(2) 7pm follow up counseling

8/9/2019 (2) 7pm Follow Up Counseling

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APAC-VHS-SAATHII-USAID Project NAKSHATRA 162

Follow up Counseling and Positive living

Session objectives: At the end of the session, the participant should be able to:

Explain the components of follow up counselling

Explain the steps in behaviour change communication

Emphasise on treatment adherence

Content Activity/ MethodResources

NeededTime Slides

Introduction, SessionObjectives

Trainer

Presentation

LCD or

Overhead

Projector

3 minutes 1-2

Components of follow

up counselling

Trainer

Presentation

LCD or

Overhead

Projector

3 minutes 3-6

Steps in behaviour

change communication

Trainer

Presentation

LCD or

Overhead

Projector

10 minutes 7-12

Importance of ART

Adherence

Trainer

Presentation,

Case Study

LCD or

Overhead

Projector,

Flip Chart,

Markers

7 minutes 13-15

Challenges to

Adherence

Trainer

Presentation

LCD or

Overhead

Projector

6 minutes 16-18

Improving Adherence

Trainer

Presentation,

Discussion

LCD orOverhead

Projector,

Flip Chart,

Markers

8 minutes 19-21

SummaryTrainer

Presentation

LCD or

Overhead

Projector

2 minutes 22


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Key points:

• Taking time for education and support of the patient are essential

• All members of the healthcare team should be involved

• High rates of adherence are vital to ensuring continued efficacy of ART

• Adherence and safer sex practise must be reinforced at every visits


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Trainer’s Notes:

• This session should take approximately 60 minutes to implement.

.

Trainer’s Notes:

• Present the module learning objectives.

• The aim of this session is to discuss the steps in behavior change

communication, the importance of patient adherence to ART, barriers to

adherence, availability of free supply, subsidized and commercial brands of

condoms.

Follow up Counselling andPositive living

Session objectives

• Explain the components of follow upcounselling

• Explain the steps in behaviour changecommunication

• Emphasise on treatment adherence


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• Ask the participants if they have any questions about the objectives before

continuing

Trainer’s Notes:

Disclosure: (partner, children and family)

Trainer’s note:

Ask the participants the following questions and brainstorm

Components of Follow upcounselling

• Disclosure

• Safer sex

• Positive living

• Mental health

• Stigma and discrimination

3

Disclosure

• Issues in disclosure

• Forms of disclosure– Full disclosure

– Partial disclosure

4


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• Who needs to know about his/her HIV status?

• What do different people need to know?

• How will family, friends and community react?

• How will it affect relationships and social life?

Full disclosure: publicly reveal their HIV status to everyone in life

Partial disclosure: To reveal only to certain people ex: family members

Trainer’s note:

Trainers note: Steps in disclosure – Why to whom when and where, how to disclose

Outcome of Disclosure

Potential positive• Accept their own status

• Reduce the stress ofcoping

• Access medical servicesthey need

• Reduce the stigma

• Safe sex

• Plan for future

Potential negative• Blame and abandonment

• Rejection and Labeling

• Abuse

• Discrimination

• Family disruption

• Issues with Coping-anger and frustration

5

Safer sex• Safe sex : No risk for infection

e.g. fantasy, masturbation• Safer sex : Minimal risk for infection

e.g. condom usage, oral sex with barriers

• Unsafe sex : High risk for infection

e.g. anal or vaginal sex without a condom

6


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Behaviour change communication

Stages Our Role1-Pre-Contemplation Provideinformation

2-Contemplation Help them think about possible damages

3-Preparation Helps identify barriers and facilitators ofchange

4- A ction Enco urage , Help addres s pro ble ms tha tmay arise

5-Maintenance Actively support efforts to maintainchange

7


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Trainer’s Notes:

Depression identifying symptoms

• Feeling sad most of the days

• Difficulty finding pleasure

• Life is not worth living ( thoughts of suicide)

Mental health

Common psychological problems• Depression

• Thoughts of suicide

• Alcohol abuse

• Low self esteem

• Others – denial , shock and anger

11

Positive living • Stop the spread of HIV

• Eat healthy food

• Get emotional support

• Personal hygiene and good habits

• Exercise regularly

• Continue to work

• Plan for your family

• Drug adherence

12


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Trainer’s Notes:

• Ask participants to discuss each of these questions.

• Note the range of answers given by the participants for later comparison.

• It may become necessary to discuss the reasons for the difference at this point itself in

the event of an advanced audience, but that discussion is best deferred for later.

Treatment Adherence

Discussion Questions

• How much regularity of therapy

(adherence ) is required in most chronicdiseases, for example diabetes?

• If HIV is a chronic, manageable diseaselike diabetes, is this level of adherenceadequate?


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Trainer’s Notes:

• HIV is increasingly considered a chronic manageable disease, and with the impressive

gains made with

ART, it is often being compared to diseases like hypertension. However, keep in mind

that a compliance level of 80% is usually adequate to ensure successful treatment in

chronic disease like hypertension. However, with ART, a much higher level of

adherence is required. For patients taking at least 95% of their medications (at least 57

of their 60 monthly tablets), the long term success (as defined by complete virologicalsuppression) is 81%.

• Even more worryingly, with even a small drop in compliance, the success rate falls

steeply. For example, in a patient taking about 55 of his or her 60 monthly tablets, the

long term success rate is less than 50%.

Reader’s Notes:

• It is important to remember that although there is enthusiasm in categorizing HIV as a

chronic manageable disease, it is not as simple as managing other chronic illnesses like

hypertension. Long-term success can only be achieved with complete virologicalsuppression (as discussed in the session on ART), and this requires very high rates of

medication compliance.

• A small reduction in the regularity of taking medications can have disastrous long-term

effects. Reflect for a minute on whether you have ever completed a full course of

antibiotics as prescribed by a doctor.

Adherence required for HIVtherapy

• >95% adherence is necessary to achieveviral load


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Trainer’s Notes:

• Ask participants to discuss the questions.

• Note the range of answers given by the participants for later comparison.

Trainer’s Notes:

• Participants may have already mentioned some of the reasons for poor adherence

during the brainstorming exercise. The following two slides review some of the

important causes.

Discussion Questions

What are the challenges to Adherence?

Challenges to Adherence

• Side effects of HIV therapies

• Lack of belief in benefits of therapy

• Lack of knowledge about the disease anddrug therapy

• Untreated depression

• Substance abuse –Alcohol

• Non disclosure


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• Side effects of therapy are a potent disincentive. This is especially true with stavudine,

where neuropathy can be very disturbing. Patients who are well counseled about the

disease and the treatment have less adherence problems. These patients report earlywith problems without resorting to methods that may be harmful in the long run. They

also report more regularly for follow up.

• Patients who believe in therapy tend to do better and this could be because such

patients generally take medicines more accurately. This process could be promoted by

a drug buddy system, a linkage group for support or by a DOTS approach.

• Drug use and psychiatric illnesses contribute to poor adherence. There may be value

in ensuring that a heavy alcohol user or drug user is rehabilitated prior to ART; patients

with depression should have psychiatric care before and during ART.

Reader’s Notes:

• There are numerous reasons why patients do not take their medications regularly.

• Side effects of ART were reviewed in a previous module. Some of these are very

acute, but most of them, like neuropathy of stavudine are long term and persistent.

Some such as lipoatrophy have little remedy; and these can be a cause for concern. If

side effects are not addressed, the patient may try to tailor therapy him or herself with

disastrous long term consequences.

• The importance of educating the patient relevant to his or her level of understanding is

very often overlooked. A patient who understands the disease, the therapy and the long

term issues involved in taking ARVs usually has better compliance and better

outcomes.

• In caring for HIV patients, often problems like drug/alcohol use and psychiatric issues

are not addressed. These issues need to be dealt with before starting a patient on ART.

• Earlier ARV therapies were characterized by unrealistic dosing schedules, making

them impossible to follow. The current regimen involves one pill twice daily. There are

many studies that support this information (see below).


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• The expertise of the physician affects adherence. An experienced physician will know

and recognize the warning signs of adherence problems at an early stage, especially of

non compliance, thus their patients tend to have better outcomes.

Reader’s Notes:

• Studies demonstrate some reasons patients miss doses; these include forgetting,

being too busy, being out of town, being asleep, being depressed, having adverse side

effects, and being too ill.

Trainer’s Notes:

• There is not one single intervention to improve adherence that is considered best. A

menu of options is necessary, one or more of which may prove useful to a given patient.

Reader’s Notes:

• The practical strategies which have been shown to improve adherence are varied, witha few consistent themes. Adherence is achieved only when there is a negotiation of the

treatment plan, where the patient feels that he or she is involved in the decision making

process.

• Assessing the patient’s substance use and psychiatric issues prior to therapy helps to

improve adherence.

• Patient education: Discussing with patients the need for treatment, the expected side

effects and management of common problems also helps improve adherence.

Improving Adherence

• ART preparedness counselling

• Address psychiatric and substance useissues

• Increase levels of support:– Social support network

– Educate patient about HIV

– Pill organisers/simplify regimen

– Reminders

– A trusting provider-patient relationship


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• Simplification of the regimen, i.e., with reduced pill numbers and frequencies, is

associated with better adherence, as is the reduction and treatment of adverse events.

• Reminders: Periodic reinforcement is important to ensure that the patient does not

forget to take the medications. In resource limited settings involving other players like

NGOs, Community Based Organizations, other organizations related to supporting

PLHIV, and some form of supervision by family or friends through DOTS could also

help.

• Recruitment of family and friends to support the therapeutic plan and its

implementation is associated with improved outcomes. Family and friends can also be

employed to supervise DOTS.

Reader’s Notes:

• The issue of assessing adherence is very complicated. No method is fool proof, but

some are more promising than others.

• Self reporting of adherence is flawed, especially when there is high expectation on the

part of health care providers for patients to be adherent. However, data has shown that

the use of a self reporting questionnaire for two week recall and one month recall are

reasonably accurate.

• The pill count is the low cost alternative for assessment of adherence. It is more

effective when unscheduled pill counts are performed and this correlates very well with

success of therapy.

Methods to Assess Adherence

• Self reporting (3 day or 7 day recall)

• Pill count

• Clinical opinion

• Biological assays


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• Pill counting is recommended by the national program. At every visit for a prescription

refill, the number of pills remaining in the medication box is counted (care should be

taken to ensure that there is no judgmental or threatening atmosphere) and the number of pills consumed is estimated. This is compared against the number of pills expected to

be consumed; this is expressed as a percentage equaling adherence. This can then be

used to decide if the patient needs help with therapy. (The adherence estimate should

be considered in context of other predictors like regularity for review visits.)

• Clinician opinion is also considered an alternative for the assessment of adherence.

This is very error prone and studies have shown that clinicians consistently over

estimate adherence. In fact, one study showed that patients with poor adherence were

identified only about 24-66% of the time. Therefore this can only be used as an adjunct

with some other form of assessment of adherence.

• When estimating adherence to any treatment, biological assay for drugs is

considered the best method.

• However, this approach is very expensive and not possible at the periphery.

Trainer’s Notes:

• It is important to increase the support and intensity of the treatment when poor

adherence is identified.

Interventions for Poor

Adherence

• Increase the intensity of clinical follow-up

• Shorten the follow-up interval

• Involve family and friends


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• In the event that the patient is going through a long difficult phase of his or her life,

where no intervention appears to help, as a last resort, temporary discontinuation may

be option, as a temporary complete stop is better than long term irregular therapy.

• Before going to the next slide, ask participants: “How can adherence be assessed?”

• Note responses on a flipchart or board before leading a discussion on the next slide.

Reader’s Notes:

• With better monitoring, more patients with adherence issues can be identified early.

• Some patients may require ongoing assistance from support team members from the

outset, such as chemically dependent patients, mentally impaired patients in the care of

another, children and adolescents, or patients in crisis.

• New diagnoses or symptoms may influence adherence. For example, depression may

require referral, management, and consideration of the short and long-term impact on

adherence. Cessation of all medications at the same time may be more desirable than

uncertain adherence during a two month exacerbation of chronic depression.

Key points

• Taking time for education and support ofthe patient are essential

• All members of the healthcare teamshould be involved

• High rates of adherence are vital toensuring continued efficacy of ART

• Adherence and safer sex practise must bereinforced at every visits

(2) 7pm follow up counseling

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