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Rethinking Nonadherence: Historical Perspectives on Triple-Drug Therapy for HIV Disease

Barron H. Lerner, MD, PhD; Roy M. Gulick, MD, MPH; and Nancy Neveloff Dubler, LLB
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From Columbia University College of Physicians and Surgeons and Cornell University School of Medicine, New York, New York; and Montefiore Medical Center, Bronx, New York. Note: This paper is an expanded version of a presentation made to the Ethical Issues in Access to HIV Treatment Workgroup of the New York State AIDS Advisory Council. Its findings are based on the discussions of the Workgroup but are not the Workgroup's official recommendations. Dr. Gulick has served as an ad hoc consultant or has received speaker honoraria from Agouron Pharmaceuticals, Bristol-Meyers Squibb, Glaxo-Wellcome, Merck, Roche Laboratories, Roxane Laboratories, and Vertex Pharmaceuticals. The views expressed are solely those of the authors. Grant Support: In part by the Robert Wood Johnson Generalist Faculty Scholars Program (grant 031491) and the Arnold P. Gold Foundation (Dr. Lerner) and AIDS Clinical Trials Group grant U01 AI27665, General Clinical Research Center grant M01 RR0096, and Center for AIDS Research grant SP30 AI27742 (Dr. Gulick). Requests for Reprints: Barron H. Lerner, MD, PhD, Department of Medicine, Columbia University College of Physicians and Surgeons, Box 11, 630 West 168th Street, New York, NY 10032; e-mail, bh15@columbia.edu. Current Author Addresses: Dr. Lerner: Department of Medicine, Columbia University College of Physicians and Surgeons, Box 11, 630 West 168th Street, New York, NY 10032.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(7):573-578. doi:10.7326/0003-4819-129-7-199810010-00012
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The advent of triple-drug therapy for HIV disease has raised the concern that disadvantaged patients with multiple social problems may be nonadherent to treatment. Fearing that partial adherence will lead to drug resistance, some clinicians are withholding these powerful new drugs from such patients. The historical record demonstrates that labeling patients as nonadherent may be both stigmatizing and inaccurate.

Since 1900, such adjectives as ignorant, vicious, and recalcitrant have been used to describe patients who do not follow medical advice.Less judgmental terms, such as nonadherent and noncompliant, are now used, but these terms still imply that patients should obey physician-imposed regimens. Studies of nonadherence have consistently shown that the problem is widespread among all persons and cannot reliably be predicted on the basis of patient characteristics.

This paper argues that physicians should deemphasize the standard approach of predicting and correcting nonadherent behavior in certain patients.Rather, clinicians should encourage all HIV-positive patients to devise individualized treatment plans that can facilitate reliable ingestion of medication. Although the potential development of resistance to triple-drug therapy remains an important public health issue, concern about this possibility must be balanced with respect for patients' rights. Encouraging the active participation of HIV-positive persons in their own treatment will help avoid judgmental and inaccurate assessments of patient behavior and may help patients take medications more successfully.





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