Non-adherence of Antiretroviral Therapy Among Hispanic-Americans Living with HIV

Authors:

Antonio J. Carrion, PharmD, MPH, AAHIVP, CPh

Associate Professor of Pharmacy Practice Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences Tallahassee, FL 32307 Antonio.carrion@famu.edu Phone: (850) 412-7376

*Briana Journee, PharmD, MBA, AAHIVP, CPh (Corresponding Author)

Assistant Professor of Pharmacy Practice Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences Tallahassee, FL 32307 Briana.journee@famu.edu Phone: (850) 599-3687

Jovan D. Miles, PharmD, AAHIVP, CPh

Assistant Professor of Pharmacy Practice Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences Tallahassee, FL 32307 Jovan.miles@famu.edu Phone: (850) 599-3301

Michael D. Thompson, PharmD, AAHIVP

Professor of Pharmacy Practice Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences Tallahassee, FL 32307 Michael.thompson@famu.edu Phone: (850) 599-3301

Fajr Hassan, PharmD, BCADM, CPh

Director of Pharmacy Encompass Health Rehabilitation Hospital Tallahassee, FL 32308 fajr.hassan@encompasshealth.com Phone: (850) 656-4832

Rashida Hudson, PharmD

Clinical Pharmacist Encompass Health Rehabilitation Hospital Tallahassee, FL 32308 fajr.hassan@encompasshealth.com Phone: (850) 656-4832

Brandi Bethune

Doctor of Pharmacy Candidate, 2020 Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences Tallahassee, FL 32307 Email: brandi1.bethune@famu.edu Phone: (334) 669-1108

Kimberly Mesumbe

Doctor of Pharmacy Candidate, 2021 Florida Agricultural and Mechanical University College of Pharmacy and Pharmaceutical Sciences Tallahassee, FL 32307 Email: kimberly1.mesumbe@famu.edu Phone: (470) 848-0291

Key Words

HIV, Hispanic-Americans, Hispanic, Latino, Latinx, Antiretroviral therapy (ART), Non-adherence

Disclosure

The authors of this article report no financial or commercial relationships with any pharmaceutical or medical education companies.

Introduction

Since 2006, Hispanic or Latinx Americans have continued to be the leading and fastest growing ethnic minority group in the United States. 1 The Hispanic/Latinx community includes people of either Cuban, Mexican, Puerto Rican, South American, Central American or other Spanish culture or origin, regardless of race. 1

From 2000 to 2007, they accounted for nearly half of the nation’s population growth. 1 As of 2018, there are approximately 59.9 million Hispanics living in the United States. Although they only comprise 18.3 percent of the U.S. population, Hispanics represent about 27 percent of all HIV/AIDS cases nationwide. 2 The incidence of new HIV infections within the Hispanic population can be attributed to an influx of immigration, meager access to care, lack of health literacy/education, intravenous drug usage and an increasing number of men who have sex with men (MSM) population. 3

Because HIV attacks CD4 cells and depletes the immune system, life-long treatment with highly active antiretroviral medications should be introduced to suppress viral progression and control the activity of the disease. Different factors act as obstacles to treatment adherence in the Hispanic population. There is also a a high level of stigma. Some of these inhibiting factors include cultural stressors that make them more apprehensive to seek or maintain treatment adherence. 4 Inadequate social support, quality of patient-provider communication and relationships, medication side effects, and language barriers all account for a rise in antiretroviral medication non-adherence in this population. 4

Medication Adherence

Maintaining an appropriate therapeutic schedule of antiretroviral medications can be a challenge, which impacts a patient’s adherence to antiretroviral therapy. Adherence to a pharmaceutical drug regimen is generally characterized as the extent to which patients properly take their medications as prescribed by their health care providers 5 . To achieve optimal efficacy, antiretroviral medication regimens require an extremely high rate of adherence (90-95 percent or better adherence to doses) to achieve an undetectable plasma HIV ribonucleic acid (RNA) level, to suppress the virus, and boost the CD4 cell count for long-term benefits. 5 Common reasons associated with non-adherence include forgetfulness (i.e. elderly), priorities, decision to omit doses (self-dosing), lack of information or patient education and emotional factors. Furthermore, social factors, stereotypes, poor family relationships and language barriers that contribute to misunderstanding medication instructions can influence adherence to treatment. 6 Many people with HIV/AIDS may be on regimens that require them to take five or more pills per day at various dosing intervals, which can also contribute to none adherence. 6 Additionally, certain types of antiretrovirals (i.e. protease inhibitors), have food restrictions or requirements due to the drug’s mechanism of action that can be burdensome to patients. 7

Social Support

The social support network is a vital part to a patient adhering to their medication regimen. Social networks can involve the absence or presence of support from family or friends, certain levels and type of support, satisfaction with

social functioning, and assessments of support received relative to what is needed. 8 The depiction of social support has been identified as a strong and consistent predictor of successful adherence management in those living with HIV/ AIDS. 8 A few elements that can improve support are encouragement, information, listening, understanding from family and friends and perceived interpersonal manner and conduct of health care providers. 8 There have been instances, however, where those who are single, live alone and have a smaller household were associated with greater adherence. Moreover, satisfaction with support from a partner was associated with medication adherence but that broader support from friends and family was not. Overall, social support is key in achieving and maintaining antiretroviral medication adherence.

Patient-Provider Relationship

A sound physician-patient relationship is critical to Hispanics learning how to accept and settle into treatment requirements. The strong rapport enables the provider to understand the patient better and establish the necessary lifestyle changes that will promote constant adherence to treatment. 9 The engagement between the patient and provider will allow respect to be garnered, access to health care that involves the patient in decision-making (information sharing), and medical support from the provider on the patient’s behalf. 10 Hispanics that were engaged in their health care proved to have greater adherence to their medication regimens than those clients who were less engaged and were less likely to follow provider advice. 9 Patients with lesser quality relationships with their providers had a deleterious effect on the attitudes of patients, ultimately impeding adherence. 10 The patient-provider collaboration can lead to lifestyle-tailored (individualized) regimens that enhance adherence and the patients’ willingness to continue therapy longitudinally. 10 Adverse Drug Effects

Treatment with antiretrovirals is associated with a number of adverse effects that have short-term and long-term consequences. Adverse effects can include nausea, skin reactions, diarrhea, lipodystrophy, hepatic toxicity, bone marrow suppression, hyperlipidemia, skin problems. These are closely associated with missing antiretroviral medications. 11 Women and men are similar in their overall reports of adverse effects, and the Latinx community reports more adverse effects to ARVs than white or African American patients. 6 Non-adherence also increased when health care professionals responded negatively to patient complaints about medication side effects. 8 When providers dismissed or minimized such side effects, some participants reported discontinuing their regimen. 9 When health care professionals reacted in a caring way to their patients’ disclosure of adherence problems and helped them solve such problems, overall the patients’ adherence improved. 10

Language Barrier

Communication plays the most prevalent role in how we interact with each other on a daily basis. Language barriers can cause significant problems for patients such as hindering them from communicating with their physician, comprehending medical regimen information and adherence. Spanish-speaking Latinos are significantly more dissatisfied with their medical care because they did not comprehend their physician’s or pharmacy’s instructions that were written in English.

Most patients have a difficult time understanding the provider’s medication administration instructions and will, therefore, force the use of a translator. Health care providers may sometimes provide translators, while others complained that they were not readily available or, if available, did not

A SOUND PHYSICIAN-PATIENT RELATIONSHIP IS CRITICAL TO HISPANICS LEARNING HOW TO ACCEPT AND SETTLE INTO TREATMENT REQUIREMENTS. THE STRONG RAPPORT ENABLES THE PROVIDER TO UNDERSTAND THE PATIENT BETTER AND ESTABLISH THE NECESSARY LIFESTYLE CHANGES THAT WILL PROMOTE CONSTANT ADHERENCE TO TREATMENT.

translate accurately and adequately enough for principal communication. 4 Since health care providers who speak Spanish are scarce, trained translators need to be readily available for HIV-infected Spanish-speaking patients in order to ensure accurate information conveyed to the patient by the provider. 9 Because communication between Latinx HIV-positive patients and health care providers is a significant obstacle, understanding and overcoming the linguistic barriers is critical in managing disparities in health care. 4

Conclusion

In 2017, HIV/AIDS was among the leading causes of death among Hispanic/Latinx men and women aged 25-44. 12 Greater acclimation into U.S. culture has both positive and negative effects on the health behaviors of Hispanics/Latinx. 3

The countless barriers to ARV therapy adherence that face monolingual HIV patients are the same as those found in non-Latinx/Hispanic English-speaking patients. 4 The management of medication adherence is more complex by the thought of multiple, overlapping factors that impact adherence. In providing social support, loved ones can remind those infected to take their medication, take command of the dosing interval and offer appropriate nutritional support by providing meals. Emotional or informational support from friends and family, quality of patient-provider relationships, side effects of antiretroviral medications and communications barriers are noteworthy in regard to adherence behaviors in Spanish-speaking Latinos receiving antiretroviral medications. 4

A focus on enhancing health literacy and maximizing communications with health care providers is particularly essential in those communities where HIV infection rates are increasing, affecting individuals’ ability to adapt to rigorous medication therapy plans and regimens. 9 However, to develop appropriate intervention programs for HIV-infected patients, the barriers to adherence must be understood and curtailed. 5 In all, empowering patients to take ownership of their therapy can significantly improve medication adherence among Hispanic-Americans and will inevitably benefit the fight in this epidemic.

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