Education and Counseling to Support Adherence with general population of PLWH

Guidelines and Recommendations for Implementation

K. Rivet Amico, PhDUniversity of Connecticut

On behalf of Guidelines Panel

July 2012 www.iapac.orgNo conflicts to report

Education and Counseling Guidelines for general clinic population Individual one-on-one ART education is recommended (II A). Providing one-on-one adherence support to patients through

1 or more adherence counselling approaches is recommended (II A).

Group education and group counselling are recommended; however, the type of group format, content, and implementation cannot be specified on the basis of the currently available evidence (II C).

Multidisciplinary education and counselling intervention approaches are recommended (III B).

Offering peer support may be considered (III C).

INDIVIDUAL ONE-ON-ONE ART EDUCATION IS RECOMMENDED (II A)

High (II) Strong evidence with important limitations; Strong evidence from observational studies

Strong (A) Almost all patients should receive the recommended course of action

Brock et al. 2007Collier et al. 2005Fairley et al. 2003Golin et al. 2006Goujard et al. 2003Holzemer et al. 2006Johnson et al. 2007Kalichman et al. 2005

Murphy et al. 2007Rawlings et al. 2003Safren et al. 2001Smith et al. 2003Tuldra et al. 2000Williams et al. 2006

14 intervention studies

10 + effects on adherence 1 study (of 8) + effects on biomarkers

INDIVIDUAL ONE-ON-ONE ART EDUCATION IS RECOMMENDED (II A)

• Content should include:• Common side-effects• Role of adherence in treatment success• Role of non-adherence in resistance

• Additionally…• Medication management skills• Review of common barriers• Framing of adherence as challenging for many

From this evidence base

INDIVIDUAL ONE-ON-ONE ART EDUCATION IS RECOMMENDED (II A)

From this evidence base

• Targets knowledge acquisition• Discussion• Exploration• Activities • Goes beyond Information Provision (e.g., booklets,

information providing without conversation or information checks).

• Diversity• Clinicians, nurses, pharmacists, counselors, health

workers. • Timing in relation to ART

• Education often combined with Counseling

INDIVIDUAL ONE-ON-ONE ART EDUCATION IS RECOMMENDED (II A)

Implementation challenges?

• Sufficient resources to provide education individually

• General education messages need to be tailored to local community and culture

• Common mis-information must be identified

• Need to determine timing, duration, and deliverer and plan for monitoring

• Confirm that approach goes beyond info deliveryMost providers/agencies surveyed in IAPAC web survey report providing some kind of education (85%*)

PROVIDING ONE-ON-ONE ADHERENCE SUPPORT TO PATIENTS THROUGH 1 OR MORE ADHERENCE COUNSELLING APPROACHES IS RECOMMENDED (II A).

High (II) Strong evidence with important limitations; Strong evidence from observational studies

Strong (A) Almost all patients should receive the recommended course of action

Brock et al. 2007Collier et al. 2005Fairley et al. 2003Golin et al. 2006Goujard et al. 2003Holzemer et al. 2006Johnson et al. 2007Kalichman et al. 2005Murphy et al. 2007Safren et al. 2001

Smith et al. 2003Tuldra et al. 2000Williams et al. 2006

Dilorio et al, 2003Dilorio et al, 2008 Johnson et al, 2011Knobel et al, 1999Parsons et al, 2005Pradier et al, 2003Reynolds et al, 2008

Weber et al, 2004Mann, 2001Wagner et al, 2006Webel, 2010Wilson et al, 2010 Garcia et al, 2005Javanbakht et al, 2006Remien et al, 2005Koenig et al, 2008

27 studies

22/25 had some positive effect on adherence5/12 positive effects on biological measures

PROVIDING ONE-ON-ONE ADHERENCE SUPPORT TO PATIENTS THROUGH 1 OR MORE ADHERENCE COUNSELLING APPROACHES IS RECOMMENDED (II A)

• Type of counseling discussions varies• Cognitive behavioral• Patient-centered • Motivation-based (e.g., motivational interviewing)]• Included a focus on motivation, social support,

and skills building • Client-centered delivery formats.

From this evidence base…

• Diversity in:• Length; Deliverer; Location; Targeting

PROVIDING ONE-ON-ONE ADHERENCE SUPPORT TO PATIENTS THROUGH 1 OR MORE ADHERENCE COUNSELLING APPROACHES IS RECOMMENDED (II A)

From this evidence base…• “Counseling”

• Use of communication skills, basic principles of therapy or problem solving approaches in interactive discussion

• Training in approach provided (varying requirements for a counseling background)

• NOT “Counseling”• Reminding and persuading• Delivering preset messages

Implementation challenges?• Sufficient resources to provide individualized counseling

• Time (15 to over 60 minutes)• Personnel (implement and supervise)• Space

• Need to figure out approach for given population…• Requires additional work!

• Review literature/models• Make use of available resources• Work with communities and patients

PROVIDING ONE-ON-ONE ADHERENCE SUPPORT TO PATIENTS THROUGH 1 OR MORE ADHERENCE

COUNSELLING APPROACHES IS RECOMMENDED (II A)

Most providers/agencies surveyed in IAPAC web survey report providing some kind of 1:1 counseling (70%*)

GROUP EDUCATION AND GROUP COUNSELLING ARE RECOMMENDED; HOWEVER, THE TYPE OF GROUP FORMAT, CONTENT, AND

IMPLEMENTATION CANNOT BE SPECIFIED ON THE BASIS OF THE CURRENTLY AVAILABLE EVIDENCE (II C)

High (II) Strong evidence with important limitations; Strong evidence from observational studies

Optional (C) There may be consideration for this recommendation on the basis of individual circumstances. Not recommended routinely

Antoni et al., 2006Berger et al., 2008Chiou et al., 2006Chung et al., 2009Kalichman et al., 2011Sampaio-Sa et al., 2008Van Servellen et al., 2005

7 intervention studies

4 generally + effects on adherence 4 generally + effects on biomarkers

GROUP EDUCATION AND GROUP COUNSELLING ARE RECOMMENDED; HOWEVER, THE TYPE OF GROUP FORMAT, CONTENT, AND

IMPLEMENTATION CANNOT BE SPECIFIED ON THE BASIS OF THE CURRENTLY AVAILABLE EVIDENCE (II C)

• Variability in participant groups, geography and methods/targets of group intervention

From this evidence base…

• Heterogeneous in• Length• Timing• Orientation; Target

GROUP EDUCATION AND GROUP COUNSELLING ARE RECOMMENDED; HOWEVER, THE TYPE OF GROUP FORMAT, CONTENT, AND

IMPLEMENTATION CANNOT BE SPECIFIED ON THE BASIS OF THE CURRENTLY AVAILABLE EVIDENCE (II C)

Implementation challenges?• Sufficient resources to

• Schedule and populate groups• Time commitment (60 to over 120 minutes)• Personnel (implement and supervise)• Space

• Like 1:1 counseling…additional work is needed • Review literature/models• Work with communities and patients

36% provide group education; 35% provide group counseling from IAPAC

MULTIDISCIPLINARY EDUCATION AND COUNSELLING INTERVENTION APPROACHES ARE RECOMMENDED (III B).

Frick et al. 2006Levy et al. 2004

Medium (III) RCT evidence with critical limitationsObservational study evidence without important limitations

Moderate (B) Most patients should receive the recommended course of action. However, other choices may be appropriate for some patients

2 intervention studies specifically evaluated

Frick et al 2006 No difference in pharm-refill adherenceSig difference in VL and change in VL at 12 months [adj]

Levy et al 2004Sig difference in adherence (phone based self-report)No difference in VL or CD4 at ~20 weeks

MULTIDISCIPLINARY EDUCATION AND COUNSELLING INTERVENTION APPROACHES ARE RECOMMENDED (III B)

• Use of multidisciplinary teams • NOT the same as having multiple team

members duplicate efforts or content concerning adherence.

• Each team member had clearly delineated roles and covered content specific to their particular areas of expertise.

From this evidence base…

MULTIDISCIPLINARY EDUCATION AND COUNSELLING INTERVENTION APPROACHES ARE RECOMMENDED (III B)

Implementation challenges?

• Need to have a team• Can teams be created?

• Time (coordination of care team meetings)

• Need to clearly identify who does what• How to coordinate the systems• What unmet needs will be addressed• How to conduct process and outcome monitory

Over half of respondents of IAPAC web survey (64%) reported coordination of care across disciplines

OFFERING PEER SUPPORT MAY BE CONSIDERED (III C).

Medium (III) RCT evidence with critical limitationsObservational study evidence without important limitations

Optional (C) There may be consideration for this recommendation on the basis of individual circumstances. Not recommended routinely

Chang et al. 2010Munoz et al. 2010Mugusi et al. 2009Nachega et al. 2010Pearson et al. 2007Ruiz et al. 2010Simoni et al. 2007Simoni et al. 2009Taiwo et al. 2009

9 intervention studies

5 generally + effects on adherence 3 generally + effects on biomarkers

OFFERING PEER SUPPORT MAY BE CONSIDERED (III C)

• Diversity in type of peer-based approach• 4 studies monitored administration of ART• 4 targeted peer support• 1 Peer included psycho-education

• Similar to other intervention approaches there was diversity in….• Type, length, location or content of peer

delivered intervention

From this evidence base…

Implementation challenges?

• Who serves as peers• Training and supervision requirements• Resources to compensate peers• Who will coordinate peer services

• What approach will be adopted or developed• How to ensure confidentiality/privacy• How to conduct process and outcome monitory

OFFERING PEER SUPPORT MAY BE CONSIDERED (III C)

27% overall reported use of peers; 67% of respondents located in Africa reported use of peers in IAPAC’s web survey

APPROACHES REPRESENTED IN EVIDENCE BASE…BUT NOT EMERGING INTO A GUIDELINE (YET)

• Dyad/couples counseling• Contingency management• Technology

GUIDELINES ARE FIRST OF SEVERAL STEPS

General GuidelineEvidence Base

One on One Education Counselling Multidisciplinary

support Peer support

Group Education Counselling Peer support

General GuidelineEvidence BaseIMPLEMENTATION OF

Evidence Based Approaches

Not specified When to provide Who to involve What to target/include How long Over what period of time How to support How to sustain How to monitor How to adapt

One on One Education Counselling Multidisciplinary

support Peer support

Group Education Counselling Peer support

GUIDELINES ARE FIRST OF SEVERAL STEPS

• Opportunities to incorporate and reflect– Local/community/cultural needs – Identify and address unmet needs– Local (clinic, organizational) resources– Building/leveraging capacities for implementation

and monitoring of outcomes

THE GREY AREAS ARE NEEDED IN BEHAVIORAL GUIDELINES…

Targeting and tailoring increases chances of implementing something effective for a given person,

at a given time, in a given context

PROCESS APPROACH TO INTERVENTION DEVELOPMENT

Suggestions for implementation of education and counseling guidelines:

1. Needs assessment (drivers of adherence)2. Identification of needs not presently met (intervention

targets) and resources available3. Identification/development of intervention

approach(theory, models) to use (packaged, general strategies)

4. Identification of how to disseminate approach to interveners (manuals, workshop)

5. Identification of how to support approach (sustainability) (opinion leaders, champions)

6. A monitoring and evaluation plan7. Plan for modifications and adaptation

Suggestions for existing education and counseling practices:

1. What does the intervention in place target? What pathways to adherence are promoted? Does that match with community work, theories, or evidence base?

2. How does the intervention try to change, promote, reduce or influence adherence or behaviors on the pathway to adherence? Does each strategy have support from community work, theories, or evidence base?

3. Is there good uptake/acceptability of intervention?4. Are implementers satisfied?5. What are the costs of implementation presently?6. Process and outcomes monitoring!

THE SCIENCE OF DISSEMINATION AND IMPLEMENTATION

EXTENSIVE AREA OF SCIENTIFIC INQUIRY

THE SCIENCE OF DISSEMINATION AND IMPLEMENTATION

CDC

Manuals and resources for specific packaged approach available

RESOURCES ALREADY AVAILABLE

“Making a difference in practice means listening to what those doing the work and those affected by the work have to say." Jim Dearing

THANK YOU!• The IAPAC guidelines reviewed were the result of sustained efforts

from numerous individuals including:• Panel Members

Frederick L. AlticeK. Rivet AmicoMA. de Ávila VitóriaDavid R. BangsbergMagda Barini-GarcíaVictoria A. CargillLarry W. ChangJohn G. BartlettCurt G. BeckwithNadia Dowshen

Vanessa ElharrarChristopher M. GordonRobert GrossCharles HolmesTim HornShoshana KahanaPeter KilmarxPrincy KumarCynthia LylesHenry MasurTia Morton

Michael J. MugaveroJean B. NachegaCatherine OrrellCelso RamosRobert H. RemienJames D. ScottJane M. SimoniMichael J. StirrattMelanie A. ThompsonEvelyn Tomaszewski

• The authors, research teams, supporting agencies and participants directly responsible for the evidence available to date.

ACKNOWLEDGEMENTS• Funding was provided by the US National

Institutes of Health, Office of AIDS Research and IAPAC

• Cindy Lyles, PhD: CDC Prevention Research Synthesis database

• IAPAC: Jose Zuniga, PhD, MPH; Angela Knudson

• Systematic reviews: Laura Bernard, MPH, Kathryn Muessig MPH, Jennifer Johnsen, MD

• Editorial assistance: Anne McDonough