Initiating HIV/AIDS Therapy in Treatment-Naïve Patients How do you handle the patient who demands a specific drug or regimen?
	Enlarged Version of Graphics Below	Dr. Wohlfeiler (OC): Patients will come in and sometimes they'll say, I want the one pill a day regimen, which doesn't exist. But you know that what they're getting at is that they want to take the least number of pills possible, the least number of times a day. It really has to do with the fact that our patients nowadays much more frequently are still working and leading active lives. In the old days, a diagnosis of HIV often meant that if somebody was sick, they went on to disability. They didn't really have anything to do except to manage their illness. And now that's more the exception than the rule. And so you really have to have regimens that fit into people's lives. Dr. Bellos (OC): My response, typically, to patients who always want the latest and greatest, but yet who are clinically doing well on their regimens-i.e., they've had a good immunologic response or robust immunologic response, and also a good virologic response-my response to those people is that if it's not broken, don't fix it. "Let's leave it alone." Dr. Wohlfeiler (OC): I think that all you can do is explain to a patient why that might not be the best regimen. A lot of patients who come in like that actually have got a certain knowledge base. They've read certain things, at least in the lay press. And they often have a certain amount of information and they're making decisions based on that or they're making decisions based on what a friend is on or something like that. And I have certainly had a lot of patients who come in like that. But my experience is that if you just take the time to explain to a patient why that may not be appropriate for them, they're generally going to defer to your judgment. I think that's why they're coming to you in the first place for the benefit of your experience and your judgment. Dr. Bellos (OC): When patients come in asking for the latest and greatest as naïve patients, we generally have some room to talk, because I have a little bit more room with those patients to consider and hear their input, because I think when someone comes in and asks you that question, the important thing, in my opinion, what the clinician should hear is, "I've heard about this. It's once a day." I'm getting the message that they really want therapy that's once a day that's going to be the least interfering with their lifestyle, so I think that's more of psychosocial issue in the naïve patients, but in the experienced patients who are doing well on their current regimens, if they are experiencing pill fatigue or medication fatigue with the twice daily dosing, then, we can consider an alteration, but for me and for the experienced patient who is really doing well, I really need to have a reason to really consider altering a regimen. Dr. Wohlfeiler (OC): I think it's all about trust. If you've got a good relationship with your patient, if you take the time to explain the reasoning behind your recommendation, and also what I do is present it to the patient as a recommendation. This would be my first choice, but if you feel like this is not a regimen that you can stick with, then we can talk about doing something different. I just think you have a dialog. And if a patient trusts you, they're most of the time going to go along with what you recommend. But you really do have to take the time to get to know the patient because there are certain patients that really twice a day might undermine their adherence as compared to once a day regimen.
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