Module_10

ART ADHERENCE AND RETENTION

IN CARE

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 ART Adherence

Pages 63-66_ZCGs 2020

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Quiz

Mr. SKM is a cross boarder truck driver, his latest viral

load is 23000 cp/mL. He explains that he has been
forgetting his ARVs during his long trips and he therefore
runs out of his medicines.

What is the primary barrier to adherence present in his

care?

a) Structural (social-economic)
b) Emotional
c) Cognitive
d) Behavioural

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Benefits of ART Adherence
• Adherence to ART is important to achieve the goals of ART
• Good adherence to ART is critical to achieving and sustaining VL
suppression among PLHIV
• Viral suppression due to ART can reduce HIV transmission by up to
96%
• HOWEVER, poor adherence increases the risk of transmission,
accumulation of resistance mutations, disease progression, and
death

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Adherence Messaging

• Several studies have shown that about 30-60% of patient

treatment failures are as a result of poor adherence
• Adherence assessment and messages must be given to patients
• during treatment preparation
• at all visits, in the community or at the health facility
• Readiness and willingness of patients to adhere changes over time

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Enhanced Adherence Counselling

• Enhanced Adherence Counselling (EAC) is a structured counselling

intervention conducted in unsuppressed patients with VL ≥ 1000 cp/mL
• Studies show that EAC leads to viral re-suppression in over 70% of
unsuppressed patient
• EAC explores the patients’ possible barriers to adherence and clients are
able to attain VL suppression after undergoing EAC with a trained
healthcare provider *

It is not just IF a patient

is non adherence, WHY

*Jobanputra, 2015; Patten, 2013 omadahealth.com

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Enhanced Adherence Counselling cont’d

• Barriers to adherence are categorized as follows; cognitive, socio-

economic, behavioral and psychological” (NB suggested solutions)

Figure 19 page 65_ZCGs 2020

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Conducting EAC Sessions

Before the Session

• The provider(s) must ensure that the following are in
place:
 Viral load results
 EAC or high viral load register
 Index register
 Appointment or ART Tracking Register (where
available)
 Patient File
 Conducive environment

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Adherence Messaging

• Summary of the EAC process. Refer to Figure 20, page 65 of the ZCGs 2020

Identify clients who need EAC Session One Session two Session three Retest VL

VL >1000 cp/mL Introduction, create a Explain the importance of
rapport adherence
On treatment >6 months Explain VL results Assess understanding of
the first session
Explore barriers Educate on treatment
failure and 2nd/3rd line
  treatment
Find strategies
Support to make personalized
Create adherence plan adherence
Explain wayplan
forward
Explain the importance of
adherence
Assess understanding of
the second session
Educate on treatment
failure
support personalized
adherence plans
Retest VL at 3 months
AFTER good adherence
Switch the regimen if
VL >1000 cp/mL
Keep on same regimen if
VL <1000 cp/mL

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
Undetectable = Untransmittable

• Evidence shows that an HIV positive

individual who has an undetectable viral
load is incapable of transmitting the
virus
• This is a powerful motivator for patients
to become suppressed
• The message of U=U must be applied
with all HIV preventative methods such
as PrEP, Condoms and Abstinence
• HIV discordant couples in need of
conception could engage in condomless
sex

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Retention in Care

Pages 67-68_ZCGs 2020

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Retention in Care

Tracking and Keeping Patients in Care

• Keeping patients in care is essential for achieving
good outcomes and preventing resistance
• Lost to follow up (LTFU), defaulting and late drug
pick-ups lead to treatment failure, emergence of
resistance, and the possibility of transmitting
resistant virus

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Retention in Care cont’d

Tracking and Keeping Patients in Care

• Health facilities can minimize Attrition by
having a creating designating
monitor all
structured linkages with health facility
missed clinic
plan to track home-based staff that can
and
patients and care workers contact
pharmacy
prevent and patients who
visits
attrition volunteers miss visits

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Attrition

Attrition in an HIV program can occur as the following: late, LTFU, defaulter,
death, transferred out to another facility, or unknown status
Late
• HIV-infected individual misses a scheduled
pharmacy refill visit
• Take immediate action with 24hrs (e.g.,
CHW follow up, text message or voice call
follow up) and document outcome

LTFU
• Patient missing for ≥30 days after missed
pharmacy refill visit and all active tracking
interventions have failed

Defaulter Unknown status

• Patient (late or LTFU) has been located, but •All active tracking interventions have not
chooses not to return to care been exhausted to determine true status of
patient (after ≥30 days)

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Active Tracking SOP
Figure 21 page 68_ZCGs 2020

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Structured HIV Appointment System

• A missed appointment is the first step of a patient’s fall-out of care

• All facilities must have a dedicated manager of the appointment system
• A list of scheduled appointments should be prepared a day prior to
appointments
• Scheduled patients must be reminded of their appointments
• If patients miss their appointments
• Actively track them as soon as possible
• All patients tracked must be documented in tracking register e.g.
community ART register

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Key Take Home Points

Adherence
• Adherence to ART is important to achieve the goals of ART
• EAC leads to viral re-suppression
• Explores with the confidence of the patients barriers to
adherence
• HIV positive individual who has an undetectable viral load
is incapable of transmitting the virus
Retention
• Avoid patients missing their appointments
• Actively track patients who miss there appointment as soon
as possible
• Prevent and manage attrition using a structure HIV
appointment system
2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV
 Any Questions

2020 Zambia Consolidated Training Package for Treatment and Prevention of HIV