Adherence Preparing to start ARVs

Dr. Kevin M Harvey MBBS, MPH (UWI), Dip. ID (Lon.)

Treatment care and support2006

Preparing for Adherence

• More sustainable response to ARVs if adherence is optimized within the first three to six months

• Must therefore prepare individuals to adhere prior to the start of ARVS

• Must also have a strategy to sustain adherence throughout life

Predictors of non adherence: Medication related

• dosing frequency

• side effects

• Number of pills

• ?type of medication

• ?complexity of regimen

Patient-related• Active substance abuse • Depression• HIV knowledge and knowledge and belief in

medications• Literacy (?more of a system problem)• Non-adherence to care• Stage of readiness• ?Distance from site• ?age• ?disclosure

System-related

• Cost of care/treatment

• Access to care and medications

• provider/patient relationship

• Stock-outs

• ?employment out of the home

• ?transportation

• ?stigma

Other reasons people do not take their ART

• Pill fatigue• Forgot• Pills not with them• Transportation• Fear of disclosure• Concern with drug interactions (prescribed or

other)• And others

Non-predictors

• Non-predictors include– Race– gender– prior substance abuse– social status or income– education

Preparing for ARVs

• Culture

• Access +Knowledge + Motivation+Cues to Action

• Stigma & Discrimination

• ADHERENCE

Access

• Potential Barriers• Distance from Clinic

• Appointment system

• User Fees

• Availability of Service

• Confidentiality

• Stigma & Discrimination

• Cost for CD4,Viral Loads + other labs

• Cost of other Medicines

• Cultural Practices

• Possible Solutions• Telephone Appointments

• Waiver from User Fees (free does not =Access)

• Waiver from General fees & lab cost via assessment Process

• Refer closest acceptable Treatment site

• Assistant with Bus Fares

• Register with the NHF

• Family support

Knowledge

• Potential Barriers• Believes

• Culture

• Myths

• Low literacy

• Lack of Exposure to Specific HIV Education

• Educational Material inappropriate

• Possible Solutions• Appropriate Literacy

Material for Individual

• HIV Basic Facts

• Condom Negotiation Skills

• Name etc of Specific Meds

Motivation

• Potential Barriers– Depression – Number of pills – Frequency of doses per day– No Family support – No disclosure /fear disclosure– Negligence/ forgetfulness – Unemployment – Lack of privacy

• Possible Solutions– Refer to Social Worker– Mental Health Professional– Reduce the number of pills If

possible link meds to something the patient does that they enjoy

– Refer to support groups – Encourage disclosure,– provide temporary support– encourage buddy system– Channel to income generating

projects

Cues to Action

• Barriers• Non Disclosure and

lack of support • Drug addiction• Stigma and

Discrimination • Attention drawn by

Reminders• Pill boxes can be too

big• Late refills • Cognitive function

• Possible Solutions• Family Support

• Media

• Pill Boxes

• Text Messages

• Alarms

• Link to Favourite radio and TV programmes

• Support at workplace

Culture

• Barriers• Patients only listen to

doctor

• Alternative Medicine Can provide a Cure

• Role of the Church

• Myths

• Solutions• Patients will listen to

Doctors

• Alternative(Herbal Medicines) can be immune boosters

• Education of Clergy

Stigma & Discrimination

• Potential Barriers• Fear Discrimination • Lack of or Low Public

education• Remove Labels• Fail to take meds in

Public• Move away from

district • Do not want to attend

Clinic in Own district• Visible side effects

• Possible Solutions– Confidentiality at the

work place is key– Reduced stigma and

discrimination at work place

– Refer to acceptable treatment site or facilitate easier access

Supportive Environment

• Knowledge Motivation

• Positive Behaviour Change

• Increased Adherence

Family-Focused Adherence Support

• It may take several weeks and several visits to ready the family for treatment.

• Before prescribing

– Family is part of and agrees with treatment plan

– Assess family life-style, priorities, beliefs

– Ask about prior medication experience: build on success and work on problems

– Educate about the disease, purpose of ARV, importance of adherence

– Repeat information as many times as necessary

Family-Focused Adherence Support

• Planning for a good start:

– Develop a simple schedule that fits the family’s daily activities. Consider differences between weekdays and weekends.

– Clarify who will be responsible for giving or supervising each dose, each day of the week

– Make the schedule visual. Use pictures of pills. Color-code everything. Consider literacy level of family members

Family-Focused Adherence Support

• Planning for a good start:

– Demonstrate medication preparation:

• measuring volumes of liquids

• crushing or dissolving tablets

• opening capsules

• using foods or liquids to mask task

– Do a trial run with “dummy” pills or liquid

– Observe medication administration in the office. If possible, start the first dose under supervision

– Follow-up with a phone call and/or home visit in the first few days

Conclusions• Adherence is hard for everyone and long term

treatment present the most difficult challenges• Adherence is critical to the successful care of

patients with HIV/AIDS – On an individual level, adherence to care and treatment

can mean the difference between life and death– On a population level, adherence to treatment can

minimize the emergence of viral resistance and prevent therapeutic failure

• Adherence needs to be to medications and care.

Conclusions• Every HIV/AIDS treatment program should

include processes to assess and support adherence• Adherence promotion must be multifaceted and

multidisciplinary and adapt to changing needs and realities– Many models/approaches in use

– Many also need to be evaluated and adapted for local needs

• Simpler and more tolerable regimens which preserve efficacy are still needed

Further Discussion & Questions