Enhanced Adherence Counseling EAC for Adults Learning Objectives

Enhanced Adherence Counseling (EAC) for Adults

Learning Objectives § To be able to conduct counselling sessions for patients with a high viral load through the identification of barriers to adherence and strategies to overcome them.

Why do EAC? • 70. 5% have a resuppressed viral load after an adherence intervention (CI 56, 6%- 84, 4%) Bonner, 2013 • Varied range of interventions • What is an optimal and feasible intervention in resource limited settings?

Adherence interventions § Different interventions developed for resource limited settings § Variations according to context: § § Programme location (high volume versus low volume sites) Available HR (doctors, nurses, professional or lay counsellors) § All in common: § Structured intervention § Supported by implementation tools like session guide, patient file and register

How to do EAC Attitudes: § Non-judgmental attitude: “What have you done wrong? ” versus “What makes it challenging for you to take drugs every day? ” § Empower patients: “You should take your drugs every day as I tell you to do. ” versus “Well done, your viral load is suppressed, keep up the good adherence. ”

How to do EAC (contd. ) Skills: § Use open-ended questions “Did you take your drugs last night? ” versus “Can you tell me how you have been taking your drugs over the last days? ” § Work on realistic solutions “You should never stop taking drugs when you travel” versus “Let’s see how we can ensure you do not run out of drugs when you travel. What do you think about coming to the health facility for a longer supply before you leave for your trip to see your family? ”

EAC Sessions Individual Session plan - overview • High VL result given 1 st EAC • 1 month refill given 2 nd EAC 3 rd EAC M 4 • 1 month refill given • 2 nd VL taken

EAC Session 1 1. 2. 3. 4. 5. Welcome and introduction Explain the viral load result Explain the EAC procedure Assess previous and current adherence Explore barriers to adherence and identify ways forward (behavioral, soco-economical, emotional) 6. Conclude the session

EAC Session 2 1. Welcome and introduction 2. Assess patient’s adherence since last visit 3. Assess patient’s knowledge regarding treatment failure 4. Review adherence barriers and implementation of solutions 5. Conclude the session

EAC Session 3 1. Welcome and introduction 2. Assess patient’s adherence since last visit 3. Review adherence barriers and implementation of solutions 4. Explain that a 2 nd VL will be taken at their next visit 5. Conclude the session

Documenting EAC § High VL & EAC register –To check if all patients with high viral load are receiving EAC –To check if all patients with a high viral load receive a 2 nd viral load –Document whether patients have been switched to 2 nd line –Any other additional comments

Documenting EAC § Referral Form for patient with High Viral Load ─ To document adherence of patient with each EAC session ─ To communicate with and inform clinician (MA, CO, or Nurse) ─ Should be in each high VL patient’s mastercard

Exercise Adherence Roleplay

Roleplays § Subgroups of 5 with participants taking turns as observer, patient or counsellor § Handout for patient & counsellor of role play, session guides, patient file and EAC register § Debriefing questions after every role play § How did this role play feel for the counsellor? § How did the role play feel for the patient? § How did the role play feel for the observers? : § what were the good points about this counselling session § what would you suggest to do differently § What will you record in the patient file and in EAC register? § Wrap up main points

Role play 1: Handout for counsellor § You are seeing a 33 years old woman who has been on ART for 4 years with a viral load of 6000 copies/ml. § She always attends for her appointments or drug refills on time.

Role play 1: Handout for patient § You are a 33 year old woman and have never heard about viral load before. § You know that sometimes they take a blood sample to measure the amount of soldiers in your blood. § You often forget to take your drugs when you are out of the house as you don’t want others to see you are taking drugs (e. g. at church, at the market) § You always come to your appointments on time.

Role play 2: Handout for counsellor § You see a 35 year old man who often fails to attend for his appointments with a viral load of 15000 copies/ml. § In his file you see he travels often which makes it impossible for him to come to his appointments.

Role play 2: Handout for patient § You are 35 years old man who often fails to take his treatment due to running out of drugs. § You get your treatment at a health centre in a village in Malawi, yet you live in Mozambique. You only come to the village once every few months, so sometimes you run out of drugs if you do not have enough money to travel back in time for your appointments.

Role play 3: Handout for counsellor • A 48 year old man who started ART 3 years ago comes to you with a viral load of 9500 copies/ml. • The nurse did a first viral load which was detectable. • In the first EAC session he told you that he often drinks and that’s why he forgets to take this treatment. • As a way forward the patient wants to ask a friend to remind him to take the drugs when out. • You see this patient now for a second EAC session.

Role play 3: Handout for patient § You are a 48 year old widowed man who lives alone in his house. You started ART 3 years ago § Your nurse has told you that your viral load was too high. § You often go out drinking with your friends and that makes you forget to take your meds. You’ve told this to the counsellor the other time. Since then you have been thinking about your health, but you do not see a way to improve your adherence. You did not dare to ask a friend to remind you of taking drugs when out. § You are now attending a 2 nd EAC session.

Role play 4: Handout for counselor • A 27 year old woman who is pregnant comes to you with a viral load of 8600. • She has been HIV+ for some time, but has only started ART during her second pregnancy. Her first child is HIV+ as well. • You see this patient now for a first EAC session.

Role play 3: Handout for patient § You are a 27 year old woman who is pregnant with her second child. You started ART 6 months ago. § You did not take ART during your first pregnancy, even though you knew your were HIV+. Your first child is HIV+ as well. § You are now attending your 1 st EAC session.

Key messages § Enhanced adherence counselling is put in place to support patients with a high viral load with the aim of resuppression. § EAC explores the patients’ barriers to adherence and identifies together with the patient a way forward § These sessions happen in a structured way, with the support of a session guide and registration in a patient file and register