This document discusses strategies to promote adherence to antiretroviral therapy (ART). It begins with a case study of a patient, Abebech, who is not taking her ART correctly. The document then covers the importance of adherence to ART, challenges to adherence, and methods for assessing and improving adherence. Key strategies discussed for improving adherence include patient education, counseling, visual schedules, reminder devices, the buddy system, and simplified treatment regimens. The pharmacist's role in adherence includes assessing barriers, developing strategies to promote adherence, monitoring adherence over time, and counseling patients.
Adults and Adolescents ART Guidelines AI.pptxshillahhungwe
Adult ART according to the the new 2022 guidelines.Viral load monitoring now is categorized as target not detectable,low viraemia and high viraemia.EAC sessions now given to both low and high viraemia recipients of care and monthly repeat viral load is collected for monitoring.
Switching to second line is only done when there is high viraemia on the second repeat viral load after EAC sessions.
Patient compliance with medical adviceRavish Yadav
The all the content in this profile is completed by the teachers, students as well as other health care peoples.
thank you, all the respected peoples, for giving the information to complete this presentation.
this information is free to use by anyone.
Medication Adherence , setting up directions .. Ahmed Nouri
presenting the terminology of adherence, statistics of non-adherence and its impact, why do patients have difficulty with treatment, how to measure and how to improve the adherence, in addition to the role of the pharmacist in improving adherence.
Strategies to improve adherence to antihypertensive medicationmagdy elmasry
Challenges in hypertension treatment.What is the definition of medication non-adherence?Who is at risk? How should
patients at risk be screened and identified?What are the negative impacts of non-adherence?What is the
practical approach for improving adherence? The ABC taxonomy for medication adherence
Adherence :3 quantifiable components: initiation , implementation , and discontinuationThe five dimensions
of non-adherence
.
Adults and Adolescents ART Guidelines AI.pptxshillahhungwe
Adult ART according to the the new 2022 guidelines.Viral load monitoring now is categorized as target not detectable,low viraemia and high viraemia.EAC sessions now given to both low and high viraemia recipients of care and monthly repeat viral load is collected for monitoring.
Switching to second line is only done when there is high viraemia on the second repeat viral load after EAC sessions.
Patient compliance with medical adviceRavish Yadav
The all the content in this profile is completed by the teachers, students as well as other health care peoples.
thank you, all the respected peoples, for giving the information to complete this presentation.
this information is free to use by anyone.
Medication Adherence , setting up directions .. Ahmed Nouri
presenting the terminology of adherence, statistics of non-adherence and its impact, why do patients have difficulty with treatment, how to measure and how to improve the adherence, in addition to the role of the pharmacist in improving adherence.
Strategies to improve adherence to antihypertensive medicationmagdy elmasry
Challenges in hypertension treatment.What is the definition of medication non-adherence?Who is at risk? How should
patients at risk be screened and identified?What are the negative impacts of non-adherence?What is the
practical approach for improving adherence? The ABC taxonomy for medication adherence
Adherence :3 quantifiable components: initiation , implementation , and discontinuationThe five dimensions
of non-adherence
.
Introduction to adverse drug reactions
Definitions and classification of ADRs
Detection and reporting
Methods in Causality assessment
Severity and seriousness assessment
Predictability and preventability assessment
Management of adverse drug reactions
Stop TB Partnership focus group session 10-20-17Bruce Thomas
The Arcady Group founder, Bruce Thomas, led the Stop TB Partnership's Focus Group Workshop On Digital Adherence Technologies. At this meeting, innovators such as Everwell Health (99DOTS), Wisepill Technologies (evriMED medication monitor), Keheala (SMS-based behavioral counseling) and SureAdhere Mobile Technology (V-DOT) were connected with representatives of key NGO implementers and country programs (including Zimbabwe, Philippines, Moldova, and South Africa) to discuss opportunities for experimentation and uptake of digital adherence technologies through TB REACH Wave 6 grants. Bruce and Ram Subbaraman shared new evidence and insights about the importance of treatment adherence to avoid TB relapse.
Impact of Pharmacist Led Medication Reviews on the Virtual Frailty Ward (Sout...Health Innovation Wessex
The AHSN Network Polypharmacy Programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications.
Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely.
To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Impact of Pharmacist Led Medication Reviews on the Virtual Frailty Ward (South West Essex), can be viewed here.
For more information about the polypharmacy programme, please visit https://www.ahsnnetwork.com/programmes/medicines/polypharmacy/
Rational Use of Medicine_Evidence Based Medicine_Therapeutic Drug Monitoring_...Dr Jeenal Mistry
Rational use of Medicine: Irrational use of medicines is a major problem worldwide. WHO estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly. The overuse, underuse or misuse of medicines results in wastage of scarce resources and widespread health hazards. Examples of irrational use of medicines include: use of too many medicines per patient ("poly-pharmacy"); inappropriate use of antimicrobials, often in inadequate dosage, for non-bacterial infections; over-use of injections when oral formulations would be more appropriate; failure to prescribe in accordance with clinical guidelines; inappropriate self-medication, often of prescription-only medicines; non-adherence to dosing regimes.
Evidence based medicine: Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.
Therapeutic drug monitoring: Therapeutic drug monitoring (TDM) is a branch of clinical chemistry and clinical pharmacology that specializes in the measurement of medication levels in blood. Its main focus is on drugs with a narrow therapeutic range, i.e. drugs that can easily be under- or overdosed.
Introduction to adverse drug reactions
Definitions and classification of ADRs
Detection and reporting
Methods in Causality assessment
Severity and seriousness assessment
Predictability and preventability assessment
Management of adverse drug reactions
Stop TB Partnership focus group session 10-20-17Bruce Thomas
The Arcady Group founder, Bruce Thomas, led the Stop TB Partnership's Focus Group Workshop On Digital Adherence Technologies. At this meeting, innovators such as Everwell Health (99DOTS), Wisepill Technologies (evriMED medication monitor), Keheala (SMS-based behavioral counseling) and SureAdhere Mobile Technology (V-DOT) were connected with representatives of key NGO implementers and country programs (including Zimbabwe, Philippines, Moldova, and South Africa) to discuss opportunities for experimentation and uptake of digital adherence technologies through TB REACH Wave 6 grants. Bruce and Ram Subbaraman shared new evidence and insights about the importance of treatment adherence to avoid TB relapse.
Impact of Pharmacist Led Medication Reviews on the Virtual Frailty Ward (Sout...Health Innovation Wessex
The AHSN Network Polypharmacy Programme is working with healthcare professionals to address problematic polypharmacy by supporting easier identification of patients at potential risk from harm from multiple medications.
Our evidence-based polypharmacy Action Learning Sets (ALS) are being rolled out across England to support GPs, pharmacists and other healthcare professionals who undertake prescribing or medication reviews to understand the complex issues around stopping inappropriate medicines safely.
To drive and accelerate changes in practice, delegates complete a quality improvement project to address problematic polypharmacy in their workplace. This poster summary, Impact of Pharmacist Led Medication Reviews on the Virtual Frailty Ward (South West Essex), can be viewed here.
For more information about the polypharmacy programme, please visit https://www.ahsnnetwork.com/programmes/medicines/polypharmacy/
Rational Use of Medicine_Evidence Based Medicine_Therapeutic Drug Monitoring_...Dr Jeenal Mistry
Rational use of Medicine: Irrational use of medicines is a major problem worldwide. WHO estimates that more than half of all medicines are prescribed, dispensed or sold inappropriately, and that half of all patients fail to take them correctly. The overuse, underuse or misuse of medicines results in wastage of scarce resources and widespread health hazards. Examples of irrational use of medicines include: use of too many medicines per patient ("poly-pharmacy"); inappropriate use of antimicrobials, often in inadequate dosage, for non-bacterial infections; over-use of injections when oral formulations would be more appropriate; failure to prescribe in accordance with clinical guidelines; inappropriate self-medication, often of prescription-only medicines; non-adherence to dosing regimes.
Evidence based medicine: Evidence-based medicine (EBM) is "the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients."The aim of EBM is to integrate the experience of the clinician, the values of the patient, and the best available scientific information to guide decision-making about clinical management. The term was originally used to describe an approach to teaching the practice of medicine and improving decisions by individual physicians about individual patients.
Therapeutic drug monitoring: Therapeutic drug monitoring (TDM) is a branch of clinical chemistry and clinical pharmacology that specializes in the measurement of medication levels in blood. Its main focus is on drugs with a narrow therapeutic range, i.e. drugs that can easily be under- or overdosed.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...
Adherence ppt.ppt
1. Adherence to ART
Unit 14
HIV Care and ART: A Course for
Pharmacists by Salahadin M.Ali
2. 2
Introductory Case: Abebech
Abebech is a HIV+ 30 year-old female who presents
to the pharmacy with refill prescriptions for the
following:
Lopinavir/ritonavir 3 caps bid
Zidovudine 300 mg bid
Lamivudine 150 mg bid
3. 3
Introductory Case: Abebech (cont.)
You are a thorough pharmacist and you ask her the
following questions before filling her prescriptions:
How are you tolerating your medication?
Are you taking any new medications?
Are you able to remember to take all of your doses?
How are you taking your doses?
4. 4
Introductory Case: Abebech (cont.)
She responds with the following information:
She has been taking her medications for 1 month. She
gets occasional diarrhea, which she controls by increasing
her intake of starchy foods
She is not taking any new medications
She is proud to tell you that she has made her medication
last for 2 months rather than one month, because she only
takes 1 rather than 2 doses a day to make her pills last
longer. She remembers to take her dose every morning,
except when she is late for work
5. 5
Introductory Case: Abebech (cont.)
Which of the following statements regarding
counseling Abebech on adherence is true?
1. A lot of doses have to be missed before ART becomes
ineffective
2. ART must be taken as prescribed to avoid the
development of resistance and possible treatment failure
3. If any doses of ART are missed, a change in ART
regimen will be necessary
4. Taking less than the prescribed dose is an effective way
to make ART last longer without going to the pharmacy
6. 6
Unit Learning Objectives
Identify challenges and barriers for adherence to
ART
Review the consequences of ART non-adherence
on patient outcomes
Explain strategies to promote adherence
Identify methods of adherence assessment and/or
monitoring
Describe the role of the pharmacist in adherence
for ART
7. 7
Individual Experiences with
Adherence
1. Describe your own experience of taking medicines
to your partner
2. How easy was it to find information about the
medicines?
3. How easy was it to follow the instructions on how to
take the medicines?
4. What made it easy or hard to take the medicines?
Please respect requests for confidentiality
8. 8
What is Adherence?
Adherence is a client’s behavior coinciding with the
prescribed health care regimen
Regimen is agreed upon through a shared decision
making process between the client and the health
care provider
9. 9
Why is Adherence to ART Important?
HAART reduces morbidity, mortality, and overall
health care costs for HIV+ persons, if properly
taken
Achieves viral suppression
Avoids development of viral resistance and treatment
failure
Prevents development of opportunistic infections
ARV should not be prescribed in the absence of
adherence assessment and support
10. 10
Consequences of Poor Adherence
Incomplete viral suppression
Continued destruction of the immune system
Disease progression
Emergence of resistant viral strains
Limited future treatment options
Transmission of HIV to others
Transmission of resistant virus to the community
Higher costs to the individual and ART program
• Increase in morbidity and mortality ,Secondary health
costs & Medication wastage
11. 11
Introductory Case: Abebech (cont.)
1. A lot of doses have to be missed before ART
becomes ineffective
FALSE
Taking less than the prescribed doses leads to reduced
virologic control
Counsel the patient on the need for adherence
Recommend that she gets a follow-up CD4 or TLC count
every 3 months to detect drug failure
12. Adherence by Pill
Count, %
NNRTI Group, % PI Group, %
94 to 100 ~90 ~65
74 to 93 ~ 75 ~60
54 to 73 ~ 60 ~30
0 to 53 ~30 ~12
Viral Load Suppression and Adherence:
NNRTI vs. PI
14. 14
Adherence and Antiretroviral
Drug Resistance
Sub-optimal adherence predisposes to resistance:
Association between poor adherence and
antiretroviral resistance is well-documented1,2
Sub-optimal adherence
Sub-therapeutic drug levels
Incomplete viral suppression
Generation of resistant HIV strains
by selection for mutant viruses
1. Vanhove G, et al. JAMA. 1996;276:1955-1956.
2. Montaner JS, et al. JAMA. 1998;279:930-937.
15. 15
Missed Doses & Development of
Drug Resistance
When blood levels fall below the level needed to
prevent resistant virus from growing, the resistant
virus overgrows the sensitive virus
16. 10% Adherence difference = 21% change in risk of progressing to AIDS
Adherence and AIDS-Free Survival
Bangsberg D, et al. AIDS. 2001:15:1181
Proportion
AIDS-Free
Months from Entry
P = .0012
0 5 10 15 20 25 30
0.00
0.25
0.50
0.75
1.00
Adherence
90–100%
50–89%
0–49%
17. 17
Introductory Case: Abebech (cont.)
2. ART must be taken as prescribed to avoid the
development of resistance and possible treatment
failure
TRUE
18. 18
How Common is Non-Adherence?
Estimated rates of non-adherence to medications
range from 10% to nearly 100%, with an average
incidence of about 50%
Non-adherence to ART, likewise, is common in all
groups of individuals on treatment
>10% patients report missing one or more doses on any
given day1
>33% report missing doses in the past 2 to 4 weeks1
Partly due to non-adherence, ART fails in
approximately half of patients for whom it is
prescribed2
1. Ickovics, J.R. et al., JAIDS, 2002..
2. Valdez L, et al., Arch Intern Med, 1999.
19. 19
Adherence to ARVs in
Resource-Limited Settings
Uganda: 88%
Cote d’Ivoire: 75%
Haiti: 88%
Senegal: 78%, 42%, 88%
South Africa: 89%
Brazil: 57%, 87%, 69%
Botswana: 54%, 53%, 58%
Nigeria: 58%
Kenya: 59%
(Results from small studies with differing definitions of adherence)
Adherence is equally
problematic in
resource-limited and
resource-rich settings.
No evidence shows
that it is more
problematic.
Source: MTCT-Plus, Columbia University 2002
20. 20
Adherence to ART versus
Adherence to Other Medications
Adherence to medications is a complicated issue,
regardless of the illness or disease
In other chronic diseases like diabetes, hypertension,
and heart disease, 20-80% of people are non-
adherent
ART non-adherence is comparable to other chronic
illnesses
Overall, 40% to 60% of people taking ART are less
than 90% adherent
21. 21
Introductory Case: Abebech (cont.)
3. If any doses of ART are missed, a change in ART
regimen will be necessary
FALSE
A change in regimen should only be done when
absolutely necessary. Although this patient has been
taking her medication incorrectly, this does not mean that
she has failed her regimen
She should be counseled that she needs to take her
medication as prescribed and should be given
suggestions on how to avoid missing her morning dose
22. 22
Challenges of Adherence to ART
ART does not cure HIV infection, therefore must be
taken regularly life long
High pill burden
Requires near perfect adherence
Specific dietary and fluid instructions
Adverse effects: short and long term
Stigma
23. 23
Five Types of Non-adherers
1. Consistent Underdoser
Regularly neglects to take one of the prescribed doses,
such as the midday dose
Regularly takes only some of the prescribed medications
2. Consistent Overdoser
Regularly takes a drug more often or in larger doses than
prescribed
3. Random Doser
Takes the medications when she or he thinks of it
24. 24
Five Types of Non-adherers (2)
4. Abrupt Overdoser
Does not take medications properly and then takes an
overdose prior to a clinic visit
Doubles up for missed doses
5. Tourist (takes “drug holidays”)
Abruptly stops all medications for a few days or weeks
Takes one day off per week
25. 25
Introductory Case: Abebech (cont.)
4. Taking less than the prescribed dose is an effective
way to make ART last longer without going to the
pharmacy
FALSE
Taking less than the prescribed dose will lead to drug
levels that are too low to prevent viral replication. This will
lead to treatment failure
Every effort must be made to take ART as prescribed to
ensure treatment success
26. 26
Factors Affecting Adherence
A variety of factors impact a patient’s ability to
adhere to a prescribed treatment regimen:
Patient variables
Patient–provider relationship
Treatment regimen
Disease characteristics
Contextual factors
Understanding these factors can increase
providers’ attention to adherence
27. 27
Patient Variables
Socio-demographic factors
Generally, socio-demographic factors do not predict
adherence behaviour
Some studies reported the following correlates of poor
adherence1-4
• Female sex
• Younger age
• Lower income
• Lower literacy
Nondisclosure of HIV status, with accompanying stigma and
isolation
28. 28
Patient Variables (2)
Psychosocial factors:
Consistent associations are found between certain
psychosocial factors and adherence behavior
Common predictors of non-adherence include:
• Depression/psychiatric illness1
• Active alcohol and substance use1
• Lack of perceived efficacy of ART2
• Lack of social support1
• Lack of knowledge1
Spirituality
29. 29
Patient–Provider Relationship
The patient-provider relationship may influence
adherence through:
Patient's overall satisfaction and trust in the provider
Patient's opinion of the provider's competence
Provider's willingness to include the patient in treatment
decisions
Tone of the relationship (warmth, openness, cooperation,
etc)
Adequacy of referrals
30. 30
Treatment Regimen
Treatment regimen include:
The number of pills prescribed (pill burden)
The complexity of the regimen (dosing frequency, ease of
administration, food instructions, etc)
The short- and long-term medication adverse effects
Cost and access to medications
Degree of behavioural change required
31. 31
Disease Characteristics
Disease characteristics include:
The stage and duration of HIV infection
Associated opportunistic infections
HIV-related symptoms
N.B. Reported predictors of poor adherence
include:
• Lack of advanced disease1
• Lack of prior experience with opportunistic infections2
1. Wenger N, et al. 6th Conference on Retroviruses and Opportunistic Infections, 1999.
2. Singh N. et al. AIDS Care 1996.
32. 32
Contextual Factors
Focuses primarily on macro-level barriers such as:
Medical practices
Systemic issues
Life situation issues
Institutional systems
33. Published Reasons for
Missed Doses
Simply forgot/too busy 52%
Away from home 46%
Change in routine 45%
Depressed/overwhelmed 27%
Took drug holiday/medication break 20%
Ran out of medication 20%
Too many pills 19%
Felt drug was too toxic 18%
Wanted to avoid other adverse effects 17%
Gifford AL, et al. J Acquire Immune Defic Syndr. 2000;23:386-395.
34. 34
Published Reasons for Missing Doses (2)
Remember:
The most common reason for missing doses is:
‘I FORGOT’
Always try to discover the reason for forgetting
If several doses were missed, is there a pattern?
36. 36
The Adherence Team
A team approach is needed to optimally maximize
adherence
Should involve physicians, nurses, pharmacists,
other health care providers, and family/friends of the
patient when possible
Use the team to ensure the patient is committed to
therapy, before beginning ART
Monitor adherence regularly over time, as a team
37. 37
ART Care Model
(Adherence Protocol)
Multidisciplinary (Team) effort:
Patient
Physician
Nursing
Nutritionist
Pharmacist
Social worker
TGK/ITECH/9.0
Gabre-Kidan, T., M.D., I-TECH Sept 2003
38. Role of the pharmacist in Adherence
Identifying barriers to adherence before a patient
begins therapy and suggest possible solutions with
the patient and /or other health care workers
Assessing patient adherence and follow up
Developing strategies to promote adherence
Monitoring adherence for patients overtime
Counseling patients
40. 40
Improving Adherence:
Before Initiation of Therapy
Pharmacists should educate patients on:
Adherence
Risk and benefits of ART
Adverse effects of ART
Drug interactions
Reminder cues
Engaging support
Seeking help quickly if problems occur
Lifelong commitment to therapy
41. 41
Improving Adherence:
Before Initiation of Therapy (2)
Don’t make assumptions about patient adherence:
Ask questions and discuss solutions
“Do you know that the medicines must be taken for
the rest of your life? Your life depends on taking
them everyday, at the right time”
“If you stop, you will become ill (not immediately, but
after months or years)”
“Do you know what resistance is?”
“Do you know you should not share these medicines
with family or friends?”
42. 42
Improving Adherence:
Before Initiation of Therapy (3)
“Have you told anyone that you are HIV-positive?
Telling someone else who can help you take your
medicines every day will help you remember”
“How far do you have to travel to the clinic, and do
you think you can keep regular appointments here?”
Ask about stigma related to taking the pills
Check the patient’s clinic attendance – ask about
reasons for missed appointments
43. 43
Make sure the patient is involved in the decision to
start therapy
Determine other medical barriers to adherence
Manage or refer for management of adherence-
limiting co-morbid conditions
Identify any potential drug interactions (with other drugs,
natural medicines, or food)
Identify and address specific cultural and/or religious
factors that may potentially affect adherence (e.g.
fasting, traditional healers, etc)
Improving Adherence:
Before Initiation of Therapy (4)
44. 44
Try to use simple regimens
Once or twice daily
Avoid food restrictions or requirements if possible
Use fixed dose combination tablets where available
Clear & simple instructions
Improving Adherence:
Before Initiation of Therapy (5)
45. 45
Inform patient of devices that can assist them in
taking their medications regularly
Alarm devices1 (wrist watch or cell phone alarms)
Pill boxes
Associating doses with daily activities
Other memory cues
• Leaving reminders around home or work
• Leave medications out where they can see them
Improving Adherence:
Before Initiation of Therapy (6)
46. 46
Develop strategies ahead of time for handling:
Adverse effects
Missed doses
Change in routine (carry an extra dose of ARVs)
Travel (time zones)
Storage of medications
Fear of taking medications in front of others
Encourage patients to talk with others about their
experiences
Improving Adherence:
Before Initiation of Therapy (7)
47. 47
Let patients practice pill-taking behavior before
starting ART with OI prophylaxis medications or
candy
Consider short term Directly Observed Therapy
(DOT)4,5
Encourage social support
Improve patient self-efficacy
Involve the multidisciplinary team to counsel about
adherence
Improving Adherence:
Before Initiation of Therapy (8)
48. 48
Remember
Cautions should be taken before starting ART
Take time to educate the patient before starting
therapy
49. 49
Maintaining Adherence
Adherence is a dynamic behaviour
Adherence is affected by factors that change
throughout a person’s life
Adherence levels will change over time
50. 50
Pill Fatigue…
Patients who have been on treatment for some time
may get tired of taking medications every day or feel
overwhelmed—‘pill fatigue’
Decision to stop treatment should be discussed with
a health care provider
If medication is stopped, stop all pills at once to avoid the
development of resistance
51. 51
Improving Adherence:
After Initiation of Therapy
Close follow-up (necessary amount will vary by
patient)
Ask patient to verbalize treatment regimen
Educate about adherence
Re-emphasize importance of adherence at each visit,
even in patients with good virologic control
Review incidence & management of adverse effects
often
52. 52
Improving Adherence:
After Initiation of Therapy (2)
Patients should be checked for adherence issues
at each visit
Adherence interventions may be similar to
techniques listed for pre-therapy preparation
Reminders
Support structures
Increase monitoring procedures if there is any
sign of adherence problems
Home visits
DOTS
55. 55
Measuring Patient Adherence to
Medications
Self reports
Pill counts
Pharmacy records
Biological markers
Electronic devices
Measuring drug levels
56. 56
Patient Self-Report of Missed Doses
Ask questions in a respectful and non-judgmental way
Ask in a way that makes it easier for patients to be
truthful
“Many patients have trouble taking their medications.
What trouble are you having?”
“Can you tell me when and how you take each pill?“
“When is it most difficult for you to take the pills?“
“It is sometimes difficult to take the pills every day and on
time. How many have you missed (yesterday, last 3 days, last
month)?
“When was the last time you missed a dose?”
57. 57
Pill Counts
Providers count remaining pills during clinic visit
Problems
• Patients can dump pills prior to visit
• Promotes a sense of distrust between patient and provider
Unannounced pill counts
Done at home
Can be more reliable
Feasibility?
59. 59
Supporting Adherence
What are common reasons for non-adherence?
How can we as pharmacists or druggists help
patients take their medications regularly as
prescribed?
How can we track adherence for our patients so that
we can recognize a problem with adherence ?
60. 60
Key Points
Antiretroviral (ARV) regimens are complex and have multiple
barriers to adherence exist
Serious potential consequences can result from non-
adherence
Patient/family education and involvement is critical for
successful treatment of HIV infection
The medical team (provider, pharmacist, nurse) and the
patient must work together to promote optimal adherence to
both HIV care and ARV regimens
The pharmacist plays a vital role in promoting adherence
and offering techniques for improvement of adherence