Attitude is key part of treatment adherence
Attitude is key part of treatment adherence
Study suggests which attitudes to watch
A small Chicago study suggests that attitudes about HIV and AIDS among HIV-infected people can be broken down into types that are predictive of how well the patients will adhere to their medication regimens.
If the study’s findings are confirmed in a larger cohort then it soon will be possible for HIV clinicians to predict which HIV patients will have the most difficulty taking their medications based on their presenting attitudes about HIV disease.
"It’s pretty clear to me that adherence is the key, at least in affluent societies like ours that have access to antiretroviral medication," says John P. Flaherty, MD, associate professor in the department of medicine at Northwestern University in Chicago.
"The people who do well over the long haul are different from those who don’t do well, principally on the basis of being able to take their medications," he states. "I think we spend most of our time in the clinic on that issue with patients."
What HIV clinicians might sense from their experience with HIV patients is that some patient personalities and attitudes appear to do much better in adhering to antiretroviral regimens.
"From my subjective viewpoint and clinical experience, there are people who when you ask them what medications they’re on, they’re not sure, and you show them pictures and they can’t recognize the pills. Right there, you know there’s a problem." Another group of patients who appear to have problems with their medication regimens, he says, are those who haven’t accepted their HIV diagnosis and who haven’t told their friends and family about it.
"They are trying to do everything on their own," Flaherty says. "And I worry about them because it’s a big task to go on the medications and to take multiple pills several times a day — that’s a tall order, particularly when you’re doing it indefinitely."
A study presented in October at the 40th Annual Meeting of the Infectious Diseases Society of America in Chicago, of which Flaherty was involved, discussed the types of patients that he mentions: The first example describes dependent and possibly depressed patients, and the second example describes patients who are in denial about their disease.
The study identified five subjective attitudes that may impact adherence to highly active antiretroviral therapy (HAART): empowered, dependent, ashamed, optimistic, and in denial.1
While the study’s findings suggested that patients who were dependent and in denial were most likely to have a low adherence, the differences were not statistically significant due to the small cohort of 72 patients, and further studies will need to be conducted to confirm this finding, says Farheen Ali, MD, fellow of infectious disease at the University of Chicago. Ali was a co-author of the study.
The study used Q methodology to find shared attitudes among patients that would point to antiretroviral adherence.1 "We looked at adherence from a patient’s point of view," he says. "It’s not new, but the Q methodology hasn’t been used in medicine until very recently, and it’s a good way of studying human subjectivity."
Q methodology has been used extensively in psychology, ethics, and journalism, but the medical community is just discovering it, Ali says. "It’s a wonderful way to study human behavior."
Its advantage over the more standard scoring methods of ranking from 1 to 5 is that it gives participants a better opportunity to express extreme agreement and disagreement, which in turn makes it easier to analyze from a statistical standpoint, he says. HIV patients were given 34 statements that they could rank according to how much they agreed or disagreed with them, and their answers were analyzed by a computer program, Ali explains.
The first part of the questionnaire dealt with demographics, the patient’s drugs, and illnesses. The second part involved ranking various attitude statements.
Participants were given pieces of paper that each had one of the 34 statements. For each statement, participants were asked to rank the statement from -4 to +4: With -4 meaning they absolutely disagreed with the statement, and +4 indicating they absolutely agreed with it, he explains.
Ali, who did most of these interviews with participants, sometimes would spend as long as an hour with one person. "It gave them an opportunity to ask questions and talk about HIV," Ali says. "They’d move the paper around, and we asked them to keep talking with us, and once they were satisfied with how they ranked it, then we took down the number."
The rankings, along with the statement sheets of paper were spread across a table, making it easier for patients to move around and change until they were certain they had selected the most accurate rating, Ali says.
Their adherence to HAART was determined by a self-report questionnaire, plus results from viral load and genotypic assays.1
The analysis revealed the five different attitudes, which are described as the following:
- Empowered: These were patients who clearly knew about HIV and AIDS and why it is important to take antiretroviral medication. The patients who fit into this group had the greatest amount of adherence, Ali says.
- Dependent: This group could be described as depressed, and they identified with statements that showed they were very dependent on physicians and family support, Ali says.
- "They didn’t understand why they were supposed to take the medications, but they did so because they were told to do so." Patients who fell into this category tended to be slightly less adherent than some of the following attitude groups.
- Ashamed: "This group predominantly expressed feelings of shame and guilt about the disease," he says. "They felt they were responsible for contracting HIV in the first place."
Still, this group tended to be more adherent than not adherent, although, again, this difference did not reach statistical significance.
- Optimistic: HIV patients who fell into this category could be described as blind optimists, who believed they were OK and who planned to continue taking their medications, Ali says.
While they tended not to know or understand much about their disease, they did appear to be adherent, Ali says.
- Denial: This is a group that requires a lot of work on the clinician’s part because of the patients’ unrealistic expectations and beliefs, Ali says. One of the Q methodology statements was "I will live my natural life span."
The people who fell into the denial group predominantly said they strongly agreed that they would live their natural life span, Ali notes.
"But they all had excuses for missing their medication doses, such as they fell asleep or were out of the house. So it seemed they felt they’d be OK, but didn’t want to deal with the medication." The denial group also reported that they had not received all the information they needed from their physicians, and they appeared to have some distrust of the medical community, he adds.
"What I found very interesting was the fact that in Southside Chicago, a more or less homogenous population, we had five different ways of looking at HIV treatment," Ali says.
The study suggests that psychological counseling, assisting patients with depression, and strong patient education are very important to improving adherence, he says.
"A patient’s motivation is very important," Ali says. It’s also crucial that HIV clinicians are able to refer patients to social workers, psychiatrists, advanced practice nurses, and others who may help them with their psychological issues that impact adherence, Flaherty says.
Reference
1. Ali F, Dau B, Mrtek R, et al. Subjective attitudes and adherence to HAART in HIV-infected adults. Presented at the 40th Annual Meeting of the Infectious Diseases Society of America. Chicago; Oct. 24-27, 2002. Poster 483.
A small Chicago study suggests that attitudes about HIV and AIDS among HIV-infected people can be broken down into types that are predictive of how well the patients will adhere to their medication regimens.Subscribe Now for Access
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