1. Adherence Preparing to start ARVs Dr. Kevin M Harvey MBBS, MPH (UWI), Dip. ID (Lon.) Treatment care and support 2006

2. Preparing for Adherence More sustainable response to ARVs if adherence is optimized within the first three to six months Must therefore prepare individuals to adhere prior to the start of ARVS Must also have a strategy to sustain adherence throughout life

3. Predictors of non adherence: Medication related dosing frequency side effects Number of pills ?type of medication ?complexity of regimen

4. Patient-related Active substance abuse Depression HIV knowledge and knowledge and belief in medications Literacy (?more of a system problem) Non-adherence to care Stage of readiness ?Distance from site ?age ?disclosure

5. System-related Cost of care/treatment Access to care and medications provider/patient relationship Stock-outs ?employment out of the home ?transportation ?stigma

6. Other reasons people do not take their ART Pill fatigue Forgot Pills not with them Transportation Fear of disclosure Concern with drug interactions (prescribed or other) And others

7. Non-predictors Non-predictors include –Race –gender –prior substance abuse –social status or income –education

8. Preparing for ARVs Culture Access +Knowledge + Motivation+Cues to Action Stigma & Discrimination ADHERENCE

9. Access Potential Barriers Distance from Clinic Appointment system User Fees Availability of Service Confidentiality Stigma & Discrimination Cost for CD4,Viral Loads + other labs Cost of other Medicines Cultural Practices Possible Solutions Telephone Appointments Waiver from User Fees (free does not =Access) Waiver from General fees & lab cost via assessment Process Refer closest acceptable Treatment site Assistant with Bus Fares Register with the NHF Family support

10. Knowledge Potential Barriers Believes Culture Myths Low literacy Lack of Exposure to Specific HIV Education Educational Material inappropriate Possible Solutions Appropriate Literacy Material for Individual HIV Basic Facts Condom Negotiation Skills Name etc of Specific Meds

11. Motivation Potential Barriers –Depression –Number of pills –Frequency of doses per day –No Family support –No disclosure /fear disclosure –Negligence/ forgetfulness –Unemployment –Lack of privacy Possible Solutions –Refer to Social Worker –Mental Health Professional –Reduce the number of pills If possible link meds to something the patient does that they enjoy –Refer to support groups –Encourage disclosure, –provide temporary support –encourage buddy system –Channel to income generating projects

12. Cues to Action Barriers Non Disclosure and lack of support Drug addiction Stigma and Discrimination Attention drawn by Reminders Pill boxes can be too big Late refills Cognitive function Possible Solutions Family Support Media Pill Boxes Text Messages Alarms Link to Favourite radio and TV programmes Support at workplace

13. Culture Barriers Patients only listen to doctor Alternative Medicine Can provide a Cure Role of the Church Myths Solutions Patients will listen to Doctors Alternative(Herbal Medicines) can be immune boosters Education of Clergy

14. Stigma & Discrimination Potential Barriers Fear Discrimination Lack of or Low Public education Remove Labels Fail to take meds in Public Move away from district Do not want to attend Clinic in Own district Visible side effects Possible Solutions –Confidentiality at the work place is key –Reduced stigma and discrimination at work place –Refer to acceptable treatment site or facilitate easier access

15. Supportive Environment Knowledge Motivation Positive Behaviour Change Increased Adherence

16. Family-Focused Adherence Support It may take several weeks and several visits to ready the family for treatment. Before prescribing –Family is part of and agrees with treatment plan –Assess family life-style, priorities, beliefs –Ask about prior medication experience: build on success and work on problems –Educate about the disease, purpose of ARV, importance of adherence –Repeat information as many times as necessary

17. Family-Focused Adherence Support Planning for a good start: –Develop a simple schedule that fits the family’s daily activities. Consider differences between weekdays and weekends. –Clarify who will be responsible for giving or supervising each dose, each day of the week –Make the schedule visual. Use pictures of pills. Color- code everything. Consider literacy level of family members

18. Family-Focused Adherence Support Planning for a good start: –Demonstrate medication preparation: measuring volumes of liquids crushing or dissolving tablets opening capsules using foods or liquids to mask task –Do a trial run with “dummy” pills or liquid –Observe medication administration in the office. If possible, start the first dose under supervision –Follow-up with a phone call and/or home visit in the first few days

19. Conclusions Adherence is hard for everyone and long term treatment present the most difficult challenges Adherence is critical to the successful care of patients with HIV/AIDS –On an individual level, adherence to care and treatment can mean the difference between life and death –On a population level, adherence to treatment can minimize the emergence of viral resistance and prevent therapeutic failure Adherence needs to be to medications and care.

20. Conclusions Every HIV/AIDS treatment program should include processes to assess and support adherence Adherence promotion must be multifaceted and multidisciplinary and adapt to changing needs and realities –Many models/approaches in use –Many also need to be evaluated and adapted for local needs Simpler and more tolerable regimens which preserve efficacy are still needed

21. Further Discussion & Questions