The human immunodeficiency virus (HIV) is a retrovirus that is responsible for the Acquired immune deficiency Syndrome (AIDS). AIDS is a pandemic that affects more than 30 million individuals worldwide (Caldbeck, et al., 2009). Despite numerous efforts, no known cure for HIV/AIDS has been found up to this moment. However, there has been marked progress in the development of antiretroviral therapy (ART) in the past decade. The effectiveness of the ARV therapy depends on patient’s adherence to the particular treatment regimen. Therefore in order for the therapy to be effective it is imperative that the drugs are taken on time to ensure that the adherence level does not go below 95% (Family health international, 2004). There are several factors that make it difficult for patients to achieve this adherence levels and thus compromise the effectiveness of the ARV therapy. This paper seeks to describe the current HIV adherence factors and the challenges faced, and then identify a suitable nursing theory and how it can be applied to improve adherence in HIV/AIDS medication.
Current HIV medication adherence factors and challenges
Successful ARV therapy results from an adherence level of 95% and above, this is according to numerous ARV adherence research studies. Such adherence levels are effective in “controlling the replication of HIV virus and therefore allowing for an optimal therapeutic response to other medications” (Cauldbeck, et al., 2009, p. 9). If the patient adherence levels fall below 95%, there is a higher chance that incomplete suppression of the HIV replication will occur (Cauldbeck, et al., 2009). In addition, the HIV virus may develop resistance to the anti-viral drugs. Development of resistance is the worst effect of suboptimal adherence as it may lead to “increased potential for regimen failure, compromise future treatment options and lead to increased risk of mortality” (Mabuse, 2008, p. 40).
Several factors are found to be associated with suboptimal adherence to ARV therapy. The life long need for the ARV drugs is a major factor, especially when patients start to feel better and thus think that there is no need for further medication. Other challenges to ARV adherence may come in the form of: side effects that are witnessed in the short term, such as nausea and headache; toxicities to body organs that occur in the long term, this may include glucose intolerance and peripheral neuropathy; the complex nature of the ARV regimen may pose a significant challenge to a patient; presence of other co-morbid conditions in HIV/AIDS patients; poor attitude towards such kind of treatment and the healthcare system in general; personal circumstances such as poverty and a prohibitive cost of health care (Family health international, 2004).
Infants and children on ART program may pose the following adherence challenges: inability to comprehend the need for drug adherence at a given age or developmental stage; resistance and inability to swallow certain formulations of drugs such as pills or liquid (Family health international, 2004).
Several evidence based measures can be taken to enhance adherence to ARV medication. Proper intervention mechanisms are required to improve the patient’s quality of life and achieve a significant reduction in AIDS related morbidity and mortality (Mabuse, 2008). The interventions can be categorized broadly into those necessary before starting the antiviral therapy and those during the therapy. In first category, the patient’s readiness for ART should be assessed (Family health international, 2004). This should be followed with the identification of the various support measures that will facilitate effective adherence. Thirdly, the “importance of adherence and consequences of non-adherence” should be well spelt to the patient (Caldbeck, et al., 2009, p. 3). After the ART program has been started, the patient should be provided with the necessary “social support, ongoing education on the importance of adherence, use of reminders such as medication charts, and improved communication with health care provider” (Mabuse, 2008, p. 5).
To assess whether a patient is or is not adhering to the ART treatment regimen, patient self reporting is usually required. This methods is however subjective and therefore a three day reporting framework is often required to maintain accuracy (Mabuse, 2008). An “ART adherence counseling form that is developed for collecting and recording data on patient ARV adherence” is usually provided (Cauldbeck, et al., 2009, p. 5).
The self care deficit theory
The driving force behind Orem’s development of the self deficit theory was the quest to find the meaning of nursing and to develop a body of nursing knowledge based on research (Reeser, 2010). Orem’s self care deficit theory can be split into the following components.
Self-care is a “human regulatory function” that relies on the individual’s ability to care for the self (Fawcett, 2005, p. 45). Nurses can reveal form their own personal encounters that there is an association between self care, self care agency and therapeutic demand (Fawcett, 2005). When a patient is so sick that he/she fails to provide self-care, self-care deficit comes into play and the nurse does the activity the patient was not able to do.
This has various meanings depending on the situation and context in which it is being applied. It can be used to describe: “the power inherent in human capabilities essential for deliberate action; a self action repertoire, and the relationship between the two” (Fawcett, 2005, p. 57). The theory of self care explains the need of taking care of self, known as the self care fundamentals, the means of utilized for taking care of self, known as the agency and the results for this which are referred to as the self care practices (Reeser, 2010).
Therapeutic self-Care Demand
“Therapeutic self-Care demand represents the totality of action required to meet a set of self-care requirements using a set of technologies” (Reeser, 2010, par. 6). There are two types of self care requirements. The first is the universal type which refers to the general self care requirements for all people but requires modification in accordance to health state, age, developmental state and sex. The second is the health deviation type, which refers to requirements that have their origins in disease processes and their effects or medical technologies (Reeser, 2010). The technologies for accomplishing the requirements include “the methodologies involving use of specific resources that are valid in meeting a requirement” (Fawcett, 2005, p. 5)
Self care deficit
Orem affirms that “if a person’s capabilities are inadequate to meet the therapeutic demand a self deficit exists”, two concepts relate to the self care deficit (Reeser, 2010, par. 5). First, “actual self-care deficit, which is defined as a descriptive statement of the relationship between the therapeutic self-care demand and self-care system in which the actions specified by the self-care demand and present or absent from the self-care system” (Fawcett, 2005, p. 82). The second is “the potential self-care deficit, a descriptive statement of the relationship between the therapeutic self-care demand and the predicted self-care limitations” (Reeser, 2010, par. 6).
Critics have pointed out that Orem’s self care deficit theory does not encompass all aspects of nursing. For example, the theory does not offer a clear definition of “family, the nurse society relationship and its public education areas are weak” (Reeser, 2010, par. 7). These areas are vital in the management and caring of patients. The other “limitation is found in the theory’s definition of health as being dynamic and ever changing with states ranging from health or non health, wellness or illness” (Reeser, 2010, par. 7). The theory is also seen to put more emphasis on provision of care while saying little about psychological care.
How the theory can be applied in HIV medication adherence
Orem’s theory of self care deficit can be used to enhance the nursing care for HIV/AIDS patients. This should include activities to enhance adherence to ant-retroviral treatment regimen (Cauldbeck, et al., 2009). Nurses can actually be effectors of the several already outlined measures that should be taken to enhance ART adherence. This is actually captured by the “therapeutic self care demand where nurses are required to be” aware of disease progression and manage it (Reeser, 2010, par. 5). As per the above section of the self deficit theory nurses should specifically carry out the following: Assess the patient’s readiness for ARV therapy through observation and evaluation of emotional status; identify the various support measures that can be used to facilitate successful patient adherence such as family, friend and counseling services; the nurses should be on the forefront in educating the patients on the importance of adherence and the consequences of non adherence (Fawcett, 2005). For instance, the nurse should let educate the patient on drug resistance and the effects of uncontrolled viral replication. Lastly nurses should ensure that patients provide accurate reports on their ART adherence. This can be achieved through constant visitations to check on the patient’s adherence (Fawcett, 2005).
Cauldbeck, M., O’Connor, C., O’Connor, M., Saunders, J., Rao, B., Mamtha, G., et al. (2009). Adherence to anti-retroviral therapy among HIV patients in Bangalore, India. AIDS Research and Therapy , 6405-7.
Family health international. (2004). Antiretroviral Therapy (ART) Program: Standard Operating Procedures, ART adherence and counselling. New York: USAID.
Fawcett, J. (2005). Contemporary Nursing Knowledge: Analysis and Evaluation of Nursing models and theories in their work. Philadelphia: F. A Davis.
Mabuse, M. (2008). Challenges of Antiretroviral Medication Adherence in HIV/AIDS infected Women in Botswana. Pretoria: University of South Africa.
Reeser, J. (2010). Dorothea Orem’s Self-Care Requiites . Web.