2. Learning Objectives
• By the end of the session, participants will be able to:
• Define adherence
• Explain the importance of adherence to cART
• Describe how to assess for adherence to therapy
• List patient-related factors that promote adherence
• Explain provider-related Strategies to Improve Adherence
• Discuss adherence in children
• Discuss adherence in adolescents
• Describe stigma and discrimination
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3. Definition of Adherence
• Taking the correct number of doses at the correct time in the correct
way for as long as prescribed is called adherence to treatment
• The client should at least take 95% of the doses to suppress the virus
• Keeping all clinic appointment and other instructions given by clinic
staff is called adherence to care
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4. Good adherence
• Taking ARV drugs at the same time of the day all the time
• Taking medication at the right time and in correct doses
• Not skipping doses
• Not stopping and restarting therapy without medical advice
• Adopting appropriate health seeking behavior
• Keeping appointments
• Not sharing medications
5. Challenges of adherence
• Patients may be unable to read the instructions on how to take the
medication
• Patients may share the ARVs with friends or family who also need
them
• Patients may not understand the many food interactions that can
occur with some ARVs
6. Adherence to Therapy
• Assess and reinforce adherence at every visit
• Ask the patient about their adherence in a way that helps them feel
comfortable
• Acknowledge that:
• Everyone misses doses sometimes
• It is common for people to forget their drugs sometimes
• Sometimes people have trouble taking their pills
• Sometimes people are pressured by family or friends to share drugs
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7. Importance of adherence to cART
• ARV regimens must be taken correctly and consistently 95% of the
time or else resistance will develop and treatment failure will occur
8. Assessing Adherence
• Ask the patient in a way that helps him or her to feel comfortable
• Other ways to assess adherence are:
• Clinical and laboratory parameters
• Ask the patient to bring the medication
• Ask the patient to tell you how s/he takes the pills and what s/he eats,
starting in the morning of a typical day
• Pharmacy pick ups
10. • Educate about goals of therapy,
side effects, what will happen if the
patient does not take all the drugs
• Treat depression or substance
abuse issues
• Treat and manage side-effects
• Monitor adherence at each visit
• Reinforce importance of adherence
at each follow-up visit
• Keep open lines after clinic hours
Provider-related Strategies to
Improve Adherence
11. Main target groups
• Late - classified as late up to 60 days of missing scheduled
appointment
• Lost to follow up (LTFU) - more than 60 days after last scheduled
pharmacy pick up (all tracking efforts have been exhausted) and
patient cannot be traced
• Defaulter - when a person who has been located as late or lost to
follow up chooses not to return to care
12. Adherence Counselling
• When? Every time you see a patient:
• Assess adherence
• Reinforce adherence (adherence is the most important factor in successful
ARV therapy)
• Help patient to solve problems
13. Adherence counselling cont’d
• Patients may wait until one bottle of medication runs out before
replacing it
• Patients may be afraid if they tell the truth about missing drugs that
the therapy will be taken away from them
14. CASE STUDY INSTRUCTIONS
• Read the assigned Case Study and discuss with other group members
• Group representative will present in plenary
• Duration: 30 minutes
• For each case study, underline the things in the patient’s history or
physical examination that may make adherence a problem. Then list
some strategies for helping improve adherence for that patient. The
strategies should address the items you have identified and
underlined as possibly being a problem.
15. Case Study #1
• Charlotte is a pregnant 34-year old mother of 4 who has been
diagnosed with HIV during this pregnancy. Her husband does not
know that she is HIV positive. She reads at a Grade 5-level and
expresses herself well. She does not work outside the home, but
takes care of the house and children. She has a sister who is HIV-
positive, but does not access ARVs from the clinic. Charlotte will be
given ARVs for eMTCT. Charlotte has been having trouble with nausea
during this pregnancy.
16. Adherence Case Study #1 cont’d
• Strategies:
• Help her with disclosure to husband (including role-playing practice session in
clinic)
• Help to encourage him to get tested if she feels she cannot tell him
• Help her plan to store and take medications if she refuses to disclose
17. Adherence Case Study #1 cont’d
• Strategies:
• Stress that complete adherence is key to successful cART
• Help understand that sharing her medication with her friends/family means
taking less drugs and increasing risk of drug resistance
• Encourage her sister to access cART from the clinic
18. Adherence Case Study #1 cont’d
• Strategies:
• Help understand that incorrect use of the drug is harmful
• Help her plan on how to deal with nausea (frequent small meals, high protein
diet etc)
• If needed, provide anti-nausea medication (but remember to think of possible
drug interactions)
21. Issues Surrounding Adherence in Children
• Children depend on caregivers for administration of medication
• Children’s developmental level influences ability and willingness to
take medications
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22. Issues of Adherence associated with the
Caregiver and family
• Careful social assessment should always precede starting therapy
• Poor family circumstances compound the adherence difficulties.
• Families’ reluctance to disclose diagnosis may limit medication
administration at daycare/school
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23. • Poor communication
• Misunderstanding/misinformati
on
• Low literacy if written
• Lack of social support
• Disclosure
• Financial barriers
• Competing priorities
• Work
• Child care
• Stigma and denial
• Alcohol and drug use by the
caregiver
• Mental illness on the caregiver
Barriers to adherence
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24. Non-Disclosure as a Cause of
Non-adherence
• This is commonly seen in children
• Child is either left with the child-minder or granny – no idea about the
child’s HIV status
• Only told that the medication is either for flu or cough
• Importance of continued medication not explained
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25. Masking the taste of medication
• Combine with 5-10 cc of non-alcoholic beverage.
• For pills, crush with a mortar and pestle until fine.
• For capsules, open the capsule into a small bowl. Add 1-2 teaspoons
of food (jelly, jam, crushed banana, cereal) and combine vigorously.
• Mix well and ensure that the caregiver gives the full amount
• Remember to give lots of praise after each dose!
26. Avoiding or Minimising Nausea
• Offer the child a small meal of bland food (cereal, crackers, and
bread). Shortly thereafter, administer medication.
• Administer tablets and capsules with only enough water or beverage
needed to swallow.
• Reassure the caregiver that the nausea is usually temporary until the
child’s body gets used to the medicine.
• Stress the importance of giving meds in a calm, unhurried manner,
especially during the first few weeks.
27. Case Study Instructions
• Read the assigned Case Study and discuss with other group members
• Group representative will present in plenary
• Duration: 30 minutes
• For the case study, underline the things in the patient’s history or
physical examination that may make adherence a problem. Then list
some strategies for helping improve adherence for that patient. The
strategies should address the items you have identified and
underlined as possibly being a problem.
28. Case Study for Group Discussion
• Paul is three years old. His mother is a housewife and his father is a
truck driver who travels quite often between South Africa and
Zambia. The father is away from home for long periods, sometimes
up to four months. Paul was started on ART eight months ago. Until
last month, he was progressing very well. Two weeks ago he was
brought in with an acute febrile illness, associated with severe oral
thrush. You treated him with Nystatin® drops, an oral antibiotic and
Coartem®. Today he still has oral thrush but he now complains of pain
when swallowing food and he has lost 1.5 kg over the past two weeks
29. • Denial and fear of their HIV
infection
• Misinformation
• Distrust of the medical
establishment
• Fear and lack of belief in the
effectiveness of medications
• Low self-esteem
• Unstructured and chaotic
lifestyle
• Lack of family and social support
Issues surrounding Adherence in Adolescents
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30. Stigma and Discrimination
• Definition
• Stigma is a degrading and debasing attitude of an individual or society that
discredits a person or a group because of an attributable condition such as an
illness
• Discrimination is the unjust or prejudicial treatment of people, especially on
grounds of race, tribe, age, or sex
31. Stigma and Discrimination
• Definition
• Stigma is a degrading and debasing attitude of an individual or society that
discredits a person or a group because of an attributable condition such as an
illness
• Discrimination is the unjust or prejudicial treatment of people, especially on
grounds of race, tribe, age, or sex
32. Effects of Stigma and Discrimination
• Stigma may:
• Reduce an individual's choices in healthcare and family/social life
• Fuels new HIV infections
• Leads to social isolation
33. Effects of stigma cont’d
• Prevents people from getting tested for HIV
• Makes people less likely to acknowledge their risk of infection
• Discourages disclosure of HIV status to sexual partners
34. Take home points
• Maximal and durable suppression of HIV replication occurs with
optimal adherence
• ARV regimens must be taken correctly and consistently 95% of the
time or else resistance will develop and treatment failure will occur
• Assess and reinforce adherence at every visit
• Stigma and discrimination leads to poor management of HIV/AIDs
programs
