Results from the landmark AIDS Treatment for Life International Survey (ATLIS 2010), a multi-country survey of more than 2,000 people living with HIV/AIDS (PLWHA), revealed a significant gap in patient-physician dialogue about critical health-related conditions that may negatively impact patients' overall long-term health, quality of life, and treatment outcomes. The data suggested that while patients believe they are engaging in meaningful conversations with their healthcare providers (HCPs), these discussions often do not focus on individual patient needs, including chronic illnesses, treatment side effects, or co-morbid conditions, such as cardiovascular disease (CVD), which is the leading cause of death worldwide. These and other ATLIS 2010 findings were presented today by the International Association of Physicians in AIDS Care (IAPAC) at the XVIII International AIDS Conference (AIDS 2010) in Vienna, Austria.
While the ATLIS 2010 findings showed a high degree of patient satisfaction with HCPs globally (97 percent), and the majority of patients believe they are being treated according to their individual needs (84 percent), some respondents claim to have never engaged in important discussions related to their long-term wellness, such as health history, present medical conditions, treatment side effects, new treatment options, or how all of these factors may impact their overall health and treatment outcomes. Findings further indicate the need for more in-depth discussions to reinforce the importance of adherence to HIV medicines and avoidance of HIV drug resistance.
"IAPAC is issuing a global call-to-action to encourage more individualised patient-physician dialogue to ensure that patients' personal needs, past health history, and current medical status are considered, as well as quality of life issues," said Jose M. Zuniga, PhD, president/CEO, IAPAC, and ATLIS 2010 Task Force member. "Expanding patient-physician conversations to include all aspects of a patient's well-being is crucial for long-term survival and positive treatment outcomes."
Co-morbid conditions are increasingly affecting people living with HIV/AIDS
As with all chronic illnesses, PLWHA need to be treated according to their individual needs. When deciding on treatment, it is important for physicians to discuss and consider factors such as family history, smoking, diabetes, depression, and CVD, since some treatments may be more appropriate than others for patients living with these conditions. However, ATLIS 2010 respondents reported inconsistent rates of discussion about these and other factors with their HCPs. Only half (51 percent) of respondents claimed to have engaged in HCP discussions about their past health status, and results indicated that co-morbid conditions are not being addressed with great consistency. Sixty-four percent of patients reported having at least one co-morbid condition, such as sleep disorders (21 percent), gastrointestinal (GI) issues (18 percent), or hepatitis C virus infection (17 percent). More than one-quarter of respondents (26 percent) reported having three or more co-morbid conditions.
CVD is the leading cause of death worldwide, and it affects a significant proportion of PLWHA. It is predicated upon risk factors, and can be exacerbated by antiretroviral therapy (ART). In addition, as the PLWHA population ages, CVD risk factors place them at higher propensity for heart disease. As a result, the need for CVD risk management has become increasingly important. The survey found that less than one-third (28 percent) of respondents had discussed their family history of CVD with their HCP, and 65 percent of respondents who qualified as high-risk for CVD were not engaging in frequent discussions related to heart disease with their HCP. Although approximately 15 percent of respondents were diagnosed with high cholesterol (16 percent) and high blood pressure (15 percent), not all of these respondents had engaged in dialogue about these conditions with their HCP (11 percent and 17 percent, respectively). Smoking, a risk factor for both CVD and respiratory illnesses, such as lung cancer and chronic obstructive pulmonary disease (COPD), should also be discussed in the HCP's office. However, while 28 percent of respondents reported that a history of smoking added to difficulty with their current health status, 44 percent of these respondents reported never having discussed the health implications of smoking with their HCPs.
"It is extremely common for patients living with HIV/AIDS to have co-morbid conditions that may be exacerbated by the HIV virus or antiretroviral medications," said Jurgen Rockstroh, MD, PhD, ATLIS 2010 Task Force member, and professor of medicine, University of Bonn, Germany. "We are seeing patients who are dying from complications related to co-morbidities, such as hepatitis C co-infection and heart disease. As treaters, we can help manage these events through individualised treatment approaches that consider the patient holistically to help achieve better outcomes."
Although rates of co-morbid conditions vary across regions, CVD risk factors were found to be most prevalent in North America. Among these respondents, 40 percent have high cholesterol, 32 percent have high blood pressure, 12 percent have diabetes, 40 percent are considered overweight, and 19 percent are obese, according to Body Mass Index (BMI) calculations. Significantly higher rates of depression were reported in North America (47 percent) than in any other region surveyed. Hepatitis C virus co-infection was highest in Russia (64 percent) and Spain (42 percent), respectively.
Side effects cause patients' burden, require attention
With the advent of ART, HIV has evolved from a fatal disease into a long-term chronic illness. As disease management has evolved, so has the need to address quality of life issues, especially related to treatment side effects. While 40 percent of respondents claimed that they do not like the way their medications make them feel, most notably in Europe and the Asia-Pacific regions (both 42 percent), and 50 percent said their medications have had a somewhat to extremely negative impact on their lives, one-quarter had never spoken to their HCP about side effects they are currently experiencing. This was particularly notable in Europe (20 percent) and Latin America (26 percent). Despite these facts, less than half (43 percent) of respondents overall had discussed new treatment options with their physician.
Respondents who reported that their medications have a negative impact on their quality of life were also more likely to have experienced side effects, such as GI issues (58 percent), fatigue (52 percent), sleep disorders (51 percent), and face and/or body shape changes (44 percent). Respondents cited pain/discomfort (48 percent) and anxiety/depression (56 percent) as the primary factors impacting their quality of life.
Additionally, respondents reported other quality of life issues, including that they dislike the way their medication makes them look (36 percent), and feel that the side effects of their medication are noticeable to other people (30 percent). Further, 38 percent of respondents in Europe and the Asia-Pacific region reported that the number of pills they take per day has a negative impact on their quality of life.
Critical need for patient literacy in treatment adherence and drug resistance
Properly adhering to HIV medications as prescribed is crucial for effectively managing the disease and avoiding the emergence of drug-resistant virus and disease progression.
According to ATLIS 2010, the majority of respondents (87 percent) claimed to have quality HCP discussions about the importance of adhering to their medications, yet nearly half (43 percent) admitted to missing at least one dose in the past month, suggesting that they may not fully understand the impact on their health. Levels of adherence varied across countries, with the highest levels reported in Brazil (89 percent) and South Africa (83 percent) and lowest in France (34 percent). Forgetfulness was most commonly cited for sub-optimal adherence (74 percent), and 11 percent of respondents thought there were no consequences to sub-optimal adherence (the correct answer being that the potential consequence is HIV drug resistance). In addition, 18 percent of respondents thought that resistance to the HIV medications they are taking is a "good thing," highlighting the need for further patient-HCP dialogue about this topic and tools to assist patients in taking medications as prescribed.
While the majority of respondents (87 percent) agreed their HCPs stress the importance of ART adherence, only 71 percent cited practical recommendations from their HCPs to maintain optimal adherence, with the lowest rates reported in North America (62 percent) and the highest among Latin-American and African respondents (80 percent for each).
"The varying levels of antiretroviral therapy adherence across geographic regions may partially be due to limitations in health literacy regarding the detrimental effects of suboptimal adherence and treatment fatigue," said Jean Nachega, MD, PhD, ATLIS 2010 Task Force member, and professor of medicine at Stellenbosch University, Cape Town, South Africa. "This critical issue requires educational, behavioural, and clinical interventions that will increase literacy about treatment adherence and HIV drug resistance to help people attain optimal adherence levels, which are crucial for achieving and maintaining treatment success."
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