Assessing Adherence to Treatment: A Partnership
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Assessing Adherence to Treatment: A Partnership






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    Assessing Adherence to Treatment: A Partnership Assessing Adherence to Treatment: A Partnership Presentation Transcript

    • Assessing adherence to Treatment: A Partnership
      Plenary Session: Tuesday, October 20, 2009
      Supporting Sustainable Adherence to HIV Prevention, Care & Treatment
      ICAP Technical Workshop
      October 19-22, 2009Kigali, Rwanda
      Shekinah Elmore
      Scott Worley
      Milena Mello
    • Sustainable Adherence: What & Why
      Multilevel Concept
      Dynamic Process and Not Static Outcome
      Adherence to Care AND Treatment
      A Transition from Evaluation to Partnership between Client and Counselor
    • Key Adherence Strategies
      Appointment systems
      Integrated tracking and tracing systems
      MDT approach to adherence counseling and assessment
      Peer education/expert client programs
      Community linkages and referral
    • Adherence Assessment: The Process
      The process
      Measuring—allows you to monitor
      Monitoring—allows you to intervene
      Intervening– allows you to achieve a good outcome
    • Overview of Presentation
      How do we define adherence to care?
      How do we define adherence to treatment?
      What methods can we use to assess adherence to treatment?
      Programmatic examples of adherence assessment from Swaziland, South Africa, and Mozambique
    • Defining Adherence to Care
      What is Adherence to Care?
      Adherence to the entire, holistic package of HIV services, not just ART
      ICAP countries define elements of ‘Care’ differently
      Marked by a continued engagement with the plan of care
      Often measured by proxy as adherence to scheduled clinic visits
      This presentation will focus on treatment, several small group sessions will focus on care.
    • Defining Adherence to Treatment
      Broader Definition: Adherence as a Biosocial Phenomenon
      “A complex process embedded in the clinical and social course of AIDS.” (Castro, 2005)
    • Adherence to Treatment: 8 Broad Categories
      Socioeconomic factors
      Health-care system
      Social capital
      Cultural models of health and disease
      Personal characteristics
      Psychological factors
      Clinical factors
      Antiretroviral regimen
      (Castro, 2005)
    • Defining Adherence to Treatment
      Specific Definition:
      >90-95% of doses taken as prescribed
      Correlates with undetectable viral load
      Works well for adult care, but we encounter complexities with pediatric (e.g. syrups) and PMTCT (e.g. single dose NVP) dosing
    • Methods that Assess Adherence
      Clinical and ‘Gold Standard’ Methods
      Quantitative Methods
      Qualitative Methods
    • Clinical & ‘Gold Standard’ Measures
    • Clinical and ‘Gold Standard’ Methods
      Viral Load and CD4 Count
      Therapeutic Drug Monitoring (TDM)
      Electronic Drug Monitoring (EDM)
      e.g. MEMS Caps, Cell Phones, Other
      Observed Therapy
    • Quantitative Methods
    • Patient Recall Methods
      3-day, 7-day, or 30-day Recall
      Visual Analog Scales (VAS) – Milena on Mozambique
      Report of Missed Doses
    • Patient Recall Methods
      Patient recall is valid and reliable: Meta-analysis by Simoni et al. (2006) confirms that patient recall methods perform well across 77 independent trials
      However, no consensus on which performs best
      Lu et al. (2007): 30-day VAS better correlated with clinical measures than 3-day and 7-day recall, because participants were less likely to over-report adherence
      Mannheimer et al. (2008): participants were more likely to over-report adherence on the 3-day vs. 7-day scale
      Choice of measure should be context-specific
    • Pill Count
      Counting the pills that a patient has left after a specified period (e.g. 30 days)
      Often conducted by the pharmacist
      Can be announced or unannounced
      More to come by Sthembile on Swaziland
    • 7 Day Recall: Pediatric Example
      Which doses were you not able to give in the last 7 days?
      A)Write in days of the week for the last seven days, and mark an “X” for missed morning and/or evening doses.
    • 7 Day Recall: Pediatric Example (Cont.)
      B) Check the option below that captures the level of adherence in the last 7 days:
       Low (5 or more missed)
       Medium (3 or 4 missed)
       High (0 - 2 missed)
    • 7 Day Recall: Pediatric Example (Cont.)
      Part of a broader adherence assessment and counseling encounter, which includes:
      Review of ART regimen
      Reasons doses were missed
      Plan for follow-up and referrals
      So we have…
    • Qualitative Methods
    • Barriers and Facilitators Analysis
      Open-ended or multiple choice questions:
      What are the barriers to adherence that you’ve had in the past month?
      What has helped you to adhere in the past month?
      Link patient with support interventions that address barriers and strengthen facilitators
      Track changes in barriers and facilitators over time
      Open ended questions may provide more honest, rich answers, yet, are harder to track over time
      Scott on South Africa
    • Choosing a Method
    • Programmatic Considerations for Choosing a Method
      Participatory and interactive
      Situated within a counseling framework
      Sensitive to staffing and time constraints
      Counselors trained and mentored
      MDT involvement
      Implementation must be systematic and reach each patient on a consistent basis
      Linked to appropriate adherence support interventions
      Structured enough to be evaluated
      Doing adherence assessment (MOC, yes/no)
      Level of adherence (SOC, quantitative measure)
    • Client and Counselor Partnership
      Adherence happens outside the clinic
      Need assessment methods that allow clients to understand and manage their own adherence
      Tools that allow clients to track adherence in parallel with counselors records
      Assessing adherence in partnership gets clients invested in their own adherence outcomes, and in turn, provides a forum for adherence support
      Example: Pediatric Adherence Calendar & Coloring Book
    • B. Scott Worley
      Technical Advisor for Care & Support
      ICAP – South Africa
      Missed Doses & Barriers Analysis
    • South Africa: Recall and Barriers Assessments
      Patient asked what medications they take, when and how
      Patient asked if they have missed any doses (and how many) in the past month
      Potential reasons for missed doses listed as a guide to help determine causes of poor adherence
      This helps identify the most common barriers to adherence, for consideration with improved patient and program support
      Implemented since 2005
      This is part of an ongoing psychosocial assessment – detailing patient & family info, clinic accessibility, pregnancy & contraceptive use, ART preparation guide, ART adherence, and issues for follow-up counseling and education
    • South Africa: Results (EL region, Aug 09)
    • South Africa: Successes & Challenges
      Strengths – addresses patient understanding of medications and how to take them; analyzes possible clinical and/or psychosocial reasons for missed doses, for purposes of further helping the patient (when possible)
      Weaknesses – Limitations with recall method (esp. over prolonged time); only reinforced with pill count
      Next Steps – Collaboration with Pharmacy Advisor, for training of peers & lay counselors to use VAS method (as directed by new national DOH guidelines)
    • SthembileMatse
      Psychosocial Support Officer
      ICAP- Swaziland
      Pill Count Form
    • Pill Count Form: How it can be used
      Implemented in January 2009 to provide a systematic way to conduct pill count
      Peer educator/expert client, physician, nurse, pharmacist
      Due to time constraints, usually conducted by expert client
      Use to assess adherence monthly for newly enrolled; every six months for patients on treatment for >6 months
      If adherence <95% or >105%, ask patient about adherence challenge
    • Pill Count Form: Strengths and Challenges
      Trained expert clients now successfully conducting pill count for all patients
      Patients appreciate the positive feedback provided by the assessment
      Expert client assess adherence, but clinicians don’t always interpret the result to provide necessary adherence support
      Since patients are aware of pill count, medications are often not brought to the clinic
    • Pill Count Form: Next Steps
      Getting physicians to recognize the importance of utilizing pill count data to support adherence as part of the clinic visit – physicians must attach meaning to the pill count, especially for patients who have been on treatment for a long time
    • Milena Mello
      Technical Advisor: APS, C&T + Training
      ICAP - Mozambique
      Visual Analog Scale
    • Visual Analog Scale
      Description of Measure
      Visual Analog Scale that measures the average adherence by patient self-report.
      Reason for Measure Choice
      Many patients have low literacy and numeracy, and thus difficulty reporting numbers and times of doses
      Necessary to use a visual, concrete instrument that facilitates the patient’s understanding about the medication, while allowing an open conversation with the counselor about adherence difficulties. Therefore, this tool is used in conjunction with an adherence questionnaire
      Short time per patient to implement (on average, 2 minutes for VAS)
    • Visual Analog Scale
      Date of Implementation
      Developed Larissa Polejack’s dissertation research (2007)
      Followed by pilot implementation in selected sites (Military Hospital in Maputo and Zambézia Sites)
      Details on Implementation:
      Scale was developed to supplement a longer adherence questionnaire, but can be implemented as a stand alone tool
      Psychologists have been trained to implement (Military Hospital)
      Presented to MISAU (Ministry of Health) and recognized as a unique instrument
      Possible use by clinicians when they are assess adherence to medication regimens
    • Visual Analog Scale
    • Mozambique: Successes & Challenges
      • Successes:
      • Facilitates patient comprehension of adherence by using a concrete, real-world example: cups ranging from “full” (high adherence) to “empty” (low adherence)
      • Adopted as a method of adherence assessment in other ICAP studies
      • Challenges:
      • Difficult to utilize an adherence assessment during each patient visit
      • Resistance from clinicians for adherence assessment extending the visit length
      • Next Steps:
      • Pilot alternative versions of the scale (e.g. inversion of the cups – low to high; empty cups = all medications taken; etc.)
      • Expand to more sites
      • Gain approval from MISAU (Ministry of Health) as national tool
    • Thanks – Obrigado – Merci–Murakoze
      Supporting Sustainable Adherence to HIV Prevention, Care & Treatment
      ICAP Technical Workshop
      October 19-22, 2009Kigali, Rwanda