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This is a draft cheat sheet. It is a work in progress and is not finished yet.


Drug adherence is a key part of highly active antire­tro­viral therapy (HAART). It refers to the whole process from choosing, starting, managing to mainta­ining a given therap­eutic medication regimen to control HIV viral replic­ation and improve function of the immune system. Non-ad­herence is the discon­tinuity or cessation of part or all of the treatment such as dose missing, underd­osing, or overdo­sing, and drug holidays.1 The signif­icance of adherence to treatment has become recogn­ised, which is important in optimising the patient's response to therapy. In contrast, non-ad­herence can lead to treatment failure, a rise in plasma viral load, and the develo­pment of drug-r­esi­stant HIV strains.

Drug adherence counse­lling programme develo­pment

A systematic approach is essential in promoting drug adherence in HIV patients. The aim of a drug adherence counse­lling programme is to enhance adherence to HAART for maximising treatment outcome. This would achieve the target of improving individual health clinically and lowering HIV infect­ivity on a public health level. Drug adherence counse­lling is prefer­ent­ially integrated in other targeted risk reduction measures, which serve the purposes of sustaining the mainte­nance of a low HIV risk in the community.
The main objectives of drug adherence counse­lling are, to:
(a) Support patients in making informed choice on HIV treatment according to individual needs
(b) Assist patient in adopting drug adherence behaviour
(c) Enhance patient's ability in managing and mainta­ining the treatment

Health care providers play an important role in drug adherence. Counse­lling is normally conducted by nurse counse­llors in accordance with establ­ished protocols. Throughout the course of disease, drug adherence counse­lling is conducted in a patien­t-c­entred and non-ju­dge­mental approach. Patients are encouraged to partic­ipate in their disease management and treatment plan. Resource materials are important. Inform­ation booklets and posters can be used to enhance patients' unders­tanding of the importance of drug adherence. Standa­rdised assessment forms are useful in tracking patients' progress. The recent develo­pment of an electronic pill planner assists the nurse counse­llors and the patient to plan the drug schedule that fits into patient's lifestyle.

Stage one: general prepar­ation

This stage serves to determine treatment readiness, charac­terise potential and actual barriers to adherence, and provide relevant treatment knowledge and educat­ional interv­ent­ions. A trusting and caring relati­onship between health care provider and patient have to be establ­ished in order to achieve mutual unders­tanding of the treatment goal.1 Stage One counse­lling is offered when a patient first attends the clinic e.g. the newly diagnosed patient. This may also be required throughout the course of disease on subsequent visits.
Key issues covered at this stage are:
(a) Thorough assessment is important to explore the potential and actual factors in a patient's life that could influence drug adherence. These include: health status, social backgr­ound, and one's perception of illness and treatment.
(b) Treatment inform­ation is provided in the same setting, covering the nature of combin­ation therapy (HAART), their availa­bility, effects, and the importance of adherence.
(c) Ongoing assessment shall follow, to track the patient's knowledge on the subject, his/her unders­tanding of the treatment process, and to evaluate one's readiness to initiating and adhering to a complex regimen.

Stage two: treatment initiation

Stage two: treatment initiation
The most important time to address the importance of adherence to treatment and medication regimens is before starting therapy. Patient's commitment to medication adherence should be assessed. Before HAART is begun, the risks and benefits of treatment must be discussed. The potential and actual factors that could influence adherence are again addressed and intervened as approp­riate prior to initiation of therapy.
Treatment is about to be initiated when CD4 count falls in a downward trend or to around 200/μL. The key objective at this stage is to ensure that the patient unders­tands the benefits of HAART and the possible side effects associated with the treatment. At the end of the counse­lling session, he/she should be able to make a self-d­ete­rmined choice to start therapy. Counse­lling shall cover the following issues:
(a) Assessment of factors that may influence one's adherence - Patient's perception of illness and desire for treatment; social stability, including such factors as housing status, regularity of life-p­attern, job nature, need to travel, and behavi­oural risk factors like substance abuse; mental status; baseline knowledge.
(b) Identi­fic­ation of potential facili­tators and barriers to drug adherence - counse­lling is conducted to remove such barriers, while special support system is identified that may be utilised, such as family network or NGOs.
(c) Develo­pment of treatment care plan.
(d) Discussion on the planned regimen.
(e) Obtaining patient's agreement to have HAART initiated.
On the day of treatment initia­tion, the objectives of counse­lling become even more focused by addressing the specif­icities of the prescribed drug regimen. The patient shall agree on the drug dosing schedule. The contents of the counse­lling are therefore:
(a) Assessment to check the patient's unders­tanding of the provided inform­ation and the importance of adherence.
(b) Discussion on the treatment regimen.
(c) Develo­pment of an indivi­dua­lised medication schedule - assessment of one's life pattern is made, followed by the establ­ishment of a schedule for medica­tions. The mutually agreed medication schedule is written down on the inform­ation and scheduling sheets and would be given to the patient.
(d) A two-week drug taking diary exercise is introd­uced. The patient would be requested to record the drug taking behaviour and side effects identified on the drug taking diary in the following two weeks. He/she is encouraged to bring back the remaining drugs for pill count at every visit.
(e) Psycho­logical support.
(f) Agreement is reached with patient on the treatment plan. Drug inform­ation sheet and schedule are given to patient to reinforce memory.

Stage three: consol­idation

The initial phase of starting treatment is a critical period for the patients in establ­ishing the confidence and adopting a drug taking behaviour. They may be unfamiliar with the treatment schedule and encounter adverse effects. The support of the healthcare worker is important for enhancing patient drug adherence and their management of adverse effects. Consol­idation counse­lling is started once the antire­tro­viral therapy is initiated and within the period of one to three months, the objectives of which are:
to monitor the drug adherence level of patient
to reinforce patient's drug adherence behaviour
to assess and manage the adverse effects of HAART
Counse­lling at this stages cover the following areas:
(a) One's knowledge of HAART is assessed.
(b) One's drug taking behaviour and adherence is monitored, and the drug adherence level is calculated (Box 13.1).
(c) Factors which may affect adherence are explored.
(d) Provision of adherence support.

Stage four: mainte­nance

When the HAART regimen is stabil­ised, frequent and regular monitoring of drug adherence is important to maintain optimal behaviour. The nurse counsellor measures and assesses adherence on an ongoing basis to allow comparison of a given patient's adherence across time. This also serves as opport­unity to evaluate side effects, identify barriers and provide support and reinfo­rcement to patient. The objectives of mainte­nance counse­lling are:
to optimise patient's adherence to HAART
to reinforce patient's drug taking behaviour

Counse­lling at this stage therefore covers the follow­ings:
(a) Assessment of drug adherence is made, using the regular drug adherence assessment form. The nurse counsellor assesses patient's knowledge on HAART, drug taking behaviour, barriers and facili­tators to drug adherence on a half yearly basis.
(b) During assess­ment, the nurse counsellor watches out for any new side effects, identifies barriers to drug adherence such as change in life pattern and such undesi­rable practices as drug holiday, partial dose omissions.
(c) Encour­agement and reinfo­rcement are given to reinforce adherence. This is done in conjun­ction with the provision of inform­ation on the results of viral load and CD4 count. This can also served as a reward to his adherence to the drug schedules.
Specific strategies to improve drug adherence may also be consid­ered, which include:1
Review with patient about his perception of health goals.
Review the regimen and the medication schedule and simplify the regimen to facilitate a better match of schedule to life pattern.
Assessment and management of side effects.

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