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Editor,—HIV infection is now considered a chronic condition. Patients will have to learn to live with the disease for their life. Therefore, the management of psychological aspects, besides clinical ones, is becoming increasingly important. In most cases the infection can be controlled by effective but complex treatments. On the other hand, people living with HIV face everyday problems related to the disease, the therapy, and a persisting social stigma which inevitably influences their behaviour. Based on this, the patients' perceptions of disease and therapy may be important in adherence of patients to treatment,1 which is now an important aspect in HIV care.2,3 The study, “Compliance in HIV” has analysed the role of these factors on adherence to therapy.
This is a multicentre observational study focused on evaluating the level of adherence to anti-HIV therapies conducted in Italy. Eligible for the study were HIV+ patients, aged >18 years using combination therapy (bi- and tri-combination therapy) identified in randomly selected days during June 1998 at five outpatient clinics (Milan, Brescia, Florence, Rome, and Naples). Patients were asked to read and sign the informed consent form. They were interviewed by trained psychologists. The questionnaire includes information on general characteristics, clinical conditions, therapy, adherence to therapy, expectation, personal relationship, and perceptions of life, the future, disease, and therapy. In particular, patients were asked to indicate how they perceive HIV disease (among the following adjectives: enslaving, cruel, threatening, invasive, constructive) and the therapy (among the following adjectives: protective, reliable, allied, exigent, enslaving). Each subject could indicate more than one adjective. Less than 5% of eligible subjects refused the interview. Adherence was measured as the number of errors made in the previous week and the past 2 months. Errors made in the previous week were indicated first and then errors made in the previous 2 months in order to help patients to recall less recent events. The kinds of errors investigated included: missing doses of one specific drug, interrupting the entire combination, altering time schedule, wrong association with food, wrong association of drugs, wrong count of pills. Adherence to treatments was defined as follows: high: less than 2 errors; medium: 3–4; low: 5 or more during the 2 months before interview.
In all, 214 HIV infected subjects were enrolled: 63.6% were males and 36.4% females. The age distribution was <24 years 3.8%; 25–34 years 43.4%; 35–44 years 37.4%; 45 years 15.4%. The average time from HIV diagnosis was 6.8 years; 61.2% of respondents reported having HIV related symptoms (currently or in the past). Combination therapies most used were: stavudine, lamivudine, indanavir (25.2%)/zidovudine, lamivudine, indinavir (10.7%)/stavudine, lamivudine (8.4%)/stavudine, lamivudine, saquinavir (7.0%)/ziduvudine, lamivudine (6.5%)/ziduvudine, lamivudine, saquinavir (6.0%).
Most respondents perceive HIV disease as enslaving (33.2%), cruel (29.4%), and threatening (29%). Among the respondents' choices, the connotation “constructive” was indicated by 36 subjects (16.8%). With regard to the perception of therapy, most patients perceived therapy as protective (88 subjects).
Table 1 shows adherence level according to perception of disease and therapy.
The perception of disease was not associated with adherence level. However, the perception of therapy as protective or reliable was associated with higher levels of adherence, and the perception of therapy as enslaving with lower ones. These findings were confirmed after taking into account potential confounding factors (including sex, age, and clinical status) and, in particular, the perception of therapy was an independent factor of adherence in strata of different perception of the disease (data not shown).
In conclusion, the patients' attitudes toward therapy emerge as important in ensuring high adherence levels. As correct adherence to treatment is a necessary condition in order to obtain therapy efficacy, these findings suggest it would be useful to consider perception of therapy by the doctor in patients' management.
We thank the patients for their participation; A Gazzani for data analysis assistance, directors of Infectious Diseases Clinics where we recruited our patients and their collaborators: Drs A Cargnel,* P Riva,* F Mazzotta,† M Di Pietro,† G Carosi,‡ S D'Elia,§ F Paoletti,§ P Filippini,¶ C Scolaro.¶ (*Osp Sacco, Milan; †Osp SM Annunziata, Florence; ‡University of Brescia; §University `Sapienza', Rome; ¶Osp “Gesú e Maria”, University of Naples.)
We also thank E Recchia, research assistance, LILA (Italian League for the fight against AIDS, National Research Center, Milan).
This study was partially granted by the Italian minister of health.