Module 9 adherence & psychosocial counselling


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Module 9 adherence & psychosocial counselling

  1. 1. <ul><li>UNIT 2 </li></ul><ul><li>Adherence Counseling </li></ul>
  2. 2. Objectives 1 <ul><li>Describe the meaning of adherence, its importance and the consequences of non-adherence. </li></ul><ul><li>Describe effective strategies that promote adherence in ART. </li></ul><ul><li>Describe factors that influence adherence and non-adherence. </li></ul><ul><li>Identify criteria for readiness to start ARV. </li></ul>
  3. 3. Objectives 2 <ul><li>Explain the importance of family involvement in adherence counseling and follow up. </li></ul><ul><li>Discuss monitoring and follow-up adherence. </li></ul><ul><li>Demonstrate basic skills to counsel patients about adherence. </li></ul>
  4. 4. Adherence vs. Compliance <ul><li>Adherence: the act or quality to stick to something, steady devotion, the act of adhering </li></ul><ul><li>- Acceptance of an active role in one’s own health care </li></ul><ul><li>Compliance: the act of conforming, yielding or acquiescing. </li></ul><ul><li>- Lack of sharing in the decision made between provider and client </li></ul>
  5. 5. Adherence to care <ul><li>Entering into and continuing in a program </li></ul><ul><li>Attending appointments and tests as scheduled </li></ul><ul><li>Modifying lifestyle as needed and avoiding risk behaviour </li></ul><ul><li>Taking medications as prescribed (adherence to treatment) </li></ul>
  6. 6. How much adherence is required for HAART? Adherence, % % virologic failure Patterson, Annals of Internal Medicine, 2000 > 95 90-94.9 80-89.9 70-79.9 <70
  7. 7. How much adherence is required for HAART? <ul><li>Adherence needed to suppress viral load to undetectable levels and for durable suppression </li></ul><ul><li>95% adherence needed to achieve above </li></ul><ul><li>Failure rates increase sharply as adherence decreases (Patterson et al, 2000) </li></ul>
  8. 8. Poor adherence and viral resistance <ul><li>Non adherence (or inappropriate prescribing) results in exposure of the virus to sub-inhibitory concentrations of ARV </li></ul><ul><li>This leads to on-going viral replication and continued CD4 destruction </li></ul><ul><li>It also leads to the development of resistance </li></ul><ul><li>Resistance to one drug man cross to other drugs in the same class </li></ul><ul><li>Resistant strains can be transmitted in the population </li></ul><ul><li>There is a limited choice of affordable combinations </li></ul>
  9. 9. How common is non-adherence to HAART? <ul><li>More than 10% of patients report missing one or more doses on a given day </li></ul><ul><li>More than 33% report missing doses in past 2-4 weeks (Chesney et al, 2000) </li></ul><ul><li>Providers cannot easily accurately guess whether a given patient will be adherent or not </li></ul>
  10. 10. Forms of Non-Adherence <ul><li>Missing one dose of a given drug </li></ul><ul><li>Missing a dose of all the three drugs </li></ul><ul><li>Missing multiple doses </li></ul><ul><li>Missing a whole week of treatment </li></ul><ul><li>Not observing the time intervals </li></ul><ul><li>Not observing the dietary instructions </li></ul>
  11. 11. Causes of non adherence <ul><li>Brainstorming 15 minutes! </li></ul>
  12. 12. Causes of non adherence <ul><li>Structural/logistics </li></ul><ul><li>Socio-economic </li></ul><ul><li>Psychological </li></ul><ul><li>Spiritual </li></ul><ul><li>Illness </li></ul><ul><li>Medicine specific </li></ul><ul><li>Other </li></ul>
  13. 13. Consequences of poor adherence <ul><li>Incomplete viral suppression </li></ul><ul><li>Continued destruction of the immune system and decrease of CD4 cell count </li></ul><ul><li>Progression of disease </li></ul><ul><li>Emergence of resistant viral strains </li></ul><ul><li>Limited future therapeutic options and higher costs for individual and program. </li></ul>
  14. 14. How to assess adherence? <ul><li>Self reports </li></ul><ul><li>Pill counts </li></ul><ul><li>Biological markers </li></ul><ul><li>Pharmacy records </li></ul>
  15. 15. Self-reports <ul><li>Patients report using a 4 day, 1 wk, 1 month or most recent recall of missing a dose </li></ul><ul><li>Can be done using a series of non-judgmental questions at clinic visits </li></ul><ul><li>Has a tendency to over estimate </li></ul><ul><li>Self-report agrees well with actual medication (when a trusting provider/patient relationship develops) </li></ul><ul><li>Easiest tool in clinic setting </li></ul>
  16. 16. Pill counts <ul><li>Providers count remaining pills during clinic visit </li></ul><ul><li>Problems: </li></ul><ul><ul><li>Patients can dump pills prior to visit </li></ul></ul><ul><ul><li>Can antagonize patient and provider </li></ul></ul><ul><li>Unannounced pill counts can be better, at the clinic or at home </li></ul>
  17. 17. Biological markers of effectiveness of treatment <ul><li>A decreasing viral load implies good adherence </li></ul><ul><li>But in some patients viral load may remain high even with good adherence: </li></ul><ul><ul><li>? Viral resistance </li></ul></ul><ul><ul><li>? Poor absorption of the drug </li></ul></ul>
  18. 18. Pharmacy records <ul><li>Pharmacists keep record of drugs dispensed to each patient: </li></ul><ul><ul><li>Can inform the relevant doctor of lapses in patients collecting their medicines (esp. good for patients who buy their own medicines) </li></ul></ul><ul><li>Problems: </li></ul><ul><ul><li>Is not a measure of ingestion </li></ul></ul><ul><ul><li>Requires patients to always use the same pharmacy </li></ul></ul>
  19. 19. How do we promote adherence <ul><li>Brainstorming! </li></ul>
  20. 20. How to promote Adherence? 1 <ul><li>Participation of the patient in a plan of care. Don’t rush to ARV, patient must be ready! </li></ul><ul><li>Counseling: Individual or in group </li></ul><ul><li>Information/Education/Communication on ARV drugs: </li></ul><ul><li>Provide simple written information (booklet, pamphlet, posters) </li></ul><ul><li>Warn patients about common side effects </li></ul><ul><li>Same adherence message by all health workers!!! </li></ul>
  21. 21. How to promote Adherence? 2 <ul><li>Buddy system (family or friend reminds client to take medicines) </li></ul><ul><li>Medication Diaries, pill boxes, pill charts </li></ul><ul><li>Incentives (transport, food etc) </li></ul>
  22. 22. Patient Readiness Assessment <ul><li>Patient knowledge on: </li></ul><ul><ul><li>Medical history </li></ul></ul><ul><ul><li>Knowledge HIV disease </li></ul></ul><ul><ul><li>Opportunistic infections </li></ul></ul><ul><ul><li>Social support </li></ul></ul><ul><li>On Drug regimen </li></ul><ul><ul><li>Action of ARV drugs </li></ul></ul><ul><ul><li>Need for continued prevention </li></ul></ul><ul><ul><li>Side effects and what to do </li></ul></ul><ul><li>On Adherence promotion strategies </li></ul><ul><ul><li>Buddies </li></ul></ul><ul><ul><li>Pill diary </li></ul></ul>
  23. 23. Adherence Counseling check lists <ul><li>Counseling session 1 </li></ul><ul><li>Counseling session 2 </li></ul><ul><li>Counseling session 3 </li></ul>
  24. 24. Factors affecting adherence ADHERENCE Disease Characteristics Prior 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
  25. 25. Barriers to adherence <ul><li>Poor communication </li></ul><ul><li>Misunderstanding/misinformations </li></ul><ul><li>Low literacy if written </li></ul><ul><li>Lack social support </li></ul><ul><li>Failure to disclose </li></ul><ul><li>Financial barriers </li></ul><ul><li>Competing priorities </li></ul><ul><ul><li>Work </li></ul></ul><ul><ul><li>Child care </li></ul></ul><ul><li>Stigmas and denial </li></ul><ul><li>Alcohol and drug use </li></ul><ul><li>Depression </li></ul>
  26. 26. Family & Community involvement <ul><li>Identify a Family Care Giver or Buddy with the patient </li></ul><ul><li>Familiarize them on ART and on adherence as they are your client </li></ul><ul><li>Involve them during medical consultations and counseling sessions </li></ul><ul><li>Home based care: educate Family Care Giver in recognizing side effects and referring to hospital if needed </li></ul><ul><li>Community involvement and understanding in ARV care is important </li></ul>
  27. 27. Adherence monitoring <ul><li>Complete adherence monitoring form with the patient </li></ul><ul><li>See table 2 page 12 Kenyan Clinical manual for ARV providers </li></ul>
  28. 28. Adherence Counseling Skills 1 <ul><li>Knowledge </li></ul><ul><li>HIV disease, Medications and Side effects </li></ul><ul><li>Attitudes </li></ul><ul><li>Positive belief and perceptions; self efficacy </li></ul><ul><li>Practices and support systems: use of “cues” or reminders, buddies </li></ul>
  29. 29. Adherence Counseling Skills 2 <ul><li>Identifying and addressing barriers </li></ul><ul><li>Integrating treatment regimen into patient’s daily routine </li></ul><ul><li>Encourage family support </li></ul>
  30. 30. Counseling Techniques <ul><li>SOLER: </li></ul><ul><li>Sit upright </li></ul><ul><li>Open your hands </li></ul><ul><li>Listen </li></ul><ul><li>Eye contact </li></ul><ul><li>Relax </li></ul>
  31. 31. Psychosocial aspects in HIV/AIDS MANAGEMENT By Dr Makanyengo
  32. 32. Different perspectives of psychosocial intervention <ul><li>Part 1.Effect of Psychosocial stressors on HIV infected patient immune system </li></ul><ul><li>Part 2.Effect of HIV/AIDS on psychosocial aspect of patients </li></ul><ul><li>Part 3.Psychosocial support in care for HIV/AIDS infected </li></ul>
  33. 33. Part 1 Effect of psychosocial stressors on immune system in HIV/AIDS <ul><li>Galen 200 AD </li></ul><ul><ul><li>Mind can influence body </li></ul></ul><ul><ul><li>Different immune abnormalities in people with psychosocial stressors </li></ul></ul><ul><ul><ul><li>Anxiety and depression reduced lymphocyte count and function </li></ul></ul></ul><ul><ul><ul><li>Academic stress reduced natural killer cell activity, blastogenisis and interferon production </li></ul></ul></ul><ul><ul><ul><li>Bereavement reduces lymphocytic proliferative response to nitrogen </li></ul></ul></ul>
  34. 34. Role of mental stressors ctd <ul><li>Impaired DNA capability in lymphocytes of stressed patients </li></ul><ul><li>Mental stress as an immune-depressive agent in relation to onset, cause, prognosis of AIDS has been discussed several times </li></ul>
  35. 35. Part 2 Psychosocial impact of HIV/AIDS in the lives of PLHWA <ul><li>BRAINSTORMING for 10 minutes! </li></ul>
  36. 36. Psychosocial impact (Stress) <ul><li>Primary stress factors e.g death or sickness of a parent if a child. </li></ul><ul><li>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'. </li></ul>
  37. 37. Psychiatric effect of HIV/AIDS <ul><li>Mood disorders </li></ul><ul><li>Neuro psychiatric symptoms which affect the executive or higher functions of the brain </li></ul><ul><ul><li>Confusion, forgetfulness, disorientation and memory loss, personality changes etc </li></ul></ul><ul><li>Psychotic symptoms </li></ul><ul><ul><li>Hallucinations </li></ul></ul><ul><ul><li>Delusions </li></ul></ul>
  38. 38. Psychiatric symptoms and dementia <ul><li>Depression or hypomania/mania </li></ul><ul><li>Confusion, forgetfulness </li></ul><ul><li>Disorientation </li></ul><ul><li>Personality changes </li></ul><ul><li>Frontal Lobe syndrome </li></ul><ul><li>Seizures </li></ul><ul><li>Agitation or aggression </li></ul>
  39. 39. Stigma <ul><li>Highly important in non adherence of PLWHA to care </li></ul><ul><li>What is stigma? </li></ul><ul><li>DISCUSSION! </li></ul>
  40. 40. Definition ctd <ul><li>Text books </li></ul><ul><ul><li>Stigma is a Spoilt entity </li></ul></ul><ul><ul><li>To stigmatize is to label someone </li></ul></ul><ul><ul><li>To see them as inferior because of an attribute </li></ul></ul><ul><ul><ul><li>HIV/AIDS </li></ul></ul></ul><ul><ul><ul><li>Unwanted teenage pregnancy </li></ul></ul></ul><ul><ul><ul><li>Mental illness </li></ul></ul></ul><ul><ul><ul><li>Epilepsy </li></ul></ul></ul>
  41. 41. Manifestation of stigma <ul><li>Stereotyping, bias, distrust, fear, embarrassment, anger, avoidance and aggression </li></ul><ul><li>Resulting in discrimination </li></ul><ul><ul><li>Stigma in action </li></ul></ul><ul><ul><li>Stigmatizing thoughts and beliefs leads to discriminatory behavior </li></ul></ul><ul><ul><li>Discrimination is an act or behavior as a result of stigma </li></ul></ul>
  42. 42. Discrimination <ul><li>Treating someone differently and may involve the following: </li></ul><ul><ul><li>Denial of rights and opportunities </li></ul></ul><ul><ul><li>Social, psychological and physical abuse </li></ul></ul>
  43. 43. HIV/AIDS and stigma <ul><li>Most affected are PLWHA </li></ul><ul><li>Worse when </li></ul><ul><ul><li>Women </li></ul></ul><ul><ul><li>Poor </li></ul></ul><ul><ul><li>Uneducated </li></ul></ul><ul><ul><li>With psychosocial instability </li></ul></ul><ul><ul><li>Communities with negative cultural practices </li></ul></ul>
  44. 44. Part 3. Psychosocial support in care of HIV/AIDS infected <ul><li>A. Counseling </li></ul><ul><li>B. Support groups </li></ul><ul><li>C. Client tracing and follow-up </li></ul>
  45. 45. Types of counselling <ul><li>Pre/post test counselling </li></ul><ul><li>Adherence preparation counselling </li></ul><ul><li>Ongoing adherence and supportive counselling </li></ul><ul><ul><li>For individuals, groups, family, youth, children and adults </li></ul></ul>
  46. 46. Counselling requirements <ul><li>Definition of counseling </li></ul><ul><li>Why </li></ul><ul><li>By whom </li></ul><ul><li>Qualities of counsellor </li></ul><ul><li>Skills and techniques </li></ul><ul><li>When not to counsell </li></ul><ul><li>Challenges </li></ul>
  47. 47. Adherence counselling <ul><li>Introduction and orientation </li></ul><ul><li>HIV information recheck and ART benefits </li></ul><ul><li>Explore support and potential barriers </li></ul><ul><li>Ways of over coming the barriers </li></ul><ul><li>Make decision to start ART </li></ul><ul><li>Ways of promoting adherence to ART </li></ul>
  48. 48. Check lists for adherence counselling <ul><li>Counselling sessions at least 3 </li></ul><ul><li>Art preparation </li></ul><ul><li>Ongoing adherence monitoring </li></ul><ul><li>Should non adherence occur find out why </li></ul><ul><li>Identify barrier and address ir seriously. If too busy refer! </li></ul>
  49. 49. Set up support groups <ul><li>Start with the patient individually </li></ul><ul><li>Pre, post and ongoing counseling </li></ul><ul><li>Follow up adherence counseling </li></ul><ul><li>Treat patient for OI medically </li></ul><ul><li>When ready refer to post test club for ongoing group support </li></ul>
  50. 50. Support groups <ul><li>Recruit clients already counseled </li></ul><ul><li>Similar ages and illnesses </li></ul><ul><li>Start of with introductions and group norms </li></ul><ul><li>One or two regular facilitator skilled in group work </li></ul><ul><li>Can set time limit and plan for exiting clients </li></ul><ul><li>Can be open or closed </li></ul>
  51. 51. Support group <ul><li>Give each other emotional support </li></ul><ul><li>Learn from each other through sharing </li></ul><ul><li>Encourage each other to adhere to treatment </li></ul><ul><li>Can benefit from ongoing talks and learning sessions </li></ul><ul><li>Empowers clients emotionally </li></ul>
  52. 52. Support groups <ul><li>Can learn social and life skills </li></ul><ul><li>Making ornaments, baskets etc for sale </li></ul><ul><li>Eldoret experience </li></ul><ul><li>South African experience </li></ul>
  53. 53. Types of support groups <ul><li>Children </li></ul><ul><ul><li>2-6 </li></ul></ul><ul><ul><li>6-10 </li></ul></ul><ul><ul><li>Above 10 </li></ul></ul><ul><li>Adolescents </li></ul><ul><ul><li>0ver 13 years </li></ul></ul><ul><li>Adults </li></ul><ul><li>Staff </li></ul><ul><li>Non staff </li></ul>
  54. 54. Client tracing <ul><li>Identify family care giver </li></ul><ul><li>Get details of contacts e.g nearest school, shop, church, chief </li></ul><ul><li>Get nearest mobile contacts </li></ul><ul><li>Network with nearest CBO or NGO in community offering services (CHW,s) </li></ul><ul><li>Refer client for ongoing adherence support at the nearest organization </li></ul>
  55. 55. Case study discussion for 15 minutes <ul><li>Lucy is a secretary in Nairobi and born again Christian. </li></ul><ul><li>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. </li></ul><ul><li>He drinks with friends and occasionally sleeps out. </li></ul><ul><li>The wife fears him as he can be aggressive if confronted </li></ul>
  56. 56. Case study <ul><li>She was diagnosed with HIV two years ago at a VCT center and was referred to a CCC started on ART. </li></ul><ul><li>Her husband was not as supportive </li></ul><ul><li>He has refused to go for the test and does not want to discuss issue with wife </li></ul><ul><li>She is lately withdrawn and has missed some doses of ART </li></ul>
  57. 57. Case study continues <ul><li>She has insomnia and misses job at times, gets irritable to the children who are two. </li></ul><ul><li>The youngest child who is 5 years is not growing well and is sickly many times. </li></ul><ul><li>Lucy is worried that the child may have been infected </li></ul>