Integrated HIV Training for Healthcare Workers

Session 10: ART Initiation

ART Adherence

In this session, we will discuss the benefits of Antiretroviral therapy, how to assess client readiness for ART in various populations, the appropriate ART regimen and dosage, and effective adherence support interventions and strategies for supporting adherence to ART.

Learning Objectives

By the end of this session, you will be able to:

  • Define ART adherence.
  • Explain factors that affect adherence.
  • Describe common barriers to adherence and strategies to address them.

Learning Activities

  • Introduction to ART Adherence: Ernest (5 min)

    As the morning sun comes streaming in through his bedroom window, Ernest stretches, but then winces as he is struck by the discomfort in his abdomen.

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    The bout of diarrhoea over the past few days has left him feeling drained and weak. His stomach feels like a hollow pit. Every time he recovers from one of these episodes of diarrhoea he eventually regains his energy and feels so good and strong that he finds it hard to believe that it will seize him again.

    But, out of the blue, each time it attacks him it seems to stay for a longer period and “steal away” more of him than the previous time. Each time he is ill it takes some of his physical substance and he is left thinner than before, but he feels like it takes away a part of his soul too. He is left feeling demoralised, low in self-confidence and somewhat depressed due to this confrontation with his imminent mortality.

    Ernest is 33 years old and has been diligent about visiting his doctor since he discovered he was living with HIV three years ago. His doctor has encouraged Ernest to take a comprehensive set of multivitamins and to monitor his symptoms carefully.

    Because he works in a gym, Ernest is highly conscious and proud of his body image. He works hard at maintaining it, but occasionally enjoys having fun too, and this often involves a night on the town consuming large amounts of alcohol. Although Ernest has spoken to a few select friends and family members about his HIV status and received unconditional support, this does not take away the difficult reality of him being HIV-positive.

    Ernest was shocked when his doctor reported a CD4 cell count of 240 cells/mm³ at his last consultation a month ago. His doctor has advised him that he should start taking anti-retroviral therapy according to the new ARV guidelines. He informed Ernest of the importance of adhering to a strict ART regimen and gave Ernest some information to read before the next consultation the following day.

    What is Adherence?

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    ART adherence means a client takes the ARV medicines exactly as prescribed by their health care worker. Adherence to a drug regimen prevents HIV from multiplying and destroying the immune system. Taking HIV medicines every day also reduces the risk of transmission.

    Therefore, your efforts to support adherence should start before ART initiation and should include basic information about HIV, the ARV medicines, expected side effects, and preparations for long-term ART.

    Definition of treatment adherence

    WHO defines treatment adherence as “the extent to which a person’s behaviour, taking medications, following a diet and/or executes lifestyle changes” corresponds with agreed recommendations from a health care provider.

    ART Adherence Involves:

    • Taking all the medicines that are part of the person’s treatment regimen at the right time and correct amount. If it is twice daily, then every 12 hours, every day, for the rest of their lives.
    • Taking medicines at the right interval in relation to the consumption of food and drinks as advised.
    • Knowing about the interaction between ARV medicines and other types of medication.

    Importance of Adherence

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    Do you remember from the earlier section what level of adherence to ART is necessary to achieve full and durable viral suppression?

    Adherence is very important to the success of the treatment. If the medicines are taken as prescribed, the client will experience the following benefits:

    • Maximum viral load suppression to undetectable levels (%).
    • An increased CD4 count and restored immune system.
    • Prevention of opportunistic infections (OIs).
    • Improved quality of life.
    • A decreased risk of progression from HIV to AIDS.
    • Reduced risk of HIV transmission to the HIV-negative partner in a discordant couple.
    • Adherence also decreases the risk of HIV becoming resistant to ARVs.

    Adherence Preparation

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    ART initiation involves effective counselling for adherence and disclosure to others who will play the role of an adherence supporter or treatment buddy. The correct ART regimen and appropriate doses must be prescribed, especially for children, and adequate pharmacy stocks must be maintained to avoid treatment interruptions at all costs.

    “Adherence preparation” refers to the special counselling required to prepare clients for ARV treatment, before they start taking the medicines. It is the process of preparing people living with HIV (PLHIV) and their caregivers for ART intervention.

    This preparation is extremely important, since taking ART is a lifelong commitment for PLHIV.

    Clients must be fully ready to make the commitment to taking ART medicines as prescribed for life.

  • Factors that Affect Adherence (5 min)

    Let’s look at some the factors that may affect a client’s adherence to ART treatment. Tap on each of the factors below to learn more.

    Clients may:

    • Forget to take their ARVs
    • Be away from home
    • Be depressed
    • May abuse alcohol
    • Be discouraged to continue taking their ARVs by faith healers or traditional healers

    Clients may:

    • Have side effects to the medication
    • Pill burden
    • Dietary restrictions
    • Medicine stock out
    • Long distances to health facilities
    • Costs related to care
    • Health care worker attitudes

    As a health care worker, you will be supporting clients by answering many questions they will have during adherence preparation.

    How might you respond if a patient asks the following questions?

    1. “How can I possibly remember to take a drug twice a day forever?”
    2. “What is the purpose of taking such a complicated treatment if I will not be cured?”
    3. “What if I go away for a few days and forget to take the drugs with me?”
    4. “How can I take ART if my wife, who is also HIV-positive, has not been given it yet?”
    5. “You are talking about side-effects that might really bother me. Why should I take drugs that make me feel so bad?”

    In the box below, type your responses. Tap the compare answer button to compare your answer to an expert's.

    Effective Adherence Support Interventions

    There are many ways you as a health care worker can provide effective support interventions for a life-long commitment to ART.

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    These include:

    • Client-centered behavioral counselling
    • Support from peer educators trained as ‘expert patients’
    • Community treatment supporters
    • Text messaging as reminders and support
    • Encouraging people to disclose their HIV status
    • Providing clients with adherence tools, such as pill boxes, diaries, and client reminder aids

    High-quality evidence from randomized trials has shown that text messages contributed to reduced non-adherence and unsuppressed viral load.

    Source
    Consolidated Guidelines on the use of Antiretroviral Medicines for treating and preventing HIV infection (2015), WHO, Geneva.
  • Supporting Children and Adolescents (5 min)

    Adherence is known to be difficult in all age groups, but particularly in adolescence. Adolescents living with HIV are especially vulnerable to adherence problems resulting from their psychosocial and cognitive developmental trajectory. Comprehensive systems of care are required to serve both the medical and psychosocial needs of adolescents living with HIV, who are frequently inexperienced with personally managing health care systems and may lack health insurance. Compared with adults, these youth have lower rates of viral suppression and higher rates of virologic rebound and loss to follow up.

    Studies on chronic disease show that adolescents with chronic disease are less adherent to treatment than adults and young children. Similarly, HIV-infected adolescents and young adults consistently have disproportionately higher rates of poor drug adherence and virological failure compared with younger children and adults (Lowenthal et al, 2014).

    Although increasing access to ART has transformed the prognosis for children born with HIV or acquiring HIV since birth, improved morbidity and mortality in this age group is at risk of being reversed if we do not ensure effective, sustained adherence support for children and adolescents on ART.

    Some of the outcomes of poor adherence in children and adolescents include the following:

    • Emergence of virus resistant to medication
    • Clinical progression of disease
    • Risk of spreading drug-resistant virus when adolescents become sexually active
    • Risk of transmitting drug-resistant virus if adolescent girls become pregnant
    • In Zimbabwe, limited second- and third-line therapies

    A study in Harare, Zimbabwe, by Africaid among 229 adolescents with HIV demonstrated that self-reported adherence to ART was sub-optimal (Mavhu et al., 2013).

    A study at Parirenyatwa Hospital found that 40% of adolescents on ART had virological failure.

    Common Barriers to Adherence Among Children and Adolescents

    The barriers to adherence in this age group are varied and often complex because not all children and adolescents will necessarily experience the same challenges. Therefore, an individualised approach to assessing and counselling children and adolescents on ART is necessary. Tap on each of the factors listed below to learn more.

    • Lack of knowledge
    • Delayed disclosure
    • Orphanhood
    • Desire for conformity with peers
    • Fear of stigmatization
    • Loss of purpose
    • Forgetting
    • Depression
    • Drug and alcohol abuse
    • Changes in guardianship
    • Absence of parental/caregiver support
    • Cultural/religious beliefs
    • Traditional medicines
    • Lack of support
    • Negative experiences of ART
    • Pill burden
    • Side effects
    • Drug fatigue
    • Past experiences of medication
    • Daily reminder of HIV status
    • Staff attitudes
    • Lack of information
    • Transport costs
    • Availability of medicines
    • Transition from paediatric to adult services

    Strategies for Promoting Adherence in Children and Adolescents

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    Children living with HIV are now growing into adolescents and adulthood, but this relies on optimal adherence to ART. Strategies you use to promote their adherence will be very similar to those used for adults.
    These include:

    • Information about HIV and ART
    • (Quality) counselling
    • Peer support/involvement
    • Life skills training
    • Client reminder aids, such as pill boxes, calendars, alarms, SMS reminders

    No single approach is enough. A combination of approaches is required if children and adolescents are to be supported effectively with adherence to ART. These may not all be possible from within your clinic, but by working together with other programmes in your community, it is possible to create a support network for children and adolescents on ART.

  • Jabu (5 min)
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    Jabu is a 24-year-old man. He discovered that he was HIV-positive when his pregnant girlfriend was tested at the ante-natal clinic two years ago. Unfortunately, their baby died a few months after birth and his girlfriend is currently very ill and suffering from the effects of full-blown AIDS. Jabu has found this situation very difficult to deal with and ends up travelling away from Bulawayo a lot of the time.

    Jabu’s girlfriend’s doctor is very interested in Jabu’s welfare and urged him to begin ART six months ago. Jabu began a triple therapy regimen but had some experiences that deterred him from continuing. He could not bear the side-effects and said that he felt worse on the treatment than he had before taking it. Due to his travelling and irregular sleep patterns, Jabu often forgot to take his pills. When his second set of medication was finished and Jabu decided that the medication wasn’t worth it and that pursuing this route was too much of a hassle.

    In your role, how could you work with these negative factors? Brainstorm the factors that are obstacles to adherence. Brainstorm the factors which would facilitate (help) adherence to ART.

    Write out your thoughts in your workbook and then tap the compare answer button to compare your answer with an experts’.

  • Kuchepa (5 min)
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    Mr. Kuchepa is a 64-year-old divorcee. He is on TDF/3TC/EFV once daily. He’s also supposed to take 2 tablets of cotrimoxazole daily. His last CD4 count was 387.

    He stays with 2 grandchildren (13 and 15 years old) and sublets the rest of his house to a family that has stayed with him for past 10 years. His 3 children are all married and stay with their families in the city. None of his children know his HIV status, but they all suspect their mum died of HIV.

    Mr. Kuchepa admits to abusing alcohol regularly and often spends the night at his girlfriend’s place (who doesn’t know her HIV status). In past 6 months, he has been missing clinic appointments. When he does come he has more pills than expected. He admits that sometimes he forgets to take his medications.

    1Mr. Kuchepa tells you that he thinks he should take his medicine only when he’s feeling bad. What will you tell him about why adherence is important? Select all that apply.

    2What plan would you suggest to help him improve adherence?

    3List 2- 3 behavioural support interventions you might suggest to Mr. Kutchepa. Tap the compare answer to compare you answer with an expert's.

  • Knowledge Check (10 min)

    1What are outcomes of poor adherence? Select all that apply.

    2Rutendo is a 14-year-old girl who has just been given ARVs and has been sent to you for counselling. In your discussion with her you tell her some important things she should remember when on ARVs. Which of the following are things you would mention? Select all that apply.

    3When you are explaining why adherence is important, what are some of the messages you might share with Rutendo? Select all that apply.

    4What are some of the reasons that adolescents lack motivation to adhere to treatment? Select all that apply.

    5What are the steps you need to take to work with a child or adolescent to achieve adherence? Select all that apply.

    6During adherence counselling, you want to ensure that the adolescent or child and caregiver receive adequate education. What are the points you need to cover?

    7Assessing adherence includes which of the following? Select all that apply.

    8What are some communication techniques that you should consider when discussing adherence? Select all that apply.

    9What are some examples of good questions for probing ongoing adherence? Select all that apply.

    10Adherence to medicines is more important for children than adherence to care (going to appointments and tests as scheduled, modifying lifestyles as needed).

    11Adherence and compliance are the same.

    12HIV positive adolescents on ART often have lower viral suppression rates when compared to adults.

    13As long as a child or adolescent is adherent, there is no need to discuss adherence again.

    14When counselling a caregiver and a child, it is not necessary to involve the child in the discussion about adherence. It is only important that the caregiver understands.

  • Key Points (5 min)
    • ART is a lifelong commitment. Thus, clients should be adequately prepared and efforts to support adherence should start prior to ART initiation.
    • For most clients, near-perfect (>95%) adherence is necessary to achieve full and durable viral suppression.
    • Adherence decreases the risk of progression from HIV to AIDS.
    • Adolescents have higher rates of poor adherence and virological failure when compared with younger children and adults.
    • Barriers to adherence among children and adolescents are complex. An individual approach to assessing and counselling is often necessary.