Review Material Adherence Brochure MD

18.Adherence MD Brochure_11rev 12-4-13

Small Talks

ABOUT:

ART

Adherence
How medical providers can positively impact
medication-taking behavior

Care IS Prevention

Small Talks

ABOUT

ART Adherence

ADHERENCE TO ART:
Vital for Patients Living with HIV
For patients living with HIV, adherence to antiretroviral therapy
(ART) is key to maximal and long-term reduction of viral load.1
The difference between adherence and nonadherence—including
inadequate or inconsistent adherence—has a profound effect on
overall treatment.

Results of Sustained
Adherence:1

2

Consequences of
Nonadherence:2,3

• Immunologic recovery is
possible

• Virologic response may be
inadequate

• Long-term control of HIV
infection can be achieved

• CD4 cell counts remain low

• Antiretroviral agents remain
durable

• Risk of viral breakthrough and
regimen failure doubles

• Viral resistance (and
subsequent virologic
breakthrough) is minimized

• Development of drug-resistant
HIV may be accelerated,
increasing treatment failure

• Viral transmission is reduced

• Viral transmission is more likely

• HIV-related morbidity and
mortality are reduced

• HIV-related morbidity and
mortality are increased

Trust: pivotal to provider-patient
relationships
It is important that the patient be able to trust
the medical provider. The patient will feel more
comfortable sharing his or her thoughts if the
provider:
• Listens carefully to the patient and pays
attention to hesitations, inconsistencies, or
strong emotions
• Speaks openly and honestly about differences
in ideas; corrects the patient’s misconceptions
tactfully and allows time for questions if he
or she doesn’t fully understand
• Involves the patient in the development of
the treatment plan.
Objectivity and a nonjudgmental attitude
are important. Medical providers can make
it clear that even if they do not share the
patient’s views, they respect them. Knowing
and respecting the patient’s views will improve
the patient-provider relationship and make the
patient more likely to be adherent.

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SMALL TALKS HELP:
Identify Barriers to Adherence
Patients may have trouble adhering to ART
for many reasons. Variables that are predictive
of inconsistent ART adherence have been
identified in the literature. These include
individual patient beliefs and behaviors such as
not accepting the HIV diagnosis or not wishing
to take medications when “feeling well.”
Other barriers to look for include:
• Cognitive factors, such as lack of organizational
skills and comprehension level
• Treatment competence and regimen-related
barriers, or the overall inability to adhere to a
potentially complicated and long-term regimen.
This includes fear of treatment of the side effects
and confusion about does.
• Comorbid conditions, such as depression,
addiction, or co-infections/STDs as well as other
chronic conditions including diabetes, high blood
pressure, and heart disease, as these may further
complicate the treatment plan
• Psychosocial barriers, such as lack of social
support
• Structural barriers, such as lack of
transportation, housing or insurance issues, or
child care needs
4

Addressing different barriers as they arise will ultimately help
patients live longer, healthier lives by encouraging consistent ART
adherence. Here are some ideas.
When the
patient
demonstrates:
Cognitive barriers

Improve adherence by:
• Encouraging pill sorting and use of dosing
devices such as weekly pill boxes
• Using a feedback strategy (such as “tell me what
you just heard”) to help patients avoid confusion
about new medications and/or changed regimen

Treatment competence • Involving the patient in decision-making,
issues
including selection of the ART regimen
• Explaining that treatment is much safer today,
and regularly evaluate and manage side effects
Regimen-related
barriers

• Modifying the treatment regimen, with
consideration for the patient’s lifestyle:
–– Link pill-taking to daily activities
–– Reduce pill burden or dose frequency
–– Reducing dietary restrictions
• Encouraging patients to recruit friends and/or
family members to help with adherence
• Regularly reviewing overall treatment plan and
simplifying total regimen if possible
• Linking to resources such as support groups,
alcohol/drug treatment or mental health services

Comorbid conditions

• Regularly reviewing overall treatment plan and
simplifying total regimen if possible
• Linking to resources such as support groups,
alcohol/drug treatment, or mental health services

Psychosocial barriers

• Letting the patient know about any support
resources available (eg, peer-to-peer groups,
adherence counselors, case managers)

Structural barriers

• When possible, referring the patient to case
management and wraparound services such as
appointment accompaniment and child care

5

Strategies for Success
Every HIV-infected patient entering care should
understand the effect ART has on CD4 count,
viral load, and HIV transmission prevention. ART
should be initiated as soon as possible according
to current guidelines.3
Before patients begin ART...
Evaluating patient readiness prior to ART initiation
can help identify predictors of suboptimal
adherence.3,4
Providers may want to test a patient’s readiness to
begin ART by:
• Prescribing a complex regimen of vitamins and
nutritionals (or even placebo tablets) for a few
weeks as a “practice run” and then determining
how well the patient was able to adhere to this
regimen5
• Prescribing an antibiotic regimen for patients
who are immunologically at risk of acquiring
an opportunistic infection and then determining
how well the patient was able to adhere to
this regimen5

6

At ART initiation…
Establishing trusting, open communication is
important at ART initiation. One way that medical
providers can enhance communication is to ask
several open-ended questions…ones that cannot
be answered with a simple “yes” or “no.”
Open-ended questions are designed to help the
medical provider better understand the patient’s
views. They may also give the provider some idea
of the patient’s ability to adhere to a treatment
regimen.

Consider these open-ended questions
to start the conversation:
• “What have you heard about HIV
medicines?”
• “What are the most important results you
hope to get from treatment?”
• “What are your concerns about HIV
medicines?”

7

SMALL TALKS HELP:
Patients Adhere to Treatment
Throughout the Course of ART
Adherence to ART over the long term can be
challenging, even for the most motivated patients.
Brief discussions about ART adherence at every
follow-up visit can help improve your patients’
success.5
Through open discussion, providers and patients
can problem-solve barriers, identify strategies, and
set behavioral goals to improve adherence.
For example, the ART schedule may need to be
adapted to a patient’s lifestyle by linking pill-taking
to activities that serve as cues to remember. Or a
side effect that needs attention may be uncovered.5

FPO
8

Consider these open-ended questions
to start the conversation:
• “How has it been going taking your
medicines?”
• “What seems to get in the way of taking
your medicines?”
• “What was going on when you missed
that dose you told me about?”

Remember, needs may change over time.
Medical providers should explain to the patient
that some people have trouble staying on the
medication schedule and help patients find ways
to identify and deal with potential adherence
problems.
Persons living with HIV are more likely to be
adherent if they help make the decisions and
choose solutions rather than being told what
to do.
In general, patients may be more likely to follow
the treatment plan if they are partners in their
treatment plan and understand the benefits of
treatment.

9

In Summary, Small Talks Work
• The ultimate goals of adherence to ART are
viral suppression, prevention of viral resistance,
maintaining overall health, and preventing HIV
transmission.
• Inconsistent or suboptimal adherence to ART
may lead to poor clinical and health outcomes
including:
–– Increased morbidity and mortality
–– Increased risk of viral transmission
–– Viral resistance.
• The provider-patient relationship can improve
adherence to ART.
–– Regular clinical evaluation at each follow-up
visit includes brief discussions that elicit and
address barriers to adherence.

8

FPO

• Effective communication techniques include:
–– Using simple, nonmedical terms
–– Using the appropriate language level
–– Limiting the amount of information provided
at one time
–– Discussing the most important topics first
and last
–– Repeating important information
–– Listening to feedback and questions from
the patients
–– Using concrete examples
–– Making the interaction with the patient a
positive experience
Brief discussions with patients at every office
visit can help improve treatment competence,
adherence, and treatment success.
References
1. CDC. Effect of antiretroviral therapy on risk of sexual transmission of HIV infection and superinfection. September
2009. 2. Atkinson MJ, Petrozzino JJ. An evidence-based review of treatment-related determinants of patients’
nonadherence to HIV medications. AIDS Patient care STDS. 2009;23:903-914. 3. 3. Panel on Antiretroviral Guidelines
for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents.
Department of Health and Human Services. Last updated February 12, 2013; Source: http://aidsinfo.nih.gov/guidelines.
Accessed October 31, 2013. 4. Thompson MA, Aberg JA, Hoy JF, et al. Antiretroviral treatment of adult HIV infection.
2012 Recommendations of the International Antiviral Society−USA Panel. JAMA. 2012;308:387-402. 5. Hardy WD. The
ART of ART adherence. HIV Specialist. 2012;4:30-32.

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Inside

Helping Patients Adhere to ART
Adherence to ART is a long-term endeavor crucial to the health of
people living with HIV. This brochure provides:
• Evidence of the importance of ART adherence
• Conversation starters to discover modifiable barriers to ART
adherence
• Proven strategies to reduce barriers to ART adherence thereby
improving the overall care of HIV.

Additional materials available in this kit

Protect Your Health
6_PIC_W3_Baseline_Screener_v13 12-4-13

NEW PATIENT QUESTIONNAIRE

Please take a few minutes to answer the following questions so we can
get to know you better and provide you with the best care possible.
Your answers will be kept confidential, so please answer as accurately
and honestly as you can.

Patient Name/ID:
Today’s Date:
Medical Provider:
To be filled out by provider/office staff.

Introduction
What is your preferred name?
What is your gender?
What is your relationship status?

❑ Single
❑ Married
❑ Civil union

❑ Separated
❑ Divorced
❑ Widowed

❑ One main partner
❑ Multiple partners

Who do you live with (check all that apply)?

❑ Partner/spouse
❑ Parent(s)
❑ Brother(s)/sister(s)
❑ Other relative(s)

❑ Friend(s)
❑ Roommate(s)
❑ Adult children
❑ Children under 18

❑ Alone
❑ Homeless

HIV Diagnosis and Treatment
When did you find out that you are HIV positive?
Have you ever seen a medical provider about your HIV?
Have you ever taken medicines to help control your HIV?
If yes, are you taking any medicines to help control your HIV now?

Month
❑ Yes
❑ Yes
❑ Yes

Year
❑ No
❑ No
❑ No

Sharing Your HIV Status
Since finding out that you are HIV positive, who have you told about your diagnosis in your family?

❑ Everyone in my family knows about my diagnosis.
❑ No one in my family knows about my diagnosis.
❑ Only the following person or persons in my family know about my diagnosis.

Since finding out that you are HIV positive, how many of your friends have you told about your diagnosis?

❑ I have told most of my friends about my diagnosis.
❑ I have told a few friends about my diagnosis.
❑ I have told one friend about my diagnosis.
❑ I have not told any of my friends about my diagnosis.

Since finding out that you are HIV positive, have you told any of the following people about your diagnosis
(check all that apply)?

❑ My partner/spouse
❑ My significant other, boyfriend, or girlfriend
❑ My sex partner(s)

• New Patient
Screener—helps
you get to know
your patient prior
to ART initiation.

LET’S TALK about

HIV medicine

Every pill
counts
Care IS Preve
n

• Action Plan—helps
you and your
patient at each
visit to identify and
address variables
affecting consistent
adherence to ART.

Make the Most of

Each Medical Visit…
and the Time Between Visits

… A new job is
making it hard
to stick to your
medicines schedule
… You recently
moved and are
having trouble
getting to medical
appointments

Maybe you have
questions about
healthy living
and healthy
relationships…

… options for
safer sex
… how to reduce
side effects from
medicines

These are all examples of topics
you can talk about with your
medical provider. Together, you
can set a goal – something
you want to work on or
change between now and your
next medical visit to help you
overcome challenges like these.

… You’re dating
someone new, but
haven’t talked to
them about STDs
or HIV yet
… You are thinking about having
kids and want
some advice

10_PIC_W3_Action_Plan_v16 12-3-13

Every medical visit gives you a chance to talk with your medical provider about
getting healthy, staying healthy, and keeping others safe.
Maybe something
in your life
changed since
your last visit…

We believe you can
achieve your goal and
protect your health.

… healthy ways to
deal with depression
and anxiety
… getting help with
alcohol or drug use.

myAction
Plan
Write your goal and
the steps you’ll take
to reach that goal
on this Action Plan.

At your next medical
visit, talk to your medical
provider about progress
you’ve made and ask for
support if you’ve had any
roadblocks to success.

Date of visit with medical provider:
Issue we discussed:

Solution I agreed to try:

Date of next appointment:

Remember… change is an ongoing process.
Understand that you may make mistakes along the way.
Don’t be afraid to ask for help from friends and family.
Care IS Prevention

Prevention Is Care:
Patient Name/ID:
Appointment Date:
Medical Provider:

What topics were discussed with your patient during today’s visit?

❑ Adherence to medication
❑ Reducing risky sexual behaviors
❑ Remaining in medical care

❑ None of these topics (patient refused)
❑ None of these topics (other issues took precedence)
❑ Other

Did you set a goal with patient at previous visit?

❑ Yes

❑ No

❑ No (Today is patient’s first visit)

Was a goal set with the patient at a previous visit?

❑ Medication adherence
❑ Reducing risky sexual behaviors
❑ Other:

❑ Today is patient’s first visit
❑ Attending all medical visits

What is the patient’s progress on previous goal:

❑ No goal set at previous visit
❑ No progress on previous goal

❑ Partially achieved previous goal
❑ Fully achieved previous goal

What barriers (if any) did your patient identify during this visit?
ART Adherence

❑ Experiences side effects from ART
❑ Forgets to take medications
❑ Experiencing treatment fatigue

❑ Forgets to pick up prescriptions
❑ Cannot pay for medication
❑ Other:

Reducing
Risky Sexual
Behaviors

❑ Lacks information about safe sex
❑ Does not have access to condoms
❑ Unaware of PrEP and PEP

❑ Uncomfortable discussing safe sex with partners
❑ Experiencing prevention fatigue
❑ Other:

Remaining in
Medical Care

❑ Feels too sick to attend appointments
❑ Does not believe medical care is necessary
❑ Lacks access to transportation
❑ Other:
❑ Is concerned about seeing family/friends at clinic

Other Barriers

❑ Mental health issues
❑ Homelessness
❑ Substance abuse:

❑ Lack of social support
❑ Financial concerns
❑ Other:

What does the patient state is his or her primary barrier to achieving optimal health?
Did you and the patient discuss a plan to overcome this barrier?

❑ Yes

❑ No

What is the plan (or goal) that the patient agrees to work on before the next visit:
Referrals:

❑ Case management
❑ Partner services
❑ Mental health services
❑ Substance use services

❑ Prevention counseling
❑ Reproductive health planning
❑ Domestic violence prevention services
❑ Food services

❑ Housing services
❑ Financial services
❑ Support groups
❑ Other:
Source: Adapted from Options Patient Record Form

14_PIC_W3_Patient_Record_Form_v11 12-4-13

PATIENT RECORD FORM

This form can be used as the basis for discussions with patients
about barriers to achieving optimal health and as a checkpoint for
future visits. Information elicited may inform an Action Plan that
can help patients achieve their goals.

• “Every Pill Counts”
Wall Poster—
helps foster open
communications.

TOWARD PROTECTING YOUR HEALTH

Protect yourself.
Protect others.

LET’S TALK about

HIV medicine

7_PIC_AdherencePatientAid_v3 12-4-13

21_PIC_AdherencePatientAid Wall Poster_v3 12-2-13

To help encourage brief discussions about barriers to and strategies for
ART adherence, the following materials are also included in this kit:

Every pill
counts
TOWARD PROTECTING YOUR HEALTH

• “Every Pill Counts”
Brochure—
reinforces your
health messages
after patients
leave their
appointments.

• Patient Record
Form—serves as
a guide to and
documents your
conversation and
helps you identify
patients at risk for
nonadherence.

Additional materials available online
• HIV Myths and Misconceptions—a patient brochure available in
English or Spanish.
• HIV Resources for Providers who Deliver Care to People Living with
HIV—a brochure for providers containing a comprehensive selection
of available resources.
http://www/cdc/gov/actagainstaids/pic/

Care IS Prevention