Date of Award

January 2014

Document Type

Open Access Thesis

Degree Name

Medical Doctor (MD)

Department

Medicine

First Advisor

Frederick Altice

Subject Area(s)

Medicine

Abstract

Adherence to therapy has dominated clinical and investigational conversation on how HIV patients take medications. Adherence, although a critical concept in medication-taking behavior, is becoming increasingly limited in its relevance to patient outcomes as treatment regimens and our understanding of antiretroviral resistance development evolve over time. In this thesis, a new construct of HIV medication-taking behavior called `persistence' is introduced and defined, in order to provide researchers and practitioners with a more comprehensive understanding of patient behavior and achieve better health outcomes. Literature review of adherence, persistence, viral suppression, development of antiretroviral resistance is performed here to reveal patient, medication, and healthcare setting characteristics associated with suboptimal persistence. Impact of persistence on resistance development and clinical outcomes is also summarized. Finally, patterns of non-persistence among HIV-infected drug users undergoing directly-administered antiretroviral therapy in a prospective, randomized-controlled trial are presented along with factors associated with non-persistence. This study suggests that decreased persistence for HIV treatment, or shorter duration on therapy, is associated with increased rates of virological failure, development of antiretroviral resistance, and increased morbidity and mortality. Additionally, frequency and duration of non-persistent episodes rather than adherence may be a better predictor of clinical outcomes in HIV-infected patients on certain regimens. More emphasis on persistence when considering HIV medication-taking behavior in both clinical and research setting is warranted.

Comments

This is an Open Access Thesis.

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