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UNIT 2

Adherence Counseling

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Objectives 1

• Describe the meaning of adherence, its importance and the consequences of non-adherence.

• Describe effective strategies that promote adherence in ART.

• Describe factors that influence adherence and non-adherence.

• Identify criteria for readiness to start ARV.

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Objectives 2

• Explain the importance of family involvement in adherence counseling and follow up.

• Discuss monitoring and follow-up adherence.• Demonstrate basic skills to counsel patients

about adherence.

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Adherence vs. Compliance

• Adherence: the act or quality to stick to something, steady devotion, the act of adhering

- Acceptance of an active role in one’s own health care• Compliance: the act of conforming, yielding or

acquiescing.- Lack of sharing in the decision made between provider and

client

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Adherence to care

• Entering into and continuing in a program• Attending appointments and tests as scheduled• Modifying lifestyle as needed and avoiding risk

behaviour• Taking medications as prescribed (adherence to

treatment)

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How much adherence is required for HAART?

0

20

40

60

80

100

Adherence, %

% virologic failure

Patterson, Annals of Internal Medicine, 2000

>95 90-94.9 80-89.9 70-79.9 <70

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How much adherence is required for HAART?

• Adherence needed to suppress viral load to undetectable levels and for durable suppression

• 95% adherence needed to achieve above

• Failure rates increase sharply as adherence decreases (Patterson et al, 2000)

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Poor adherence and viral resistance

• Non adherence (or inappropriate prescribing) results in exposure of the virus to sub-inhibitory concentrations of ARV

• This leads to on-going viral replication and continued CD4 destruction

• It also leads to the development of resistance• Resistance to one drug man cross to other drugs in the same

class• Resistant strains can be transmitted in the population• There is a limited choice of affordable combinations

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How common is non-adherence to HAART?

• More than 10% of patients report missing one or more doses on a given day

• More than 33% report missing doses in past 2-4 weeks (Chesney et al, 2000)

• Providers cannot easily accurately guess whether a given patient will be adherent or not

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Forms of Non-Adherence

• Missing one dose of a given drug• Missing a dose of all the three drugs• Missing multiple doses • Missing a whole week of treatment • Not observing the time intervals• Not observing the dietary instructions

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Causes of non adherence

• Brainstorming 15 minutes!

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Causes of non adherence

• Structural/logistics• Socio-economic• Psychological• Spiritual• Illness• Medicine specific• Other

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Consequences of poor adherence

• Incomplete viral suppression• Continued destruction of the immune system

and decrease of CD4 cell count• Progression of disease• Emergence of resistant viral strains• Limited future therapeutic options and higher

costs for individual and program.

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How to assess adherence?

• Self reports

• Pill counts • Biological markers

• Pharmacy records

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Self-reports

• Patients report using a 4 day, 1 wk, 1 month or most recent recall of missing a dose

• Can be done using a series of non-judgmental questions at clinic visits

• Has a tendency to over estimate• Self-report agrees well with actual medication (when a

trusting provider/patient relationship develops)

• Easiest tool in clinic setting

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Pill counts

• Providers count remaining pills during clinic visit• Problems:

– Patients can dump pills prior to visit– Can antagonize patient and provider

• Unannounced pill counts can be better, at the clinic or at home

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Biological markers of effectiveness of treatment

• A decreasing viral load implies good adherence• But in some patients viral load may remain high

even with good adherence:– ? Viral resistance– ? Poor absorption of the drug

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Pharmacy records

• Pharmacists keep record of drugs dispensed to each patient:– Can inform the relevant doctor of lapses in patients collecting

their medicines (esp. good for patients who buy their own medicines)

• Problems: – Is not a measure of ingestion– Requires patients to always use the same pharmacy

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How do we promote adherence

• Brainstorming!

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How to promote Adherence? 1

• Participation of the patient in a plan of care. Don’t rush to ARV, patient must be ready!

• Counseling: Individual or in group • Information/Education/Communication on ARV drugs: - Provide simple written information (booklet, pamphlet, posters)- Warn patients about common side effects- Same adherence message by all health workers!!!

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How to promote Adherence? 2

• Buddy system (family or friend reminds client to take medicines)

• Medication Diaries, pill boxes, pill charts

• Incentives (transport, food etc)

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Patient Readiness Assessment

• Patient knowledge on:– Medical history– Knowledge HIV disease– Opportunistic infections– Social support

• On Drug regimen– Action of ARV drugs– Need for continued prevention– Side effects and what to do

• On Adherence promotion strategies– Buddies– Pill diary

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Adherence Counseling check lists

• Counseling session 1• Counseling session 2• Counseling session 3

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Factors affecting adherence

ADHERENCEDisease

CharacteristicsPrior OI

Patient/Provider Relationship

Trust and confidence

Treatment Regimen

Number, food/ fluid restrictions, side-effects Patient variables

Sex, age, employment, education, alcohol, social support depression, etc

Clinical setting

Friendly, supportive non-judgmental staff

confidentiality, convenient appointments

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Barriers to adherence

• Poor communication• Misunderstanding/misinformations• Low literacy if written• Lack social support• Failure to disclose• Financial barriers• Competing priorities

– Work– Child care

• Stigmas and denial• Alcohol and drug use• Depression

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Family & Community involvement

• Identify a Family Care Giver or Buddy with the patient• Familiarize them on ART and on adherence as they are your client• Involve them during medical consultations and counseling sessions• Home based care: educate Family Care Giver in recognizing side effects

and referring to hospital if needed

• Community involvement and understanding in ARV care is important

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Adherence monitoring

• Complete adherence monitoring form with the patient

• See table 2 page 12 Kenyan Clinical manual for ARV providers

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Adherence Counseling Skills 1

• KnowledgeHIV disease, Medications and Side effects• AttitudesPositive belief and perceptions; self efficacy• Practices and support systems: use of “cues” or

reminders, buddies

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Adherence Counseling Skills 2

• Identifying and addressing barriers• Integrating treatment regimen into patient’s

daily routine• Encourage family support

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Counseling Techniques

• SOLER:- Sit upright- Open your hands- Listen- Eye contact- Relax

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Psychosocial aspects in HIV/AIDS MANAGEMENT

By Dr Makanyengo

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Different perspectives of psychosocial intervention

• Part 1.Effect of Psychosocial stressors on HIV infected patient immune system

• Part 2.Effect of HIV/AIDS on psychosocial aspect of patients

• Part 3.Psychosocial support in care for HIV/AIDS infected

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Part 1 Effect of psychosocial stressors on immune system in HIV/AIDS

• Galen 200 AD– Mind can influence body– Different immune abnormalities in people with

psychosocial stressors• Anxiety and depression reduced lymphocyte count and

function• Academic stress reduced natural killer cell activity,

blastogenisis and interferon production• Bereavement reduces lymphocytic proliferative response to

nitrogen

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Role of mental stressors ctd

• Impaired DNA capability in lymphocytes of stressed patients

• Mental stress as an immune-depressive agent in relation to onset, cause, prognosis of AIDS has been discussed several times

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Part 2 Psychosocial impact of HIV/AIDS in the lives of PLHWA

BRAINSTORMING for 10 minutes!

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Psychosocial impact (Stress)

• Primary stress factors e.g death or sickness of a parent if a child.

• These may be made worse by other factors, such as loss of home, worsening poverty, dropping out of school, stigma and discrimination and separation from brothers and sisters. These are called 'secondary stress factors'.

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Psychiatric effect of HIV/AIDS

• Mood disorders• Neuro psychiatric symptoms which affect the

executive or higher functions of the brain– Confusion, forgetfulness, disorientation and memory

loss, personality changes etc• Psychotic symptoms

– Hallucinations– Delusions

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Psychiatric symptoms and dementia

• Depression or hypomania/mania• Confusion, forgetfulness• Disorientation• Personality changes• Frontal Lobe syndrome• Seizures• Agitation or aggression

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Stigma

• Highly important in non adherence of PLWHA to care

• What is stigma?• DISCUSSION!

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Definition ctd• Text books

– Stigma is a Spoilt entity– To stigmatize is to label someone– To see them as inferior because of an attribute

• HIV/AIDS• Unwanted teenage pregnancy• Mental illness• Epilepsy

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Manifestation of stigma

• Stereotyping, bias, distrust, fear, embarrassment, anger, avoidance and aggression

• Resulting in discrimination– Stigma in action– Stigmatizing thoughts and beliefs leads to

discriminatory behavior– Discrimination is an act or behavior as a result of

stigma

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Discrimination

• Treating someone differently and may involve the following:– Denial of rights and opportunities– Social, psychological and physical abuse

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HIV/AIDS and stigma

• Most affected are PLWHA• Worse when

– Women– Poor– Uneducated– With psychosocial instability– Communities with negative cultural practices

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Part 3. Psychosocial support in care of HIV/AIDS infected

• A. Counseling

• B. Support groups

• C. Client tracing and follow-up

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Types of counselling

• Pre/post test counselling• Adherence preparation counselling• Ongoing adherence and supportive counselling

– For individuals, groups, family, youth, children and adults

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Counselling requirements

• Definition of counseling• Why• By whom• Qualities of counsellor• Skills and techniques• When not to counsell• Challenges

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Adherence counselling

• Introduction and orientation• HIV information recheck and ART benefits• Explore support and potential barriers• Ways of over coming the barriers• Make decision to start ART• Ways of promoting adherence to ART

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Check lists for adherence counselling

• Counselling sessions at least 3• Art preparation• Ongoing adherence monitoring• Should non adherence occur find out why• Identify barrier and address ir seriously. If too

busy refer!

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Set up support groups

• Start with the patient individually• Pre, post and ongoing counseling• Follow up adherence counseling• Treat patient for OI medically• When ready refer to post test club for ongoing

group support

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Support groups

• Recruit clients already counseled• Similar ages and illnesses• Start of with introductions and group norms• One or two regular facilitator skilled in group

work• Can set time limit and plan for exiting clients• Can be open or closed

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Support group

• Give each other emotional support• Learn from each other through sharing• Encourage each other to adhere to treatment• Can benefit from ongoing talks and learning

sessions• Empowers clients emotionally

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Support groups

• Can learn social and life skills• Making ornaments, baskets etc for sale• Eldoret experience• South African experience

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Types of support groups

• Children– 2-6– 6-10– Above 10

• Adolescents– 0ver 13 years

• Adults• Staff• Non staff

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Client tracing

• Identify family care giver• Get details of contacts e.g nearest school, shop,

church, chief• Get nearest mobile contacts • Network with nearest CBO or NGO in community

offering services (CHW,s)• Refer client for ongoing adherence support at the

nearest organization

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Case study discussion for 15 minutes

• Lucy is a secretary in Nairobi and born again Christian.• Was infected with HIV. Her husband is a traditionalist and

financially stable. He believes in men can have more than one wife. He is not sick and has not been tested.

• He drinks with friends and occasionally sleeps out.• The wife fears him as he can be aggressive if confronted

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Case study

• She was diagnosed with HIV two years ago at a VCT center and was referred to a CCC started on ART.

• Her husband was not as supportive• He has refused to go for the test and does not

want to discuss issue with wife• She is lately withdrawn and has missed some

doses of ART

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Case study continues

• She has insomnia and misses job at times, gets irritable to the children who are two.

• The youngest child who is 5 years is not growing well and is sickly many times.

• Lucy is worried that the child may have been infected