Facilitating Adherence to Highly Active Antiretroviral Therapy in Children with HIV Infection
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Facilitating Adherence to Highly Active Antiretroviral Therapy in Children with HIV Infection What Are the Issues and What Can Be Done? Emanuele Pontali Department of Infectious Diseases, Galliera Hospital, Genoa, Italy
Abstract
Treatment of HIV infection with highly active antiretroviral therapy (HAART) requires sustained adherence to treatment to maintain efficacy. In pediatric patients, adherence to HAART represents a significant challenge for treated children and for their caregivers and healthcare providers. Many factors can affect adherence to HAART including: (i) factors related to the patient and his/her family; (ii) factors related to the drug/medication; and (iii) factors related to the healthcare system. Different strategies can be employed to tackle the specific obstacles identified in these three groups, and thus to facilitate adherence. Among the key interventions centered on the patient and his/her family are the tailoring of the HAART regimen to the daily activities of the child and his/her family, and the implementation of an intensive education program on adherence for the child and the caregiver, prior to starting the treatment. Specific medication-related problems (depending on drug pharmacokinetic and pharmacodynamic properties, taste and palatability, food interactions, etc.) exist; such problems can not be solved solely by clinicians or by families. Greater commitment of the pharmaceutical industry is needed, and innovative solutions have to be identified by clinicians in partnership with drug manufacturers. Furthermore, the development of an ‘adherence strategy/program’ can be recommended to all institutions working in pediatric HIV infection. Most of the necessary interventions to be included in such progams can be easily implemented, but they require trained and committed staff (and institutions), and time to be spent with patients and their caregivers.
Highly active antiretroviral therapy (HAART) consists of a combination of at least three different antiretroviral drugs.[1,2] It has been proven that HAART can suppress HIV replication, reduce HIV-related morbidity and mortality, and improve the quality of life of HIV-infected children and adults, thus dramatically changing the natural course of HIV infection.[3-6] For these reasons, HAART has become the recommended regimen for the treatment of HIV infection in both adults and children.[1,2,7] However, many factors can affect the ability of HAART to suppress viral replication, including low potency of one of the drugs in the combination, viral resistance, inadequate drug expo-
sure, and poor adherence to therapy. Indeed, the major factor determining the success of HAART appears to be the simplest of all – adherence; ideally, patients need to take each dose of all the prescribed drugs.[8-11] In the presence of partially suppressive therapy, viral replication would select for viral variants with resistance to one or more of the drugs that are being used. Thus, since t
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