AIDS Community Research Initiative of America (ACRIA) - Summer 2005

Over the past nine years, many people living with HIV and AIDS have been treated with highly active antiretroviral therapy (HAART) - three or four drug combinations. Just as the effectiveness of HAART varies from person to person, so too does the profile of side effects and problems related to the medications. In this article, I will focus on the experiences reported by over 300 individuals currently receiving HAART. We interviewed these people for the "Choices in Care Study," a project that we are conducting with the New York State Department of Health AIDS Institute to look at patients' perceptions of care in the Medicaid program, including both those in Special Needs Plans (SNPs) and fee-for-service clients. SNPs are Medicaid health plans for people with HIV/AIDS in New York. They offer primary care by providers who are HIV specialists, case management, and other supportive services.

As part of this study, we asked people about the medications they are taking, their pattern of adherence over the past weeks and months, and their reasons for missing medications, including side effects. We also included questions to look at the impact of medication problems on individuals' emotional well-being, level of activity, and overall health. In a follow-up interview, we also asked a subset of people who mentioned difficulties with their medications whether or not they have sought assistance from their providers and, if so, whether this assistance has helped to resolve their problems. It will be useful to consider some of our main findings to get a sense of the problems people on HAART encounter and how they have tried to get help. Overview of Sample We conducted the interviews discussed here between April 2003 and December 2004, including 289 Medicaid fee-for-service clients and 92 Special Needs Plan clients. This sample was quite diverse, including 48% women, 59% African American, and 36% Latino. The average age of the participants was 46 years, with about 25% age 40 or younger and 25% age 51 or older. In terms of education, 35% of the sample had less than a high school education, 40% had a high school diploma or the equivalent, and 25% had at least some college. About 94% reported monthly incomes of $1000 or less, with about 13% of participants working for pay. Just over 10% of the sample was unstably housed. At this stage in our study, we can use our data to examine trends in the sample as a whole. As our sample grows over the next few years, we will be able to examine choices in care related to gender, ethnicity, age and other important characteristics.

On average, people received their HIV diagnosis 9.7 years ago, with 21% of the participants diagnosed in the past five years and 14% diagnosed more than fifteen years ago. Many study participants reported a history of multiple risk factors for HIV exposure, including 31% injection drug users, 19% men who had unprotected sex with other men, and 80% unprotected heterosexual sex. In terms of health status, 75% of participants reported knowing their current HIV viral load, and of these, 46% said that it was undetectable. Among 78% who were able to answer, 16% stated that their CD4 count was under 200. People in our sample started receiving treatment for HIV an average of 7.3 years ago. In terms of current medications, 41% said that they started their present regimen within the past year, while 25% said that they have had the same prescriptions for three or more years. Who Is Taking Antiretrovirals? The majority of study respondents (299 out of 381, or 78%) reported that they were currently taking antiretroviral treatment. The remaining participants stated that they had never taken antiretroviral medications (9%), were not currently taking medications (8%), or were on a prescribed (3%) or self-initiated (2%) drug holiday. Patients not receiving medication for any reason were more likely to have used crack cocaine or heroin in the past three months or to be unstably housed. Of those participants currently prescribed antiretroviral medications, the number of all types of pills (antiretrovirals, other prescription, and non-prescription) taken each day varied, with 36% taking 5 to 9 pills, 31% taking 10 to 14 pills, and 24% taking 15 or more pills per day. Most participants (66%) took pills twice per day, although 10% had to take pills four or more times per day.

We first asked people whether or not they were seeking help for their concerns. We found that about half of the people in both groups were already receiving professional help. Although the numbers were small, people in the side effect group were twice as likely to be looking for professional help (15% versus 7%) or to be considering help in the future (23% versus 12%). In contrast, only 13% of people experiencing side effects said that they would not consider professional assistance, compared with 29% of people with other medication issues.

When we asked people about factors that they considered in deciding whether to seek help, we found similar concerns in the two groups (see Table 2). Although they expressed similar considerations, these factors seemed to carry different weight for people in the two groups. For people affected by side effects, the strongest factor influencing whether they had not or would not look for professional assistance was the fear that nothing would help. Alternatively, people with other treatment issues were mainly deterred by a lack of information.

We next turned our attention to those people who were receiving assistance for their medication-related concerns (30 with side effects and 21 with other treatment issues), to examine their experiences in care. Satisfaction with assistance for the specific problem at hand was quite high among both groups, with 83% of those experiencing side effects and 81% of those with other treatment issues indicating that they were "very satisfied," the highest rating on a four-point scale. In fact, no one in either group indicated that they were "very dissatisfied," the lowest rating on our four-point scale.

Despite these overall high satisfaction ratings, 33% of people with side effects and 19% of those with other treatment issues did experience one or more problems in getting their need addressed (see Table 3). Compared to the other group, people with side effects were particularly concerned about the lack of time to discuss problems. Although these concerns were relatively infrequent, when they arose they did impact satisfaction. On average, people seeking help for side effects expressed concerns about their care twice as often as people who sought help for other reasons. Unresolved Problems With Medications Overall, people experiencing side effects tended to have more difficulty resolving these problems than people who mentioned other treatment issues. Problems were fully or mostly resolved for 28% of people experiencing side effects, compared to 49% of people with other treatment issues. Resolution of problems concerning side effects were most related to help-seeking and to having necessary information. When we asked people what they did to address problems they encountered in care, several expressed a tenor of frustration:

• It's always about taking the pills.
• I feel I had to fight for what I wanted.
• Never a clear plan - a feeling of uncertainty.

A number of people felt that they had to go it alone:

• I feel rushed. My provider does not take this problem seriously.
• I'm doing nothing…dealing with the situation.

Some people were trying to cope with medication problems independently:

• I have spaced out medication so my body is not overwhelmed all at once by medication.
• I try to remind myself to take meds.

Others were able to pursue help from their primary care providers (PCPs):

• They reduced my dosage of medications and they are running more tests.
• PCP has helped establish a method/routine to help me get back on track with my meds.
• PCP has been advising me and suggested I go into recovery.
• I've been given medications to help with back problems.

Still others sought help from outside sources:

• I've talked to my gynecologist about it.
• Talked to my significant other.
• I've talked to the social worker about it.
• I'm going to wait and see if the drug study at [local hospital] will help me, otherwise I will make a decision to get off meds.

One surprising finding that helps to illuminate this point involves lipodystrophy. We expected to hear more about this concern when we asked about medication side effects. In fact it was rarely mentioned. When we dug a bit deeper into our data set, we found that about 8% of our full sample did mention concerns related to deposition of body fat in response to later interview questions about wellness and prevention. People specifically mentioned the desire to lose weight, control diabetes, or improve diet and exercise. We checked to see whether these weight-related concerns were more common among people who also experienced medication side effects. Instead, we found that only 2% of people with side effects also expressed concerns related to excess weight, compared to 12% of the people who mentioned other medication problems and 10% of the remaining sample with no medication concerns. In other words, people seemed to focus on weight loss when they were otherwise feeling better. They did not equate weight loss with getting help with a medication problem. Alternatively, weight-related concerns seemed to be less important to people coping with discomfort, fatigue, and other side effects. This finding was specific to weight loss and did not hold true for other preventive health behaviors, like smoking cessation or cancer screening.

When people in our sample of Medicaid clients did seek help for side effects, they encountered few barriers to getting care. However, about one third of patients reported some concern that arose involving the care they were receiving, including advice that interfered with other roles, disagreements about care, providers' lack of time to address problems, and their problems not being taken seriously.

Taken together, study findings point to a need for further education of both consumers and providers. Many side effects do not show up on a lab test. The only way to detect them is from a patient's self report. It seems that some providers need to take time to draw out these concerns and pay more attention to the serious effect that they can have on a patient's well-being. Perhaps more important, consumers must feel comfortable in expressing their concerns. It is indeed troubling to hear some patients saying that they just need to learn to live with side effects or symptoms before they seek help. Other patients were focused on coping with current symptoms at the expense of more comprehensive assistance. For some respondents, seeking help for side effects raised the specter of unwanted treatment changes: patients felt that they had to tough out their discomforts in order to stick with a medication that was working. The only remedy for these concerns is open and informed problem solving, with patients and providers working at mutually acceptable strategies to promote longevity and maximize quality of life.

Bruce D. Rapkin, PhD directs the Community Research and Health Disparities Program at Memorial Sloan-Kettering Cancer Center in New York City. His work focuses on developing and strengthening community-clinical research partnerships to promote access to care and quality of life for diverse populations.

[The information presented in this article was collected as part of an evaluation of patient choices and outcomes supported by the New York State Department of Health AIDS Institute.]

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