Adherence issues in HIV therapeutics. Introduction: The situation

A 25-year-old well-educated, middle-class man came to our clinic in August 1995, as a referral from one of the district health centers. Three years after a negative HIV test, he was found to be HIV positive, with a CD4+ count of 32 celis/mm 3. In August 1995, his medication regimen was d4T monotherapy and Septra. At the AIDS Clinic, he began treatment with AZT/3TC and then added indinavir in May 1996. Baseline viral load was 34,000 HIV RNA copies/mL; the CD4+ count was 40 cells/mm 3. He experienced fairly severe gastrointestinal (GI) discomfort during the first 2 weeks on indinavir but was able and willing to continue the combination therapy. In September 1996, viral load decreased to 24,000 copies/mL, and his CD4+ count had increased to 82; in November 1996, his viral load was down to 1,600. He went to Europe for a month's vacation, and on his return he commented that he might have missed a couple of pills because indinavir was not available in the areas he traveled. The patient actually missed an entire week of treatment. He tried to ration the medication before he ran out and essentially reduced the dose. Importantly, he did not think this situation was significant, even though he had received extensive education regarding the importance of adherence. He continued to do well clinically, with no opportunistic infections. In December 1996, his viral load increased to