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Peer Counselor Training Course August 2005

ART Adherence

Adherence and Incomplete Viral Suppression

viral load >400 copies/ml
100 90 80 70 60 50 40 30 20 10 0 82.1 71.4 66.7 54.6

% Patients with







% Adherent
Paterson DL et al. Ann Intern Med. 2000:133:21

Effect of missed doses

Prevalence of 3 Day Adherence in Kampala, Uganda

Prevalence of Adherence in Kampala, Uganda 80 70


60 40 20 0 0-12 13-70 71-94 95-100 % adherence 16 8 6

Tusiime, et al. CROI, 2003

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

Barriers to adherence
Communication difficulties Literacy levels Inadequate knowledge or awareness of HIV disease Inadequate understanding of treatment regimen

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

Barriers to adherence
Difficult life conditions Unstable Living conditions Negative or judgemental attitude of health providers

Keys to successful adherence

1. Education
2. Ongoing Support 3. Anticipate Patient factors preventing good adherence 4. Lifestyle modification


Adequate information on HIV, ARV, how to take medications Awareness of side effects Provide adherence materials REPETITION

Ongoing Support

Establish trust between patient and provider Ongoing education PEER Counsellors Individual counseling Involve family and friends SUPPORT GROUPS Family Based Care

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 support systems


Minimal number of pills and twice a day dosing FIT TREATMENT INTO PERSONS LIFE Few food requirement Self monitoring tools

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 person can help you to take your medication Check if patients clinic attendance/previous OI treatment adherence was good How far are you travelling, are you able to come to the clinic on regular basis?

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

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

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

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


PRESENT? a.m. p.m.


Pregnancy and post partum

Adherence more difficult Cannot use certain ARVs - EFAVIRENZ Pregnancy associated morning sickness and GI upset Concern over effects of ARVs on fetus Caring for newborn may compromise maternal drug adherence Consider: Pregnancy/postpartum centered support groups

MANY UNIQUE ISSUES Lack of proper pediatric formulationscrush tablets Liquid formulations: bad taste, lots of liquid Regular dose readjustment based on childs weight


Child dependant on others for treatment May be many caregivers- disclosure to all?? Child unaware of own HIV status- when to disclose Health of caregivers

Some possible solutions: Family based care Same regimens as caregivers Constant reassessment of home situation Crush tabletsEDUCATION Family oriented support groups Disclosure to child

Adherence is the most important aspect that must be followed up with ARV treatment
Information/Education Ongoing Support Lifestyle considerations Personal Beliefs

Thank you Siyabonga Tatenda