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Home-based Care Home-based Care &&
Adherence CounselingAdherence Counselingfor for
Patients Living with HIVPatients Living with HIV
Sonya Shin, MD MPHSonya Shin, MD MPHBrigham and WomenBrigham and Women’’s Hospitals Hospital
Harvard UniversityHarvard UniversityPartners In HealthPartners In Health
Boston, MABoston, MA
Gallup Indian Medical CenterGallup Indian Medical CenterGallup, NMGallup, NM
No disclosures
How well are we doing?
How well are we doing?
Diagnosis
Treatment
Adherence
Favorable outcomes
How much of this is controlled within our clinic walls?
Diagnosis
Treatment
Adherence
Favorable outcomes
Who does not
establish care?
Who is not getting regular
follow-up?
Who is not taking
his/her meds?
NAIHS Annual HIV Report, 2011
Established care within first yr of dx (n=39): 71%
Retention in care, among those living (n=303):-Regular follow-up/seen elsewhere55%-Intermittent follow-up (<50% appointments)14%-No follow-up 31%
Virologic suppression: 55%
NAIHS Annual Report, 2011
Follow-up study of 100,375 people diagnosed with HIV
through 2008, USEstablished care within a year of dx (n=5137): 64%-White: 75%-African-American: 54%-Hispanic: 69%-Other: 68%
Retention in care (n=100,375): 45%-White 50%-African-American: 41%-Hispanic: 40%-Other 58%
Virologic suppression: 77% (last viral load)
53% (all viral loads)Hall et al, JAIDS 2012
Can we do better?
• At the national level:• > one third do NOT establish care within a year
of HIV dx• > one half do NOT receive regular HIV care• At least 23% are not virologically suppressed
Partners In Health (PIH) Accompagnateur model
• Community health workers
• Since 1985• Paid health workers• Responsible for
referrals, vaccines, hygiene, maternal and infant health
• Initial training plus ongoing training
• The “missing infrastructure” in many resource poor settings
• 100% directly-observed therapy (DOT) coverage for TB and HIV patients
Accompagnateurs: The “Backbone” of PIH
Expansion to other resource-poor settings
1041 people initiating ART 2005-2006,
PIH-MOH HIV Program in Rwanda
Established care within a year of dx: not reported
Retention in care among those living (n=989): 97%
Virologic suppression (n=275): 98%
Rich et al, JAIDS 2012
CHW accompaniment Directly observed therapy (?) Psychosocial support
Adherence coaching
Screen for side effects
Liaison with providers
Additional supports Nutrition
Transportation costs
Patient support groups
So, what’s the magic ingredient?
How much of this is controlled within our clinic walls?
Diagnosis
Treatment
Adherence
Favorable outcomes
Who does not
establish care?
Who is not getting regular
follow-up?
Who is not taking
his/her meds?
What are the underlying reasons for falling through
the cracks?
Often not biological Poverty & marginalization Forces priorities other than health
Difficult access to care Poor utilization of health services Mental health, substance use Education, health literacy, language barriers System not designed for the vulnerable Stigma (HIV status, race, sexual orientation)
Root causes of health disparities:
Universal themes
Can this be done in Indian Country?
Step 1:Create an outreach team
Who is the outreach worker? Role: e.g. case manager, health technician,
community health worker Institution: IHS, tribe, NGO, etc Cultural considerations
Care coordination Link the clinic &
outreach team
What is the role of the outreach worker? Deliver medications? Adherence coaching? Counseling? Directly observed therapy?
Modified? Case management?
Referrals? Other?
Step 2:Define the home-based
intervention
Training HIV content Counseling skills, motivational interviewing
Materials Teaching / coaching materials Four-wheel drive?
Support Access to care team Clinical “back-up” for challenging cases Support for their own wellbeing (burn-out, safety,
trauma)
Step 3: Equip the outreach worker with the necessary
resources
Step 4: Match the intervention to your population
All patients? High-risk only? (clinical criteria?
Psychosocial?) Tiered interventions depending on
needs?
HOPE in Navajo: HIV Outreach & Patient Empowerment
Hiring Health technician at Gallup Indian Medical Center Case manager at Navajo AIDS Network
Training Adherence Counseling Motivational interviewing Harm Reduction Wellness & self-care
Materials Patient flipcharts Pill boxes and keychains Transportation and food vouchers
Support Case management rounds
HOPE in Navajo Flipcharts:
HIV basics HIV and nutrition HIV: Know my meds Taking my meds Harm reduction Health maintenance Exercise Coping with stress Caring for the caregiver HIV and substance use HIV and mental health Hepatitis C Tuberculosis Other sexually transmitted infections Communicating with my provider
Client-centered approach:Meeting them where they’re
at!Boy, I hate those pills. They give me an upset stomach, and it’s so easy to forget them, especially at night when I’m out partying...
So, it looks like you’ve missed three doses in
the past week.
How would you counsel this
patient?
It’s important to take your meds every day so that you can stay
healthy.
Let’s try the 5 A’s of counseling:Ask permission
AssessAdviseAssist
Arrange follow-up
Is it ok if I ask you a little more about taking your
meds?
The 5 A’s of counseling:Ask permission
AssessAdviseAssist
Arrange follow-up
What is the most difficult part of taking your meds?
Problems remembering? When you’re drinking?
Any side effects?
The 5 A’s of counseling:Ask permission
AssessAdviseAssist
Arrange follow-up
It’s important for your health to take your pills every day without missing any doses.
The 5 A’s of counseling:Ask permission
AssessAdviseAssist
Arrange follow-up
Maybe we can come up with a plan together so you don’t miss
any more pills.
How about a pillbox?Would it help if I called to
remind you?How about taking them in the
morning instead of night?
The 5 A’s of counseling:Ask permission
AssessAdviseAssist
Arrange follow-up
Great! I’m proud of you!
I’ll be back next week to see how you’re doing.
The 5 A’s of counseling:Ask permission
AssessAdviseAssist
Arrange follow-up
Step 5: Get started!
AcknowledgementsGIMC
Bennie Yazzie, Paula Mora, Carla Baha-AlchesayBruce Forman, Maricruz Merino,
Jon Iralu, Bill Monroe
Navajo AIDS Network
Brigham & Women’s Hospital / Partners In Health
Chip Thomas (B&W photo)RX Foundation
Contact information: [email protected]
