every day is hard for any patient,” said Klibanov, who also works with local pharmacies to further ease medication compliance for patients. “But it’s because of these medicines that there’s been such a dramatic decrease in death and disease caused by HIV.”
— Eryn Jelesiewicz