ROLE OF SOCIAL WORK IN MEDICAL TREATMENT...

I. Introduction

Introduce yourself and co-trainer.

Reference the participant manual and stress completion of evaluations.

Objectives and Agenda

Review objectives and agenda for the day.

II. Key Concepts

Social workers are part of a community of persons that can promote and support adherence to complex medication regiments.

During today’s presentation, several key concepts will be highlighted:

the bio-psycho-social spiritual perspective of our work;

the social work role in promoting strength-based practice;

diversity and culturally competent practices; and

ADHERE, a model for facilitating and supporting medication adherence.

III. Defining Adherence

Pose the Question:

NASW HIV/AIDS Spectrum Project – (2009)Role of Social Work in Medication Treatment Adherence - Trainer Manual 1

SHOW OH 2: Objectives

SHOW OH 3: Agenda

SHOW OH 1:

Trainer Note: Refer participants to their participant manual for an “overview” of the day.

Group Exercise ( 5 minutes)

What does the term “Adherence” mean to you?

Explain we will return to these responses throughout the day.

A. Definition of Adherence

Here are some definitions of adherence:

Adherence – the quality or state of adhering; fidelity, steady attachment. To follow a prescribed course of action.

Adherence: the extent to which a person’s behavior (in terms of taking medications, following diets, or executing lifestyle changes) coincides with medical or health advice” (Morse et al., 1991)

Adhere – to stick to .

Stress the following:

Adherence is more than just taking a lot of pills at a specific time every day.

For example, in traditional social work language, a more effective term may be following through (Linsk & Bonk 2000).

Adherence goes beyond medication. It includes diet, sleep, exercise, completing appointments, and impact or level of alcohol and drug intake.

Adherence gives control to the client, not the health care provider.

B. Adherence as a continuum

Stress the following:


Trainer Note: Note response on NP. Post on the wall.

SHOW OH 4

SHOW OH 5

Attitudes and behaviors towards taking medication (adherence) are present in all persons, prior to and after a diagnosis of HIV/AIDS or other chronic or live-threatening illness.

It is critical to assess these attitudes with all clients. The goal is to incorporate beliefs and practices into the treatment plan.

Set- up and exercise ;

Take a moment to think about taking medications, whether for you, your children or partner, or talking with a client.

Write down examples of challenges we all experience with taking medication – that we share with persons who may or may not be living with HIV/AIDS – as shown in the continuum (OH5)

Include feelings or attitudes that might be experienced by clients and/or affect adherence.

Reconvene Group

Ask participants to share a few examples.

Ask participants to review the case vignette

Pose the question/facilitate dialog:

From the case notes, we know that Danielle is on HAART medications. We also know she is taking other medications.

Where do we find Danielle on the continuum of treatment

adherence?

What are her dietary needs? Or medical issues?

Are there ways she may need to modify her daily habits to

promote adherence?


Large Group Exercise (5-7 minutes)

SHOW OH - CASE STUDY PART ONE – 6

LARGE GROUP EXERCISE

Trainer Reference:

Examples:

Substance Use

Family Violence

Trauma

Housing

Multiple illnesses

Side-effects

Others:

C. Why is adherence so important for persons living with HIV/AIDS?

Review the content.

Understanding HIV/AIDS promotes adherence

Understanding HIV/AIDS and the complexities of the disease and available medications helps us in our work to help clients achieve and sustain adherence.

This slide highlights some aspects of HIV/AIDS. Basically, HAART requires consistent (strict) adherence to treatment plan. The goal of HAART is to maintain undetectable levels of viral load and to restore or preserve immunologic functioning.

For most people, strict adherence to HAART will significantly reduce the production of the virus, often to an undetectable level.

Prevention of treatment interruptions (reducing risk of drug resistance to the FDA approved HIV/AIDS medications )

Adherence is important because the virus mutates rapidly As a result of changes in the virus, drug resistance may develop despite successful adherence.

Resistance to Drugs

Non-adherence, not taking the drugs on schedule or consistently, may make resistance to the drug or that class of drugs more likely. Resistance can be measured using genotype and phenotype methods.

Goal is to prevent treatment interruptions so that drug resistance to the FDA approved HIV/AIDS medications (now 28 are approved) can be avoided.


SHOW OH 7

SHOW OH8

Trainer Reference: Another benefit of HAART and adherence is to lower the risk of spreading HIV/AIDS because of lower viral load and higher CD4, but again it is important to stress that transmission is still possible.

III. Understanding HIV/AIDS

A. Stages of HIV reproduction

This overhead shows the Life Cycle of HIV/AIDS or how HIV is reproduced in the cell.

Stages shown in this graphic: 1. Binding and Fusion2. Reverse Transcription:3. Integration4. Transcription5. Assembly6. Budding / Maturation

Source: http://aidsinfo.nih.gov

B. HAART Introduction

HAART medications and HIV/AIDS have become the classic example of client-centered practice. For example, a client referred to begin antiretroviral treatment may or may not wish to initiate HAART.

Multiple classifications of drugs/medications now exist since the first antiretroviral drug of AZT in 1987.

The chart demonstrates how highly active anti-retroviral treatments , or HAART, stops HIV reproduction at each stage of the disease process.

Different class of drug attack HIV in unique ways. It is critical to use combination therapies to ensure anti-retroviral treatments at each stage of viral reproduction.

Provider Role

The client needs to assess whether they are ready to make a life-long commitment to a prescribed course of treatment.


SHOW OH 9 - Replication

Trainer Reference: S ages of HIV Reproduction.

HIV enters a CD4+ Cell. CD4+ cells are white blood cells which help fight infections. They are also called "helper cells" or "T cells."

HIV is a retrovirus, meaning that its genetic information is stored on single-stranded RNA instead of the double-stranded DNA found in most organisms. To replicate, HIV uses an enzyme known as reverse transcriptase to convert its RNA into DNA.

HIV DNA enters the nucleus of the CD4 cell and inserts itself into the cell's DNA. Once they are taken over by HIV, CD4 cells can no longer protect your immune system. HIV DNA then instructs the cell to make many copies of the original virus.

New virus particles are assembled and leave the cell, ready to infect other CD4 cells. The constant attack and growth of the virus gradually wears down the immune system and weakens the body's defenses.

Cite: Colorado Pharmacy: http://www.coloradopharmacy.net/stagesofhiv.html

SHOW OH 10 - HAART

http://aidsinfo.nih.gov/

The social worker, and other mental health and health providers, are key allies in helping the client with this decision.

C. Common HAART/ART medication side effects

Point out that the content is a list of some of the more common side effects to HAART medications.

Refer participants back to the case vignette (part 1)

Pose the question:

Are there any symptoms that we may revisit and reassess their origins?


SHOW OH 11

Trainer Reference:For example: fatigue could be:1) side effect from medications, 2) withdrawal from substance use), 3) side effects of psychotropic medications, and/or4) or the effects of daily challenges of living with a chronic illness.)

Trainer Reference:What is combination therapy?

The most common drug combination at start of treatment: two NRTIs combined with either an NNRTI or a "boosted" protease inhibitor.

Some antiretroviral drugs have been combined into one pill, which is known as a ‘fixed dose combination’. This reduces the number of pills to be taken each day.

What is first line therapies?

At the beginning of treatment, the combination of drugs that a person is given is called first line therapy.

What is second line therapies?

If HIV becomes resistant to the first line therapy (or bad side effects, HAART is changed. Will ideally include a minimum of three new drugs, with at least one from a new class of drugs.

IV. ADHERE Model

This slide highlights the ADHERE Model. The next section of the workshop will take us through six steps to promote a comprehensive approach to working with clients to promote and sustain treatment adherence.

State: we will now use the case study of Danielle to review the ADHERE model.

A. Assess

Review Slide

1. Assessing Client Level of Health Literacy

Health literacy is the degree to which we are able to obtain, process, and understand basic health information and services needed to make appropriate health decisions". (HHS, Healthy People 2010).

Health literacy includes the ability to understand instructions on prescription drug bottles, appointment slips, medical education brochures, doctor's directions and consent forms, and the ability to negotiate complex health care systems.

Health literacy is not simply the ability to read. It requires a complex group of reading, listening, analytical, and decision-making skills, and the ability to apply these skills to health situations. (NNLM, 2007)

Provider Role

Understand how clients and (we) learn new information. Learn ways that we can prepare clients. This is the idea of

starting where the client is and enhancing their ability to learn and change.


SHOW 14: Assess

SHOW OH 13 CASE STUDY - PART TWO

SHOW OH 12

Provide verbal and written information in the appropriate language and after having assessed ability to read, at an appropriate reading level.

2. Bio/psycho/social-spiritual Perspective

A "bio-psychosocial–spiritual" framework commonly is used for assessment and intervention with clients, including those living with HIV and or other chronic illness. This is the basis of our overall assessment, our beginning point.

For today’s program, we will use the following definitions:

bio (biology ) is the physical or medical aspects of ourselves, (Biological characteristics speak to our genes, subtypes; aspects of virology and immunology and more)

psycho (psychology) is the emotional aspects (how people wrap their mind around what it means to be HIV-infected or be living with advanced AIDS), and

social is the socio-cultural, sociopolitical, and socioeconomic issues in our lives. (how policy makers, Food and Drug administration personnel, pharmaceutical companies, workplace employers, insurance providers and family and friends affect daily life)

spiritual takes into account how people find meaning in their lives. (and what people value as they age and progress in their course of illness)

This model draws from the strengths perspective.

The strengths perspective recognizes an individual’s strengths and abilities to cope with problems.

This perspective helps clients to ‘dream’ and plan and identify what they want out of life— and doesn’t impost social level stigma based on class, gender, age or job classification or status, for example.

The strengths perspective is seen in social work practice through our clinical role of enhancing personal strengths and resources, helping clients solve both interpersonal


SHOW OH 15

and environmental problems, and helping clients mobilize for change.

The strengths perspective helps clients use their past successful choices and behaviors, skills, and insights to resolve or “work through” a current crisis or new challenge. It builds on the client’s resiliency.

The bio-psycho-social-spiritual perspective examines people from a holistic perspective. and in context

Connecting Statement

The strengths perspective also includes cultural competence.

That is, clients bring a cultural context into the relationship, and the social worker must work toward cultural competence (an ongoing process) to better understand the client and help the client build upon their cultural strengths.

Assessing the client’s readiness to begin HAART must also examine the client’s Cultural perspective.

For example: How do they define illness? How is disease treated? Are prescriptions seen as a positive way of treating a “symptomless” disease. What is the role of their spiritual self in health care and treatment?

3. Cultural Competency and Diversity in Social Work Practice

Diversity

Read the following:

Culturally competent social work practice recognizes that people communicate differently, value different experiences, and have different needs. Depending on one’s race, ethnicity, culture, nationality, disability, gender, religion, socioeconomic class, sexual orientation, marital status, age, and class, options or solutions for life challenge may vary.

Some aspects of culture are enduring (such as values and worldview) while others change (such as idiomatic, expressions, style, mode of dress) Some cultural differences are visible and others are invisible. Both


SHOW OH 16: Diversity in Practice

matter and influence behavior and people’s responses to chronic illness, shame, and stigma.

While it remains important to respect and understand the differences between people, emerging thinking on CULTURAL COMPETENCE suggests that it is also important to search for and honor the similarities, which might enhance understanding and the development of the helping relationship. (NASW HIV/AIDS Spectrum Project, 2002).

People self-identify with multiple ethnic and cultural identities.

Cultural Competence

Culture is how we receive, organize, rationalize and understand our particular experiences in the world. Knowledge is created, not discovered, and context is all important.

Before we move on – let’s look at our own experiences around culture and cultural competency.

Pose the question:

Think of an occasion – perhaps when you were a child or younger – when you got sick (such as a cold, sore throat, fever).

What was the family remedy for your illnesses? Who told you this?

Ask for volunteers to share their family stories. Note answers.

Debrief:

Stress that psychologically we often did or do feel better. These remedies may have worked because of our shared experiences with family, rooted in our own cultural practices. It is important to recognize that adherence is affected by and supported by cultural beliefs about illness and treatment.

Pose the question:


SHOW OH 17: Cultural Competence

Trainer Note: point out that some of the examples (e.g., chicken soup) have been found to have some medicinal qualities - while others (e.g., teas, herbs, castor oil, garlic, “hot toddies”) may or may not.

Trainer Reference:The content is drawn from the NASW Standards for Cultural Competence.

Brief Exercise: (5-7 minutes)

Think of some of the examples you have heard clients talk about in reference to remedies for their current HIV, or other health issues……

How, as practitioners, have you worked with these “cures.” ?

What benefit does our supportive role have with clients?

Can you think of some ways that the client’s cultural context may reflect upon their adherence to medication?

How may we see the cultural context affecting Danielle’s success or lack of success in terms of adherence?

Connecting statement:

Understanding a client’s culture and cultural context is critical to a comprehensive assessment

Sample Adherence Assessment Checklist

4. Adherence: Assessment of Knowledge and Readiness

When assessing a client’s readiness to begin HAART we want to include questions that look at coping skills, social supports, medical care, their current use of services, and perception of quality of life.

Take a client’s medical history, social history, substance use history, mental health history.

For example, help to identify client’s supports, living situation, finances, employment, and transportation.

Identify cultural needs, including who is important to the client’s treatment planning, how the client views/defines disease. And what are their financial realities?

Assess client’s coping styles, capacity for coping, strengths and challenges.

Assess current and past functioning levels– what worked and did not work? Why? How have they handled taking any prescribed drugs in the past?


SHOW OH 18: Example: working with diverse clients

SHOW OH 19: Assess Knowledge and Readiness

Trainer Note:

Prepare for and review two or three questions from the “Knowledge and Readiness” slide. Use Danielle to guide the exercise.

B. Dialog

We Dialog to de-stigmatize problems associated with non-adherence.

Dialog with clients about options.

Normalize the reasons for non-adherence.

Clarify that drug resistance can occur even with excellent adherence due to complexity of virus, speed of virus replication, and medications.

Review purpose of HAART and drug names.

Remind the client that adherence is a common challenge for everyone. Give examples: meds, exercise, diets.

Inform your client that sharing challenges, concerns and successes with adherence has been shown to improve outcomes.

Develop harm reduction strategies to reduce stigma regarding non-adherence.

Challenges and Benefits of Adherence

Talk openly and honestly with your client about both the challenges and benefits of adherence (pros and cons).

Assessing a client’s readiness for medications can utilize a tool that has long been used in the field of addictions and public health: Stages of Change

Each client or patient is unique. Yet the stages of change, most often used in the field of addictions, is a model that can


SHOW OH 20: Dialog

SHOW OH 21: Challenges /Benefits of Adherence

SHOW OH 22: Stages of Change

help us to better understand the decision-making processes in any major lifestyle change. For example, assessing client’s capacity to maintain medication treatment, and integrate adherence strategies into everyday, is for many a complex process done in stages.

1. Precontemplation:

People are not yet considering the possibility of change in the foreseeable future.

Talk with your client about life with HIV/AIDS and/or other chronic illness. Help clients identify short and long-term goals

Show concern, respect. Ask how the person is feeling. Reframe negative statements.

Determine the client’s understanding about their HIV disease. And assess their fears and hopes about both the present and future

Acknowledge that this task involves reconstructing one’s life physically, mentally, and emotionally.

2. Contemplation:

People are aware that a problem exists, consider change, but reject it.

At this stage, the client may consider taking medications.

Help client compare pros and cons of changing and staying the same. Find success in past attempts to change. Help link to positive role models.

3. Planning and Preparation:

People try the behavior, usually inconsistently at first, assess outcome; if favorable, move to action.

Help to identify barriers (psychosocial or environmental).

Help determine best course of action by looking at a detailed plan with small steps. Prepare them mentally, emotionally, and practically.

Consider role-playing activities related to this stage.


4. Action:

People modify their behavior, experience, or environment to overcome their problems.

Reaffirm and plan how a medication regimen fits into their daily living. Learn about drug interactions and side effects so that realistic and frank communication can occur about what to do while at work, on vacation, or amidst friends and families.

Assess need for formal treatment or other referrals. Problem-solve when and how. Reaffirm decisions, work on triggers. (I’m not sure what the original writers meant by “triggers?” I think our curriculum should be more specific here.

5. Maintenance:

People adopt the behavior as a routine part of their lives. They work to identify strategies and support networks to prevent relapse and to consolidate gains.

Reinforce success. Allow grieving/loss. Check in about reasons for change and benefits of change.

Clients may be opening up to experiencing new emotions, consider new friends.

Refer clients to current resources so they can be can be lifelong learners about HIV disease

6. Relapse:

Regression to an earlier stage. People work to renew Contemplation, Pre-action, and Action without giving up.

Avoid demoralizing and discouragement. Reframe circumstances and consider discussing the positive benefits of gratitude, forgiveness, as they relate to their present level of coping and happiness.

Reinforce determination to change Build upon pros and cons of change.


Resume action and maintenance efforts.

Relapse can occur at any stage of the model.

The ADHERE MODEL encourages incorporation of relapse prevention techniques, risk reduction, and the use of incremental steps that move the client towards change within the context of the helping relationship and ongoing counseling with clients.

Ask participants to return to the case vignette. Using the stages of change model, briefly talk about Danielle.

Pose the question:

1. What stage might she be in with regard to HIV treatments and/or adherence? Her substance use? Other clinical issues?

2. How might the stages of change model help us to work with Danielle in providing strengths based case management?

C. Holistic

Stress that a Holistic approach

includes contextual/environmental and cultural issues.

providing resources for services that promote adherence (e.g., mental health services, child care, support groups, financial and housing assistance).

Is based on goals that are client-centered and include the health provider, the family, friends, and other identified support networks.

Pose the questions:

1) From what we know in working with Danielle, which of the services from our holistic approach promote adherence? What is missing in our work with Danielle?


Small Group Discussion – case vignette

Trainer notes:

Inform participants there is a copy of the worksheet “fitting treatment in our lives” in their participant manual.

Small Group Exercise For participants wanting more practice.

Time permitting (20 minutes total)

Ask participants to gather in small groups (4-6).

Ask for one person in each group to volunteer to be interviewed and the group completes the form.

At 15 minutes:

Ask each group to help the “volunteer” identify strengths/supports and gap that can impact medication adherence.

Trainer Note:

Prepare NP with small group questions to help facilitate discussion.

SHOW OH 23: Holistic Approach

2) What are some strategies Danielle can implement for success?

Review the overhead.

This overhead outlines examples of how we can help clients fit treatment into their everyday life.

The content of this overhead can readily be adapted into a worksheet for use with clients – both in individual sessions and in a group setting.

Encourage participants to utilize this worksheet with clients.

Review Slide

D. Empower

Point out that empowerment is a complex concept that has personal and political implications. So empowerment has personal, interpersonal, and structural dimensions which apply to social systems at all levels.

On a personal level it refers to feeling competent and having a sense of control.

On the political level it refers to how power is allocated across social structures. (Gutierrez,1994; Rappaport,1987).

When clients with HIV feel powerless, oppressed and experience victim blaming, social workers can provide clinical intervention and system intervention that can build greater competence and increase or improve resources.


SHOW OH 24: Fitting treatment in our lives

Show OH 26: Empower

SHOW OH 25: Case Study – Part Three

Trainer note: Stress that as providers we cannot empower someone.. but our efforts can work to DISempower a client. Strengths based social work uses empowerment strategies and techniques to help clients build and sustain their own lives.

Supporting Empowerment with Clients and systems to create success

Empowerment begins with supporting self determination.

Promote client centered contracting.

Build empowerment by providing your client with the knowledge and skills and encourage his/her participation in their own health care decisions.

Consider how both the HOLISTIC and EMPOWER aspects are important in Danielle’s situation

E. Reinforce

Highlight the following:

There are many strategies to promote adherence. For example:

Work with the client to identify and reinforce cultural strengths.

Support their efforts to remain clean and sober and/or their effort to lower their risk and/or reduce their drug or alcohol intake.

Review clients progress on a regular basis to provide support, either in face to face visit, telephone or other ways of staying in touch.

Provide positive feedback for achievements Assist in problem solving Continue to instill hope for successful adherence Refer and work with health care team as needed.

Assist the clients to develop ongoing systems of support Use of support groups Obtaining help from friends, family, children

Are there issues of who knows about HIV and HAART that limit support? Assist client to resolve these issues


SHOW OH 27: Reinforce

Trainer reference:Characteristics of Empowerment-centered social work practice include a focus on context, collaboration, strengths and opportunities emphasis, political action, and a commitment to reflection. (Miley et al., (1998)

Review the content of OH.

F. Evaluate

Helping a client to evaluate their own success depends on where they are in the course of HIV/AIDS treatment.

Help clients evaluate progress and resources.

For a client who is currently on HAART and/or other medications

Review with your client the treatment plan and personal challenges of plan.

Ask directly, “How are you currently coping with this plan?”

Inquire about non-adherence by asking your client to be specific regarding non-adherence – How many doses have you missed in the past 24 hours? 2 days? week? month? What’s your diet and exercise patterns been like?

Ask client to “self-assess” the challenges.

Always reinforce your client’s successes and ability to minimize non-adherence. Be an encouraging coach and cheerleader for clients who have to take lots of medicine. Discuss or role-play viable adherence strategies together.

As a provider:

evaluating from a holistic perspective must include ourselves!

Pose the question:

1) How do we evaluate our own success?

Debriefing Notes:


SHOW OH 28: Evaluate

Large Group Discussion

Check in with the client and client supports to identify greatest benefits and challenges to their personal ADHERE plan.

Do so from a bio-psychosocial-spiritual perspective.

Seek feedback regarding the overall performance of the interdisciplinary team and the larger health/mental health care system.

2) How may use of consultation and supervision enhance our practice in helping clients adhere to medications?

Debriefing Notes

o Supervision and peer consultation is a way to assess success and gaps in services.

o It can be a way to measure how or if the client’s outcomes been achieved? Maintained?

V. The Role of Social Work in Micro and Macro Practice

Working with clients to promote successful adherence to medications is not solely an issue for social workers in medical or health care settings.

Similar to other life events and chronic illnesses or problems, clients living with HIV/AIDS can be any client. Therefore, adherence success involves practitioners working together to help a client succeed with their treatment plan.

A. The Unique Role of Social Work in Health Care Provision

1. Social workers and health care provision


This slide highlights our role as members of multi-disciplinary and inter-disciplinary teams.

Clearly, social workers and other mental health clinicians play a significant role with the medical/health care team efforts to


SHOW OH 29

assess the client/patient’s potential for HAART and their ability to meet the challenges to successful adherence.

2. Social work training - our unique role in care and treatment:

Through our professional training, social workers bring unique and critical skills to the multi-disciplinary team. For example:

Mediators

Social workers often are the consultant/liaison between physicians and other medical and service personnel when helping clients succeed with medication and treatment adherence.

Educators

Social workers educate clients or patients about “changing protocols” - which may or may not translate to fewer pills or needle injections.

Advocates

Social workers ensure the healthcare team supports all clients access to HAART (or Highly Active Anti-Retroviral Therapies) – even those actively using substances or diagnosed with mental illness.

3. Social Work: our role in the National HIV/AIDS Strategy

Social workers and allied providers each have a critical role in supporting and implementing the National HIV/AIDS Strategy.

The NHAS is a strategic response by the US government, that challenges each of us – providers, community members, family members, and clients – to work to end HIV/AIDS in the United States.

The NHAS has three main goals.

Pose the question


Trainer reference:Studies have shown that provider teams that are multi-disciplinary and involve clients’ primary medical provider and mental health providers foster a treatment approach that is based on a more holistic bio-psychosocial perspective (Acuff, C., et. al. 1999).

SHOW Slide 30

REVIEW SLIDE

Based on today’s discussion and your own work, what are other examples of how your profession can support and grow the response to the National HIV/AIDS Strategy?

4. Health and mental health care provision – the social work perspective

Social work approaches prevention, care, and treatment from a strengths based perspective. As social workers, we understand the importance of addressing concerns from both the micro and macro perspective.

This slide expands the view of the role of social work beyond the bio-medical or health care provision associated with adherence.

It identifies the range of practice areas or clinical issues that social workers address with clients and communities.

For example:

Clients present with multi-faceted problems requiring social work knowledge of systems theory and socio-cultural context.

Clients bring issues of being homeless, living with a mental illness, actively using drug/alcohol, victims of violence or abuse, suicidal, and have other medical complications.

Pose the Question:

Based on the ADHERE model, and your own practice experiences, what unique role can we have in helping clients address these micro and macro level issues in an effort to promote and sustain adherence?

VI. Determinants and Challenges to Adherence

A. Challenges to Medication Adherence


SHOW OH 32: Challenges

SHOW OH 31 – Micro/Macro

Large Group Discussion – Micro/Macro Continuum

Trainer Note: Point out that ADAP programs vary significantly by state, that the funds for HAART are often tied to Ryan White funds.

Trainer Note:

Use NP.

Note responses for the Micro/Macro discussion – to use as reference in Section VI.

Briefly review the content.

Pose the Question:

Think for a moment about the barriers to treatment adherence that you have seen in your work. Or those you may identify in our case vignette.

1. What are some of the macro level issues that might not be captured on this overhead?

2. Are there any issues at the micro or macro level that might be unique for women or girls? For people in corrections facilities? Older adults? For clients in rural settings?

B. Determinants of Successful Adherence

Factors that promote successful adherence include issues that move beyond the bio-medical aspects, and take into account individual, a client’s strengths or supports, as well as the role of the mental health care provider.

These three arenas – 1. Access and Resources;

2. Social Support

3. Adherence Techniques

All provide examples of areas to assess a client’s level of awareness and existing supports, as well as ways for the social worker to ensure practices that promote successful adherence.

Social support is a multidimensional concept with lots of definitions. Research on social support has often acknowledged the importance of individual social support as well as environmental social support. Often times, emotional, economic and tangible (day-to-day) support are ways in which the broad term “social support” is measured or conceptualized.


SHOW OH 33: Success Time permitting:Ask participants identify the range of mental health issues and diagnosis within their client population.

Note on newsprint.

Facilitate discussion on the implication or impact on adherence.

VII. Substance Use and Mental Health Issues

A. HIV and Mental Health

True to all assessments, assessing a client living with HIV/AIDS requires a complete Bio/Psycho/Social/Spiritual assessment that includes screening for substance use and/or behavioral health and mental health concerns.

Research has shown that many clients with HIV/AIDS experience mental health concerns that affect their day-to-day functioning.

A large number of clients are going to experience reactions and concerns that are common to people living with a chronic illness.

Adjustment issues Depression Feeling anxious

Depending on the client population, some clients may be diagnosed with mental health problems that emerge as a result of coping with the stresses of a diagnosis of HIV/AIDS.

mood and anxiety disorder adjustment disorders Post-traumatic stress.

As the overhead highlights - it is important to remember that

There is also the common co-occurrence of mental health problems among drug users with HIV.

The combination of substance use and mental illness may vary in severity, chronicity, disability and degree of impairment in functioning level.

people with serious and persistent mental illnesses (or SPMI) may use alcohol and other drugs to manage or mask symptoms of their mental illness (that is, self-medicate).

A holistic or comprehensive assessment will take into account presenting issues, longevity of symptoms, family and social history, substance use and psychiatric history.


SHOW OH 34: HIV and Mental Health

As highlighted earlier, the cultural perspective of coping and living with a chronic illness must be considered.

B. Substance Use and Medication adherence

As the overhead highlights - continued drug/alcohol use after infection with HIV

o may complicate a client’s capacity to adhere

o may also lead to increased vulnerability to opportunistic infections, as well as complications with the co-infections of hepatitis, tuberculosis, or other sexually transmitted infections (STI’s).

Medication adherence is challenged by those clients in recovery who relapse.

For example, a client in relapse may:

o Return to at-risk sexual or drug taking behaviors

o Stop or modify stop medication schedule

o Forget medications because of substance use

o Mistaking a “lapse” for a “relapse” and “give up”

HAART regimen

Substance use may significantly impact the medication schedule:

o missing doses, negative effect on therapeutic dose of HAART drugs, increasing the risk to develop resistance

What are some of the challenges faced by dually diagnosed clients?

Can we think of both micro and macro aspects?

Debrief


SHOW OH 35: Substance use and medication adherence

Trainer notes:

On NP:

Jot down some notes regarding the micro and macro level issues.

Facilitate a dialog with the participants as time allows.

LARGE GROUP DISCUSSION - USE NP


Persons actively using, as well as those in recovery, are also faced with other challenges associated with HIV/AIDS. For example:

stigma and discrimination, multiple stressors (financial, declining health), dealing with treatment failures or substance use relapse; and limited access to regular health care or other services

coping pattern that may result in self-medicating to reduce negative feelings or psychosocial stressors; missed or tardiness to appointments, failing to follow treatment plans or abiding by program rules, for example

As social workers we recognize that there are insufficient services for substance use and mental health treatment across the country yet these are two key issues that impact access to primary health care and adherence. We also recognize that advocacy within communities will be part of our social work practice

There are numerous clinical issues to consider.

Within some programs and/or policies, substance abuse treatment must be initiated prior to beginning HAART.

When to start medications is a fundamental yet highly debatable question that still exists between health care providers and HIV infected people.

Treatment can include recovery related strategies that reduce harm to the client (e.g. needle exchange programs)

Connecting Statement

Whether we work with clients in recovery, those with a serious or persistent mental illness that requires daily medication adherence, or clients living with other life-affecting chronic illnesses, a client may lapse or relapse in their attempt to cope with a diagnosis of HIV/AIDS - or the progression of the disease process and how it affects their life.

The interrelationship or connection of substance use, mental health, HIV/AIDS, and other chronic illness clearly speaks to the benefits of a single provider, one who has a close and sustained relationship with the client.


G. Summation:

In promoting adherence, clinical skills can be used to help the client reframe challenges into strengths. For example:

Affirming a client’s ability to monitor their illness and their medications (even missing doses); or

Identifying the way the client deals with side-effects; or How relationships and cultural and spiritual beliefs have

provided support are all example of strengths-based practice.

Stress we have addressed this comprehensive approach through the use of the ADHERE model and accompanying information.

As providers, can we say YES to the following question:

Has each of these areas been addressed?

VIII. Questions and Answer

Ask for any final questions or comments.

Thank audience and remind them to do the evaluation.


SHOW OH 37: Please remember to do your evaluation

SHOW OH 36

References

Acuff, C. et. at. (1999) Mental Health Care for People Living with or affected by HIV/AIDS: a practical guide. Research Triangle Institute: NC.

AIDS Action Committee of Massachusetts (2003) Talking with your Healthcare Provider [online] Retrieved from http://www.aac.org/site/PageServer?pagename=info_doctor AIDS Action: A Guide to CBO Adherence Programs (2001) Washington, DC: Author

Coping with Hope: HIV/AIDS Treatment Decisions/Adherence. (2001) [Multiple authors]. Center for Mental Health Services (CMHS) Mental Health Care Provider Education in HIV/AIDS Programs. Rockville: MD

Despotes, J., Noel, E., Novak, E., and Farrington, B., (2003) Adherence Counseling: A Client Centered Approach. Midwest AIDS Training and Education Center. Chicago, IL.

Haynes RB. Determinants of compliance: the disease and the mechanics of treatment. In: Haynes RB, Sackett, DL, (Ed.) Compliance in Health Care. Baltimore: Johns Hopkins University Press; 1979:49–62.

Healthy People 2010. Retrieved from: http://www.healthypeople.gov/2020/default.aspx

HIV/AIDS, Mental Health, and Substance Use: An Integrated Response. (2002). Tomaszewski, E. (Ed.) HIV/AIDS Spectrum: Mental Health Training and Education of Social Workers Project, National Association of Social Workers, Washington, DC.

Ka’opua, L.S. (1998). Multicultural competence. In D.M. Aronstein & B.J. Thompson (Eds.), HIV and social work, a practitioner’s guide (pp.51-64). Binghampton, NY: Haworth.

Linsk, N., and Bonk, N., (2000) Adherence to Treatment as Social Work Challenges. In HIV/AIDS in the Year 2000: A Sourcebook for Social Workers. Lynch, V. (editor), Allyn and Bacon. Needham Heights: MA.

Miley, K. K., O'Melia, M., & DuBois, B. (1998). Generalist social work practice: An empowering approach (2nd ed.). Boston: Allyn & Bacon

NASW Standards for Cultural Competence in Social Work Practice. (2001) National Association of Social Workers Washington, DC:author.National Association of Social Workers (2003). Practice research network survey project 2: Final report. Washington, DC: Author.

National Network of Libraries of Medicine (2007). Retrieved from: http://nnlm.gov/outreach/consumer/hlthlit.html

Paterson, D. (1989) In Abstracts of the 6th conference of retroviruses and opportunistic infections. Chicago, IL. January 31-February 4, 1989. Abstract No. 92.

Prochaska, J. O., and DiClemente, C. C. (1986). Toward a comprehensive model of change. In W.R. Miller and N. Heather (Eds.) Treating addictive behaviors: processes of change (pp. 3-27). New York: Plenum Press.

Ross, M. (2005) Return to Work Issues. Journal of HIV/AIDS & Social Services: Research, Practice, Policy. Linsk, N., and Gilbert, D. (Eds.) New York: Haworth Press.


http://nnlm.gov/outreach/consumer/hlthlit.html

http://www.healthypeople.gov/2020/default.aspx

http://www.aac.org/site/PageServer?pagename=info_doctor

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