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The Impact of Religion on Adherence With Antiretrovirals
Letter to the Editor JANAC Vol./ Letter Melbourne 10, No.to3,the May/June Editor 1999
The Impact of Religion on Adherence With Antiretrovirals Dear Editor, I read with great interest the supplement from Volume 8 of the Journal of Association of Nurses in AIDS Care, published in 1997. Throughout the journal, nationally recognized leaders in HIV/AIDS discussed the numerous and complicated aspects of medication adherence (Katzenstein, 1997; Katzenstein et al., 1997; Lyons, 1997; Williams, 1997). Since then, a breadth of information has been published on adherence in HIV/AIDS. Few sources have addressed the important issue of religious beliefs creating adherence challenges for patients on antiretroviral therapy. Therefore, this case is being submitted for consideration. We have a 44-year old Egyptian male who was diagnosed with the HIV virus in May of 1989. He is cur® rently on indinavir (Crixivan , Merck Laboratories) ® 800mg orally every 8 hours, stavudine (Zerit , BristolMyers Squibb Laboratories) 40mg orally twice a day, ® and lamivudine (Epivir , Glaxo Wellcome) 150mg orally twice a day. On his current antiretroviral regimen, his HIV RNA by PCR (Roche Diagnostics Systems, Somerville, NJ) dropped from 60,092 copies/mL to < 400 copies/mL, which remained stable for several months. His CD4+ lymphocyte count rose 3 3 from 214 cells/mm to 289 cells/mm . His adherence was well documented. In January, he presented to our office for his usual follow-up visit. While evaluating his most recent adherence behavior, we discovered that he had missed approximately one third of his indinavir doses (estimated at 24 doses missed in the previous 28 days) due to his activities during Rhamadan. During Rhamadan, individuals of the Islamic religion fast from sunlight to sundown, which is approximately 12 hours a day. During the fast, intake of water or other substances is prohibited. According to our patient, Islams who require chronically prescribed medication
are usually excused from fasting. However, many individuals with strong religious beliefs will fast and avoid medications during daylight hours despite their medical necessity. For Islamic patients who take protease inhibitors, such fasting conditions and avoidance of medications during sunlight hours may have devastating clinical consequences. Nonadherence with protease inhibitor doses, food requirements, and/or dosing intervals may cause viral breakthrough and may lead to the development of drug resistance (Katzenstein, 1997). Nursing Implications: Certainly, Rhamadan led to adherence challenges for our patient that we had not anticipated. Although the long-term effects of his nonadherence are not known at this time, a change in therapy may be warranted. We believe it is important for healthcare providers caring for a diversity of HIVinfected individuals to take religious beliefs into account when counseling about adherence with antiretrovirals. Sincerely, Kathleen M. Melbourne, Pharm.D. Coastal Medical—Providence, RI
References Lyons, C. (1997). HIV drug adherence: Special situations. Journal of the Association of Nurses in AIDS Care, 8(Suppl.), 29-36. Katzenstein, D. A. (1997). Adherence as a particular issue with protease inhibitors. Journal of the Association of Nurses in AIDS Care, 8(Suppl.), 10-17.
Kathleen M. Melbourne, PharmD, is director of pharmaceutical care at Coastal Medical, and is clinical assistant professor of pharmacy at the University of Rhode Island, College of Pharmacy.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 10, No. 3, May/June 1999, 99-100 Copyright © 1999 Association of Nurses in AIDS Care
100
JANAC Vol. 10, No. 3, May/June 1999
Katzenstein, D. A., Lyons, C., Molaghan, J. P., Ungvarski, P., Wolfe, G. S., & Williams, A. (1997). HIV therapeutics: Confronting adherence. Journal of the Association of Nurses in AIDS Care, 8(Suppl.), 46-58.
Williams, A. (1997). Antiretroviral therapy: Factors associated with adherence. Journal of the Association of Nurses in AIDS Care, 8(Suppl.), 18-23.
The Impact of Religion on Adherence With Antiretrovirals Dear Editor, I read with great interest the supplement from Volume 8 of the Journal of Association of Nurses in AIDS Care, published in 1997. Throughout the journal, nationally recognized leaders in HIV/AIDS discussed the numerous and complicated aspects of medication adherence (Katzenstein, 1997; Katzenstein et al., 1997; Lyons, 1997; Williams, 1997). Since then, a breadth of information has been published on adherence in HIV/AIDS. Few sources have addressed the important issue of religious beliefs creating adherence challenges for patients on antiretroviral therapy. Therefore, this case is being submitted for consideration. We have a 44-year old Egyptian male who was diagnosed with the HIV virus in May of 1989. He is cur® rently on indinavir (Crixivan , Merck Laboratories) ® 800mg orally every 8 hours, stavudine (Zerit , BristolMyers Squibb Laboratories) 40mg orally twice a day, ® and lamivudine (Epivir , Glaxo Wellcome) 150mg orally twice a day. On his current antiretroviral regimen, his HIV RNA by PCR (Roche Diagnostics Systems, Somerville, NJ) dropped from 60,092 copies/mL to < 400 copies/mL, which remained stable for several months. His CD4+ lymphocyte count rose 3 3 from 214 cells/mm to 289 cells/mm . His adherence was well documented. In January, he presented to our office for his usual follow-up visit. While evaluating his most recent adherence behavior, we discovered that he had missed approximately one third of his indinavir doses (estimated at 24 doses missed in the previous 28 days) due to his activities during Rhamadan. During Rhamadan, individuals of the Islamic religion fast from sunlight to sundown, which is approximately 12 hours a day. During the fast, intake of water or other substances is prohibited. According to our patient, Islams who require chronically prescribed medication
are usually excused from fasting. However, many individuals with strong religious beliefs will fast and avoid medications during daylight hours despite their medical necessity. For Islamic patients who take protease inhibitors, such fasting conditions and avoidance of medications during sunlight hours may have devastating clinical consequences. Nonadherence with protease inhibitor doses, food requirements, and/or dosing intervals may cause viral breakthrough and may lead to the development of drug resistance (Katzenstein, 1997). Nursing Implications: Certainly, Rhamadan led to adherence challenges for our patient that we had not anticipated. Although the long-term effects of his nonadherence are not known at this time, a change in therapy may be warranted. We believe it is important for healthcare providers caring for a diversity of HIVinfected individuals to take religious beliefs into account when counseling about adherence with antiretrovirals. Sincerely, Kathleen M. Melbourne, Pharm.D. Coastal Medical—Providence, RI
References Lyons, C. (1997). HIV drug adherence: Special situations. Journal of the Association of Nurses in AIDS Care, 8(Suppl.), 29-36. Katzenstein, D. A. (1997). Adherence as a particular issue with protease inhibitors. Journal of the Association of Nurses in AIDS Care, 8(Suppl.), 10-17.
Kathleen M. Melbourne, PharmD, is director of pharmaceutical care at Coastal Medical, and is clinical assistant professor of pharmacy at the University of Rhode Island, College of Pharmacy.
JOURNAL OF THE ASSOCIATION OF NURSES IN AIDS CARE, Vol. 10, No. 3, May/June 1999, 99-100 Copyright © 1999 Association of Nurses in AIDS Care
100
JANAC Vol. 10, No. 3, May/June 1999
Katzenstein, D. A., Lyons, C., Molaghan, J. P., Ungvarski, P., Wolfe, G. S., & Williams, A. (1997). HIV therapeutics: Confronting adherence. Journal of the Association of Nurses in AIDS Care, 8(Suppl.), 46-58.
Williams, A. (1997). Antiretroviral therapy: Factors associated with adherence. Journal of the Association of Nurses in AIDS Care, 8(Suppl.), 18-23.