1. Kjersti Schmitz ICAP New York Clinical Unit October 5, 2007 Psychosocial Support, Adherence and Measurement

3. Psychosocial Support and Adherence Patients require a fortified psychological capacity to cope with HIV disease. Psychosocial support can strengthen patient internal capacity to seek positive treatment outcomes. Sense of Meaning or Life Purpose “Why do” Patient Self-Efficacy “Can do”

5. Psychosocial Support and Adherence Psychosocial support addresses emotional, mental, spiritual, and social needs. In the context of our programs, psychosocial support can be said to include emotional, informational, instrumental and appraisal support which underpin and facilitate all aspects of patient care and adherence.

6. Psychosocial Support and Adherence Emotional support: Communicates care to patient, building therapeutic relationship between patient and provider or other supporter. Instrumental support: Provides tangible assistance such as transportation, food aid, or referral to needed services. Informational support: Provides information, education, and advice on HIV, care regimen, and adherence. Appraisal support: Provides feedback to help patient assess progress towards a goal, such as adherence assessment.

7. Begin with a Common Goal Patient adherence to HIV care and treatment is a goal shared by providers along the continuum of care To achieve this goal, the ICAP Model of Care includes a range of interventions to improve patient adherence such as: Individual and group counseling Support group meetings Peer or ‘expert patient’ education Tracking and tracing systems Referral to social assistance

11. Identify Integration Opportunities Continuum of Care Each encounter along the Continuum of Care is an opportunity to offer psychosocial support! ART Eligible ART Ineligible CD4/Lab Enrollment Diagnosis Pharmacy Pre-ART Counseling 1st Follow-up CD4/Lab Referral: FP,STI,TB,PMTCT… Counseling/Support .. Counseling LTFU LTFU LTFU LTFU Follow-up

12. Develop a Common Approach With start-up emphasis on enrollment, clinical services, and reporting requirements, psychosocial support can be an adjunct to clinical services. This situation changes when psychosocial support becomes a primary component of patient care. Suggested Two-Fold Strategy: 1. Integrate psychosocial support throughout the Continuum of Care, building program capacity to support patient adherence. 2. Triangulate program characteristics , patient-level adherence measures and measures of adherence support to enable continuous program quality improvement to support patient adherence.

16. Piloted Measures of Adherence Support 60% % of patients seen with at least one counseling session that addresses adherence to care and treatment 27.9% % of patients on ART assessed for adherence to care and treatment at follow-up visit 69.7% % of patients with completed baseline psychosocial assessment and follow-up plan Result Pilot Measure

17. Piloted Measures of Adherence Support ** Appointment attendance, on-time CD4 testing and ART pickup measures were also piloted as measures of patient adherence to care 65.6% % of patients with documented supporter 60.5% % of patients eligible for ART with completed adherence readiness assessment and ART counseling before starting treatment Result Pilot Measure

18. Triangulate Site A Program Characteristics: Site A Patient-level Site A Patient-level Adherence Measure: Adherence Support Measure: ART patients with on-time ART patients assessed for CD4 test result( %) adherence (28%) A more complete picture is closer to the truth and suggests where to seek clarity.

20. Take Home Message… Integrate - Psychosocial Support with all Adherence and Clinical Services and Triangulate – Facility Characteristics, Patient-level Adherence and Adherence Support Data