Module 9 adherence & psychosocial counselling

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  • 1.
    • UNIT 2
    • Adherence Counseling
  • 2. 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.
  • 3. 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.
  • 4. 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
  • 5. 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)
  • 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. 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)
  • 8. 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
  • 9. 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
  • 10. 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
  • 11. Causes of non adherence
    • Brainstorming 15 minutes!
  • 12. Causes of non adherence
    • Structural/logistics
    • Socio-economic
    • Psychological
    • Spiritual
    • Illness
    • Medicine specific
    • Other
  • 13. 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.
  • 14. How to assess adherence?
    • Self reports
    • Pill counts
    • Biological markers
    • Pharmacy records
  • 15. 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
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. How do we promote adherence
    • Brainstorming!
  • 20. 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!!!
  • 21. 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)
  • 22. 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
  • 23. Adherence Counseling check lists
    • Counseling session 1
    • Counseling session 2
    • Counseling session 3
  • 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. 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
  • 26. 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
  • 27. Adherence monitoring
    • Complete adherence monitoring form with the patient
    • See table 2 page 12 Kenyan Clinical manual for ARV providers
  • 28. Adherence Counseling Skills 1
    • Knowledge
    • HIV disease, Medications and Side effects
    • Attitudes
    • Positive belief and perceptions; self efficacy
    • Practices and support systems: use of “cues” or reminders, buddies
  • 29. Adherence Counseling Skills 2
    • Identifying and addressing barriers
    • Integrating treatment regimen into patient’s daily routine
    • Encourage family support
  • 30. Counseling Techniques
    • SOLER:
    • Sit upright
    • Open your hands
    • Listen
    • Eye contact
    • Relax
  • 31. Psychosocial aspects in HIV/AIDS MANAGEMENT By Dr Makanyengo
  • 32. 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
  • 33. 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
  • 34. 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
  • 35. Part 2 Psychosocial impact of HIV/AIDS in the lives of PLHWA
    • BRAINSTORMING for 10 minutes!
  • 36. 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'.
  • 37. 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
  • 38. Psychiatric symptoms and dementia
    • Depression or hypomania/mania
    • Confusion, forgetfulness
    • Disorientation
    • Personality changes
    • Frontal Lobe syndrome
    • Seizures
    • Agitation or aggression
  • 39. Stigma
    • Highly important in non adherence of PLWHA to care
    • What is stigma?
    • DISCUSSION!
  • 40. 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
  • 41. 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
  • 42. Discrimination
    • Treating someone differently and may involve the following:
      • Denial of rights and opportunities
      • Social, psychological and physical abuse
  • 43. HIV/AIDS and stigma
    • Most affected are PLWHA
    • Worse when
      • Women
      • Poor
      • Uneducated
      • With psychosocial instability
      • Communities with negative cultural practices
  • 44. Part 3. Psychosocial support in care of HIV/AIDS infected
    • A. Counseling
    • B. Support groups
    • C. Client tracing and follow-up
  • 45. Types of counselling
    • Pre/post test counselling
    • Adherence preparation counselling
    • Ongoing adherence and supportive counselling
      • For individuals, groups, family, youth, children and adults
  • 46. Counselling requirements
    • Definition of counseling
    • Why
    • By whom
    • Qualities of counsellor
    • Skills and techniques
    • When not to counsell
    • Challenges
  • 47. 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
  • 48. 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!
  • 49. 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
  • 50. 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
  • 51. 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
  • 52. Support groups
    • Can learn social and life skills
    • Making ornaments, baskets etc for sale
    • Eldoret experience
    • South African experience
  • 53. Types of support groups
    • Children
      • 2-6
      • 6-10
      • Above 10
    • Adolescents
      • 0ver 13 years
    • Adults
    • Staff
    • Non staff
  • 54. 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
  • 55. 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
  • 56. 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
  • 57. 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