Antiretroviral Therapy (ART): ART Adherence

Learning Objective:

  • Conduct adherence counselling

  • Quiz

    Tell your mentee you would like to assess his or her knowledge related to ART adherence with a short scenario. Ask your mentee the following questions and see the facilitation notes for help with the assessment.

    Mr. Kuchepa is a 64-year-old divorcee. He is on TDF/3TC/EFV once daily. He’s also supposed to take cotrimoxazole 2 tablets 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 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 their 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.

    • You do a pill count and calculate his adherence rate, which is 90%. For all patients, what level of adherence to ART is necessary to achieve full and durable viral suppression?

      [note text]

      95%. Studies have shown that for Mr Kuchepa to be adherent, he must take at least 27 out of 28 doses. This means that an adherence rate of more than 95% must be sustained for virological suppression, i.e., control of HIV) to be achieved.

    • What questions would you ask Mr. Kuchepa about adherence?

      we’re looking for open-ended questions. If mentee is not good at this, see the open-ended questions activity.

      Give some sample open-ended questions.

    • Mr. 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?

      Ask your Mentee to answer using terms that patients will understand and avoid medical terminology.
      1. Maximum viral load suppression to undetectable levels
      2. Increased CD4 count/restored immune system
      3. Prevention of OIs
      4. Improved quality of life
      5. Decreased rate of disease progression from HIV to AIDS
      6. Reduced risk of HIV transmission to HIV negative partner
      7. Decreases risk of becoming resistant to ARVs

    • What are some behavioural support interventions you might suggest to Mr. Kuchepa?

      [note text]
      1. Client-centred behavioural counselling and support
      2. Support from peer educators trained as “expert patients”
      3. Treatment buddy
      4. PLHIV support groups
      5. Encouraging people to disclose their HIV status
      6. Providing clients with adherence tools, such as pill boxes, diaries, and client reminder aids
      7. Education on the importance of adopting safer sexual practices

    • (If they recommended a treatment buddy) Mr. Kupecha asks why he needs a treatment buddy. What would you say in response?

      [note text]

      “Treatment buddies provide support and assistance to persons living with HIV disease. After many years of providing HIV care and medication to persons like yourself and based on research conducted in many countries, we have seen that people who identify a treatment buddy do better with taking their medication every day than people who do not have a buddy. The person you choose should be someone who you respect, who will keep the information about you private and confidential, and who lives nearby and can assist you when needed. That person can remind you to take your medication and help you if you are having difficulty remembering.”

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

      [note text]
      • Provide reminding devices if available, for example:
        • Setting an alarm on his mobile if he has one.
        • Setting up a free text message system provided by some network service providers, such as Econet wireless, which remind him to take his medication.
        • Providing or making pill box that will hold one week of medication and teaching Mr. Kupecha and his treatment buddy how to fill the box each week.
        • Providing written reminders in his own language that he can put in a place that he will see in the evening when the doses are due.
        • Encouraging client to store medication in a visible place near something that he handles at about the same time every day, such as a tooth brush, where seeing it would remind him to take his medication.
      • Providing risk reduction counselling.
      • Assessing the amount of alcohol Mr. Kupecha is drinking using the CAGE questionnaire.
      • Discussing with Mr. Kupecha the benefits of lowering the amount of alcohol he consumes each day or the possibility of him stopping drinking. This is better for his overall, long-term health living with HIV disease and will improve his adherence to his medication, which will keep him healthy.
      • Exploring the potential reasons why he may find it difficult to reduce the amount of alcohol or stop drinking completely.
      • Advising Mr. Kupecha to make sure he has taken his daily medication every evening before he consumes any alcohol ensuring that he will not miss a dose.
      • Referring him to HIV and/or substance use support groups if available.

    • What strategies do you employ at your stations to ensure optimum adherence to ART?

      [note text]

    • [activity type]

      Tell your mentee that you will review a case study and ask some questions to help him/her improve skills in ART adherence counselling.

      Tinaye is 17 years old and lives with her mother and father. She is going to start taking ART and, now that she has attended the 3 adherence counselling sessions, you have been asked to help prepare her and make an adherence plan. Tinaye is at the clinic with her older cousin and says she and her mother and father do not talk much about HIV. Her cousin has agreed to be her treatment buddy/supporter.

      How would you prepare Tinaye and her cousin to start taking ART?

      Possible responses:

      • Ask Tinaye what information she received from her adherence preparation visits was helpful. What information was not helpful or confusing? What additional questions does she have for you about HIV, the medication, the follow-up needed, or anything else that she does not understand?
      • Does she have any fears or concerns based on information received?
      • Does she have any problem swallowing pills?
      • Based on the feedback you receive from Tinaye and which regimen she will be prescribed, ask Tinaye what is the best time in the evening she can remember to take her medication every day.
      • What reminder aids would she like to use along with her cousin’s support. Calendar? Pill box? Mobile phone alarm or SMS reminder? Storage of medication?
      • What will she do if she forgets to take her medication?
      • What to do in situations which interfere with daily routine such as travelling and attending functions such as funerals.
      • Medication should never be shared.
      • What possible side effects would she need to have to come back to the clinic to be evaluated as soon as possible?
      • Explore readiness and commitment to take lifelong medication.
      • Since Tinaye is 17 years old she might be going to college/school. You should explore any challenges in taking her medicine that she will likely face.

    • [activity type]

      Tell your mentee that you will review a case study and ask some questions to help him/her improve skills in ART adherence counselling.

      Ernest, a 33 year-old-man, has been diligent about visiting his doctor since he discovered he was living with HIV 3 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 from the difficult reality of being HIV positive.

      Ernest was shocked when his doctor told him that his CD4 T-cell count was 387/mm³ at his last consultation a month ago. His doctor began talking to Ernest about antiretroviral therapy, explaining that Ernest might wish to start thinking about this as a long-term intervention option. He gave Ernest some information to read before the next consultation in two months’ time.

      Questions

      1. What are the factors that Ernest and his doctor need to take into account prior to Ernest beginning ART?
      2. Brainstorm ART readiness assessment questions that you would explore with Ernest if you were his counsellor.

      Possible responses:

      • Can Ernest be sure that he will have constant access to the ART?
      • How will he manage the side-effects?
      • What impact could the side-effects have on his day-to-day life?
      • Who will he talk to in his private circle about going on ART?
      • Will his lifestyle promote or challenge ART adherence?
      • How might this experience (including the bodily changes) affect Ernest’s self-image?

    • [activity type]

      Explain to the mentee that you are going to engage in a role play to help him or her conduct adherence counselling. He or she will play the role of health care provider, and you will be the patient.

      Show the mentee the instructions below for the health worker. Then, tap on the box for the patient instructions. Do not show this to the mentee.


      Jabu is a 24-year-old man who discovered he was HIV-positive when his pregnant girlfriend was tested at the antenatal 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 began EFV/TDF/3TC = FDC 6 months ago. He tells you he stopped taking the medication a few weeks ago.

      • Play the role of the patient described above. You have found this situation very difficult to deal with and end up travelling away from Harare a lot of the time.

        You began EFV/TDF/3TC = FDC regimen 6 months ago but had some experiences that deterred you from continuing. You could not bear the side-effects and you felt worse on the treatment than you had before taking it. Due to your travelling and irregular sleep patterns, you often forgot to take your pills. A few weeks ago you decided that this isn’t worth it and taking medicine is too much of a hassle.

        Check the boxes below to indicate whether the mentee asked the appropriate questions. At the end of the role play, review any problem areas with the mentee.

        Questions the mentee should be asking you:

        Listen to the way the mentee:

        Was the mentee able to get Jabu to:

        or

        Important: The mentee should not force Jabu to resume treatment. If his CD4 count is less than 200, the mentee needs to ensure that Jabu will take cotrimoxazole, practice safer sex, avoid or minimize alcohol and other substance use, and return to the clinic if he is feeling sick. A CD4 count less than 200 also means he is more prone to OIs and needs vigorous adherence counselling to ensure that he resumes treatment before he develops life-threatening OIs. Patients must understand what their choices may result in, but they can’t be forced into taking treatment.

    • [activity type]

      Discuss with your mentee the following questions about adherence.

      Ask the mentee to list some of the issues he/she has experienced with clients coming to the health facility as deterrents against taking ART?

      Which of these issues are more common and how has he/she been educating patients and convincing them to still take their medication despite the listed issues?

      What are some deterrents for patients against taking ART?

      What are some incentives for patients for taking ART (advantages)?

    • [activity type]

      Explain to your mentee that you’ll be working with him/her on asking open-ended and non-judgmental questions. For each close-ended question below, ask the mentee to change the question so that it is open-ended. Tap on the question to reveal open-ended examples.

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      2.
      3.
      4.
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