ARV Adherence Counseling

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ARV Adherence Counseling

• Sangworn SombatmaiSombat TapanyaChiang Mai
  University, Thailand

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Adherence vs Compliance

•   Adherence the act or quality of sticking to
  something, steady devotion the act of adhering
• - acceptance of an active role in ones own
  health care
• Compliance the act of conforming, yielding or
  acquiescing.
• - lack of sharing in the decision made between
  provider and client

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Main causes of treatment failure in HIV AIDS

• Advanced disease
• Viral Resistance
• Pharmacokinetics
• Medication intolerance
• Adherence

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Adherence in ARV

• Successful HIV therapy requires superior
  adherence
• gt 95 adherence necessary to achieve therapeutic
  goal (undetectable viral load) in 80 of
  individuals (Paterson et al, 2000)
• Every 10 reduction in adherence leads to a
  doubling of the viral load level (Bangsberg et
  al 2000)

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Adherence in ARV

• Suboptimal adherence leads to
• Incomplete viral suppression
• Emergence of resistant strains
• Immune failure and disease progress
• Limited future therapeutic options and higher
  costs for the individual / program
• (Bangsberg et al 2000, Carpenter et al 2000)

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Levels of Adherence

• Levels of adherence to ARV vary widely
• 2035 of HIV patients have difficulty in
  maintaining even 80 adherence levels
• ( Altice et al 2001, Moatti et al 2000)

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• More than 10 of patients report missing one or
  more medication doses on any given day, and more
  than 33 patients report missing doses in the
  past four weeks.
• (Chesney et al 2000, Ickovics et al 2002)

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Factors Influencing Adherence

•  

Patient-Provider Relationship
Disease Characteristics
Adherence
Treatment Regimen
Clinical Setting
Patient variables Sociodemographic
psychosocial factors
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Measures of Adherence (1)

• No Gold Standard
• Self report
• Pill counts
• Provider assessments
• MEMS
• Pharmacy refill tracking
• Biological markers (VL)
• Therapeutic drug monitoring

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Measures of adherence (2)

• Self Report
• 1, 3, 4, 7, 30 days recall
• Correlate with Viral load
• Tends to overestimate

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Accuracy of self report can be optimized by

• Approaching the client in a matter of fact and
  non judgmental way!
• Asking about the most recent days, asking about
  missed doses
• Use prompts to help recall

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Measures of adherence (3)

• Pill counts
• Clinic based pill counts
• Overestimates - pill dumping
• Unannounced pill counts
• Higher reliability but are they feasible?
• (personnel, hygiene, cost, confidentiality,
  cultural sensitivity)

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Measures of adherence (5)

• Provider assessments
• Poor indicator of adherence
• Biological Markers
• Viral Load
• Pharmacy Refill Tracking
• Therapeutic drug monitoring
• Short circulating times of drugs in blood
• Expensive

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Strategies and tools to enhance adherence

• Counselling
  (treatment, financial, nutritional, preventive
  behaviour, linking with other services)
• Pillboxes (weekly use, daily use and 2-3 days)
• Electronic devices (pagers, alarms, beepers in
  pill boxes)

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Strategies and tools (2)

• Telephone
• Medication diaries
• Buddy system (Friend, peer or family member)
• Incentives

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Adherence Counseling
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Adherence Counseling

• Knowledge of the treatment regimen
• Knowledge of side effects and ways to manage side
  effects

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Adherence Counseling (2)

• Assess the barriers to adherence that the patient
  faces, discuss ways to address them
• Integrating the treatment into the patients
  daily routine

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Adherence Counseling (3)

• Using drug reminder cues, checklists
• Involving family members
• Explore patients beliefs and perceptions
  regarding ARV.

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Profile of a patient with excellent adherence

• Believed adherence rates needed to be between
  90-100
• Trusted his provider greatly
• Took medications even when actively using
  substances of abuse

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Profile of a patient with excellent adherence (2)

• Open about HIV status and received substantial
  support
• Cited staying healthy as key motive
• Not actively depressed.
• Malcolm et al, AIDS Care 2003

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Adherence is a Dynamic Behaviour

• Adherence levels change over time
• Adherence is determined by a matrix of
  inter-related factors that shift over time. No
  factor stands alone.

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Dynamic Behaviour (2)

• Adherence requires an integrated,
  multidisciplinary approach physicians, nurses,
  counselors and pharmacists
• Adherence requires a combination of adherence
  promoting strategies.

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Motivational Enhancement Stages of Change 
Permanent Exit
Recurrence / Relapse
Precontemplation
Maintenance
Contemplation
Action
Preparation
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• Motivational Enhancement Principle
• DARES
• 1. Develop Discrepancy
• 2. Avoid Argumentation
• 3. Roll with Resistance
• Express Empathy
• 5. Support Self-efficacy

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Develop Discrepancy

• To raise the clients consciousness and awareness
  of consequences of their behavior
• To point out how current behavior and future
  goals are contradicting each other

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Avoid Argumentation

• Argument only serves to increase the clients
  defensiveness and resistance

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Roll with Resistance

• Blending with the clients perception but
  shifting the direction slightly to reach a
  different conclusion

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Express Empathy

• Reflecting clients feelings / thoughts /
  perception without judging
• Accepting and being with the clients needs and
  in turn setting the stage for increasing
  motivation and change

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Support Self-efficacy

• Convey the message you can do it to the client
• Believe in the possibility of change

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Motivational Enhancement Techniques
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Ask open-ended questions

• To elicit problem recognition
• What makes you think that you have a health
  problem?
• To induce concern
• What do you think would happen if you dont take
  ARV medication regularly?
• To encourage behavior change
• What would be the advantages of taking ARV
  medication?
• To instill positive attitude toward change
• If you decide to take this medication, what would
  help you to adhere to the regimen?

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Listen reflectively

• Try to detect and communicate clients underlying
  meanings or feelings as they speak
• You sound worried about possible side-effects
  from this regimen
• Financial concern seems to have high priority for
  you

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Affirm

• Express positive regard and support for the
  client and their willingness to speak openly
  about their concern
• Thank you for letting me know about the
  challenges you have to overcome to get here on
  time

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Elicit Self-Motivational Statement (SMS)

• Problem recognition
• I never realized the potential consequences of my
  non-adherence
• Expression of concern
• Im really worried about this
• Intention to change
• Ive got to do something different
• Optimism I think I can do it

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Summarize

• Repeat SMS, reflect both sides of ambivalence,
  and check the accuracy of your summary
• You want to try this treatment but are still
  unsure about how to deal with side-effects
• (this also reflects what stage the patient is at
  Contemplation)

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Overview of Adherence Counseling Process
Inclusion Criteria
Preparatory Counseling Session 1
Preparatory Counseling Session 2
Receive the first pill
Preparatory Counseling Session 3
Action Stage Session 4-7 (first 3 months)
Maintenance Stage Session 8-16 (9 months)
Permanent Behavior
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I.    Preparatory Counseling

• Establish a trusting relationship.
• Introduction to the treatment program.
• Inform the principles number of appointments

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4. Patient Assessment

• Use open-ended questions to explore the
  following
• Prior use of antiretrovirals and patients
  experience with adherence

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• 4. Patient Assessment (contd)
• A detailed medical history
• Current health status
• Drug abuse/ alcohol use
• Mental Health
• Sources of social support for the patient,
  Socio-economic problems such as housing,
  employment and income

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I. Preparatory Counseling (cont.)

• 5. Review patients relationship with health
  care-provider
• 6. Plan the treatment
• -Discuss the treatment regimen medication,
  dosing, instructions, storage of
  medications.-Discuss potential side effects and
  plan for a response. -Discuss the follow up plan
  for routine appointments

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• 7. Discuss Adherence Strategies
• 8. Identify barriers of Adherence
• 9. Set the next appointment

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II. Ongoing Adherence counseling Action Stage
Session 4-7

• 1. Review treatment regimen
• 2.Discuss current experience on receiving ARV
• 3.Assess adherence (pill-count form)
• 4.Discuss about adherence and its barriers
• 5.Discuss about side effects and resolutions
• 6.Discuss about follow-up plan

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II. Ongoing Adherence Counseling Action Stage
Session 4-7 (Con.)

• 7. Review the treatment goals, current
  achievement, and tailoring pill-taking into daily
  life.
• 8. Discuss about family involvement and support.
  Encourage patient to disclose HIV status with
  partner, and emphasize on disease prevention.

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• 9. Record the information
• 10. Fix a date for the next appointment

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III. Ongoing Adherence Counseling Maintenance
Stage Session 8-16

• Review patients experience on treatment and
  adherence during the past month
• Discuss about long-term side effects and
  responses
• Review the barriers service system, medication
  storage, boredom of taking medication, etc.

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Maintenance Stage Session (Contd)

• Review the follow-plan, contact information.
• Review the treatment goals, and current
  achievement, success in removing barriers.
• Record the information
• Fix a date for the next appointment

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Counseling Manual is compiled from Ekstrand,
M.L., et al. (1999). Challenges in HIV/AIDS
treatment. University of California, San
Francisco Center for AIDS Prevention Studies.
Miller, W., and Rollnick, S. (1991).
Motivational Interviewing. The Guilford
Press. Sarna, A., et al. (2003). Adherence to
Antiretroviral Therapy A guide for trainers.
Horizons / Population Council and International
Centre for Reproductive Health.