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Adherence communication: a qualitative analysis of physician-patient dialogue

Johnston Roberts, Kathleen; Volberding, Paula

Epidemiology and Social: Original Papers

Objective:  To explore how HIV/AIDS care physicians communicate with HIV-positive patients about the need for adherence to antiretroviral treatment regimens.

Design:  Semi-structured, face-to-face interviews, a qualitative research method.

Setting:  A comprehensive, multidisciplinary, HIV/AIDS practice at San Francisco General Hospital.

Participants:  Fifteen physicians, most of whom (73%) were board certified in internal medicine and/or infectious diseases; all were involved in HIV continuity care.

Results:  Most physicians engaged in both pre- and post-prescription phases of adherence communication with their patients. During the pre-prescription phase, physicians made decisions about offering prescriptions to patients, often based on their beliefs about the patient‚s likelihood of adhering to therapy. During the post-prescription phase, physicians asked patients questions about if/how they were adhering to the regimens. Physicians‚ practices, such as the length of time spent in the pre-prescription phase, the timing of the ‚check-ins‚ in the post-prescription phase, and the overall content of both phases, varied significantly.

Conclusions:  Physicians have diverse ways of communicating with patients regarding adherence to antiretroviral medications. The effect of such communication on treatment outcomes needs to be assessed; however, the potential benefit suggests that training programs should be developed to improve physicians‚ skills in this area. Further studies should be done to assess how generally applicable these findings are to other groups of physicians.

From the Department of Sociology, University of California, Los Angeles and the aSan Francisco General Hospital, University of California, San Francisco, USA.

Sponsorship: This research was supported by funds from the Universitywide AIDS Research Program, University of California, grant No. D97-SF-001.

Correspondence to Dr K. J. Roberts, UCLA Department of Sociology, 264 Haines Hall, Box 951551, Los Angeles, CA 90095-1551, USA.

Received: 8 February 1999; revised: 7 May 1999; accepted: 20 May 1999.

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Antiretroviral medications are helping many HIV-positive patients to live longer and healthier lives[1-3]. However, current regimens are complex, with numerous proscriptions regarding the timing of doses as well as patients‚ intake of food and water. If patients do not take antiretroviral medications essentially as prescribed, if doses are missed or taken improperly, resistance selection is expected, leading to clinical failure[4-6]. Moreover, resistant HIV may be transmitted[7]. Hence, adherence to antiretroviral regimens is imperative, not only for the health of individual patients, but also for the health of the public as a whole.

The United States Department of Health and Human Services (DHHS) recently acknowledged the importance of physician-patient communication concerning adherence to antiretroviral treatment regimens[8]. In a document entitled Guidelines for the Use of Antiretroviral Agents in HIV-infected Adults and Adolescents, the DHHS suggested that physicians communicate with patients regarding the importance of adhering to antiretrovirals before writing patients an initial prescription for _therapy[8]. Experts on the United States panel of the International AIDS Society (IAS-USA) also endorsed this type of physician-patient communication[2,3].

Patient adherence is a complex phenomenon that can be affected by a number of variables, including the difficulty of the treatment regimen, patients‚ access to social support, and patients‚ beliefs about the efficacy of the treatment[9]. Decades of social and behavioral science research suggest that physician-patient communication can have particularly powerful effects on patient adherence to medication regimens[9-14]. Patients who receive adequate information about their treatment regimens and believe that they are listened to and respected by their physicians are more likely than others to comply with medical advice[15]. Similarly, patients who play an active role in medical consultations, such as by asking their physician questions to clarify unfamiliar terms, are more likely than others to adhere[12,14,16,17].

In contrast, patients who receive inadequate information from their physicians and/or do not understand what they are told during medical visits are unlikely to adhere to therapy[11,13,14]. Patients who are dissatisfied with the treatment they receive from a physician and/or have unfulfilled expectations of care are also unlikely to adhere to medical recommendations[13,18,19]. Patients of physicians who use language that confuses or depersonalizes (i.e., such as use of excessive jargon) are especially unlikely to adhere to treatment recommendations[12,14].

Despite its importance, little information is available about physicians‚ patterns of communication with HIV-positive patients regarding adherence to medications. This study explored how physicians communicate with HIV-positive patients about the need for adherence to antiretroviral treatment regimens.

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This project was part of a larger study conducted by _K. J. Roberts[20]. The aims of the larger study were to explore the adherence beliefs and practices of HIV-_positive patients as well as how such individuals and physicians communicate with each other about adherence to antiretroviral therapies. This paper draws on data collected only from the physician participants; data from patient respondents will constitute a separate paper.

The goal of the study was to explore patterns of adherence communication from within physicians‚ own frames of reference, as opposed to verifying researchers‚ a priori hypotheses about such communication. For this reason, in-depth qualitative interviews were chosen as the research method. Qualitative interviews allow investigators to collect narrative data that provide rich descriptions of interviewees‚ views of their world[21].

The study consisted of semi-structured interviews with physicians who work in a comprehensive, multidisciplinary, HIV/AIDS care program. The interviews were conducted between June 1997 and January 1998. All interviews lasted between 30 and 45 minutes and were tape-recorded. Physicians were asked to describe if, how, and why they discuss treatment adherence with patients. Probe questions were asked to elicit data regarding physicians‚ own experiences communicating with patients about adherence. The following comprised the communication adherence questions from the interview guide:

  1. If yes, probe for details regarding when _discussions take place, who initiates them, what information is discussed, etc.
  1. Is your idea about the likelihood of patient adherence a factor in your decision to prescribe? Explain.
  2. Will you prescribe the drugs to a patient you believe will not be adherent to the regimen? Why or why not?

Brief summary fieldnotes were written after the interviews, and the tapes were transcribed. The resulting transcripts constituted a verbatim, written account of the interview sessions.

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The study site

Participants were recruited from the University of California San Francisco (UCSF) AIDS Program of San Francisco General Hospital (SFGH). This well-regarded, urban, public health clinic serves primarily low-income individuals from diverse racial/ethnic backgrounds. There were no formal clinic policies in place for communicating with patients about adherence at the time of the study.

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The participants

Physician subjects were recruited from the list of _physicians practicing at the clinic; 18 prospective respondents (physicians who cared for patients who were on antiretroviral therapy) were mailed a letter describing the study and soliciting their participation. Of the 18 physicians who received the letter, 15 (83%) agreed to participate.

Eight men and seven women participated. Twelve of the participants were Caucasian, one was African-American, one was Asian-American, and one reported a mixed racial/ethnic background. The age range was from 29 to 57 years, with a mean of 41 years. All physicians were board-certified, 11 in internal medicine and/or infectious diseases, one in family medicine, one in both internal medicine and oncology, and two in both internal medicine and pulmonary disease. The average length of time physicians had been practicing at SFGH was 5 years, although this ranged from _16 months to 14 years. The average number of patients the physicians had in their caseloads was 90, although this ranged from 26 to 200.

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Data were analyzed using standard qualitative techniques, including contact summary sheets, inductive generation of coding categories, marginal remarks, and memos[22,23]. Each of these techniques will be described in more detail.

According to Miles and Huberman, ‚A contact sheet is a single sheet with some focussing or summarizing questions about a field contact‚[23]. In this study, after each interview, a contact sheet was written that answered the following questions: (i) What people were involved? (ii) What was the ‚feel‚ of the interview (i.e., rapport, unusual circumstances, unexpected _happenings, etc.)? (iii) Which areas of inquiry in the initial study framework did the interview bear on most centrally? (iv) What new hypotheses, speculations, or hunches about the study were suggested by the _interview? (v) What changes, if any, should be made in subsequent interviews?

The inductive generation of coding categories is called ‚open coding‚[22]. In this, investigators break down, conceptualize, and categorize the data. Concepts are created when investigators place a label on ‚happenings, events, or other instances or phenomena‚[22]. In this project, all transcripts were perused on a line-by-line basis and codes were developed to label key themes in the data. Ethnograph (a software program for computer-based text search and retrieval) was used to help to manage data during the coding process. Specifically, all the coded segments of data were entered into Ethnograph and the program was then used to print all the data corresponding to each individual coding _category. These data were then again reviewed on a line-by-line basis and subcodes were developed for each category.

Next, marginal remarks are reflective comments that occur to a researcher as coding proceeds[23]. In this study, remarks were noted in the margins of the transcripts and were further developed into memos during the analysis process. According to Strauss and Corbin, ‚memos represent the written forms of our abstract thinking about data‚[22]. Memos are used for analytical purposes; they do not simply summarize data, they make sense of it. In this study, memos were written throughout the duration of the project to help with all phases of data collection and analysis.

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Adequacy and plausibility of data

Informal respondent validation and peer review were employed to ensure the adequacy and plausibility of the data[23,24]. First, throughout the interviews, the interviewer asked participants if she was understanding what they were saying, thus providing respondents with the opportunity to correct any misunderstandings that may have arisen and adding additional data to the project that was used to enrich the analyses and increase the credibility of the findings. Also, the interviewer often ‚checked‚ information gleaned from one respondent with another (e.g., ‚Some physicians have told me that they may not prescribe antiretroviral _medication to a patient whom they consider unlikely to adhere. What do you think about this?‚). Next, peer review was accomplished by having the method of analysis and results critiqued by two independent medical sociologists. Neither of these individuals expressed concerns about the accuracy of the findings.

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All physicians stated that they spoke to their patients about how and when to take antiretroviral medications properly, including the importance of patient adherence to these regimens. The majority of physicians revealed that this adherence communication occurred in two stages. The first stage occurred before they gave patients a prescription for the medications. During this first stage, physicians made decisions about which patients should be offered antiretroviral medications. The second stage occurred after patients began taking the medications. These two stages are described in more detail below.

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Pre-prescription adherence communication

Educate and evaluate

Most physicians stated that the pre-prescription stage of adherence communication was an extremely important part of patient education. Physicians discussed rarely being in a hurry to give a patient a prescription; rather, they preferred to take their time, giving patients a lot of information about the medications, including what to expect in terms of side effects, how to take the medications, etc. Physicians wanted patients to be ready to begin therapy before therapy began. As Md07 stated: ‚At this point, I don‚t think I ever feel that it‚s urgent to start therapy. I think that that‚s a real change over the past few months. And I think that we made a mistake earlier on, which was not that long ago, where we had the sense of urgency. We started people on meds and then we assessed their adherence. And what I‚m trying to do, as best I can, is to try to evaluate adherence as much as I can before I start people on meds.‚

Individual differences did exist among physicians regarding the length of this pre-prescription phase of adherence communication. For example, Md02 spent over a month in this phase: ‚Before I start patients on antiretrovirals, I spend at least a month just trying to tell them how important it is. So I spend the first visit talking about antiretrovirals, I give them an idea of how long the regimen they‚re going to be on, and I see them again in 2 weeks just to reinforce that and give them some time to think about it. And then after a month of them thinking about it and really trying to figure out how it‚s going to affect their lives, then we will talk and then we will prescribe the medications.‚

Other physicians reported spending more time (up to _7 weeks) or less time (a couple of patient visits) in this pre-prescription phase.

Many physicians stated that evaluating patients‚ current psychosocial situations, including where they live, how they eat, if they use street drugs, if they are depressed, and so on is another important component of this pre-prescription communication phase. Any conditions that may affect patients‚ abilities to adhere to the regimens are carefully evaluated. Physicians may do such assessments themselves or may refer patients to one of the clinic‚s social workers. As Md13 stated: ‚Usually within those three or four visits is also a visit to one of the social workers, sort of getting an assessment of their financial situation, their sort of non-medical, if you will, although I guess clearly it‚s part of their medical situation, but some of their issues in terms of ≡ housing, support, substance use, psychiatric illnesses.‚

Physicians stated that they aimed to ‚trouble-shoot‚ any psychosocial problems patients may have been having before they went on the medications. Otherwise, such problems could impede patients‚ adherence.

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HIV understanding

Most physicians reported that they discussed the range of possible antiretroviral medications available to each patient, the dosing requirements and side effects of possible regimens, and then provided some education regarding the concept of viral resistance and its relationship to adherence. Md11 stated that she had to have a good sense that patients understood all of these ‚basics‚ (or, in her words, had a good ‚HIV IQ‚) before she would be willing to prescribe the antiretroviral medications. The following is an excerpt from her interview: S: I have to really have a sense that [patients‚] HIV IQ is good, that they know what they‚re getting into.

I: Tell me what you mean when you say HIV IQ?

S: That they understand why I‚d be prescribing three or four medicines, that they have a≡really good sense of how to take them, how to manage their food, how often they have to pick up the medicines, what needs refrigeration. So just do they really understand what it involves, how good is their HIV IQ.

Although communication about the medications and patients‚ situations was an important part of this pre-prescription phase, some physicians went a step beyond such communication. For example, a couple of physicians revealed that they sat down with patients and actually wrote down a medication schedule based on the patient‚s normal daily routine. Some physicians found other ways to go beyond normal patient education and counseling. For example, one physician stated that she had all of her patients bring in their medications before they began taking the pills so that they could fill out a medi-set together. Another had her patients bring her their medications so they could look at the medication labels together, and write in _additional instructions.

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To prescribe or not to prescribe

What if physicians had a feeling that patients did not have a good HIV IQ, that they may have been unlikely to adhere to the antiretroviral regimens? Most physicians stated that if such a patient really wanted a _prescription and had been duly informed of all the risks and benefits, they would give the patient the prescription. As Md05 stated, ‚I don‚t≡play God.‚ In _contrast, two physicians stated that they would not give patients whom they believe will be non-adherent a prescription, as they feel that doing so would be doing more harm than good. Interestingly, most physicians stated that they had not actually had to withhold _antiretroviral medications from patients in their own practices, mainly because they used a variety of tactics to deal with this difficult situation.

Specifically, many physicians stated that part of their job in the pre-prescription phase of counseling was to let patients know how difficult it may be for them to adhere to the antiretroviral regimens, and how dangerous it is to miss doses. Many physicians said that they often ‚slanted‚ these discussions in particular ways with patients whom they believed had the likelihood of being non-adherent. This usually resulted in the patients themselves deciding to delay starting therapy. As Md03 explained, ‚I always ask about whether or not they‚re going to be able really to adhere to this _regimen, and I talk about how important it is. And then usually, seriously, the patients≡say, “I can‚t do that“.‚ Likewise, Md05 stated: ‚I‚ve never had a patient who I thought was very, very unlikely to take the medication who said they wanted it. ≡For some patients, I may say, “You know, your viral load is low, your T cells are high, we already - we know that with no intervention you‚re not likely to get sick in the next 5 years. Do you want to do this?“ They may say “No“. I suppose I am leading them and framing it in a way.‚

If patients persisted in wanting to begin therapy, and physicians still had doubts about the patients‚ likelihood of adhering, some physicians chose to give patients some form of ‚test‚ to see if they could be adherent. This test could involve taking medications other than antiretrovirals. For example, Md15 stated, ‚I can‚t refuse them, so what I‚ll try is, you know, the do no harm thing≡[I‚ll say,] “Okay, let‚s start with multivitamins, Septra≡and see how you do for a couple weeks, and then come back“.‚ Another physician gave patients a ‚candy test‚ to assess their adherence to the regimens. As Md07 described: ‚I came up with a new idea the other day. I‚m giving people medi-sets and I‚m getting jelly beans or Skittles or M&Ms and I‚m picking out the colors that most closely resemble the drugs that I‚m thinking about and literally filling the medi-sets, and telling people, “You don‚t necessarily have to eat these at 8:00 in the morning, but I want you to throw them away or something and I want you to figure out which ones you‚re missing and what‚s going on when you‚re missing it≡..“ This is like “let‚s see if this is going to work for you“.‚

Other physicians revealed that they gave some patients a less-than-fully suppressive antiretroviral regimen to ‚see how they do‚. As Md07 explained: ‚I saw this guy yesterday≡he‚s real clear with me that there‚s no way in the world that he‚s going to be adherent. And, I just told him, “I want you to know that there is an alternative between nothing, and everything, and that‚s something“.‚

What Md07 was referring to was giving the patient a regimen that included two nucleosides without a protease inhibitor. This is not currently considered the gold standard of therapy. Her theory, however, was to have the patient at least do ‚something‚ while there were concerns about his/her likelihood of adhering. If she prescribed ‚everything‚ (i.e., combination therapy that included a protease inhibitor) and the patient did not adhere, all of his/her bridges would have been burned, so to speak.

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Post-prescription adherence communication

Checking in

The second phase of adherence communication occurred after patients began taking the antiretroviral medications. Here, the majority of physicians stated that they did routine (often at every patient visit) check-in assessments with patients about if/how they were adhering to the regimens. Importantly, physicians had different ways of inquiring about adherence. For example, some physicians, such as Md12, asked rather general questions to assess adherence, ‚How are you doing with your medications?‚; ‚how are you taking them?‚; ‚are you having any trouble taking them?‚ Other physicians revealed that they often began with such general questions but then asked very specific ones about missed doses. As Md15 stated: ‚I‚ll start out with their drug stuff, it‚s you know, “How‚s it going with the drug use?“ or, “How‚s it going with taking the medicines?“ and, “In the last day≡did you get all the doses?“ “Over the last week how often do you think you‚ve missed doses?“.‚

Some physicians believed that asking specific questions about missed doses was a critical part of the assessment. Md07 provides an illustration of this:

S: I don‚t even say anymore ‚are you missing them?‚ ‚Are you pretty good about taking them?‚ Yeah, _everybody‚s pretty good about taking them. So be really specific. ‚How many have you missed recently?‚

I: Do you think it‚s important to ask that versus a _general ‚How are you doing with your meds‚ kind of question?

S: Yeah, yeah.

I: Say why.

S: Because I have always asked people ‚How are you doing with your meds‚ and everybody‚s ‚Oh, fine‚. And then every time I say, ‚How many have you missed recently?‚ ‚Oh, just a couple.‚ ‚A couple in the last week, a couple in the last day, a couple in the last month?‚ And then I get very specific. And I‚m learning great stuff.

Interestingly, physicians who did not ask the specific questions about missed doses stated that they believed doing so was probably a good idea; they simply had not yet incorporated it into their routines. As Md06 revealed:

I: Do you ever ask direct questions like ‚have you missed dose this week‚ or ‚did you miss a dose yesterday‚, specific questions such as those?

S: I don‚t do that much, and which I think is a good idea≡

I: And why don‚t you ask the specific questions, just out of curiosity?

S:I think I just haven‚t incorporated it into my strategy._≡But, I think asking about exactly how many: ‚Have you missed any doses?‚ I think would be a good way to get more information about it.

The time frame that physicians inquired about during the specific questions about missed doses varied: yesterday, last week, last 2 weeks, last month, last 3 months, etc. Md07 stated that she was uncertain about what time frame to use with her patients, ‚I‚m not sure yet whether I should be saying, “How many doses have you missed in the last 3 days?“ “How many have you missed in the last week?“ I‚m still kind of developing, trying to figure that out.‚

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Several physicians stated that they asked such specific questions not simply to learn the answers but also to help the patients to work out why they were missing doses, and to develop strategies to help them to do better in the future. As Md10 declared, ‚I‚m not trying to do this just so I can write a number down in the chart. It‚s to figure out strategies for addressing problems that come up.‚ Likewise, Md02 explained: ‚And then I ask them specific questions in terms of why they could be missing doses. Is it because they‚re not able to remember the evening dose for some reason or they work late sometimes and they‚re not able to get home in time to take the medicines? So I can make specific suggestions: take their medicines with them and stick it in their pocket, or carry a watch with a timer, something like that.‚

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It is important to note that not all physicians used the two-phase process of adherence communication. Rather, two physicians provided alternative examples of if and how physicians communicate with patients about adherence. Specifically, Md05 stated that he talked about adherence only when he first gave patients a prescription. He did not do extensive pre-prescription counseling; instead he gave patients written handouts. He also did not do routine check-ins after patients began the medications. Instead, he used the results of the patients‚ viral loads as a proxy for adherence. Below is an excerpt from this physician‚s interview:

I: Do you ever talk to your HIV-positive patients about adherence?

S: Yes.

I: Can you tell me about that?

S: I don‚t spend a lot of time on it. I give them handouts. I tell them≡that there‚s ample evidence to believe that if you‚re not really adherent that you‚ll become resistant._≡It‚s an ongoing iterative process, and as they get follow-up viral loads back - I think the viral load does reflect, to some extent, adherence. And I give them that information, and we talk about that.

The other ‚negative case‚ physician, Md08, also placed a lot of emphasis on the results of viral load tests. He stated: ‚I talk about it [adherence] always to people who seem to have viral loads that are increasing≡[but] the people who seem to be doing well≡I don‚t give them a big adherence lecture≡I don‚t dwell on that._≡I selectively do it with people who seem to be having a problem or who - in people whom I can assess or predict might have trouble.‚

Moreover, when Md08 talked to patients about adherence, he stated that he did not go into many of the schedule-specific, minute, detail-oriented points that other physicians did with patients. As he stated, ‚I generally don‚t≡tell the patients, “Put this on your toilet in the mornings so when you get up it‚s the first thing there, and then put this in your lunch box and put this“ - you know, I‚m not that in loco parentis.‚ Using the Latin phrase for a parental authority figure emphasized that this physician felt that dwelling on adherence, and going into specific details about manageable _routines, was outside his scope of authority.

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Most physicians in this study engaged in pre- and post-prescription phases of adherence communication with their HIV-positive patients. However, physicians‚ practices, such as the length of time that they spent in the pre-prescription phase, the timing of the check-ins in the post-prescription phase, and the overall content of both phases, varied significantly. Therefore, physicians do not have a standard method for communicating with patients about adherence to antiretroviral medications. Instead, physicians decide on their own to whom they should talk about adherence, how long to engage in such communication, and how best to phrase _questions about missed doses and other obstacles to adherence.

Importantly, physicians in this study were not always certain that they were communicating with their HIV-positive patients about adherence issues in the most effective way. Some physicians expressed uncertainty regarding how to broach the topic of adherence with patients, what time frame to use when inquiring about missed doses, etc. These findings indicate that physicians may benefit from additional training about adherence communication, especially how best to ask questions about adherence (general versus specific, what time frame to inquire about, etc.). Any such training should be flexible enough to allow physicians to tailor adherence communication to each patient‚s specific needs at each specific time (as needs may change over time).

While most physicians in this study engaged in both pre- and post-prescription adherence communication with their patients, two physicians (the ‚outliers‚) did not. Rather, these physicians preferred to limit the amount of time that they spent communicating with patients about adherence to antiretroviral medications. This suggests that even physicians who practice at one of the premier AIDS clinics in the United States may not always be willing to discuss medication adherence with patients.

Hence, guidelines such as those of the DHHS [8] or the IAS-USA [2,3] that recommend that physicians discuss adherence issues with patients may not be always appropriately translated into clinical practice. Reasons for this are unclear. It may be that some physicians are uncomfortable talking with patients about adherence, believe that discussions about medication have little tangible effect on patients‚ behaviors, or are simply too busy with other clinic responsibilities to spend much time on this task.

If physicians are unable or unwilling to talk to their HIV-positive patients about adherence to antiretroviral medications, it is imperative that patients have access to other sources of information and support. Some clinics may wish to employ a specially trained health educator for this task. Others may wish to consider the development of multidisciplinary ‚adherence teams‚ consisting of physicians, nurses, social workers, etc. who can jointly share responsibility for the assessment and monitoring of HIV-positive patients‚ adherence to antiretroviral medications.

Data from this project underscore the dilemmas that physicians face when making decisions about offering patients prescriptions for antiretroviral therapies. Some physicians stated that patients who appear unlikely to comply are not given a prescription. Most physicians stated that rather than completely denying patients the medications they will try to convince the patient that the timing is not right to start medications and then try to ‚trouble-shoot‚ problems in that person‚s life, such as substance abuse, that may impede his/her adherence. Other physicians had patients take some rendition of a test, such as taking jelly beans as if the candies were antiretroviral pills, to see if the patients could be adherent to strict and arduous regimens before they received a prescription for the antiretroviral medicines.

Most physicians stated that they sought to assess patients‚ life situations before they wrote an antiretroviral prescription. If they found that patients were currently in situations that may hinder their abilities to adhere, they sought to ‚remedy‚ the situations as best as possible before having the patient begin therapy (e.g., they may have helped a patient get into a detoxification program or find a place to live). Hence, physicians were delaying rather than withholding the medications. Importantly, most physicians stated that they had never actually had a patient wish to begin antiretroviral therapy while the physician recommended delaying such therapy. Interestingly, the outcome is the same for both delaying and denying a patient‚s access to antiretroviral therapy (i.e., the patient does not begin therapy). The difference between these two concepts is that physicians who delay therapy do so while also helping to stabilize the social/environmental conditions of a patient‚s life (e.g., help a patient to enter a drug treatment _program, get treatment for depression, or find a place to live). More stable life conditions hopefully will allow the patient a better chance at success once he/she _actually begins antiretroviral therapy. In contrast, a physician who simply denies a patient a prescription for antiretroviral medication may not be actively searching for such ways to make a patient ‚ready and able‚ to adhere to therapy.

From an ethical standpoint, some researchers and clinicians believe that delaying antiretroviral medications is preferable to withholding them. For example, in a recent commentary regarding the use of protease inhibitors in homeless people, Bangsberg and colleagues [25] argued: ‚It is ethical to delay treatment until the patient‚s life stabilizes if there is a strong likelihood that immediate treatment will lead to resistance._≡[T]here is no evidence that the time of starting therapy is critical over a period of months._≡Immediate prescription of protease inhibitors may be a disservice since patients who develop resistance while they are unstable will have lost the benefit of therapy.‚

Consequently, if there are concerns regarding patients‚ abilities to adhere to therapy, physicians may wish to delay beginning therapy, help patients to get into stable life situations, and then offer as much help and support as possible to help patients take their medications.

Lyons argued that withholding protease inhibitors from an entire population group, such as homeless people, is the ‚epitome of practicing bad medicine‚[26]. In contrast, other clinicians and researchers may believe that it is ethical to withhold medications from individuals who have a great chance of becoming resistant through non-adherence. Clearly, there are many varied and strong opinions about this issue. Hence, withholding of antiretroviral medications from HIV-positive patients should receive increased scholarly attention in the future.

While the data from this study provide a rich example of how physicians communicate with patients regarding adherence, there are some limitations to the study that should be noted. First, this study utilized a small sample of physicians recruited from one of the premier HIV/AIDS clinics in the United States. Future studies should explore the patterns of adherence communication in locales such as rural health care centers that have fewer AIDS cases and physicians who do not specialize in AIDS. It may be that physicians who do not specialize in HIV/AIDS communicate differently (if at all) with their patients about adherence to the regimens than do the ‚AIDS experts‚ interviewed for this project.

Next, this study relied solely on interview data. Further research is needed to capture actual interactions between physicians and patients in HIV/AIDS care. Future studies could employ some form of observation, either having a researcher frequent AIDS clinics and observe consultations between doctors and patients or have such consultations videotaped, with participants‚ permission. An important aim of such work could be to examine the effects of adherence communication on various patient outcomes, such as adherence to _antiretroviral regimens, morbidity, or mortality. This type of research would be a useful next step as it would document which styles of physician-patient communication concerning adherence are most related to desired clinical outcomes.

In conclusion, antiretroviral medications can help many HIV-positive patients slow the spread of HIV in their bodies, improve their health status, and extend the duration of their lives[1-3]. Adherence to such medications is likely to remain of the utmost importance for years to come. Physicians can help patients with their regimens by providing thorough information and clear communication about the need for adherence before patients begin treatment, and by periodically monitoring patients‚ progress once therapy is initiated.

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Antiretroviral medications; patient compliance; physician-patient relations; HIV/AIDS communication

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