1. Home-based Care
&
Adherence Counseling
for
Patients Living with HIV
Sonya Shin, MD MPH
Brigham and Women’s Hospital
Harvard University
Partners In Health
Boston, MA
Gallup Indian Medical Center
Gallup, NM
4. How well are we doing?
Diagnosis
Treatment
Adherence
Favorable
outcomes
5. How much of this is controlled
within our clinic walls?
Diagnosis
Treatment
Adherence
Favorable
outcomes
Who is not Who is not
Who does
getting taking
not establish
regular his/her
care?
follow-up? meds?
6. NAIHS Annual HIV Report, 2011
Established care within first yr of dx (n=39): 71%
Retention in care, among those living (n=303):
-Regular follow-up/seen elsewhere 55%
-Intermittent follow-up (<50% appointments) 14%
-No follow-up 31%
Virologic suppression: 55%
NAIHS Annual Report, 2011
7. Follow-up study of 100,375 people
diagnosed with HIV through 2008, US
Established care within a year of dx (n=5137): 64%
-White: 75%
-African-American: 54%
-Hispanic: 69%
-Other: 68%
Retention in care (n=100,375): 45%
-White 50%
-African-American: 41%
-Hispanic: 40%
-Other 58%
Virologic suppression: 77% (last viral load)
53% (all viral loads)
Hall et al, JAIDS 2012
8. Can we do better?
• At the national level:
• > one third do NOT establish care within a year of HIV dx
• > one half do NOT receive regular HIV care
• At least 23% are not virologically suppressed
10. Accompagnateurs:
The “Backbone” of PIH
• Community health workers
• Since 1985
• Paid health workers
• Responsible for referrals,
vaccines, hygiene, maternal
and infant health
• Initial training plus ongoing
training
• The “missing infrastructure”
in many resource poor
settings
• 100% directly-observed
therapy (DOT) coverage for
TB and HIV patients
13. 1041 people initiating ART 2005-2006,
PIH-MOH HIV Program in Rwanda
Established care within a year of dx: not reported
Retention in care among those living (n=989): 97%
Virologic suppression (n=275): 98%
Rich et al, JAIDS 2012
14. So, what’s the magic ingredient?
∗ CHW accompaniment Directly observed therapy (?)
Psychosocial support
Adherence coaching
Screen for side effects
Liaison with providers
∗ Additional supports Nutrition
Transportation costs
Patient support groups
15. How much of this is controlled
within our clinic walls?
Diagnosis
Treatment
Adherence
Favorable
outcomes
Who is not Who is not
Who does
getting taking What are the
not establish
regular his/her underlying reasons for
care?
follow-up? meds? falling through the
cracks?
16. Root causes of health disparities:
Universal themes
∗ Often not biological
∗ Poverty & marginalization
∗ Forces priorities other than health
∗ Difficult access to care
∗ Poor utilization of health services
∗ Mental health, substance use
∗ Education, health literacy, language barriers
∗ System not designed for the vulnerable
∗ Stigma (HIV status, race, sexual orientation)
18. Step 1:
Create an outreach team
∗ Who is the outreach worker?
∗ Role: e.g. case manager, health technician, community
health worker
∗ Institution: IHS, tribe, NGO, etc
∗ Cultural considerations
∗ Care coordination
∗ Link the clinic &
outreach team
19. Step 2:
Define the home-based intervention
∗ What is the role of the
outreach worker?
∗ Deliver medications?
∗ Adherence coaching?
∗ Counseling?
∗ Directly observed therapy?
Modified?
∗ Case management? Referrals?
∗ Other?
20. Step 3: Equip the outreach worker
with the necessary resources
∗ Training
∗ HIV content
∗ Counseling skills, motivational interviewing
∗ Materials
∗ Teaching / coaching materials
∗ Four-wheel drive?
∗ Support
∗ Access to care team
∗ Clinical “back-up” for challenging cases
∗ Support for their own wellbeing (burn-out, safety, trauma)
21. Step 4: Match the intervention to
your population
∗ All patients?
∗ High-risk only? (clinical criteria? Psychosocial?)
∗ Tiered interventions depending on needs?
22. HOPE in Navajo: HIV Outreach
& Patient Empowerment
∗ Hiring
∗ Health technician at Gallup Indian Medical Center
∗ Case manager at Navajo AIDS Network
∗ Training
∗ Adherence Counseling
∗ Motivational interviewing
∗ Harm Reduction
∗ Wellness & self-care
∗ Materials
∗ Patient flipcharts
∗ Pill boxes and keychains
∗ Transportation and food vouchers
∗ Support
∗ Case management rounds
23. ∗ Flipcharts:
∗ HIV basics HOPE in Navajo
∗ HIV and nutrition
∗ HIV: Know my meds
∗ Taking my meds
∗ Harm reduction
∗ Health maintenance
∗ Exercise
∗ Coping with stress
∗ Caring for the caregiver
∗ HIV and substance use
∗ HIV and mental health
∗ Hepatitis C
∗ Tuberculosis
∗ Other sexually transmitted infections
∗ Communicating with my provider
24. Client-centered approach:
Meeting them where they’re at!
Boy, I hate those pills. They give
me an upset stomach, and it’s so
easy to forget them, especially at
night when I’m out partying...
25. So, it looks like you’ve
missed three doses in the
past week.
How would you
counsel this patient?
26. It’s important to take your
meds every day so that you
can stay healthy.
27. Let’s try the 5 A’s of counseling:
Ask permission
Assess
Advise
Assist
Arrange follow-up
28. Is it ok if I ask you a little more
about taking your meds?
The 5 A’s of counseling:
Ask permission
Assess
Advise
Assist
Arrange follow-up
29. What is the most difficult part of
taking your meds?
Problems remembering?
When you’re drinking?
Any side effects?
The 5 A’s of counseling:
Ask permission
Assess
Advise
Assist
Arrange follow-up
30. It’s important for your health to
take your pills every day without
missing any doses.
The 5 A’s of counseling:
Ask permission
Assess
Advise
Assist
Arrange follow-up
31. Maybe we can come up with a plan
together so you don’t miss any more
pills.
How about a pillbox?
Would it help if I called to remind you?
How about taking them in the morning
instead of night?
The 5 A’s of counseling:
Ask permission
Assess
Advise
Assist
Arrange follow-up
32. Great! I’m proud of you!
I’ll be back next week to see how
you’re doing.
The 5 A’s of counseling:
Ask permission
Assess
Advise
Assist
Arrange follow-up
34. Acknowledgements
GIMC
Bennie Yazzie, Paula Mora, Carla Baha-Alchesay
Bruce Forman, Maricruz Merino,
Jon Iralu, Bill Monroe
Navajo AIDS Network
Brigham & Women’s Hospital / Partners In Health
Chip Thomas (B&W photo)
RX Foundation
Contact information:
sonya.shin@ihs.gov
Editor's Notes
Kept more than 50% of appointments out of 39 new cases Of note 22% of initial group deceased
Established care within a year of diagnosis: >= 2 visits at least 3 months apart within 12 months of diagnosis (n=5137 diagnosed in 2008 Most recent vl < 400
Established care within a year of diagnosis: >= 2 visits at least 3 months apart within 12 months of diagnosis (n=5137 diagnosed in 2008 Virologic suppression: < < 500
