AIDS Treatment Update, Issue 65, May 1998

Uncertainties about the safety of using Ecstasy at the same time as a protease inhibitor appear to play a big part in non-adherence. In many cases people taking protease inhibitors are deliberately missing doses of these medications in order to take recreational drugs, says Dr John Walsh of the Chelsea and Westminster Hospital.

"We've observed two patterns amongst patients. One group actively plan to miss doses. For example they won't take the Saturday night dose and then they'll go out and take an E, and not take another dose until Sunday night. The other group forget to take their protease inhibitor as a result of going out and taking recreational drugs, and don't remember to take another dose until Sunday night or Monday morning."

"Patients are planning to miss doses because they don't know enough about interactions, and may not always discuss it with their doctor, but to be fair, we don't know the answers either."

59% of the interviewees reported that they had missed at least one dose in the previous month. 25% of patients had missed more than 20% of the doses (one in five), but the average number of doses missed was 13% (one in six).

Recreational drug use was the most significant factor associated with non-adherence. No other factor showed such a strong association, although Dr Walsh pointed out that it was very difficult to tell whether alcohol was associated with non-adherence, because almost all patients, non-adherent or not, had quite a high alcohol intake.

Researchers are not able define how many doses need to be missed in order for resistance to develop, and there may be differences between drugs. In the case of the ritonavir/saquinavir combination, Dr Bill Cameron of Ottawa General Hospital in Canada has shown that people who missed more than 30% of doses (one in three) had a lower chance of achieving and maintaining viral load below 200 copies. It is unknown whether or not missing one in five or one in six doses will lead to loss of viral suppression, and how frequently this is likely to happen in non-adherent patients.

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