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Peer Counselor Training Course August 2005
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ART Adherence
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Adherence and Incomplete Viral Suppression
Paterson DL et al. Ann Intern Med. 2000:133:21
21.7
54.6
66.771.4
82.1
0
10
20
30
40
5060
70
80
90
100
<70 70-80 80-90 90-95 95
% Adherent
% P
a t i e n t s w i t h
v i r a l l o a d > 4 0
0 c o p i e
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Effect of missed doses
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Prevalence of 3 Day Adherence in Kampala, Uganda
Prevalence of Adherence in Kampala,Uganda
168 6
70
0
20
40
60
80
0-12 13-70 71-94 95-100
% adherence
P e r c e n t
Tusiime, et al. CROI, 2003
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For optimal adherence the ideal regimen
Have one pill twice a day dosing
Have no food requirements
Have few side effects
Have no special storage requirements
Be efficacious
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Barriers to adherence
Communication difficulties
Literacy levels
Inadequate knowledge or awareness of
HIV disease
Inadequate understanding of treatment
regimen
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Barriers to adherence
Discomfort with disclosure of HIV status
Patient attitudes and beliefs in treatment
efficacy
Depression and other psychiatric problems
Alcohol and/or active drug use
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Barriers to adherence
Difficult life conditions
Unstable Living conditions
Negative or judgemental attitude of health
providers
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Keys to successful adherence
1. Education
2. Ongoing Support
3. Anticipate Patient factors preventing good
adherence
4. Lifestyle modification
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Education
Adequate information
on HIV, ARV, how to
take medications Awareness of side
effects
Provide adherence
materials
REPETITION
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Ongoing Support
Establish trust between
patient and provider
Ongoing education PEER
Counsellors
Individual counseling
Involve family and friends SUPPORT GROUPS
Family Based Care
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Patient Factors preventing good
adherence Cultural beliefs about
disease and treatment
Patients knowledge of
what to expect Satisfaction with
medical care
Co-morbidities- TB,mental illness
Utilization of supportsystems
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Lifestyle
Minimal number of
pills and twice a day
dosing FIT TREATMENT
INTO PERSON”S
LIFE
Few food requirement
Self monitoring tools
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Questions to ask before patient
starts on ART Do you know that ART is lifelong. Your life depends on
taking the drugs every day at the right time
If you stop, you will become ill, not immediately, but after
months or years Do you know that you should not share the medication
with your relatives or friends
Did you disclose your status to somebody? This personcan help you to take your medication
Check if patients clinic attendance/previous OI treatmentadherence was good
How far are you travelling, are you able to come to theclinic on regular basis?
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Clinic visit schedule
National ART program Basic counselling session I
Basic counselling session II
ARV I
ARV II (patients ready-ness assessment)
Patients starts on ARVs Monthly clinic visits
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Assessment of patient ready-ness
( ARV II session) Patient should demonstrate an understanding of
his/her disease and health status
Patient should demonstrate an understanding of
his/her treatment regimen and follow up plan Patient should appear to make commitment to
adhere to treatment
Potential barriers should have been identified
and addressed to the best possible extent Patient should appear to be ready to start
HAART
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Adherence monitoring
Ask questions on adherence in a respectful and non judgemental way
Many people have difficulties to take their treatment,
what are your problems? Can you tell me when and how you are taking each pill?
When is it most difficult to take your pill?
How many pills did you miss in the last days, last week,
last month? Stigma to take pills?
Do pill count
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Adherence problems
Difficulties to take pills in the presence of others
Did not understand how to take the drugs
Change in routine Ran out of pills
Depressed
Alcohol/drug problems Side-effects
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a.m.a.m.
p.m.p.m.
VOILÀ CE QU'UN MALADE DU SIDADOIT AVALER CHAQUE SEMAINE,
SANS GUERIR POUR AUTANT
PAST
PRESENT?
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Pregnancy and post partum
Adherence more difficult
Cannot use certain ARV’s - EFAVIRENZ
Pregnancy associated morning sickness and GIupset
Concern over effects of ARV’s on fetus
Caring for newborn may compromise maternal
drug adherenceConsider: Pregnancy/postpartum centered support
groups
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Children
MANY UNIQUE ISSUES
Lack of proper
pediatric formulations-crush tablets
Liquid formulations:bad taste, lots of liquid
Regular dosereadjustment basedon child’s weight
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Children
Child dependant onothers for treatment
May be manycaregivers- disclosureto all??
Child unaware of own
HIV status- when todisclose
Health of caregivers
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Some possible solutions:
Family based care
Same regimens as
caregivers
Constant reassessment
of home situation
Crush tablets-
EDUCATION
Family oriented support
groups
Disclosure to child
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Summary
Adherence is the most important aspect that
must be followed up with ARV treatment
Information/Education
Ongoing Support
Lifestyle considerations
Personal Beliefs
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