It is well known and understood by everyone who treats HIV and by those who are taking medications for HIV that excellent adherence to the medication regimen is required in order for the medications to work and to prevent the virus from becoming resistant to the medications that are prescribed, as well as to other medications that may be needed in the future. The development of drug resistance is a very complicated issue. The bottom line is that many well-executed clinical trials have proven that these medications must be taken exactly as prescribed, following instructions for taking them with or without food, at the proper times and intervals. Adherence to these medications needs to be at least 95%, which doesn't leave much room for error, complacency, or "forgetting".

HIV treaters and the adherence counselors and nurses working with them spend many hours educating patients and assessing their adherence to medications. This issue is addressed intensively when a patient starts medications, and on all followup office visits. Most AIDS Service Organizations and HIV providers have a formal Adherence Program, which evaluates a patient's knowledge of HIV and his or her readiness to start medications and helps to identify any potential barriers to their success in being able to take the medications consistently. Drug and alcohol abuse and mental illness issues need to be addressed at this point, although in many cases patients with these issues are able to take the medications as prescribed. Close one-on-one counseling and support is provided, and the patient is empowered to incorporate the medication regimen into his or her daily life by examining daily routines and ways to be reminded to take the medication as well as how to prepare for unforeseen circumstances (such as working an extra shift at work). Education itself is the best tool for adherence; if patients know why medications are prescribed, believes that they will benefit from them and be healthier, and understands the implications of not taking them consistently, they will be more likely to be adherent. In addition to education, other tools to assist with adherence are the involvement of family or friends to provide reminders, charts with medication times to post in conspicuous areas of the home, organization of pills into weekly pillboxes, keeping an extra dose of medications at work, in the car, or in a purse, and electronic medication reminders.

So, what do we do when all of this fails, and a patient keeps "forgetting" to take their medications? It's back to square-one. The first thing is to re-assess the person's understanding of the importance of taking the medications as prescribed and the implications of missing doses. Next, reassess what is going on in his or her life; unusual or new stress, the breakup of a relationship, recent relapse or increase in drug or alcohol use, and transportation problems to get to the pharmacy are just a few of the many things that could result in someone becoming careless with their regimen. It might be that the patient needs to be referred for substance abuse or short-term mental health counseling.

If the patient convinces us that he or she is committed to taking the medications, but just keeps "forgetting" them, it may be helpful to help the patient to identify a reliable friend or family member who will be willing to commit to making a reminder phone call for each dose. The problem with this is that people get busy in their own lives and may forget to make the phone calls. Still, the idea of phone calls is a great one; most of us won't go anywhere without a cell phone anymore, so it makes sense that phone reminders would work. I did an Internet search for "telephone reminder calls" and "telephone wake-up calls" on Google, and came up with many services that could be utilized for this purpose. There are many different options and rates; the best I found was a place called "MyCalls". Their website is : http://www.mycalls.net/index.asp Pricing is by the minute or by the month (both are very reasonable), depending on the plan selected. The patient can choose the exact time of the calls, and can change these times online or over the phone if needed. The patient can set the ring-tone on his or her phone specifically for these calls, so that they are not ignored.

I realize that most people don't want another bill to pay each month, especially if they are not working. But the price paid for non-adherence to these medications is much higher than what one of these plans would be. Realistically, if someone can afford a cell phone, there is most likely a way to fit a reminder call service into their budget. A referral for Case Management services or Financial Planning may be beneficial.