assessing adherence to treatment: a partnership
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ASSESSING ADHERENCE TO TREATMENT: A PARTNERSHIP
Plenary Session: Tuesday, October 20, 2009
Supporting Sustainable Adherence to HIV Prevention, Care & TreatmentICAP Technical WorkshopOctober 19-22, 2009Kigali, Rwanda
Shekinah ElmoreScott WorleySthembile MatseMilena Mello
Sustainable Adherence: What & Why
Multilevel Concept Dynamic Process and Not Static
Outcome Adherence to Care AND Treatment A Transition from Evaluation to
Partnership between Client and Counselor
Key Adherence Strategies
Appointment systems Integrated tracking and tracing systems MDT approach to adherence counseling
and assessment Peer education/expert client programs Community linkages and referral
Adherence Assessment: The Process
The process Measuring—allows you to monitor Monitoring—allows you to intervene Intervening– allows you to achieve a good
outcome
Overview of Presentation
How do we define adherence to care? How do we define adherence to
treatment? What methods can we use to assess
adherence to treatment? Programmatic examples of adherence
assessment from Swaziland, South Africa, and Mozambique
Defining Adherence to Care
What is Adherence to Care? Adherence to the entire, holistic package of HIV
services, not just ART ICAP countries define elements of ‘Care’ differently
Marked by a continued engagement with the plan of care
Often measured by proxy as adherence to scheduled clinic visits
This presentation will focus on treatment, several small group sessions will focus on care.
Defining Adherence to Treatment
Broader Definition: Adherence as a Biosocial Phenomenon
“A complex process embedded in the clinical and social course of AIDS.” (Castro, 2005)
Adherence to Treatment: 8 Broad Categories
Socioeconomic factors
Health-care systemSocial capitalCultural models of
health and disease
Personal characteristics
Psychological factors
Clinical factorsAntiretroviral
regimen
(Castro, 2005)
Defining Adherence to Treatment
Specific Definition: >90-95% of doses taken as prescribed
Correlates with undetectable viral load Works well for adult care, but we
encounter complexities with pediatric (e.g. syrups) and PMTCT (e.g. single dose NVP) dosing
Methods that Assess Adherence
Clinical and ‘Gold Standard’ Methods Quantitative Methods Qualitative Methods
Clinical & ‘Gold Standard’ Measures
Clinical and ‘Gold Standard’ Methods
Viral Load and CD4 Count Therapeutic Drug Monitoring (TDM) Electronic Drug Monitoring (EDM)
e.g. MEMS Caps, Cell Phones, Other Observed Therapy
Quantitative Methods
Patient Recall Methods
3-day, 7-day, or 30-day Recall Visual Analog Scales (VAS) – Milena on
Mozambique Report of Missed Doses
Patient Recall Methods
Patient recall is valid and reliable: Meta-analysis by Simoni et al. (2006) confirms that patient recall methods perform well across 77 independent trials
However, no consensus on which performs best Lu et al. (2007): 30-day VAS better correlated with
clinical measures than 3-day and 7-day recall, because participants were less likely to over-report adherence
Mannheimer et al. (2008): participants were more likely to over-report adherence on the 3-day vs. 7-day scale
Choice of measure should be context-specific
Pill Count
Counting the pills that a patient has left after a specified period (e.g. 30 days)
Often conducted by the pharmacist Can be announced or unannounced More to come by Sthembile on Swaziland
7 Day Recall: Pediatric ExampleWhich doses were you not able to give in the last 7
days?
A)Write in days of the week for the last seven days, and mark an “X” for missed morning and/or evening doses.
Day
MorningDose
EveningDose
7 Day Recall: Pediatric Example (Cont.)
B) Check the option below that captures the level of adherence in the last 7 days:
Low (5 or more missed)
Medium (3 or 4 missed)
High (0 - 2 missed)
7 Day Recall: Pediatric Example (Cont.)
Part of a broader adherence assessment and counseling encounter, which includes: Review of ART regimen Reasons doses were missed Plan for follow-up and referrals
So we have…MeasuredMonitoredIntervened
Qualitative Methods
Barriers and Facilitators Analysis
Open-ended or multiple choice questions: What are the barriers to adherence that you’ve had
in the past month? What has helped you to adhere in the past month?
Link patient with support interventions that address barriers and strengthen facilitators
Track changes in barriers and facilitators over time
Open ended questions may provide more honest, rich answers, yet, are harder to track over time
Scott on South Africa
Choosing a Method
Programmatic Considerations for Choosing a Method
Participatory and interactive Situated within a counseling framework Sensitive to staffing and time constraints Counselors trained and mentored MDT involvement Implementation must be systematic and reach each
patient on a consistent basis Linked to appropriate adherence support interventions Structured enough to be evaluated
Doing adherence assessment (MOC, yes/no) Level of adherence (SOC, quantitative measure)
Client and Counselor Partnership
Adherence happens outside the clinic Need assessment methods that allow clients to
understand and manage their own adherence Tools that allow clients to track adherence in parallel
with counselors records Assessing adherence in partnership gets clients
invested in their own adherence outcomes, and in turn, provides a forum for adherence support
Example: Pediatric Adherence Calendar & Coloring Book
B. Scott WorleyTechnical Advisor for Care & SupportICAP – South Africa
Missed Doses & Barriers Analysis
South Africa: Recall and Barriers Assessments
Patient asked what medications they take, when and how
Patient asked if they have missed any doses (and how many) in the past month
Potential reasons for missed doses listed as a guide to help determine causes of poor adherence
This helps identify the most common barriers to adherence, for consideration with improved patient and program support
Implemented since 2005 This is part of an ongoing psychosocial assessment –
detailing patient & family info, clinic accessibility, pregnancy & contraceptive use, ART preparation guide, ART adherence, and issues for follow-up counseling and education
South Africa: Results (EL region, Aug 09)
Site # ART patients assessed
# poorly adherent
% poorly adherent
Cecilia Makiwane Hospital
928 67 7.2
Zone 2 PHC 372 6 1.6
Zone 8 PHC 615 9 1.5
Zone 13 PHC 605 37 6.1
Nkqubela TB Hospital
97 0 0
Frere Hospital 1912 32 1.7
Empilweni Gompo HC
1342 27 2.0
Duncan Village DH
1598 37 2.3
South Africa: Successes & Challenges
Strengths – addresses patient understanding of medications and how to take them; analyzes possible clinical and/or psychosocial reasons for missed doses, for purposes of further helping the patient (when possible)
Weaknesses – Limitations with recall method (esp. over prolonged time); only reinforced with pill count
Next Steps – Collaboration with Pharmacy Advisor, for training of peers & lay counselors to use VAS method (as directed by new national DOH guidelines)
Sthembile MatsePsychosocial Support OfficerICAP- Swaziland
Pill Count Form
Pill Count Form: How it can be used
Implemented in January 2009 to provide a systematic way to conduct pill count
Peer educator/expert client, physician, nurse, pharmacist
Due to time constraints, usually conducted by expert client
Use to assess adherence monthly for newly enrolled; every six months for patients on treatment for >6 months
If adherence <95% or >105%, ask patient about adherence challenge
Pill Count Form: Strengths and Challenges
Successes Trained expert clients now successfully
conducting pill count for all patients Patients appreciate the positive feedback
provided by the assessment Challenges
Expert client assess adherence, but clinicians don’t always interpret the result to provide necessary adherence support
Since patients are aware of pill count, medications are often not brought to the clinic
Pill Count Form: Next Steps
Getting physicians to recognize the importance of utilizing pill count data to support adherence as part of the clinic visit – physicians must attach meaning to the pill count, especially for patients who have been on treatment for a long time
Milena MelloTechnical Advisor: APS, C&T + TrainingICAP - Mozambique
Visual Analog Scale
Visual Analog Scale
Description of MeasureVisual Analog Scale that measures the average adherence by patient self-report.
Reason for Measure Choice Many patients have low literacy and numeracy, and thus difficulty reporting numbers and times of doses
Necessary to use a visual, concrete instrument that facilitates the patient’s understanding about the medication, while allowing an open conversation with the counselor about adherence difficulties. Therefore, this tool is used in conjunction with an adherence questionnaire
Short time per patient to implement (on average, 2 minutes for VAS)
Visual Analog Scale
Date of Implementation Developed Larissa Polejack’s dissertation research (2007) Followed by pilot implementation in selected sites (Military Hospital in Maputo and Zambézia Sites)
Details on Implementation: Scale was developed to supplement a longer adherence questionnaire, but can be implemented as a stand alone tool
Psychologists have been trained to implement (Military Hospital)
Presented to MISAU (Ministry of Health) and recognized as a unique instrument
Possible use by clinicians when they are assess adherence to medication regimens
Visual Analog Scale
ALWAYS ALMOST ALWAYS
SOMETIMES
RARELY NEVER
Mozambique: Successes & ChallengesSuccesses:
Facilitates patient comprehension of adherence by using a concrete, real-world example: cups ranging from “full” (high adherence) to “empty” (low adherence)
Adopted as a method of adherence assessment in other ICAP studies
Challenges: Difficult to utilize an adherence assessment during
each patient visit Resistance from clinicians for adherence assessment
extending the visit length
Next Steps: Pilot alternative versions of the scale (e.g. inversion
of the cups – low to high; empty cups = all medications taken; etc.)
Expand to more sites Gain approval from MISAU (Ministry of Health) as
national tool
Supporting Sustainable Adherence to HIV Prevention, Care & TreatmentICAP Technical WorkshopOctober 19-22, 2009Kigali, Rwanda
Thanks – Obrigado – Merci – Murakoze