As a variety of new drugs prolongs the lives of AIDS patients, both clinicians and patients are being forced to grapple with the fruits of this success, including the need for patients to follow a complex medication regimen scrupulously.

The importance of ensuring that patients adhere to difficult medication regimens was the focus of an all-day session at this year’s Institute on Psychiatric Services in New Orleans in October. The session was sponsored by APA’s AIDS Education Program.

A key concern among clinicians is that many patients who experience a remission of symptoms and a drop in detectable levels of HIV may behave as if they are cured, according to panelists. This may result in poor adherence and unsafe sexual or other behavior.

Being on antiretroviral drugs "is not the same thing as being healthy," said panelist Francine Cournos, M.D., vice chair of the APA Commission on AIDS and a professor of psychiatry at the Columbia University College of Physicians and Surgeons.

The medications have many side effects, particularly gastrointestinal and, given that they must be taken daily in large quantities, may be difficult for people to tolerate. A consensus view expressed by panelists was that patients on multiple antiretroviral drugs must make taking those drugs a routine part of their day if they are to succeed in adhering rigorously to the drug therapy; otherwise, the odds of adherence diminish greatly.

Clinicians across different disciplines must learn how to speak with young, HIV-positive people about how having HIV and being on antiretroviral drugs has affected their lives, said session chair Marshall Forstein, M.D., chair of the APA Commission on AIDS and assistant professor of clinical psychiatry at Harvard Medical School.

The key issue is "how do people make their self-preservation a priority?," said Forstein. Many people with HIV struggle with low self-esteem, which may result in a disregard for their own well-being and that of others. Societal condemnation of homosexuality, particularly in males, imposes a huge additional psychological burden on HIV-positive homosexuals, he observed. And the new anti-AIDS drugs impose a demanding regimen where missing more than one dose every two weeks can neutralize the antiretroviral effects of the drugs and contribute to the development of drug-resistant strains of HIV. In fact, said panelists, drug-resistant strains already exist. The proliferation of drug-resistant HIV is a major challenge to those working to stem the spread of HIV and poses a major challenge to public health officials in the next decade.

Strategies for tracking adherence vary, but among the more creative is the development of a special lid for pill vials containing a computer chip that records precisely when the vial is opened and closed, said Forstein. Although it is possible for a patient to open a pill vial without taking medication, that is unlikely, said Forstein. Another tool is having patients keep a diary. The use of such tools is further reinforced by good patient-therapist communication on a regular basis, several panelists observed.

The federal Centers for Disease Control and Prevention (CDC) reports that half of all new AIDS cases start with syringe sharing among intravenous drug users. Efforts to reduce transmission by this route have been hampered by legal obstacles to needle-exchange programs despite compelling evidence that such programs effectively reduce HIV transmission. The APA Commission on AIDS supports use of needle exchange. Infected intravenous drug users serve as a major vector in transmitting HIV to nonintravenous drug users through sexual contact.

Given this reality, clinicians who wish to help patients confront their own behavior and its relevance to spreading HIV must inquire explicitly about sexual activities and substance use, said panelists Richard Herman, M.A., and Meg Kaplan, Ph.D. Herman is the administrator of Washington Heights Community Service, and Kaplan is the director of the Sexual Behavior Clinic, both of which are located at the New York State Psychiatric Institute. The importance of taking a thorough sexual and substance use history cannot be exaggerated, said Herman. It is not enough to ask about sexual behavior or drug use; the clinician must know how to do so to elicit an honest response.

Learning how to question patients is critical, said Herman. For example, among a group of men and women with mental illness asked simply if they were "gay or straight," 100 percent said they were "straight," said Herman. When the men in the group were specifically asked if they had ever engaged in any homosexual sex, 23 percent of the same group said that they had, and 3 percent said that they had done so recently. Yet none of them described themselves as homosexual when asked the first question.

Carrying the inquiry further, Herman found that 50 percent of the sexually active men and women in the group reported that they had engaged in some exchange of sex for a commodity. Sixty percent of those interviewed met the diagnosis for primary substance abuse, said Herman, and this was after the investigators had screened and excluded obvious substance abusers.

Many psychiatric caregivers, whether psychiatrists or allied practitioners, have little or no training in taking a sexual history, observed Kaplan. Caregivers may lack an understanding of which variants of sexual behavior are an acceptable part of the subculture to which patients belong. Caregivers may be uncomfortable with use of explicit terminology, particularly slang, and they may fear that either they or their patients could become sexually aroused if matters are discussed in explicit terms.

But the failure to speak to people in language they understand can literally be fatal in the realm of AIDS prevention, Herman observed. Those interested in having Herman and colleagues visit them on site to discuss AIDS prevention and medication issues at no cost can contact him via e-mail at rh189@columbia.edu. He will need at least one month’s advance notice.

Other participants included J. Stephen McDaniel, M.D., medical director of the Emory-Grady HIV-AIDS Mental Health Program and an associate professor of psychiatry at the Emory University School of Medicine; Perry Halkitis, Ph.D., associate director of the Center for HIV-AIDS Education Studies and Training and a clinical assistant professor in the department of applied psychology at New York University; Jane Martin, M.A., R.N., project director of the Delta Region AIDS Education and Training Center and an assistant professor of nursing and instructor of medicine at the Louisiana State University Medical Center; and Laura Kaplan, L.C.S.W., a member of the National Association of Social Workers Spectrum Project on Mental Health and HIV.

The Web address for APA’s AIDS Education Program is <www.psych.org/AIDS>. Other information is available at the Public Health Service Hotline at (800) 342-AIDS or the National AIDS Information Clearinghouse at (800) 458-5231.