If you are taking medications to control HIV, you have been told—hopefully!—about the importance of adherence.
Why is adherence so vitally important to the success of your HIV therapy? For the answer to that question, we talked with Joel Gallant, MD, MPH. Dr. Gallant is a Professor of Medicine and Epidemiology and Associate Director of Johns Hopkins AIDS Services, Division of Infectious Diseases, Johns Hopkins School of Medicine.
“HIV medicines are unique,” Dr. Gallant told us. “Although it’s not good to miss doses or stop medications for diseases like high blood pressure or diabetes, if you do, the medicine will still work when you take it again. It’s not like that with HIV, because missing doses can lead to resistance.”
That’s what makes adherence so vitally important. Missing doses or interrupting treatment can make the drugs less effective. Breaks in treatment give your HIV the chance to mutate and become resistant to the drugs you’re taking.
Dr. Gallant explained the process to us.
“The way to prevent drug resistance is to stop the virus from replicating by taking medications,” he said. “If the virus can’t replicate, it can’t mutate, and if it can’t mutate, it can’t develop resistance. The drugs we have today can absolutely stop the virus from replicating, but only if you take them! If you miss doses, there may not be enough of the drug in your system to keep the virus from mutating, but just enough to give mutant virus an advantage over drug-sensitive virus. You can prevent this from happening by keeping drug levels high all the time.”
Missing doses lets drug-resistant strains of virus multiply, while the small amount of drug still left in your bloodstream keeps only the drug-sensitive virus in check. So the worst virus is the one that replicates fastest!
“I describe it to my patients like this,” Dr. Gallant says. “Imagine a can with a lid on it. Inside the can are all kinds of nasty creatures—snakes, bugs, rats, or whatever scares you the most. As long as you keep the lid on the can you’re OK, but if you open the lid, the strongest creatures get out. You can’t get them back, and they’re now breeding more strong creatures. You keep the lid on the virus by taking your meds. Missing doses opens the lid. That’s why adherence is so important.”
What happens if you develop resistance to your current drug regimen? You won’t get sick or die, but you’ll use up treatment options, which means that you might have to switch to a drug combination that’s more complex, includes more pills, or has more side effects.
“Treatment for HIV has become much easier,” Dr. Gallant says. “We can now control the virus with very simple regimens. We can even treat HIV in some people with a single pill once a day. As far as we know, these simple, non-toxic regimens can last a lifetime if you take them correctly. We’re no longer talking about extending your life for just a few years, but about keeping you going well into old age. That’s why it’s so important to make that first regimen work.”
Today’s HIV drugs are much better than the ones used a few years ago. One advantage is that they have longer “half-lives”—they stay active in your bloodstream longer. As a result, an occasional late or missed dose isn’t as critical as it used to be. Ask your doctor what to do if you accidentally miss a dose.
But interrupting therapy is still dangerous. “Interruptions in therapy are especially bad for people on NNRTIs—Sustiva or Viramune,” Dr. Gallant says. “I like to use Sustiva because it’s very effective, relatively well tolerated, and you only have to take it once a day. But because of its long half-life, the drug will hang around in your blood long after you’ve taken your last dose. If you stop therapy, you may have decreasing levels of Sustiva in your blood, without other drugs to protect it from resistance. And the virus only needs one mutation to develop resistance to this class of drugs. Treatment interruptions are more serious with NNRTIs than with protease inhibitors.”
So how do you make sure you don’t miss doses? “Make a connection between taking your pills and something else you do every day without fail,” Gallant says. “If you take meds before bedtime, then put your pills next to your toothbrush. If you take your pills with breakfast, put them in the cupboard next to the Cheerios.”“Having a pillbox is important, even if you only take one pill a day,” Dr. Gallant says. “Use the kind with a separate compartment for each day. With a pill box, you’ll never have to wonder whether you’ve already taken your pills or not.”
It’s also important to plan ahead. “Re-order long before you run out,” Dr. Gallant says. “People run out on a Friday and find they can’t get a refill until Monday. Some mail-order pharmacies take weeks to deliver your pills, so plan ahead.”
Traveling is tricky, too. “Don’t pack your pills in a suitcase,” Dr. Gallant says. “Keep them in your carry-on. That way if your checked baggage is lost or delayed, you still have your medications.”
“Adherence is a lot easier than it used to be,” Dr. Gallant says. “We can often get it down to as little as one pill a day, and the alternatives aren’t much harder. But I still see people fail therapy and develop drug resistance because they don’t take even that one pill.”
Don’t let that happen to you!
Copyright 2018, Positive Health Publications, Inc.
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