Journal of General Internal Medicine

, Volume 19, Issue 11, pp 1096–1103 | Cite as

Better physician-patient relationships are associated with higher reported adherence to antiretroviral therapy in patients with HIV infection

  • John Schneider
  • Sherrie H. Kaplan
  • Sheldon Greenfield
  • Wenjun Li
  • Ira B. WilsonEmail author
Original Articles


BACKGROUND: There is little evidence to support the widely accepted assertion that better physician-patient relationships result in higher rates of adherence with recommended therapies.

OBJECTIVE: To determine whether and which aspects of a better physician-patient relationship are associated with higher rates of adherence with antiretroviral therapies for persons with HIV infection.

DESIGN: Cross-sectional analysis.

SETTING: Twenty-two outpatient HIV practices in a metropolitan area.

PARTICIPANTS: Five hundred fifty-four patients with HIV infection taking antiretroviral medications.

MEASUREMENTS: We measured adherence using a 4-item self-report scale (α=0.75). We measured core aspects of physician-patient relationships using 6 previously tested scales (general communication, HIV-specific information, participatory decision making, overall satisfaction, willingness to recommend physician, and physician trust; α>0.70 for all) and 1 new scale, adherence dialogue (α=0.92). For adherence dialogue, patients rated their physician at understanding and solving problems with antiretroviral therapy regimens.

RESULTS: Mean patient age was 42 years, 15% were female, 73% were white, and 57% reported gay or bisexual sexual contact as their primary HIV risk factor. In multivariable models that accounted for the clustering of patients within physicians’ practices, 6 of the 7 physician-patient relationship quality variables were significantly (P<.05) associated with adherence. In all 7 models worse adherence was independently associated (P<.05) with lower age, not believing in the importance of antiretroviral therapy, and worse mental health.

CONCLUSIONS: This study showed that multiple, mutable dimensions of the physician-patient relationship were associated with medication adherence in persons with HIV infection, suggesting that physician-patient relationship quality is a potentially important point of intervention to improve patients’ medication adherence. In addition, our data suggest that it is critical to investigate and incorporate patients’ belief systems about antiretroviral therapy into adherence discussions, and to identify and treat mental disorders.

Key words

patient compliance HIV infections physician-patient relations HIV infections/drug therapy 


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  1. 1.
    Becker MH. Patient adherence to prescribed therapies. Med Care. 1985;23:539–55.PubMedCrossRefGoogle Scholar
  2. 2.
    Lerner BH, Gulick RM, Dubler NN. Rethinking nonadherence: historical perspectives on triple-drug therapy for HIV disease. Ann Intern Med. 1998;129:573–8.PubMedGoogle Scholar
  3. 3.
    Friedland GH, Williams A. Attaining higher goals in HIV treatment: the central importance of adherence. AIDS. 1999;13(suppl 1):S61-S72.PubMedGoogle Scholar
  4. 4.
    Mehta S, Moore RD, Graham NM. Potential factors affecting adherence with HIV therapy. AIDS. 1997;11:1665–70. Editorial.PubMedCrossRefGoogle Scholar
  5. 5.
    Holzemer WL, Corless IB, Nokes KM, et al. Predictors of self-reported adherence in persons living with HIV disease. AIDS Patient Care STDS. 1999;13:185–97.PubMedCrossRefGoogle Scholar
  6. 6.
    Murphy DA, Roberts KJ, Martin DJ, Marelich W, Hoffman D. Barriers to antiretroviral adherence among HIV-infected adults. AIDS Patient Care STDS. 2000;14:47–58.PubMedCrossRefGoogle Scholar
  7. 7.
    Laws MB, Wilson IB, Bowser DM, Kerr SE. Taking antiretroviral therapy for HIV infection: learning from patients’ stories. J Gen Intern Med. 2000;15:848–58.PubMedCrossRefGoogle Scholar
  8. 8.
    Murphy DA, Roberts KJ, Hoffman D, Molina A, Lu MC. Barriers and successful strategies to antiretroviral adherence among HIV-infected monolingual Spanish-speaking patients. AIDS Care. 2003;15:217–30.PubMedCrossRefGoogle Scholar
  9. 9.
    Malcolm SE, Ng JJ, Rosen RK, Stone VE. An examination of HIV/AIDS patients who have excellent adherence to HAART. AIDS Care. 2003;15:251–61.PubMedCrossRefGoogle Scholar
  10. 10.
    Mostashari F, Riley E, Selwyn PA, Altice FL. Acceptance and adherence with antiretroviral therapy among HIV-infected women in a correctional facility. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18:341–8.PubMedGoogle Scholar
  11. 11.
    Altice FL, Mostashari F, Friedland GH. Trust and the acceptance of and adherence to antiretroviral therapy. J Acquir Immune Defic Syndr. 2001;28:47–58.PubMedGoogle Scholar
  12. 12.
    Bakken S, Holzemer WL, Brown MA, et al. Relationships between perception of engagement with health care provider and demographic characteristics, health status, and adherence to therapeutic regimen in persons with HIV/AIDS. AIDS Patient Care STDS. 2000;14:189–97.PubMedCrossRefGoogle Scholar
  13. 13.
    Vincke J, Bolton R. Therapy adherence and highly active anti-retroviral therapy: comparison of three sources of information. AIDS Patient Care STDS. 2002;16:487–95.PubMedCrossRefGoogle Scholar
  14. 14.
    Gordillo V, del Amo J, Soriano V, Gonzalez-Lahoz J. Sociodemographic and psychological variables influencing adherence to antiretroviral therapy. AIDS. 1999;13:1763–9.PubMedCrossRefGoogle Scholar
  15. 15.
    Golin CE, Liu H, Hays RD, et al. A prospective study of predictors of adherence to combination antiretroviral medication. J Gen Intern Med. 2002;17:756–65.PubMedCrossRefGoogle Scholar
  16. 16.
    Roter DL, Hall JA. Doctors Talking with Patients. Patients Talking with Doctors. Westport, Conn: Auburn House; 1992.Google Scholar
  17. 17.
    Gordon GH, Rost K. Evaluating a faculty development course on medical interviewing. In: Lipkin M Jr, Putnam SM, Lazare A, eds. The Medical Interview: Clinical Care, Education, and Research. New York, NY: Springer-Varlag; 1995:436–47.Google Scholar
  18. 18.
    Thompson TL, Parrott R. Interpersonal communication and health. In: Knapp ML, Daly JA, eds. Handbook of Interpersonal Communication. Thousand Oaks, Calif: Sage Publications; 2002:680–725.Google Scholar
  19. 19.
    Roter DL, Cole KA, Kern DE, Barker LR, Grayson M. An evaluation of residency training in interviewing skills and the psychosocial domain of medical practice. J Gen Intern Med. 1990;5:347–54.CrossRefGoogle Scholar
  20. 20.
    Levinson W, Roter D. The effects of two continuing medical education programs on communication skills of practicing primary care physicians. J Gen Intern Med. 1993;8:318–24.PubMedCrossRefGoogle Scholar
  21. 21.
    van Dulmen AM, van Weert JC. Effects of gynaecological education on interpersonal communication skills. BJOG. 2001;108:485–91.PubMedCrossRefGoogle Scholar
  22. 22.
    van Dulmen AM, Holl RA. Effects of continuing paediatric education in interpersonal communication skills. Eur J Pediatr. 2000;159:489–95.PubMedCrossRefGoogle Scholar
  23. 23.
    Moral RR, Alamo MM, Jurado MA, de Torres LP. Effectiveness of a learner-centred training programme for primary care physicians in using a patient-centred consultation style. Fam Pract. 2001;18:60–3.PubMedCrossRefGoogle Scholar
  24. 24.
    Sliwa JA, Makoul G, Betts H. Rehabilitation-specific communication skills training: improving the physician-patient relationship. Am J Phys Med Rehabil. 2002;81:126–32.PubMedCrossRefGoogle Scholar
  25. 25.
    Hulsman RL, Ros WJ, Winnubst JA, Bensing JM. The effectiveness of a computer-assisted instruction programme on communication skills of medical specialists in oncology. Med Educ. 2002;36:125–34.PubMedCrossRefGoogle Scholar
  26. 26.
    Roter DL, Hall JA, Kern DE, Barker LR, Cole KA, Roca RP. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155:1877–84.PubMedCrossRefGoogle Scholar
  27. 27.
    Wilson IB, Kaplan S. Physician-patient communication in HIV disease: the importance of patient, physician, and visit characteristics. J Acquir Immune Defic Syndr. 2000;25:417–25.PubMedCrossRefGoogle Scholar
  28. 28.
    Kaplan SH, Gandek B, Greenfield S, Rogers W, Ware JE. Patient and visit characteristics related to physicians’ participatory decision-making style. Results from the Medical Outcomes Study. Med Care. 1995;33:1176–87.PubMedCrossRefGoogle Scholar
  29. 29.
    Dukes KA, Kaplan SH, Sullivan RA, Silliman RA, D’Agostino RB, Greenfield S. The differential effect of physicians’ egalitarian decision-making style on the health outcomes of women with type II diabetes. J Gen Intern Med. 1994;9:51.Google Scholar
  30. 30.
    Davies AR, Ware JE. GHAA’s Consumer Satisfaction Survey and User’s Manual. 2nd ed. Washington, DC: GHAA; 1991.Google Scholar
  31. 31.
    Safran DG, Kosinski M, Tarlov AR, et al. The Primary Care Assessment Survey: tests of data quality and measurement performance. Med Care. 1998;36:728–39.PubMedCrossRefGoogle Scholar
  32. 32.
    Hays RD, Cunningham WE, Sherbourne CD, et al. Health-related quality of life in patients with human immunodeficiency virus infection in the United States: results from the HIV cost and services utilization study. Am J Med. 2000;108:714–22.PubMedCrossRefGoogle Scholar
  33. 33.
    Hausman J. Specification tests in econometrics. Econometrica. 1984;52:1219–40.CrossRefGoogle Scholar
  34. 34.
    Hausman J. Specification tests in economics. Econometrica. 1978;46:1251–71.CrossRefGoogle Scholar
  35. 35.
    Joos SK, Hickam DH, Gordon GH, Baker LH. Effects of a physician communication intervention on patient care outcomes. J Gen Intern Med. 1996;11:147–55.PubMedCrossRefGoogle Scholar
  36. 36.
    Roter D, Rosenbaum J, de Negri B, Renaud D, DiPrete-Brown L, Hernandez O. The effects of a continuing medical education programme in interpersonal communication skills on doctor practice and patient satisfaction in Trinidad and Tobago. Med Educ. 1998;32:181–9.PubMedCrossRefGoogle Scholar
  37. 37.
    Brown JB, Boles M, Mullooly JP, Levinson W. Effect of clinician communication skills training on patient satisfaction. A randomized, controlled trial. Ann Intern Med. 1999;131:822–9.PubMedGoogle Scholar
  38. 38.
    Stillman PL, Sabers DL, Redfield DL. Use of trained mothers to teach interviewing skills to first-year medical students: a follow-up study. Pediatrics. 1977;60:165–9.PubMedGoogle Scholar
  39. 39.
    Maguire P, Fairbairn S, Fletcher C. Consultation skills of young doctors: I—Benefits of feedback training in interviewing as students persist. Br Med J (Clin Res Ed). 1986;292:1573–6.Google Scholar
  40. 40.
    Bowman FM, Goldberg DP, Millar T, Gask L, McGrath G. Improving the skills of established general practitioners: the long-term benefits of group teaching. Med Educ. 1992;26:63–8.PubMedGoogle Scholar
  41. 41.
    Smith MY, Rapkin BD, Morrison A, Kammerman S. Zidovudine adherence in persons with AIDS. The relation of patient beliefs about medication to self-termination of therapy. J Gen Intern Med. 1997;12:216–23.PubMedGoogle Scholar
  42. 42.
    Stone VE, Clarke J, Lovell J, et al. HIV/AIDS patients’ perspectives on adhering to regimens containing protease inhibitors. J Gen Intern Med. 1998;13:586–93.PubMedCrossRefGoogle Scholar
  43. 43.
    Laws MB, Wilson IB, Bowser DM, Kerr SE. Taking antiretroviral therapy for HIV infection: learning from patients’ stories. J Gen Intern Med. 2000;15:848–58.PubMedCrossRefGoogle Scholar
  44. 44.
    Horne R, Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res. 1999;47:555–67.PubMedCrossRefGoogle Scholar
  45. 45.
    Paterson DL, Swindells S, Mohr J, et al. Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med. 2000;133:21–30.PubMedGoogle Scholar
  46. 46.
    Singh N, Squier C, Sivek C, Nguyen MH, Wagener M, Yu VL. Determinants of nontraditional therapy use in patients with HIV infection. A prospective study. Arch Intern Med. 1996;156:197–201.PubMedCrossRefGoogle Scholar
  47. 47.
    Holland JC, Tross S. The psychosocial and neuropsychiatric sequelae of the acquired immune deficiency syndrome and related disorders. Ann Intern Med. 1985;103:760–4.PubMedGoogle Scholar
  48. 48.
    Perry S. HIV-related depression. In: Price R, Perry S, eds. HIV, AIDS, and the Brain. New York, NY: Raven Press; 1993:233–8.Google Scholar
  49. 49.
    Lyketsos CG, Hutton H, Fishman M, Schwartz J, Treisman GJ. Psychiatric morbidity on entry to an HIV primary care clinic. AIDS. 1996;10:1033–9.PubMedCrossRefGoogle Scholar
  50. 50.
    Lyketsos CG, Federman EB. Psychiatric disorders and HIV infection: impact on one another. Epidemiol Rev. 1995;17:152–64.PubMedGoogle Scholar
  51. 51.
    Sherbourne CD, Hays RD, Fleishman JA, et al. Impact of psychiatric conditions on health-related quality of life in persons with HIV infection. Am J Psychiatry. 2000;157:248–54.PubMedCrossRefGoogle Scholar
  52. 52.
    Markowitz JC, Kocsis JH, Fishman B, et al. Treatment of depressive symptoms in human immunodeficiency virus-positive patients. Arch Gen Psychiatry. 1998;55:452–7.PubMedCrossRefGoogle Scholar
  53. 53.
    Rabkin JG, Wagner GJ, Rabkin R. Fluoxetine treatment for depression in patients with HIV and AIDS: a randomized, placebo-controlled trial. Am J Psychiatry. 1999;156:101–7.PubMedGoogle Scholar
  54. 54.
    Zisook S, Peterkin J, Goggin KJ, Sledge P, Atkinson JH, Grant I. Treatment of major depression in HIV-seropositive men. HIV Neurobehavioral Research Center Group. J Clin Psychiatry. 1998;59:217–24.PubMedGoogle Scholar
  55. 55.
    Nielson AC, Williams TA. Depression in ambulatory medical patients: prevalence by self-report questionnaire and recognition by nonpsychiatric physicians. Arch Gen Psych. 1980;37:999–1004.Google Scholar
  56. 56.
    Seller RH, Blascovich J, Lenkei E. Influence of stereotypes in the diagnosis of depression by family practice residents. J Fam Pract. 1981;12:849–54.PubMedGoogle Scholar
  57. 57.
    Goldberg D, Steele JJ, Johnson A, Smith C. Ability of primary care physicians to make accurate ratings of psychiatric symptoms. Arch Gen Psych. 1982;39:829–33.Google Scholar
  58. 58.
    Kessler LG, Cleary PD, Burke JD. Psychiatric disorders in primary care: results of a follow-up study. Arch Gen Psych. 1985;42:583–7.Google Scholar
  59. 59.
    Liu H, Golin CE, Miller LG, et al. A comparison study of multiple measures of adherence to HIV protease inhibitors. Ann Intern Med. 2001;134:968–77.PubMedGoogle Scholar
  60. 60.
    Zaslavsky AM, Zaborski LB, Cleary PD. Factors affecting response rates to the Consumer Assessment of Health Plans Study survey. Med Care. 2002;40:485–99.PubMedCrossRefGoogle Scholar
  61. 61.
    Etter JF, Perneger TV. Analysis of non-response bias in a mailed health survey. J Clin Epidemiol. 1997;50:1123–8.PubMedCrossRefGoogle Scholar
  62. 62.
    Landon BE, Wilson IB, Wenger NS, et al. Specialty training and specialization among physicians who treat HIV/AIDS in the United States. J Gen Intern Med. 2002;17:12–22.PubMedCrossRefGoogle Scholar
  63. 63.
    Greenfield S, Kaplan S, Ware JE Jr. Expanding patient involvement in care. Effects on patient outcomes. Ann Intern Med. 1985;102:520–8.PubMedGoogle Scholar
  64. 64.
    Greenfield S, Kaplan SH, Ware JE, Yano EM, Frank HJL. Patients’ participation in medical care: effects on blood sugar control and quality of life in diabetes. J Gen Intern Med. 1988;3:448–57.PubMedCrossRefGoogle Scholar
  65. 65.
    Kaplan SH, Greenfield S, Ware JE Jr. Impact of the doctor-patient relationship on the outcomes of chronic disease. In: Stewart M, Roter D, eds. Communicating with Medical Patients. Newbury Park, Calif: Sage Publications; 1989:228–45.Google Scholar

Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • John Schneider
    • 4
  • Sherrie H. Kaplan
    • 3
  • Sheldon Greenfield
    • 3
  • Wenjun Li
    • 5
  • Ira B. Wilson
    • 1
    • 2
    Email author
  1. 1.the Institute for Clinical Research and Health Policy StudiesTufts-New England Medical CenterBoston
  2. 2.Department of MedicineTufts-New England Medical CenterBoston
  3. 3.Health Policy and ResearchUniversity of California IrvineIrvine
  4. 4.Department of MedicineUniversity of ChicagoChicago
  5. 5.the Division of Preventive and Behavioral MedicineUniversity of Massachusetts Medical SchoolWorcester

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