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1 Maintaining counselling nurses for HIV patients treated by HAART at Nice University Hospital (France) : theory versus practice L.Bentz, M.Morin, C.Tourette-Turgis, M.Rébillon, P.Dellamonica, J.G.Fuzibet, J.P. Cassuto, J.P.Moatti, C.Pradier 13th international Conference on Health Promoting Hospitals (HPH) Dublin May 18-20th, 2005
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2 Background In 1998, effectiveness of HAART on mortality In 1999 at Nice University Hospital, 2500 HIV infected patients followed yearly in 3 main departments
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3 New problems concerning treatment adherence Idea of an intervention-research program, including counselling by professionals
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4 Background (2) Principles of HIV counselling aiming at treatment adherence An operational definition of adherence addressing the 4 components affecting adherence A patient-centred intervention Empathic approach based on active listening as well as acceptance of diversity of life styles Active intervention
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5 MOTHIV model : concept and strategies Voluntary nurses An intensive training for nurses, follow up and supervision. A structured and brief counselling intervention (4 x 45 mn sessions) Nurse’s tools : interview script and adherence assessment sheet
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7 MOTHIV : tool samples Intervention script N°1
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8 Tool samples Adherence assesment sheet
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9 Background (3) The program was launched in June 1999 On-going from 1999 to 2005 Assessment of impact Assessment of activity
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10 Results Randomized study 310 patients offered participation 246 patients included (79%) intervention group (IG) n=124 control group (CG) n=122 1 death 123 patients (IG)121 patients (CG) 8 lost to follow-up 2 deaths 7 lost to follow-up 2 deaths 112 patients (CG) M0 M6 M24 113 patients (IG)
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11 Results At M0 comparable patients in IG and CG : Age Gender Mode of transmission Education level CDC stage VL / CD4 HAART Average duration of HAART % of treatment change
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12 Results Assessment M0/M6 Positive impact of counselling consultations on : adherence and VL at 6 months Pradier, Bentz et al, HIV Clinical Trials, 2003, 4, 121-131
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13 Results Assessment M0/M24
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14 Results Assessment M0/M24 Comparison of the average differences in VL (M0/M24) -0,22 -0,47 0,12 -0,07 -0,12 -0,36 Deltas VL (log cp/ml) IGCG M6 M12 M18M24 p=0,013p=0,027 p=0,002 p<0,001 NS
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15 Results Medical consultations Overall population
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16 Results Qualitative survey of patient satisfaction with counselling consultations : CG (n=9) : Ambiguity between progress and constraints of new treatments Deep questioning about adherence IG GI (n=9) : Satisfaction with the information provided and the listening Feeling of ability to handle the treatment Development of a spirit of critical participation in treatment follow-up The consultation appears as a social support
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17 Results: counselling nurses’ activity 1999-2004 (1)
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18 Results: counselling nurses’ activity 1999-2004 (2) 2 consultations/year/patient
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19 Discussion (1) National factors encouraging this activity Political support for treatment education of chronic diseases in general (Law 2004-806 relative to Public Health Policy) Recent development of a « counselling culture » in France Increase in counselling activities addressing HIV-infected patients, in spite of assessment gaps
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20 http://www.counselingvih.org A Counselling, Health, Development & « Comment Dire » Project
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21 Discussion (2) : Local factors in favour of this activity Involvement of Nice University Hospital management to encourage health promotion and patient education activities. Elaboration of a permanent program with on-going assessments by the Public Health Department High degree of motivation on the nurses’ part Participation of physicians.
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22 Discussion (3) : Positive assessment results for the patients Positive impact on long-term viral load Fewer medical consultations Patients participate in a more active way in the management of their treatment.
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23 Discussion (4) Local difficulties 2 of the 3 care units have diversified their recruitment in terms of pathology –Change in patient recruitment profile – HIV activity increasingly concentrated in a single care unit and nurse Nurses ’ availability for counselling activities has decreased due to : – Reduced number of nurses available for patient education in favour of technical care –Recognition of nurses ’ skills : involvement in teaching and scientific communication tasks
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24 Discussion (5) National difficulties No economic evaluation of counselling activity : Time consuming activity Need of an identification system, systematic data collection and processing of activity Implementation of payment system based on diagnosis- related groups in French hospitals (2004) : no price setting from Health Ministry for educational activities
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25 The program confirms its permanence and benefit for patients A contextual fragility in spite of institutional involvement Need for economic evaluation Conclusion
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26 Acknowledgments To nurses in charge of counselling interventions G. Valentini, M. Borghi, P. Asplanato To hospital care units : Pr P. Dellamonica, J. Durant, V. Mondain, I. Perbost, P. Pugliese,V. Rahelinirina, C.Rascle, Pr J.G. Fuzibet, F.Sanderson P. Heudier, E. Rosenthal, M. Pietri, Pr JP Cassuto, H. Vinti, C. Ceppi, J. Massiera, M.Chavaillon To data managers: N. Oran, JN Mazza, S. Déric To « How to say » : C.Tourette-Turgis, M. Rébillon To the Health Direction : M. Rubolini, M. Mazard To INSERM U 379 (JP Moatti, B. Spire, M. Souville) and to the laboratory of social psychology in Provence (M. Morin, J. Scherer) To P. Touboul and B. Dunais, MD, for their availability
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28 Results Assessment M0/M24
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