Breaking Barriers to Medication Adherence in HIV: An Interview With Robert Gross, MD

Robert Gross, MD; Shira Berman


August 05, 2013

In This Article

Treating Depression to Improve Adherence?

Medscape: One presentation found a high rate of comorbid depression in HIV patients and an even higher rate of multiple concurrent psychiatric conditions.[6] How does psychiatric illness affect adherence to medication?

Dr. Gross: Disordered thinking is certainly a relative barrier to taking medication, and depression is a known barrier to adherence.[7] But there are also other issues at play in these patients. The National Institute of Mental Health is funding research on patients who have concurring mental illness and HIV, focusing on: (1) how HIV drugs affect mental illness; (2) how mental illness affects HIV drugs; and (3) how the two interact. Does taking a mental health drug affect drug concentrations of the HIV drugs, and vice versa? It's a very complicated population to care for, and a lot of patients with mental illness are doing well, but it is certainly an added challenge.

Of note, there is not a lot of evidence that treating the depression improves adherence. We developed an intervention program called "Managed Problem Solving"[8] (and gave a how-to at the conference on implementing the intervention in the clinic.[9]) We showed that the intervention improved adherence and improved depressive symptoms, but they were independent phenomena, and one did not affect the other.

It's not clear to me that the treatment of depression as a way to improve adherence is necessarily going to result in better outcomes. Dr. Steven Safren published a paper last year[10] showing that an intervention targeted to depressed people with HIV can improve the depression, but the improvement did not result in sustained improvement in adherence or have any effect on virologic outcome.

Literacy is another example where we have assumptions about how it affects adherence that may not be true. Dr. Seth Kalichman presented the details of an intervention that used pictograms to help people who are illiterate understand the disease and the importance of medication adherence.[11] But it didn't work -- those with lower literacy showed little if any benefit. Clearly, it's not just about the information being conveyed to them, it's also related to all of the other complications that low literacy creates in their lives.

We have to be careful not to conflate the mechanisms by which each of these barriers results in treatment failure.