RETHINKING NONADHERENCE - HISTORICAL PERSPECTIVES ON TRIPLE-DRUG THERAPY FOR HIV DISEASE

The advent of triple-drug therapy for HIV disease has raised the conce rn that disadvantaged patients with multiple social problems may be no nadherent to treatment. Fearing that partial adherence will lead to dr ug resistance, some clinicians are withholding these powerful new drug s from such patients. The historical record demonstrates that labeling patients as nonadherent may be both stigmatizing and inaccurate. Sinc e 1900, such adjectives as ignorant, vicious, and recalcitrant have be en used to describe patients who do not follow medical advice. Less ju dgmental terms, such as nonadherent and noncompliant, are now used, bu t these terms still imply that patients should obey physician-imposed regimens. Studies of nonadherence have consistently shown that the pro blem is widespread among all persons and cannot reliably be predicted on the basis of patient characteristics. This paper argues that physic ians should deemphasize the standard approach of predicting and correc ting nonadherent behavior in certain patients. Rather, clinicians shou ld encourage all HIV-positive patients to devise individualized treatm ent plans that can facilitate reliable ingestion of medication. Althou gh the potential development of resistance to triple-drug therapy rema ins an important public health issue, concern about this possibility m ust be balanced with respect for patients' rights. Encouraging the act ive participation of HIV-positive persons in their own treatment will help avoid judgmental and inaccurate assessments of patient behavior a nd may help patients take medications more successfully.