An 18-year-old woman comes to the office to discuss test results. She was evaluated one week ago for recurrent vulvovaginal discharge and reported being sexually active with two partners, using oral contraceptives sometimes. The patient was counseled on safe sexual practices and tested for sexually transmitted diseases. The results have returned as positive for HIV. She has no significant medical history and takes no medications other than oral contraceptives. The patient's family history is significant for a mother with schizophrenia and a paternal uncle with alcohol use disorder who lives in the home with them. On hearing her test results and the recommendation to start antiretroviral therapy, she is visibly upset. Which of the following is the most important intervention to promote adherence to treatment in this patient?

Question

An 18-year-old woman comes to the office to discuss test results.  She was evaluated one week ago for recurrent vulvovaginal discharge and reported being sexually active with two partners, using oral contraceptives sometimes.  The patient was counseled on safe sexual practices and tested for sexually transmitted diseases.  The results have returned as positive for HIV.  She has no significant medical history and takes no medications other than oral contraceptives.  The patient's family history is significant for a mother with schizophrenia and a paternal uncle with alcohol use disorder who lives in the home with them.  On hearing her test results and the recommendation to start antiretroviral therapy, she is visibly upset.  Which of the following is the most important intervention to promote adherence to treatment in this patient?

Quizplus · Accepted Answer

11ec160b_3692_6dd9_9249_afe7a2564342_MD0001_00 This patient has a new diagnosis of HIV infection and will require lifelong antiretroviral therapy. Nonadherence to antiretroviral drugs is associated with greater probability of treatment failure and drug resistance, and this patient is likely at risk for nonadherence due to significant stressors (eg, family mental illness). Young patients also commonly have decreased adherence due to financial instability and frequent changes in health insurance coverage. The first step in maximizing long-term adherence is building a solid therapeutic environment characterized by openness and mutual trust. Establishing a good physician-patient partnership in which the patient feels his or her goals and priorities are being addressed and the physician is acting in the patient's interest is a necessity. Once the therapeutic relationship is established, specific interventions to maximize adherence are likely to be more effective. Strategies with proven benefit include simplifying the drug regimen (eg, combination pills, once-daily dosing), automated reminder systems (eg, smartphone application), and frequent review of medication adverse effects. (Choice B) As the patient's fund of knowledge and understanding of HIV infection increase, progressively sophisticated education can be provided regarding the natural history and complications of the disease. However, focusing on complications at the initial visit is likely to overwhelm the patient and distract from forming a therapeutic alliance. (Choice C) Once a medication plan has been determined and the patient is instructed on implementation, frequent follow-up should be scheduled to review the treatment plan and identify any ongoing barriers to adherence. However, this is not a primary objective in the initial encounter. (Choice D) This patient has significant psychosocial stressors and may benefit from counseling or other interventions. However, as with antiretroviral therapy, the success of these measures will be greatest if provided in the context of an established physician-patient therapeutic relationship. (Choice E) Reinforcing verbal counseling with written instruction can improve adherence, especially for patients with multiple conditions and medications. However, the medication regimen should not be initiated until the patient fully understands the diagnosis and trust has been established between the physician and patient. Educational objective: The first step in maximizing long-term medication adherence is building a therapeutic environment characterized by openness and mutual trust. Developing a trusted partnership that incorporates the patient's goals into the management plan is a necessity, and can make specific interventions to maximize adherence more effective. __________ References: Medication adherence: truth and consequences. (http://www.ncbi.nlm.nih.gov/pubmed/27079345)

An 18-Year-Old Woman Comes to the Office to Discuss Test