The document discusses adherence counseling for antiretroviral (ART) treatment. It defines adherence and describes how at least 95% adherence is needed to suppress viral loads and avoid resistance. Barriers to adherence like socioeconomic factors, mental health issues, and stigma are discussed. Effective counseling techniques are described to help patients overcome barriers, integrate medications into daily routines, and promote family support to improve long-term adherence.

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