1. 1 Lecture 9: Adherence in ARV Therapy delivered by Dr. Ndwapi Ndwapi, BHP KITSO AIDS Training Program

2. 2 Objectives Define adherence. Understand importance of adherence in ARV therapy. Identify factors that influence adherence. Identify potential barriers to adherence. Discuss strategies to maximize adherence.

3. 3 Definition of Adherence The extent to which a client’s behavior coincides with the prescribed health care regimen as agreed upon through a shared decision making process between the client and the health care provider.

4. 4 Compliance vs. Adherence (the old way) (the new way) Compliance is defined as acting in accordance to a command. The doctor/nurse tells the patient what to do and he/she must do it without question. Adherence is defined as mutual decision making. The patient understands and together with the doctor/nurse agrees to make behavior changes to improve health.

5. 5 COMPLIANCEADHERENCE Willing submission to the commands of others Shared decision making Compliance vs. Adherence (2)

6. 6 Overview of Adherence Adherence to most drug regimes is poor across all populations and all diseases. Most information we have about adherence comes from studies of diabetes, heart disease & TB.

7. 7 The percent of patients who fail to take their medications as ordered can range from 20% to 100%. The average being 50%. Adherence is considered successful for most other chronic diseases when the patient takes their medications > 80% of the time. Overview of Adherence (2)

8. 8 HIV treatment is DIFFERENT To be successful ARV medications must be taken 100% of the time…

9. 9 Why is this different in HIV? The virus rapidly multiplies in the absence of the drugs. With the increasing viral load, more mutations will occur that cause resistance to the drugs. Once resistance develops, the drugs stop working.

10. 10 Relationship between Adherence and Successful Outcome AdherenceViral Load <400 >95%81% 90-95%64% 80-90%25% <70% 6% (INCAS data, Paterson, et al. One year on combination therapy with protease inhibitors.)

11. 11 Maintaining adherence is the MOST IMPORTANT factor for success in ARV therapy

12. 12 ARV Adherence Research Studies Show: Health Care Workers are often unable to predict who will adhere correctly and who will not. Health care workers usually overestimate the number of patients who will adhere correctly. Patient self-reports of excellent adherence may or may not be true. However, patient self-reports of sub-optimal or poor adherence are probably true and should be taken seriously.

13. 13 Why is Adherence with ARV therapy such a challenge?

14. 14 The Drugs Complicated dosing regimens, number of pills. Interference with daily life. Requires commitment to lifelong therapy. Side effects. Requires ongoing availability of medications

15. 15 The Provider Must have up to date knowledge of HIV, ARV, side effects and drug-drug interactions. Must understand the relationship between adherence and resistance. Must display confidence in the therapy.

16. 16 The Provider (2) Must have effective communication skills to create trusting relationships with patients. Must have skills in patient education. Must understand and use the Botswana National Program guidelines for proper use and combination of ARV medications.

17. 17 The Patient Requires knowledge of HIV pathogenesis and treatment options. Must develop confidence in the treatment. May need to overcome distrust of the medical system.

18. 18 The Patient May have numerous psychosocial/ lifestyle issues that could impact on adherence. May have competing cultural beliefs and practices. –i.e., Traditional medicine

19. 19 Adherence Research Reasons for Missed Doses Just Forgot Did not understand the regimen Slept through dose time Travel Change in daily routine, weekend Felt sick Depression (ACTG-Adherence to Combination Therapy)

20. 20 Successful Adherence With so many challenges, is good adherence even possible? Is it realistic? What is the best approach to maximize success ?

21. 21 Botswana Research In a study of 94 adults on ARV therapy, responses showed that good adherence was associated with: –Belief that medications help –Understanding of risks of not taking medications correctly –Advice and support from doctors –Family support –Personal determination –Improvement of symptoms on therapy (Weiser, Marlink, 2001)

22. 22 Strategies for Successful Adherence Strategies MUST be individualized. A combination of interventions is most effective. Adherence must be addressed at EVERY patient visit.

23. 23 Adherence Strategies must be: Ongoing -- every visit. Repetitive -- consistent information. Revised -- to meet the changing needs of each patient. Multidisciplinary -- involving doctors, nurses, pharmacists, counselors. Doctors MUST address adherence at every visit and not just refer the patient to other providers for counseling.

24. 24 The question is never WHETHER to start treatment but WHEN and HOW. Before ANY medications are started, every patient must be assessed for treatment readiness with all potential barriers identified and addressed. Never rush to treat, always assess carefully.

25. 25 Assessing Patient Readiness: Determine level of understanding of: –HIV pathogenesis and its implications. –Purpose and effect of ARV therapy. –Treatment options and limitations.

26. 26 Also Determine: - Cultural beliefs and practices regarding disease and treatment. - Previous experiences with illness and treatment.

27. 27 Stability of environment Income, food, shelter, access to clean water and refrigeration Lifestyle Single, married, children - potential for other positive or sick family members Family, friends, community - potential supports and/or barriers

28. 28 Transportation Ability to return to clinic for follow up. Routines Work/job – time off to attend clinic. Migration/travel – cattle post, lands. Use of alcohol, other recreational drugs. Educational level Ability to read Setswana or English.

29. 29 Current state of physical health - Can they manage treatment on their own or will they need other caregivers. Mental health - Depression related to HIV status. - Stigma, discrimination. - HIV related neurological effects.

30. 30 Starting Treatment Reaffirm the patient’s choice to begin therapy. - Lifetime commitment. Review relationship between adherence and resistance. - Goal = 100% adherence.

31. 31 Explain the medications, timing, and any restrictions. Discuss use of other medications: - Drug/drug interactions. - Traditional medicines. - Always inform other providers of ARV use. - Always inform clinic staff of other medications.

32. 32 Side Effects Prepare for potential side effects and offer practical coping strategies. Make sure that patient understands exactly what to expect from each drug. Reassure that side effects can be managed medically.

33. 33 Practical Support Adherence is enhanced if the regime fits into the person’s daily routine. Ask the patient to decide on the best times within the dosing guidelines. Provide a picture schedule for the drugs Ask patient to repeat schedule.

34. 34 Show samples of the medications Have patient do a return demonstration of each drug and time of administration. Pediatric tip: Have family give child first doses in clinic. - This allows for immediate problem solving.

35. 35 Assist patient to plan ahead for changes in routine, travel. - Problem solve for different situations. Use adherence helpers: - Pill boxes. - Alarm clocks. - Cell phone alarms.

36. 36 Adherence Buddies Patient should involve family member or friend to assist with medication regime. Explain how patient can access support from clinic. - Clinic phone numbers, contact persons. - Health care providers MUST be accessible.

37. 37 IMPORTANT Patients need to understand: ARV treatment is NOT a CURE HIV TRANSMISSION can still occur - If resistance develops, this can also be transmitted.

38. 38 Ongoing Treatment At EVERY visit assess: Medication regime - what pills are to be taken and at what times Doses missed - how often and why - problem solve with patient for future success. Side effects -- patient response Use of other medications, traditional medicine Positive reinforcement of patient efforts, challenges

39. 39 ARV Management in the setting of Non-Adherence If non-adherence is believed to be the cause of treatment failure, HAART should be stopped, and the cause of non-adherence should be addressed. Once adherence has been reestablished and HAART has been restarted, viral load should be checked after 4 weeks of treatment.

40. 40 Remember Reasons for missing doses change over time: - Lifestyle changes. - Pill fatigue. - Improved health.

41. 41 Summary Never start treatment without assessing patient readiness. Educate patient on all aspects of HIV/AIDS, treatment options and outcomes. Be directive in counseling to promote the goal of 100% adherence. Be accessible, approachable, supportive and KIND. Monitor and counsel for adherence at EVERY VISIT.