1. 1 Assessing and Improving ARV Adherence HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 2 By the end of this session, participants will be able to: Explain factors related to each patient’s adherence before beginning ARV Assess a patient’s medication adherence while on ARV Provide interventions to help a patient improve or maintain his adherence Learning Objectives

3. 3 To help patients improve ỏ maintain good adherence, assessing need to be conducted: Before the patient begins ARV therapy When the patient begins ARV therapy During ARV therapy When do We Need to Assess Adherence?

4. 4 Assessing Adherence before Beginning ARV

5. 5 Patient’s attitudes and beliefs About medication in general About HIV/AIDS specifically Patient’s experiences with other medications What patient observed from other patients taking ARVs Information Need to Know (1)

6. 6 To whom has the patient disclosed? Who is the patient’s primary source of social support? Does this person know that the patient has HIV? How does this person feel about medications? Information Need to Know (2)

7. 7 Living situation Is there a stable home? Work? Do other in the home know about the diagnosis? Are there small children in the home? Childcare? Information Need to Know (3)

8. 8 Expectations What does the patient think will happen if he takes ARV? Benefits and costs of therapy Life expectancy Change in physical symptoms (or not) Side effects Information Need to Know (4)

9. 9 Assessing Adherence When Beginning ARV Therapy

10. 10 If a patient is non adherent to his first ARV regimen, he loses his best chance at treatment success Beginning ARVs is never an emergency Keep in Mind (1)

11. 11 Nurses and health care workers should take the time to be sure : that the patient understands how to take the medications to understand his personal circumstances and help him plan for good adherence Keep in Mind (2)

12. 12 To achieve good treatment result, health care workers should help patients to: Be involved in the decision to begin ARVs Understand: how to take the medications and why it is important improves adherence. Frequent education is good adherence interventions Keep in Mind (3)

13. 13 Names of medications (ALL the names) How many to take When to take them What’s the “window” for missed dose Food restrictions Storage requirements What the Patient Needs to Know about ARVs

14. 14 What are the potential side effects? How severe are they likely to be? How long are they likely to persist? What can be done to ameliorate them? When to call the clinic What are probably NOT side effects What the Patient Needs to Know about Side Effect

15. 15 Where will the patient keep the medications? Does the patient have a plan for remembering the medications? Patient’s usual daily schedule Week end changes Is the patient often away from home? What the Nurse Needs to Know

16. 16 Assessing Adherence

17. 17 Check how the patient took the drugs the number of drugs left: Ask the patient (Self-report) Count the pills in the box or bottle Check to see if prescriptions have been filled Combined patient’s self-report with patient’s tests to assess adherence: Ex: if self-report correlated to viral load, we can have a correct assessment about that patient’s adherence Assessing Adherence

18. 18 What to ask? Number of missed doses? Over what time period? 3 days, 7 days, 1month? How to ask? Non judgmentally Specific Open ended Self-Report

19. 19 Waiting-room questionnaires: Deliver print out questionnaires to patients when they are waiting Visual analogue scale -VAS: Put an X on the line below showing your best guess about how much of each medication you have taken in the past 30 days Assessing Adherence When Time is Short 0%50% 100%

20. Common Patterns of Adherence Howard AIDS 2002; Ickovics Antiviral Ther 2002; Moss CID 2004 Adherence Time on Therapy (months) 100% 0% 0 1224 Three Standard Patient Types Exceptionally Adherent Diminishing Adherence Non Adherent

21. 21 Reasons% Simply forgot or busy66% Away from home57% Change in daily routine51% Fell asleep40% Illness28% Depression18% Privacy concerns14% Side Effects12% Commonly Reported Reasons for Nonadherence to HIV Medications

22. 22 Medication interferes with daily life Alcohol or drug use Stress Pessimism about HIV disease Lower levels of coping efficacy Depressed mood Other Factors Associated With Nonadherence to HIV Medications

23. 23 Improving/maintaining adherence are building on both didactic and interactive components Multiple elements that are best helpful in improving/maintaining adherence: Education Counseling Skills training Reminder devices Improving/Maintaining Adherence

24. 24 Discussion Make use of devices Alarms, pill boxes Consider home visits Have been shown to be effective Allow nurse to understand the patient’s situation Trainings to Improve/Maintain Adherence

25. 25 BarriersResponse Fear of disclosure (stigma) Provide social support Substance abuse Refer to substance abuse treatment Forgetfulness Reminder devices-alarms, pill boxes Suspicion about treatment Education – oral and written Complicated regimens, too many pills Simple regimens Poor quality of lifeSymptom management ResponsibilitiesSocial Support Access to medication Improvement in distribution system Improving Adherence: What we know? What we can do?

26. 26 FacilitatorsMethod Feelings of self-worthCounseling Seeing positive effectsRole models Accepting diagnosisSupport groups Understanding reason for adherence Education Improving Adherence: Educate Patients

27. 27 Who should do it? All of us: Doctors, nurses, counselors When? Every visit (and sometimes in between) Where? Waiting room Exam room Counseling room Home Adherence Assessment and Support

28. d4T + 3TC + NVP Treatment Adherence Tools - ARV Pill Boxes During first two weeks After first two weeks Morning (blue) and afternoon (pink)

29. 29 Adherence information Peers with HIV Nurses, counselors, treatment adherence Counselors, Case managers Families/ friends Pharmacist Doctor Adherence Supporting Groups

30. 30 Unanswered questions: Sustainability of adherence and adherence interventions How long are the interventions needed? Who will pay? Adherence Interventions

31. 31 Assessing adherence should be conducted: Before the patient begins ARVs and During continuously the time that patient is on ARV Interventions to improve adherence include education, reminder devices, and home visits Key Points

32. 32 Thank you! Questions?