1. Adherence to ART:
Why is it so important? 1

2. Learning Objectives
By the end of this session, participants should be able to:
Define adherence
Explain the importance of adherence in ART therapy
Explain the consequences of poor adherence.
Explain factors that influence adherence
List the barriers to adherence and give options on how to address them with patients.
Discuss how to measure patient adherence

3. Introduction
Poor adherence is the most frequent cause of treatment failure and the subsequent development of resistant strains of HIV
There are many factors involved in ARV success; However, adherence is the single most important factor
There are multiple factors that influence adherence and they change over time

4. Introduction
Adherence is difficult but there are effective strategies that can significantly maximize adherence.
Counselors play an essential role in the promotion of successful adherence.

5. ‘When a patient’s behaviour matches the health advise they are given'
What Is Adherence?
‘When a patient’s behaviour matches the health advise they are given'
It means taking drugs:
at the right time
in the right dose
in the right way
ASK participants for a definition
EXPLAIN It is a collaborative process, a partnership, between the patient and his care providers. Thus, the patient is engaged and actively participates in the care plan.

6. Difference between adherence & compliance
Adherence indicates that all are working together to make behaviour change and to improve health.
The patient and the care provider are participating in and understanding the plan of care and treatment.
ASK Can anyone tell us what adherence is?

7. Difference between adherence & compliance
The term “compliance” indicates that the patient follows medical instructions in taking their medication as exactly prescribed.
In that case the patient is acting in accordance to command. i.e. nurse tells the patient what to do and s/he must do it without question.
ASK Does anyone know what compliance is?s

8. The objectives of adherence counselling:
Prepare the patient to initiate and continue treatment.
Provide ongoing support for clients to adhere to treatment over the long term.
Help clients develop good treatment taking behavior.
EXPLAIN That adherence counseling should help patients develop an understanding of their treatment and its challenges in addition to the above objectives.
Adherence counseling should also contain information to assist patients in preventing HIV transmission to others and maintaining positive sexual behavior changes.
ASK How might enhanced adherence counselling for those with increased VL have some different objectives?

9. Importance of Adherence in ART
In the absence of sufficient levels of drugs, the virus rapidly multiplies…a little bit of drug is NOT better than no drug.
Once the viral load has increased and mutations have occurred, resistance to the prescribed drugs can occur. Once resistance develops, the drugs stop working.
EXPLAIN There is a direct relationship between treatment adherence & treatment effectiveness.

10. Consequences of Poor Adherence Incomplete viral suppression
Continued destruction of the immune system
Disease progression
Emergence of viral resistance
Need to change drug regimen
Limited future to treatment
Higher cost to the individual and the ARV program
ASK What do you think are some of the consequences of poor adherence?

11. Factors that enhance adherence
Assessing patient readiness and starting only when appropriate:
Before starting ARV therapy, patients should work closely with their healthcare provider to assess whether or not they are ready to begin treatment.
EXPLAIN Assessment can take time…. often multiple encounters…before a patient understands the importance of adherence and accepts the concept of life-long therapy.

12. Factors that Enhance adherence (contd.)
Use a treatment plan that best fits into the patient's life:
Walk through the daily schedule of the patient and together find the best times to take the medications. Make plans for situations when a daily schedule is altered, e.g. travel, weekends.
EXPLAIN The approach needs to be individualized so that the regime fits into patient's daily activities and lifestyle. Give the patient positive feedback when appropriate.

13. Factors that enhance adherence (contd.)
An educated patient:
Discuss the importance of adherence, how it impacts the treatment of HIV/AIDS, and what can happen as a result of poor adherence with a patient.
EXPLAIN The better understanding a patient has about HIV, how the medications work, and the relation between adherence and resistance, the more likely it is that the patient will successfully adhere.

14. Prepare patient for side effects:
Factors that enhance adherence (contd.)
Prepare patient for side effects:
If a patient knows what to expect and knows how to deal with expected side effects they are more likely to adhere to their prescribed therapy.

15. Factors that enhance adherence (contd.)
Supportive relationships:
Research has shown that patients who have a trusting relationship and feel supported by their healthcare provider, have greater adherence to ARV therapy.
Support by family, friends, and HIV community support groups also improves adherence.

16. Exercise Adherence Barriers Small group discussion (4-6 people)
Think about patients you know that had difficulties to adhere to their treatment. What made patients being unable to adhere to their treatment?
Can you group certain barriers together that make part of a same "family"?
Patients can face several challenges or barriers to adhere to their treatment
We willd do an exercise to brainstorm around these barriers
- Ask participants what barriers they came up with and write them on a flipchart
- While writing them down, - try to categorise them along the categories of following slide (cognitive / behavioral / socio-economical/ emotional)
Ask them what « families » they came up with

17. Disease Characteristics:
Barriers to adherence 
Disease Characteristics:
Feeling well
Too ill to take medications
Taking other medication
Drug interaction
EXPLAIN There are different ways to classify barriers to adherence - this way (Disease, Treatment, Patient, Institution) or Behavioral, Socio-economic, Emotional, or Understanding/Motivation, remembering, support and logistics, healthcare system/meds. The point is to have some system to help you remember to explore all areas.

18. Treatment Characteristics:
Barriers to adherence (contd.)
Treatment Characteristics:
Physical difficulties—swallowing pills
Regimen complexity
Side effects
Interference with daily life (duration of treatment— commitment is lifelong)
Dietary restrictions
Expenses related to care. (time spent, travel)
(if the drug make the patient ill or cause un comfortable side effects it is likely that they will not take their medications on regular basis.)

19. Patient Characteristics:
Barriers to adherence (contd.)
Patient Characteristics:
No understanding of the purpose of therapy (lack of treatment literacy)
No belief in treatment efficacy
Lack of knowledge/false beliefs about HIV
Cultural or religious beliefs (fasting, mourning, etc.)
Disclosure issues (lack of social support, stigma)

20. Barriers to Adherence (patient characteristics contd.)
Lack of self esteem, depression or other mental illness.
Substance abuse issues
Competing priorities—work, family, and food access.
Forgetting to take their pills or their date of appointment - 'Human error'.

21. Barriers to Adherence (contd.)
Clinician or Institution Issues:
Lack of confidentiality
Difficulty accessing health centre
Insufficient time
No appropriate education provided
Language & communication barriers
Negative/judgmental attitude of health care workers

22. Organizing medication:
Adherence strategies
Organizing medication:
Divide medication into labeled bags of drugs or pill boxes to help organize dosage and schedule.
Streamline regimens to minimize the number of pills and doses per day.
Draw up a medication schedule using words or pictures.
EXPLAIN Practical ways to support adherence include working with the person to problem-solve difficulties with taking their ARVs, referring them to a support group encouraging them to find an ‘adherence supporter’ or ‘buddy,’ and linking them with an Home Based Care team.

23. Adherence strategies (contd.)
Remembering to take medication:
Incorporate into the daily routine: take medication at the same time every day, associate with another daily activity (meals, tooth-brushing, bedtime, etc…)
Plan ahead - carry extra doses when traveling far from home.

24. Adherence strategies (contd.)
Anticipating and managing side effects:
Advise patient on typical side effects of his or her regimen.
Explain that side effects may decrease as body adjusts.
Advise when to self manage and when to report.
is lack of food often a contributor?

25. Adherence strategies (contd.)
Disclosure:
Counseling to support disclosure. Can do role plays, offer to see the partner with the patient, etc.
Identify other people (i.e. friends, members of PLWHA group) who patient can disclose to first if disclosure to spouse/family seems to difficult

26. Measuring Adherence
The assessment of an individual’s adherence to ART by health care workers is often inaccurate.
Health care workers should spend more time supporting adherence than trying to assess it.
The best way to support adherence is to focus on the needs of the person taking ARVs.

27. Measuring adherence (contd.)
Biological Markers:
Decrease in viral load implies good adherence.
However, in some patients viral load may remain high even with good adherence
EXPLAIN This can be because of many factors such as viral resistance, treatment failure or poor absorption of drugs

28. Measuring adherence (contd.)
Pill Count:
Providers count remaining pills during clinic visits.
 Problems:
Patients know how many pills they are supposed to have and can dump pills prior to visit.
Can promote a sense of distrust between patient and provider.
can try to “catch” patient but promotes distrust

29. Measuring adherence (contd.)
Self-Report:
If not mentioned by the patient, ask about missing pills (various periods of recall of missing pills at 1, 3 and 7 days)
Approach the patient in a matter of fact and non- judgmental way (emphasize to the patient that any answer will not have an adverse impact)
EXPLAIN Let the patient explain how he has been taking the treatment and talk about any adherence problems

30. Measuring adherence (contd.)
Calculations:
Can be based on returned pills or on self report
Can be time consuming, and again, patients learn how many pills they are supposed to bring back.
does this happen here?

31. Measuring adherence (contd.)
Morisky Medication Adherence Scale:
Are you careless at times about your medications?
When you feel better, do you sometimes stop taking your medicines?
Do you ever forget to take you medications?
EXPLAIN This is a well validated scale for adherence but need to ask these questions specifically
what about “careless?”
this is the one we want to use here

32. Measuring adherence (contd.)
Morisky Medication Adherence Scale:
4. Sometimes if you feel worse when you
take your medicines, do you stop taking
them?
No to all questions: good adherence
Yes to one or more questions: adherence should be improved

33. Measuring adherence (contd.)
   
Self-Report:
Advantage:
Easy to do in our clinic setting.
Disadvantage:
Tends to overestimate adherence.

34. Conclusion Adherence works best when:
Relationship between patient and health care provider is based on trust.
Patient has adequate support.
There is a multidisciplinary health care team and client centered approach.
And remember:

35. Adherence is a process not an event!