How Substance Abuse Impact the Ability of Adults with HIV Disease to Adhere to Medications

HowSubstance Abuse Impact the Ability of Adults with HIV Disease toAdhere to Medications



Howsubstance abuse impact the ability of adults with HIV disease toadhere to medications


Thepaper has investigated how substance abuse impacts the ability ofadults with HIV disease to adhere to medications. With HIV being akey public issue, investigating ways of ending the disease is vital.From the literature, substance abusers have been found to have lowadherence levels with HIV medications. This is a major implication innursing practice considering that non-adherence results in resistantstrains to medication, affects quality of life and longevity. Forthis paper, adherence among HIV infected gay and bisexual men who arealso drug abusers has been investigated. The results indicate that,this group has a poor adherence rate. For some, adherence isconscious and deliberate, whilst for others it is unplanned. Theheightened degree of non-adherence among this group requires theformulation of various strategies to boost adherence. These includeeducation, counseling, providing social support, and monitoring. TheShuler nurse practitioner practice model has been used as thetheoretical framework which indicates the exceptional involvement ofnursing practitioners in primary care.

Introduction&amp Purpose

Thedevelopment of novel HIV drugs in the current time has considerablychanged the face of HIV disease. Since 1995, drugs which disruptviral reproduction have been developed, and this has resulted in theavailability of complex combinations of medication treatments toinfected persons. According to the Centers for Disease Control andPrevention (CDC), the advancement has contributed greatly to lifequality as well as longevity to HIV infected persons (Hinkin et al.,2004). One such medication is highly active antiretroviral therapy(HAART), which has led to enhanced clinical outcomes and virologicalimmunological (Hinkin et al., 2007). This includes low mortalityrates among HIV infected individuals. In order to attain the bestvirological and clinical response, through commitment to HAART isvital. A number of studies indicate that best viral controlnecessitates an adherence rate of no less that 90-95 percent (Hinkinet al., 2004). Though researches are currently underway toinvestigate the effectiveness of structured treatment disruption,failure to adhere to HAART results in advent of medication-resistantHIV strains, as well as amplified viral replication, with undesirablecommunity and personal health impacts.

Similarwith the management and treatment of most chronic diseases whichencompass asthma, diabetes, cancer, and hypertension, theeffectiveness of HIV medication is weakened when the infected personsfail to adhere to recommended drug treatments. A number of factorsare linked with non-adherence encompassing forgetting, changingroutines, side impacts of the drugs, emotional distress, complexityof treatment, depression, being busy, lack of support, deficiency ofopportunistic infection, and substance abuse (Hinkin et al., 2007).In addition, system level aspects for instance, quality of careoffered by medical personnel, also results in non-adherence. Thepurpose of the current paper is to investigate how substance abuseaffects the ability of HIV infected adults to adhere to medications.The paper is divided in various sections which include healthphenomenon and nursing conceptual model, literature review, clinicalimplementation and assessment methods, plan for assessment of theproblem, discussion and recommendation, and plan for assessment ofthe problem. The Shuler nurse practitioner practice model isincorporated in the research and used as the conceptual nursingmodel.

Healthphenomenon and Nursing Conceptual Model

Humanimmunodeficiency virus (HIV) has been in existence for three decades.The virus results in acquired immune deficiency syndrome (AIDS), andit has been a major global health phenomenon especially in thecurrent time. Various organizations such as the World HealOrganization have listed HIV as a world health issue. In thebeginning, the disease was characterized by limited occurrences,before reaching epidemic levels. The development of HAART togetherwith various preventive strategies has assisted in restraining thevolatile increase of HIV virus. It has been shown that in the UnitedStates, about 50,000 cases of new HIV infections are reported everyyear (Hinkin et al., 2007). This number excludes persons who are notaware whether they are infected. It is estimated that one in everyfive persons infected with HIV are uninformed regarding their status(Hinkin et al., 2007). As a result of scientific inventions, andsteps being taken to end the virus, an AIDS-free society is beingenvisioned. Some of the strategies being taken currently to reachthat goal include the following: amplifying the use of condom,providing awareness regarding male circumcision, enhancingaccessibility to the treatment of drug abuse, providing awareness andavailability of antiretroviral therapies, expanding HIV screeningwith the aim of identifying infected persons in order to provide therequired care, and prevention of transmission from mother to child(Hinkin et al., 2004). Besides, novel research is being conducted inHIV biology with the purpose of fighting suppressed HIV-virus ininfected individuals. All this effort is directed towards attainingtrue treatment for the pandemic.

Theuse of a theoretical framework by nursing practitioners (NP)indicates their exceptional involvement to primary care. It reflectsthe mutual medical and nursing responsibility of clinicians. In thiscase, the Shuler Nurse Practitioner Practice Model is used as thetheoretical framework. The model is founded on various beliefs,perceptions, as well as theoretical underpinnings mirrored in thefollowing assumptions.

  • Individuals are psychological, physiological, environmental, social, cultural and spiritual beings.

  • The NP and patient act as associates within the health care.

  • Individuals have the right of accepting or rejecting health care.

  • NP helps patients to obtain health promotion, wellness, restoration and maintenance by use of self-care actions.

  • NPs work as patient role-model during interactions, and this way, they have the possibility of influencing health associated behaviors and attitudes of the patient.

  • Wellness is a continuing procedure while health is a dynamic condition.

  • Providing health education for patients can enhance wellness and health conditions.

  • A patient’s health behaviors can be influenced by his/her family considering that it determines and supervises health practices, beliefs, attitudes, and values.

  • NP major responsibility is to offer health education for patients, that is, acts as a health educator.

  • The teaching process identifies patients as dynamic members.

  • Learning need and capabilities modify all through the lifespan.


Theemployment of nursing theory necessitates the incorporation ofbeliefs and values concerning the aspects of health, person,environment, and nursing (Shuler, 1993). These aspects in conjunctionwith the role of NP are inherent in Shuler’s model. The model ismade up of various components. To start with are the inputs whichinitiate from the NP and the patient. This means that the model hasthe ability of letting in information and energy from the environment(Shuler, 1993). Thetype of visit directsthe NP-patient interaction. This may be episodic or comprehensivewith or without a subsisting health issue. NProle modeling togetherwith datagathering actsas channels of exchanging information and energy. In the throughputsphase,the obtained information is synthesized by the NP throughidentification and diagnoses of problems whilst establishingexceptional combination of factors, needs, as well as linked problems(Shuler, 1993). The aspects of interaction are regulated by the NP toensure that the patient stays as a dynamic participant all throughthe process. This includes the input of patient concerning diagnosis.Besides, through contracting, the patient is incorporated in thehealthcare planning procedure (Shuler, 1993). The interaction betweenthe patient and the NP aims at enhancing the wellness and healthcondition of the patient through various aspects including takingpart in self-care, illness prevention, restorative actions, wellnesscare, and health promotion. These are evidenced in the model’saspects such as consultation, treatment plan development,implementation and self-care planning (Shuler, 1993).

Theoutputphase entailsreleasing information and energy to the environment through thepatient and NP. Feedbackis received both internally and externally in the model. The lastaspect is evaluationwhichaddresses the efficiency of the interaction between the patient andNP. Through feedback, it also establishes if alterations are requiredin the treatment plan or not (Shuler, 1993). The Shuler NursePractitioner Practice Model is significant for nurse practitioners infour domains which include clinical, theoretical, research andeducation (Shuler, 1993).

Reviewof Literature

HIVhas been in existence for three decades and it has become a majorpublic health issue. Nations worldwide are worried about the diseasedue to high transmission levels in spite of existing knowledge andawareness among the public. With regard to this, various strategieshave been formulated with the intention of ending the virus. Theseinclude creating awareness of antiretroviral therapies, amplifyinguse of condom, prevention of transmission from mother to child, andexpanding HIV screening with the aim of identifying infected personsin order to provide the required care. Most researchers haveinvestigated the health phenomenon in relation to effectiveness ofmedication regimen, incidence levels, as well as adherence tomedication due to various factors. Based on my readings and pastclinical experiences there was need to investigate how adherence toHIV medication is impacted by drug use, as there is a gap inliterature. Professional interest in this topic also contributed toits research in order to gain more knowledge. The health concept isof great significant to nursing practice in two domains which includeclinical and research.

Literaturehas indicated various factors which result in non-adherence to HIVmedications. Among the factors is substance abuse which results inhigh levels of non-adherence. It is argued that, as compared to otherfactors, substance abusers suffer additional complexities as a resultof interruption attributable to behavioral disorder (Hinkin et al.,2004). According to studies, substance abusers have difficulties inadhering to HIV medication regimen (Hinkin et al., 2004). Evidenceindicates that such strategies as social support, counseling,education, and monitoring can increase the adherence rates of drugabusers. Nevertheless, assisting HIV infected persons who abuse drugsto terminate drug use is projected to generate optimal outcomes forHIV medication adherence.

Accordingto Arnsten et al. (2002) substance abuse is linked with anxiety anddepression. Among HIV infected individuals, depression is a majoraspect of non-adherence as well as poor treatment results. Mostresearches have indicated the positive relationship of drug abuse andnon-adherence, with some pointing out that substance abuse among HIVinfected persons complicates their treatment and obstructs healthpromotion and life quality (Hinkin et al., 2007). Low adherencelevels of below 95 percent along with substance abuse results inviral repression.

Themajority of the researches which explore HIV medication problemsamongst drug abusers have targeted ethnic minorities, injection drugabusers, homeless persons, low income individuals as well asheterosexuals (Arnsten et al., 2002). These studies have tried torelate sexual behaviors and substance abuse. Such drugs asmethamphetamine are used by the gay community to commence and improvesex encounters. The drug has been incorporated in various aspectsincluding sex clubs, circuit parties, and bathhouses. Theseindividuals, who are at high risk of HIV infection, have reportedhigh levels of non-adherence to medications. As revealed by studies,adherence to HIV drug regimen is as significant as adhering to theprescribed dose (Reback &amp Shoptaw, 2003). Studies have alsoindicated that non-adherence can be planned or unplanned. Somepatients deliberately ignore to take medication pills whilst forothers it is unconscious.

Aspointed out in the Shuler Nurse Practitioner Practice Modelindividuals have the right of accepting health care. This impliesthat HIV infected drug abusers who deliberately ignore to take pillshave the right of doing so, at the expense of their wellness. Asindicated in the literature, formulating strategies to increaseadherence levels is paramount. Such strategies encompass counseling,education, social support and monitoring. This is in line with Shulermodel which indicates that providing health education for patientscan enhance wellness and health conditions. Besides, patient’shealth behaviors can be influenced by his/her family considering thatit determines and supervises health practices, beliefs, attitudes,and values. NP helps patients to obtain health promotion, wellness,restoration and maintenance by use of self-care actions. These mayinclude terminating or reducing drug use in order to experienceoptimal adherence.

ClinicalImplementation and Assessment Methods

Thestudy examines how substance abuse impacts the ability of adults withHIV to adhere to medications. The study targets gay and bisexual menwho are drug abusers. A sample of 50 HIV infected persons isutilized. A urinalysis test is carried out in order to test whetherthese patients are under drug abuse. Out of the 50 participants, fivepatients are free from substance abuse and they act as a controlexperiment. Adherence to medication is tracked for a period of threemonths. The assessment method to be used in this case is MedicationEvent Monitoring System (MEMS) cap which acts as an electronicexamination device. It is used to record the date and time of everypill opening. It is an effective assessment tool of monitoringadherence amongst patients who are infected with HIV. The validity ofMEMS is evidenced as it is used in clinical setting as an assessmenttool. Besides, studies have been conducted to investigate thevalidity and effectiveness of the tool. Qualitative comprehensiveinterviews would be used where the participants would be questionedregarding their HIV drug adherence behaviors. Questions range frompast and present treatment experience, history of substance abuse,social support and relationships, sexual behaviors, as well as issuesrelated to HIV. With regard to adherence to HIV medications,questions encompass prescribed regimens, modifications in regimens,medication compliance as recommended, as well as obstacles toadherence. Interviews take duration of two hours and will beaudiotaped and then transliterated. QSR.Nudist, a qualitative programwill be employed in refining and breaking down broad codes into datasections.

Thethree months study indicated that substance abusers have pooradherence to medication as compared to substance negativerespondents. Substance use was linked with more than a fourfold highrisk of failure to adhere. This results in the conclusion thatnon-adherence to HIV medication among substance abusers is a statefunction but not a trait. This implies that the acute impact ofsubstance intoxication is the key characteristic among drug abusers,which results in complexities in medication adherence. Clinicalimplication of this finding is that while dealing with HIV patientswho are drug abusers, NPs should first come up with strategies ofsolving the issue of substance abuse, to ensure high adherence rates.

Discussionand Recommendation

Thefindings of this study add up to the body of knowledge of manyresearchers who have endeavored to investigate the relationshipbetween substance abuse and adherence to medication. The findings arein line with the review of literature, which indicate that substanceabuse is linked with non-adherence to medication. According to theparticipants, non-adherence was conscious and deliberate, whereasothers were not aware and in this case, it was unintended. Those whomade deliberate choices reported a range of kinds of non-adherenceincluding skipping the whole dose, taking some drugs and skippingothers, and extending the recommended time span before taking doses.They perceived these drug alterations as constructive copingstrategies which created a sense of life control. As stipulated inthe Shuler Nurse Practitioner Practice Model, individuals have theright of accepting or rejecting health care (Shuler, 1993). Theinconsistent and limited adherence was viewed as full adherence bythe participants. As revealed in the literature review, adherence toHIV drug regimen is as significant as adhering to the prescribed dose(Hinkin et al., 2007). However, in this study, participantsconsidered that boosting their doses for some days after a period ofnon-adherence, would make them eligible as drug adherent.

Behavioraldisruption is one way in which substance abuse obstructs adherence toHIV medication (Reback &amp Shoptaw, 2003). In this study, mostparticipants reported a logical decision making procedure whileestablishing their drug adherence. According to them, the use ofdrugs for a long time impacted their capability of sustaining therequirements of HIV medication treatments. This made them toterminate their HIV medications at that period. The decisions made byparticipants mirrored their concerns regarding sustaining theirwellbeing, while taking part in harmful behaviors. This can be viewedas a self-care activity by the patient of maintaining wellness andpromoting health (Shuler, 1993).

Itis important for nursing practitioners to have an understanding ofregimen alteration while discussing about HIV medication withsubstance abusers. Certainly, most of them do not regard suchmodifications as non-adherence, and as a result, they would notreport them to nursing practitioners. This indicates the highprevalence of misinterpretations concerning medication adherence,which is harmful to patient’s health as it can result indrug-resistant strains. The complexity with medication adherenceamong HIV infected-drug abusers has made some nursing practitionersconsider it as an adequate basis of denying such patients HIVmedications. The reason is that failure to adhere results inresistant strains of HIV medications as well as other public healthissues. Nevertheless, literature indicates that not only aresubstance abusers non-adherent to HIV medication, but alsonon-substance abusers (Reback &amp Shoptaw, 2003). The implicationof this to advanced nursing practice is to come up with properassessment and evaluation tools to reduce non-adherence, forinstance, provision of counseling by NP who acts as a health educatorin the nursing practice. Besides, providing appropriate socialsupport from the family is paramount. According to Shuler model, apatient’s health behaviors is influenced by his/her familyconsidering that it determines and supervises health practices,beliefs, attitudes, and values (Shuler, 1993).

HIVinterventions are underway, and they aim at amplifying adherenceamongst substance abusers. Some of these interventions includeprovision of health education to increase awareness among thepatients on the effects of non-adherence. The main responsibility ofNP in this case is helping patients obtain health promotion,wellness, restoration and maintenance by use of self-care actions.While designing HIV interventions, one recommendation to consider isdevising culturally definite interventions which are directed to acertain population. The reason is that drug abusers are aheterogeneous grouping.

Thisstudy has greater impacts on my future clinical nursing practice.First, it has added to my body of knowledge regarding HIV medicationnon-adherence among gay and bisexual men substance abusers. Having agreater understanding of this heterogeneous group and the barriers tonon-adherence will assist me as a nursing educator to come up withstrategies of helping these patients obtain optimal health promotionand wellness. Understanding that learning needs keep on changing andintegrating patients as active members in the learning process isparamount.

Planfor Assessment of the Problem

Theheightened degree of non-adherence to HIV medication has become apublic health concern. This study has revealed that adherence rateamong substance abusers is extremely low. Certainly, drug adherenceamongst this group of individuals is essential in improving lifequality and long life, as well as reducing drug resistant viralstrain. However, research has evidenced that HIV patients fail toadhere to recommended medications, and that adherence has beenpredicated to be hard. This means that medication regimes aredifficult to sustain while adherence varies greatly.

Futureresearch should focus on the relationship of substance abuse,neuropsychological dysfunction, and adherence to HIV medication. Thisresearch is essential in helping understand the reason behindnon-adherence to medication, besides shedding more light on thisvital topic. Qualitative research is also necessitated in order tocomprehend appropriate factors in the identification of optimalcombination of interventions.

Inorder to ensure health promotion by amplifying adherence levels amongHIV infected gay and bisexual men, various intervention strategieshave been recommended. The first strategy is ensuring pharmaceuticaladvancement which is vital in lessening non-adherence challenges. Forinstance, combination of medications into a single pill, as well asdeveloping drugs with less side effects. This also means reducing thenumber, frequency and size of tablets taken every day. The secondstrategy is offering health education, counseling, as well as socialsupport to the patients. These strategies have been evidenced to beeffective. This is the work of a NP who acts as a health educator.The third strategy entails the development of good associationbetween the NP and patient, and addressing issues regardingmedications and their projected side effects. The last strategy isstrengthening support from the family members as well as monitoringadherence.


Arnsten,J., Demas, P., Grant, R., Gourevitch, M.,Farzadegan, H.,Howard, A. &ampSchoenbaum, E. (2002). Impact of active drug use on antiretroviraltherapy adherence and viral suppression in HIV-infected drug users.Journalof General Internal Medicine,17(5), 377-381.

Hinkin,C. H., Barclay, T. R., Castellon, S. A., Levine, A. J., Durvasula, R.S., Marion, S. D., Myers, H. F., Longshore, D. (2007). Drug use andmedication adherence among HIV-1 infected individuals. AIDSBehav,11(2):185-94.

Hinkin,C. H., Hardy, D. J., Mason, K. A., Castellon, S. A., Durvasula, R.S., Lam, M. N. &amp Stefaniaka, M. (2004). Medication adherence inHIV-infected adults: effect of patient age, cognitive status, andsubstance abuse. AIDS18(1): 19–25.

Reback,C. J. &amp Shoptaw, S. (2003). Methamphetamine abuse as a barrier toHIV medication adherence among gay and bisexual men. AIDSCare,15 (6): 775-785.

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