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