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Assessing and Improving ARV

Adherence

HAIVN Harvard Medical School AIDS

Initiative in Vietnam

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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

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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?

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Assessing Adherence before Beginning ARV

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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)

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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)

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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)

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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)

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Assessing Adherence When Beginning

ARV Therapy

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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)

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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)

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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)

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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

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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

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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

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Assessing Adherence

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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

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What to ask?Number of missed doses?Over what time period?

• 3 days, 7 days, 1month?

How to ask?Non judgmentally SpecificOpen ended

Self-Report

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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 AdherenceWhen Time is Short

0% 50% 100%

Common Patterns of Adherence

Howard AIDS 2002; Ickovics Antiviral Ther 2002; Moss CID 2004

Ad

her

ence

Time on Therapy (months)

100%

0%0 12 24

Three Standard Patient Types

Exceptionally Adherent

DiminishingAdherence

NonAdherent

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Reasons %

Simply forgot or busy 66%

Away from home 57%

Change in daily routine 51%

Fell asleep 40%

Illness 28%

Depression 18%

Privacy concerns 14%

Side Effects 12%

Commonly Reported Reasons for Nonadherence to HIV Medications

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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

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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

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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

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Barriers Response

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 life Symptom management

Responsibilities Social Support

Access to medication Improvement in distribution system

Improving Adherence: What we know? What we can do?

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Facilitators Method

Feelings of self-worth Counseling

Seeing positive effects Role models

Accepting diagnosis Support groups

Understanding reason for adherence

Education

Improving Adherence:Educate Patients

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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

d4T + 3TC + NVP

Treatment Adherence Tools- ARV Pill Boxes

During first two weeks After first two weeks

Morning (blue) and afternoon (pink)

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Adherence Supporting Groups

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Unanswered questions:• Sustainability of adherence and adherence interventions

• How long are the interventions needed?

• Who will pay?

Adherence Interventions

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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

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Thank you!

Questions?