Departement Gesondheidswetenskappe

Faculty of Health Sciences

Home-based counseling to

enhance adherence to

antiretroviral therapy

among patients living with

HIVAshraf Kagee

The context: Prevalence of HIV

• HIV prevalence in SA is very high:- 28% of women attending antenatal

clinics- 11% of general population are

living with HIV• The national roll out of ART started

in 2004.

Sources:National Department of Health, 2008UNAIDS/ WHO Working Group 2008HSRC, 2005

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The context: People on treatment

• In 2007 460,000 on treatment• Estimated national coverage was

28% (UNAIDS).• Coverage will increase over the

next few years.

Sources:SA National Department of Health, 2008UNAIDS/ WHO Working Group 2008Western Cape Department of Health, 2006, 2007.

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Antiretroviral Treatment

• The mere provision of ART may be insufficient for patients to make gains in terms of health status.

• Close to 95% adherence is required for adequate viral suppression.

• Two levels of adherence: - clinic attendance (retention)- pill-taking

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Poor adherence can result in:

• Increased viral load; decreased CD4 count.

• More rapid disease progression.• Increased number of opportunistic

infections.• Slower recovery time.• Decreased QOL for patients and

families.• Increased mortality, and effect on

families and economy • Wastage of resources: consultations,

drugs, etc.• Worker absenteeism – due to illness.• Development of drug-resistant strains of

HIV.

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What is adherence?

• Dose adherence - number and proportion of doses taken.

• Schedule adherence - adherence to doses taken on time.

• Dietary adherence - doses taken correctly with food.

• Adherence to care - attendance of clinic appointments.

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Non-adherence

• Not taking the medication at all. • Taking the medication at the wrong

time.• Taking the wrong doses.• Prematurely terminating treatment.• Self-adjusting doses to modulate side

effects.• Not filling prescriptions.• Not attending clinic

appointments.

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Retention in HIV care at a peri-urban public hospital

Number of patients enrolled on treatment since beginning of roll-out

1113

Number of patients retained in the ART programme

762

Died or transferred out 66

Number of patients that have been lost to follow up

285

68.5% of patients have been retained in care. Almost 1/3 have dropped out.

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What accounts for poor adherence?

• Health literacy – treatment in the absence of symptoms

• Poor social support• Mental health problems, e.g. depression• Fear of disclosure• Substance abuse• Forgetfulness, no alarm clocks, etc.• Suspicions of treatment• Treatment complexity and side effects• Self-efficacy and motivation

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Mental health problems

• Lots of evidence that depression is associated with poor adherence

• Depressed patients are unmotivated, fatigued

• Hopelessness about themselves and the future

• Diminished ability to think and concentrate which can affect memory

• Does treating depression result in good adherence?

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Other mental health problems

• Substance abuse• Anxiety• PTSD• Psychotic disorders

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Structural factors

Structural factors are the social, economic, institutional, political, and cultural domains that collectively make up the social structures that to a greater or lesser extent influence behavior.

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Some structural barriers

• Stigma-related barriers• Relationships with clinic staff• Lack of privacy at clinics• Transport difficulties• Patient waiting times• Disability grants as disincentives• Food insecurity• Migration• Social discouragers

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RESEARCH QUESTION

• Is it practically, logistically, and financially feasible to train patient advocates in enhanced counseling skills?

• Can patient advocates implement an enhanced home-based counseling programme?

• Is the counseling intervention effective in increasing ART adherence?

Study aims

• To determine whether it is practically, logistically, and financially feasible for patient advocates to be trained in enhanced counseling skills.

• To assess the skill level of trained patient advocates and compare this level to that of untrained patient advocates.

• To test whether the enhanced home-based counseling provided by the trained patient advocates is effective in helping patients increase their level of ART adherence.

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Study design

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12 patient advocates

6 receive enhanced

training

6 receive no enhanced

training

PAs work with patients

PAs work with patients

Assessment of patients’ level of adherence

Assessment of patients’ level of adherence

Clinic attendancePill countsViral LoadCD4 count

Self-reported adherence

Training of patient advocates

• Introduction: Setting the scene for the workshop; Introduction to HIV counseling; Emotional distress/ Typical responses to receiving a positive result; Normal distress vs psychiatric disturbance

• Recognising psychopathology: Common psychiatric disorders and how to recognize them; Depression and anxiety; Brief assessment of psychiatric disturbance; Suicide assessment; Referral for psychiatric services.

• Observational skills: Non-verbal behaviour (facial expressions, body language); Verbal behaviour (selective attention, key words, concreteness vs abstraction); Discrepancies; Practice and role play. 

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Training of patient advocates

• Listening skills: Attending behavior; Encouraging, Paraphrasing, and Summarising; Questions; Practice and role play.

• Observing and reflecting feelings: The emotional world of patients; Observing emotional intensity; Reflection of content; Reflection of feeling; Practice and Role play. 

• Integrating listening skills: The basic listening sequence; Searching for positive strengths; Conducting a full interview using listening skills; Positive regard, respect, warmth, concreteness, immediacy, being non-judgmental, authenticity and congruence; Practice and role play.

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Training of patient advocates

• Confrontation: Challenging patients in a supportive fashion; Helping patients move from inaction to action; Practice and role play.

• Influencing skills: Interpretation/ reframing; Logical consequences; Self-disclosure; Feedback; Information/ advice/ opinion/ suggestion; Directives; Practice and role play.

• Skill integration: The 5 stages of interviewing and counseling: Initiating the session; Gathering data; Mutual goal setting; Exploring alternatives, confronting client incongruities and conflict; Terminating – generalizing and acting on new stories; Practice and role play.

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Training of patient advocates

• Applying counseling skills to increase ART adherence

• Role play and feedback • Ethics in counseling

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Training of patient advocates

• Patient advocate self-care and supervision

• Problems that might come up when working with clients

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Evaluation of the intervention

• Rating patient advocates skill level, fidelity to the intervention (observation of role plays and sessions with clients).

• Evaluation of patients: - self-report (distress, depression, coping, QOL), - adherence (clinic attendance, pill-counts, viral load, CD4 count).

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Data Analysis

• Qualitative assessment of patient advocates experiences of counseling training.

• Comparison of ratings of trained and untrained patient advocates following training: t-tests?

• Comparison of adherence-related outcomes from pre- to posttest (clinic attendance, self-report, pill-counts, VL, CD4): MANOVA, Hotellings T2?

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Expected outputs and outcomes

• It will be determined whether it is practically, logistically, and financially feasible for patient advocates to be trained in enhanced counseling skills.

• It will be determined whether the enhanced counseling provided by patient advocates is effective in increasing adherence levels.

• If it is successful, the intervention will be tested in other hospital contexts as well.

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Other benefits

• Research capacity development• Credibility of psychological

interventions in public hospital setting

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