Concordance, Compliance, and HIV/AIDS
The Importance of Patient Concordance in the Treatment of HIV/AIDS
The notion of medical “compliance” has long been important when considering the issue of HIV/AIDS. The complex dosing schedules and strong drug side effects associated with treatment for HIV are so notorious that the notion of “pill burden” became linked with HIV over any other condition, prompting two rival drug companies to take the rare step of combining their patented drugs into a single medication, Atripla, in order to decrease pill burden and increase compliance among HIV patients needing treatment. The current lack of a universal treatment regiment due to factors such as cost and the complexity of CD4 count management further complicates the issue. This begs the question, is “compliance” truly the appropriate word to be using when discussing how HIV patients are treated?
Concordance versus Compliance: The Compliance Paradigm Limits Prescription of Anti-Retroviral Treatment to Marginalized Patients
The term “compliance” has come under increasingly scrutiny in medical society. Many have expressed concerns that it creates a paradigm which places the doctor at the centre of care, rather than the patient. Increasingly the medical community emphasizes the primacy of the patient in health care, and one way of doing this is by using the term “concordance” in place of “compliance.” The idea behind this is that the term “concordance” emphasizes that the patient is a full partner in their treatment, and not just a passive observer. In recognition of the value of the term, it has been embraced by Britain’s National Health Service, and is taught at some medical schools in North America as a term that is preferable to compliance.
The debate over “concordance vs. compliance” is not a pedantic squabble over semantics. Within the current Western medical “compliance paradigm”, patient communication can be stifled and demographic groups marginalized. Researchers have shown in various studies (such as the study “Why Is Highly Active Antiretroviral Therapy (HAART) Not Prescribed or Discontinued?” (Basseti Et al., 1999)) that individuals from groups which are perceived as not having the ability to follow HIV drug regimens (due to factors such as education level), not only have their ART treatment discontinued more often by physicians, in many cases it is not even offered. This punishment for the failure to follow “doctor’s orders” can be disastrous and contradicts clinical studies which show that giving ARTs to marginalized patients has consistently positive results, it also ignores the success of ART in areas of Africa where individuals are more marginalized than in the developed world and access to education is nearly non-existent. Despite this evidence, discriminatory prescribing behaviour continues.
The Concordance Paradigm Facilitates Communication between Physician and Patient, May Help Structure Treatment Breaks
Not all agree with the use of the term concordance, in a 1999 editorial in the British Medical Journal entitled “Taking Medicines: Concordance is Not Compliance”, three health professionals from the Concordance Coordinating Group expressed their concern:
“Concordance requires the agreement of two parties. It is not possible to impose concordance. If concordance is successful some patients will decide not to take their medicine and some may decide to alter their treatment, and the outcome may not be what the clinician thinks is best”
This statement is misguided. The editorial assumes that a medical paradigm currently exists that does not require the agreement of two parties, and that it is possible to impose compliance. According to the World Health Organization’s publication "Adherence to Long term Therapies: Evidence for Action", 50% of chronically ill patients in the west are ‘non-compliant’ under the current compliance paradigm; clearly the illusion of an all powerful doctor with the ability to impose his will on patients has no basis in reality.
The importance of the term concordance lies in the communication it facilitates, so that both doctor and patient can understand the other's motivations. Under a concordance system, an HIV patient experiencing harsh side effects from treatment may be more likely to be able to work out a structured treatment break with their physician. Under a compliance system, a physician is more likely to not understand the patient’s motivation and ‘order’ them to continue their treatment, possibly resulting not in the treatment continuing, but in the patient implementing their own unsupervised treatment breaks. Under either system the patient may make decisions which ultimately are maladaptive to the maintenance of their health, however under the concordance paradigm it is more likely that the patient will make less of these decisions, and when they do make them, the doctor will be aware of this and better able to adjust the patient’s care appropriately.
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