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

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

3 New problems concerning treatment adherence Idea of an intervention-research program, including counselling by professionals

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

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

6

7 MOTHIV : tool samples Intervention script N°1

8 Tool samples Adherence assesment sheet

9 Background (3) The program was launched in June 1999 On-going from 1999 to 2005 Assessment of impact Assessment of activity

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 M patients (IG)

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

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,

13 Results Assessment M0/M24

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

15 Results Medical consultations Overall population

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

17 Results: counselling nurses’ activity (1)

18 Results: counselling nurses’ activity (2) 2 consultations/year/patient

19 Discussion (1) National factors encouraging this activity Political support for treatment education of chronic diseases in general (Law 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

20 A Counselling, Health, Development & « Comment Dire » Project

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.

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.

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

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

25 The program confirms its permanence and benefit for patients A contextual fragility in spite of institutional involvement Need for economic evaluation Conclusion

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

27

28 Results Assessment M0/M24