Evidence indicates that adherence diminishes as time progresses. Thus, monitoring and support of adherence is essential. A trusting relationship between the patient and members of the health care team is important. Optimal adherence requires full participation by the health-care team, with every patient’s interaction representing an opportunity for reinforcement. Sticking to appointment dates needs particular emphasis as this practice is not common everywhere. Supportive and non-judgmental attitudes by care providers will foster patient adherence practices. Clinicians should show commitment in dealing with their patients during clinic visits, ongoing adherence monitoring, and timely response to adverse events or interim illness. Interim management during clinician’s absences must be clarified with the patient. Adherence support must be intensified when problems arise (e.g. investigate new barriers, more frequent visits, involve home care programs, enlist support of family/friends, review teaching, increase home visits, etc.). For all health care team members, specific training regarding ART and adherence should be offered and updated periodically.
Ideal adherence means a patient must take more than 95% of their doses (i.e. missing less than 3 doses in a month). If a patient is taking less than 95% of their doses, they are at risk for developing viral resistance and ultimately treatment failure. Patients taking < 80% of their doses are unlikely to have any durable viral suppression and should be targeted urgently for adherence improvement, and 6 month follow-up, while adhering to the following strategies:
Spend time and have multiple encounters to explain goals of therapy and need for adherence.
Consider monitoring of medications such as Cotrimoxazole or other surrogate prior to ART initiation.
Negotiate a treatment plan that the patient can understand and to which he/she commits.
Encourage disclosure to identified adherence assistant(s) among family or friends who can support the treatment plan.
Inform patient beforehand of potential side effects - severity, duration, and coping mechanisms.
Establish ‘readiness’ to take medications before ART initiation.
Provide adherence tools where available: written calendar of medications, pill boxes etc.
Encourage use of alarms, pagers or other available mechanical aids for adherence.
Avoid adverse drug interactions; full disclosure for over-the-counter drugs and traditional medicines.
Anticipate, monitor and treat side effects.
Include adherence discussions in support groups.
Develop links with community-based and home based care organizations to support adherence.
Encourage participation in peer support groups.
Basic adherence package at each visit for patients on treatment include:
Pill return counts (i.e., number of doses not taken during the period) are particularly important to capture those individuals who may not have understood clearly their adherence instructions e.g., not stopping treatment even when they feel better, not taking medication in correct dosages or frequency etc1. Pill counts would therefore be an ideal activity to be carried out at each patient visit, but would clearly depend on the clinic load and capacity to undertake. At the very least, it should be done for the first 3 patient visits and then at random. The tablet count may be done before the patient sees the doctor, and the count reviewed by the doctor during the early/initial visits to evaluate adherence.
1 Pill counts are sometimes criticized because they are viewed as encouraging pill dumping from patients who have not been adherent. While this is true, it is a crucial way of discovering whether patients have understood their medication directions and the critical need for proper adherence. For those patients that throw away their pills right before their clinic visit, it is an indication that they do understand the directions and counselling given.
Missed/late clinic visits should trigger concerns about adherence.
Routine adherence discussion/education with counsellor is of value. This should be an open-ended discussion, with time for questions and repetition,
Feedback from treatment counsellors to the rest of the team is important to get a better profile of the patient and their environment,
Encourage participation in a support group,
Continue monthly visit with treatment counsellors
Develop an individual adherence plan by identifying daily activities that act as triggers/reminders to take their medication, such as fixed broadcast programs or praying hours
When the adherence assessment is < 80% at any visit, with or without viral or clinical failure:
The treatment counsellor needs to re-educate the patient and any adherence assistant (their close friends or family) about the importance of adherence. The long-term benefits need to be re-emphasised.
Evaluate the support structures in place. Are they appropriate? How can they be improved? What alternatives are there?
Consider the use of pillboxes and/or daily dosing diary.
Insist on participation in a support group.
Consider doing a psychological profile.
Check family situation (through social worker and treatment counsellor).
Assess effect of alcohol intake on adherence.
Assess use of traditional medicines and its potential effect on ART adherence.
Increase home visits by treatment counsellors to daily or weekly at a minimum (spot pill counts to be done at home), and
Consider directly observed therapy for an agreed period.
For further information on Counselling, refer to the following documents developed by the National AIDS Control Programme, Ministry of Health:
Skills manual for Hospital based Counsellors (June 1999)
A guideline for Counsellors in Tanzania with special emphasis on HIV/AIDS/STDs Counselling (June 1999).
Guidelines and Standards for Counselling and Supervision (June 1999)
A guideline for District Management (DHMT) on counselling Services (1999)
National VCT Guidelines
National PMTCT Guidelines