1. Communicating with Patients and Providers HIV Care and ART: A Course for Pharmacists

2. 2 Unit Learning Objectives  Describe the team approach to HIV care and treatment  Explain basic principles and behaviors of ART counseling  List the 5 points that should be covered when counseling a patient  Describe essential steps in communicating with an HIV-positive patient  Demonstrate effective communication with patients and providers

3. 3 Team Approach in ART  Involves pharmacist or druggist, physician and nurse working together towards comprehensive patient care  Involves information sharing between providers and patients  Ensures patient confidentiality May involve others (family members) as patient chooses

4. 4 Objective of ART Counseling  Pharmacists and druggists need to be able to share information in order to work effectively with patients, physicians and nurses On a professional level with physicians and nurses With an individual patient on a level that he/she can understand

5. 5 Communicating with Physicians and Nurses  Begin by identifying yourself  Identify the patient you are to discuss  Present the issue or concern that you have identified Do not be judgmental Use professional rapport to gain respect  Be prepared to discuss the issue on a professional level  Propose a solution  Await feedback

6. 6 Communicating with Physicians and Nurses (2)  You may not always have all of the answers to the questions that follow  Be comfortable saying that you do not know the answer at the moment, that you will look into it and get back to the provider as soon as you can  The provider will respect that you provide only information about which you are confident  Over time, you will build a working relationship with the physicians and nurses that you work with

7. 7 Essential Counseling Points when Communicating with Patients  Assess readiness to start ART Identify barriers to success with ART, for example, knowledge about ART, fears of side effects, financial concerns, sustainability, non-adherence Work with the team to correct barriers before starting therapy. Every patient has unique barriers to success  Provide specific ART information Dosing, schedule, meal requirements, early and late side effects, side-effect management, drug interactions, storage requirements, efficacy

8. 8 Five-Point Counseling Summary  Review 5 points for all new prescriptions: Name of drug Directions for use Common or severe side effects Significant drug interactions Storage  Ask patient to tell you how they will use the medication  Correct misunderstandings before they leave

9. 9 Counseling Points when Communicating with Patients  Review need for strict adherence > 95% adherence necessary for treatment success (< 3 missed doses per month) Prevents resistance and treatment failure, which may limit future treatment options  Give patients specific examples of how to remember to take their doses: for example, when they brush their teeth or when they wake up their children  Assist patients in preparing for changes in their routine: for example, vacation or visiting family

10. 10 Counseling Points when Communicating with Patients (2)  Review the need for ongoing clinical and laboratory monitoring Success/failure of ART regimen Toxicities Detect ART side effects that the patient may not feel Evaluate symptoms

11. 11 Counseling Points when Communicating with Patients (3)  Assess adherence each time patients refill their ART  Ask “When did you last miss a dose?” rather than, “Have you missed any doses?”  Congratulate the adherent patient  Identify the reason for missed doses and provide possible solutions to avoid missing doses in the future

12. 12 Counseling Points when Communicating with Patients (4)  If written information is provided, identify whether the patient has any learning barriers such as low literacy Use pictures to communicate information Indicate colors of the pills to familiarize patients with their regimen Ensure written information is provided in patient’s native language

13. 13 Counseling Points when Communicating with Patients (5)  Show patients their regimen before they start ART Familiarize them with the medication and allow them to express any concerns, for example, tablet or capsule size

14. Role Plays

15. 15 Role Play Scenario  A patient brings a prescription to the pharmacist for stavudine + zidovudine + nevirapine  Contact the patient’s physician to alert them to the drug interaction between stavudine and zidovudine and recommend an alternative regimen

16. 16 Role Play Scenario (2)  A patient comes to your pharmacy and through your conversation with him you discover that he meets the criteria for starting PCP prophylaxis (he just completed treatment for PCP 2 weeks ago). He is not currently taking Bactrim for PCP prophylaxis  Ask the patient if he has had Bactrim in the past and try to find out if he has any drug allergies. Then, contact the patient’s nurse/physician to suggest that the patient be started on Bactrim DS daily for PCP prophylaxis, if appropriate

17. 17 Role Play Scenario (3)  A patient that you have gotten to know over the past few months lets you know that he has been losing weight lately. He has lost 5 kg and now weighs 55 kg. You look at his medication record and notice that he is taking stavudine + lamivudine + nevirapine  Contact the patient’s physician or nurse and ask that the dose of stavudine be reduced from 40mg to 30mg BID

18. 18 Role Play Scenario (4)  A patient comes to your pharmacy with new prescriptions for: Stavudine Lamivudine Nevirapine  He or she has never taken these medications before  Counsel the patient about these medications

19. 19 Role Play Scenario (5)  A patient comes to the pharmacy and tells you that he has been feeling itchy. He pulls up his shirt and shows you a rash on his skin  You look at his medication profile and see that he started the following regimen 3 weeks ago: stavudine + lamivudine + nevirapine  You need to gather more information from the patient to determine if the patient is having a mild rash or a serious rash. Talk with him and try to determine the severity of the rash

20. 20 Role Play Scenario (6)  You have established that the patient discussed in Role Play Scenario 5 has a mild rash  Contact the patient’s nurse or physician and pass on the information about the Nevirapine drug reaction

21. 21 Role Play Scenario (7)  A patient comes to your pharmacy with prescriptions for: Nelfinavir, Stavudine, Lamivudine Rifampin, Isoniazid & Pyridoxine, Pyrazinamide, Ethambutol  You remember the drug interaction between Nelfinavir and Rifampin and recognize that these two drugs should not be combined together  Contact the patient’s physician/nurse with this information. Recommend an alternative regimen (or beginning ART after TB 2-month initiation)

22. 22 Role Play Scenario (8)  A woman comes to your pharmacy to refill her prescriptions for stavudine + lamivudine + nevirapine. She also has a new prescription for oral contraceptives  You notice the drug interaction between the oral contraceptives and Nevirapine  Counsel her that she needs to use an alternate form of birth control to prevent becoming pregnant

23. 23 Role Play Scenario (9)  A 24 year-old young man comes to your pharmacy to refill his prescriptions for stavudine + lamivudine + nevirapine. Since you have been keeping a history of his previous refills, you notice that he has been 10 to 15 days late picking up his refills for the past 2 months  Use your patient counseling skills to find out if the patient has been missing doses, and if so, why. Offer him solutions to correct the problem

24. 24 Key Points  A team approach to HIV care and treatment is an effective way to care for HIV-positive patients  Good communication with providers and patients is essential for successful HIV care and treatment  Pharmacists need to counsel patients on ART readiness, ART information, and the importance of adherence and ongoing monitoring