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									                   HIV Medication Adherence

There are different stages identified in HIV medication adherence. These will be looked
at under the following headings:
   Pre HIV test discussion                                              page 2
   New HIV positive diagnosis or a known HIV positive
    person transferring their care                                       page 2
   When the patient and / or doctor are considering starting
    medication                                                           page   3
   Patient definitely starting medication                               page   5
   Maintenance/ Ongoing Management                                      page   6
   Changing Medication                                                  page   7
   Stopping Treatment                                                   page   8
   Auditing Adherence                                                   page   8

   Appendices

I-Antiretroviral Starter Clinic –Pharmacist Lifestyle Assessment         page 9
II-Health Adviser (Or CNS In The Community) Checklist For                page 11
Assessment Prior To Commencing Antirtroviral Therapies


There is a weekly multidisciplinary team clinic meeting where all HIV +ve patients
attending the service are discussed. Patient’s medical and social care is reviewed and
there is a specific focus on adherence. The consultants, nurses, health advisers,
pharmacist, clinical nurse specialist, and dietitian all regularly attend these meetings.




December 2000
Pre HIV test discussion
Health Advisers

Where a positive result is expected the health adviser will check out the
persons health / treatment beliefs and reasons for testing. They will give brief
information on blood monitoring- viral load / CD4 count and brief information
about combination therapy and adherence.



Newly diagnosed HIV positive or transfer of care
Health Advisers

   Give the positive result and as part of that session or follow up sessions
    discuss blood monitoring- viral load /CD4 count and will give information
    about combination therapy. The amount of information given at this point
    will vary dependant on the patients needs. Ideally all patients should have
    some knowledge of how HIV affects the immune system and the role of
    monitoring and antiretroviral therapy.

   Resources may be given where appropriate such as the NAM leaflets on
    anti HIV drugs, viral load, nutrition leaflets

   Discuss roles of different staff in the clinic and give the HIV services
    information leaflet i.e. pharmacist/ nurse etc.

   Book a double appointment with the consultant as soon as possible, and
    with dietitian and pharmacist where appropriate ie if a transfer of care who
    is on Antiretroviral medication

Consultants

   Discussion of natural history of HIV infection

   Discussion of blood monitoring - viral load / CD4 count

   Introductory discussion on when medication is indicated in HIV disease

   Broad information on Types of HIV medication

   Book appointment with pharmacist and dietitian as an introduction.

Pharmacist

   Should ideally see all new patients once baseline blood results are
    available ( or before if indicated or requested)

   Introduce service provided by pharmacist / how pharmacist can help with
    adherence


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   Ensure receipt and understanding of information / concepts introduced by
    Doctor & HA, reiterate if necessary

   Provide more detailed information about medication / adherence according
    to the individual’s interest and request

Nurses

   Will see patients for blood tests. This is often a consolidation point for the
    patient who may ask further question that they either forgot to ask before,
    did not want to ask the doctor or pharmacists or where they are confused
    by what they have been told or have forgotten the answer.

   The nurse plays an important role in the feedback of this information and
    referring queries back to the relevant staff either directly to the individual or
    at the weekly multidisciplinary team meeting.

Clinical Nurse Specialist

   Where a patient may need more support in the community then the patient
    should be referred for a review by the CNS. The CNS may offer the
    support the health adviser can give but in the persons home.



When the patient and / or doctor are considering
medication
At present doctors would usually consider treatment for any patient who
had a CD4 count of 300-350 or below. The patient may consider
treatment at any stage. See Antiretroviral Prescribing Protocol for fuller
details

Consultant

   The need to consider medication would be raised by the consultant

   The consultant would usually try to introduce the idea of medication over a
    period of time to enable the patient to think over the issues of treatment
    prior to it being necessary. New patients with low CD4 counts or existing
    patients whose immune function has significantly deteriorated may need to
    reach decision more quickly.

   The consultant would briefly discuss what taking medication would involve
    practically and the importance of adherence and life long commitment.
    The patient will be referred to the pharmacist for further discussion.

   There would need to be some discussion about how the patient would
    cope with taking medication. The consultant would refer to the HA to
    explore these issues and health beliefs further.



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Pharmacist

   Lifestyle questionnaire (see attached) to explore scheduling issues etc.

   Ensure continued understanding of viral load / CD4/ resistance / principles
    of therapy and educate further as necessary

   Show the patient individual tablets and the pots they come in

   Discuss likely regimens as indicated by consultant

   Reinforce importance of adherence and the reasons for scheduled visits to
    monitor tablet taking. Introduce some ideas on how to help remember
    e.g. leaflets on adherence tips.

   Consider / offer possibility of jelly bean / smartie trial

   Discuss practical issues of drug taking plus short term and long term side
    effects and restrictions

   Discuss non prescribed medication

   Discuss with consultant any anticipated problems with suggested regime

Health Adviser (or CNS in the community)

Should use counselling skills to address the following and feed back the
relevant information to the multidisciplinary team:

   General coping mechanisms and state of physical and mental health

   Look at their health beliefs and whether they are congruent with HIV
    medication. Explore how HIV has affected their health and check out their
    perception of the disease process, their treatment beliefs and how taking
    medication could impact their life

   Are there any cultural or religious/ spiritual beliefs which make it hard to
    take medication and have a medical model of HIV care

   Look at their lifestyle issues- e.g. chaotic lifestyle, work and travelling
    abroad issues, immigration status

   Check that they are not taking recreational drugs, and warn about drug
    interactions specifically with PI's

   Look at issues of disclosure to work colleagues, household companions
    and partners




 Page 4
Nurses

   Will see patients for blood tests. This is often a consolidation point for the
    patient who may ask further questions that they either forgot to ask before,
    did not want to ask the doctor or pharmacists or where they are confused
    by what they have been told or have forgotten the answer.

   The nurse plays an important role in the feedback of this information and
    referring queries back to the relevant staff either directly to the individual or
    at the weekly multidisciplinary team meeting.



Patient definitely starting medication
The consultant would strongly recommend treatment for patients with a
CD 4 count of 250- 200 or less. See the Antiretroviral Prescribing
Protocol for fuller details

Consultant

   Will indicate most likely regimen in the notes

   Will select a proposed start date and follow up and document in notes

   Will go through medication and side effects (short and long term)

   Discuss how to take the medication and the importance of adherence

   Tell the patient not to stop without consultation – especially re NNRTIs

   Write script for one month and arrange for the patient to pick up first script
    from pharmacist

   Check they have been seen by pharmacist / have appointment booked
    before starting.

   Check they have been seen by dietitian for baseline anthropometric
    measurements and dietary restriction advice

   Review the patient two weeks after commencing medication

Pharmacist

   Reinforcement session, hope not to be giving any major new information
    at this point.

   Will have the tablets there in the session 'this is them'

   Check nothing has changed in lifestyle

   Feedback to the consultant



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   Print out NAM wheel when to take medication regime or other medication
    record card which the patient has selected

   Give watch/ dosset box advice about how to remember as appropriate

   Concentrate on HOW to take and the importance of adherence

   Confirm their understandings of their instructions with regard to frequency
    and timing of doses and food/ fluid restrictions

   1-2 week follow up with pharmacist bringing drugs / all medication in with
    them (and offer telephone support if appropriate)

   further follow up at 1 month (or 6 weeks), 2 months, 3 months then 3
    monthly bringing drugs / all medication in with them. Review food and fluid
    restrictions, timing and frequency of medication

Dietitian

   baseline anthropometric measurements

   dietary restriction advice

Health Adviser

   If not already assessed see HA section 'considering medication’

Nurses

   May see patients

   Reinforcing importance of adherence



Maintenance / ongoing management
Consultant

   Raise adherence at every visit and record in the notes at every main
    review. Explore any reasons for difficulties/ concerns and practical
    solutions

   Check exact schedule to ensure correct doses & timing with regard to
    spacing of doses and any food restrictions. Use laminate with pictures of
    drugs to avoid confusion over drug names

   Refer to other team members as appropriate




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Nurse

   Discuss how they are getting on with medication adherence and feedback
    any difficulties.

   Refer to other team members as appropriate

   Noticing when prescriptions are not picked up

CNS

   Home visits should be offered where appropriate

Pharmacist

   Review i.e. adherence assessment for all patients taking HIV medications
    ideally every six months, but at least annually. The consultant and
    pharmacist select suitable patients from the clinic list. ( Adherence
    assessment consists of 2 or more of the following :

           tablet count,

           visual review with laminate/ actual drugs

           compliance questionnaire,

           prescription collection review,

           viral load data.

   Noticing when prescriptions are not picked up or when patients drugs
    should be running out. Know your drugs i.e. 27 pill packet, 30 days

   Develop ways of picking up poor compliance? develop a standard
    compliance questionnaire to be developed

   ? viral load as a marker to discuss compliance blood levels



Changing Medication
Consultant

   Depends on reason for change – 'side effects' or 'failure'

   Review causes for failure/ side effects – consider drug level monitoring if
    appropriate

   Refer to appropriate discipline i.e. HA, pharmacist, dietitian




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Pharmacist

   Will probably do most of the work reviewing any problems/ concerns re
    adherence

   Refer to appropriate discipline i.e. HA, dietitian



Stopping Treatment
This includes ‘drug holidays’

All patients taking NNRTIs need to stop nevirapine and efavirenz one week
before stopping other drugs

Don’t just stop without discussion

Consultants

   Need to discuss with all patients on or considering treatment

Pharmacist

   Need to discuss with all patients on or considering treatment



Auditing Adherence
Review the percentage of patients on Antiretroviral treatments with
undetectable viral load every 6 months when the SOPHID report is completed.

Discuss all patients with detectable viral load at team meeting and explore
whether any additional action/ support is indicated.




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                                   ANTIRETROVIRAL STARTER CLINIC –

                                  PHARMACIST LIFESTYLE ASSESSMENT
Hosp/Clinic Number : …………………… Name : …………………………… DOB : …………

      WAKING HOURS                      WEEKDAY / WORKDAY     WEEKEND / DAY OFF
Get up at
Latest get up at / lie in until
Go to bed at
Latest go to bed at

              FOOD                      WEEKDAY / WORKDAY     WEEKEND / DAY OFF
Breakfast at
Breakfast consists of

Lunch time at
Lunch consists of

Evening meal at
Evening meal consists of

Any dietary restrictions

        SOCIALISING
How often do you go out
Do you often travel away from
home
Do you often travel abroad
Are you ever on a plane for
more than 8 hours/ how often
Regular activities e.g. TV
programs, taking child to
school, church

            WORK
Do you work
What hours do you work
Do your work colleagues know
about your condition

      HOME / FAMILY
Language preferred                    Speak                   Read

Other language (s)                    Speak                   Read
HIV status known by family /
partner
Practical help / support with
drug administration
Children / planning to have
children
Housing
Ability to store safely and
correctly e.g. access to fridge



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      HEALTH ISSUES
Other diseases

Any history of depression,
anxiety, memory loss
Regular medication                 If yes complete a medication history
Dietary restrictions / special
requirements
Alcohol ( units / week)
Smoking ( quantity & duration)
IV / Recreational drug use



Understanding and Expectations of Treatment

1. Is the HIV disease process understood ?

2. Ensure understanding of terminology e.g. viral load, CD4 count

3. What are the baseline knowledge, experience and opinion of ARV therapy ?



4. What are the 3 most important factors to the patient ?

   Belief that the drugs will delay disease process
   Decreasing the viral load below the limit of detection
   Increasing the CD4 count
   Avoiding side effects
   Treatment that is simple to take
   Other. Please specify……………………………………………………………………………

5. Would the patient consider entering a clinical trial ?




Completed by : ……………………………….                         Print Name :………………………………

Bleep Number : …………..                                Date :………………………………...




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       Health Adviser (Or CNS In The Community) Checklist For Assessment
                  Prior To Commencing Antiretroviral Therapies

                                                                                                  Sticker

     HA/ CNS name:__________________                       Date:________


The Health Adviser will review the following:

   General coping mechanisms and state of physical and mental health

   Look at their health beliefs and whether they are congruent with HIV medication. Explore how HIV has
    affected their health and check out their perception of the disease process, their treatment beliefs and
    how taking medication could impact their life

   Are there any cultural or religious/ spiritual beliefs which make it hard to take medication and have a
    medical model of HIV care

   Look at their lifestyle issues- e.g. chaotic lifestyle, work and travelling abroad issues, immigration status

   Check that they are not taking recreational drugs, and warn about drug interactions specifically with PI's

   Look at issues of disclosure to work colleagues, household companions and partners




      Page 11

								
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