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Education and Counseling to Support Adherence with general population of PLWH Guidelines and Recommendations for Implementation K. Rivet Amico, PhD University of Connecticut On behalf of Guidelines Panel. No conflicts to report. Education and Counseling Guidelines for general clinic population.

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  1. Education and Counseling to Support Adherence with general population of PLWHGuidelines and Recommendations for ImplementationK. Rivet Amico, PhDUniversity of ConnecticutOn behalf of Guidelines Panel No conflicts to report

  2. Education and Counseling Guidelines for general clinic population • Individual one-on-one ART education is recommended (II A). • Providing one-on-one adherence support to patients through 1 or more adherence counselling approaches is recommended (II A). • Group education and group counselling are recommended; however, the type of group format, content, and implementation cannot be specified on the basis of the currently available evidence (II C). • Multidisciplinary education and counselling intervention approaches are recommended (III B). • Offering peer support may be considered (III C).

  3. Individual one-on-one ART education is recommended (II A) 14 intervention studies 10 + effects on adherence 1 study (of 8) + effects on biomarkers

  4. Individual one-on-one ART education is recommended (II A) From this evidence base • Content should include: • Common side-effects • Role of adherence in treatment success • Role of non-adherence in resistance • Additionally… • Medication management skills • Review of common barriers • Framing of adherence as challenging for many

  5. Individual one-on-one ART education is recommended (II A) From this evidence base • Targets knowledge acquisition • Discussion • Exploration • Activities • Goes beyond Information Provision (e.g., booklets, information providing without conversation or information checks). • Diversity • Clinicians, nurses, pharmacists, counselors, health workers. • Timing in relation to ART • Education often combined with Counseling

  6. Individual one-on-one ART education is recommended (II A) Implementation challenges? • Sufficient resources to provide education individually • General education messages need to be tailored to local community and culture • Common mis-information must be identified • Need to determine timing, duration, and deliverer and plan for monitoring • Confirm that approach goes beyond info delivery Most providers/agencies surveyed in IAPAC web survey report providing some kind of education (85%*)

  7. Providing one-on-one adherence support to patients through 1 or more adherence counselling approaches is recommended (II A). 27 studies 22/25 had some positive effect on adherence 5/12 positive effects on biological measures

  8. Providing one-on-one adherence support to patients through 1 or more adherence counselling approaches is recommended (II A) From this evidence base… • Type of counseling discussions varies • Cognitive behavioral • Patient-centered • Motivation-based (e.g., motivational interviewing)] • Included a focus on motivation, social support, and skills building • Client-centered delivery formats. • Diversity in: • Length; Deliverer; Location; Targeting

  9. Providing one-on-one adherence support to patients through 1 or more adherence counselling approaches is recommended (II A) From this evidence base… • “Counseling” • Use of communication skills, basic principles of therapy or problem solving approaches in interactive discussion • Training in approach provided (varying requirements for a counseling background) • NOT “Counseling” • Reminding and persuading • Delivering preset messages

  10. Providing one-on-one adherence support to patients through 1 or more adherence counselling approaches is recommended (II A) Implementation challenges? • Sufficient resources to provide individualized counseling • Time (15 to over 60 minutes) • Personnel (implement and supervise) • Space • Need to figure out approach for given population… • Requires additional work! • Review literature/models • Make use of available resources • Work with communities and patients Most providers/agencies surveyed in IAPAC web survey report providing some kind of 1:1 counseling (70%*)

  11. Group education and group counselling are recommended; however, the type of group format, content, and implementation cannot be specified on the basis of the currently available evidence (II C) 7 intervention studies 4 generally + effects on adherence 4 generally + effects on biomarkers

  12. Group education and group counselling are recommended; however, the type of group format, content, and implementation cannot be specified on the basis of the currently available evidence (II C) From this evidence base… • Variability in participant groups, geography and methods/targets of group intervention • Heterogeneous in • Length • Timing • Orientation; Target

  13. Group education and group counselling are recommended; however, the type of group format, content, and implementation cannot be specified on the basis of the currently available evidence (II C) Implementation challenges? • Sufficient resources to • Schedule and populate groups • Time commitment (60 to over 120 minutes) • Personnel (implement and supervise) • Space • Like 1:1 counseling…additional work is needed • Review literature/models • Work with communities and patients 36% provide group education; 35% provide group counseling from IAPAC

  14. Multidisciplinary education and counselling intervention approaches are recommended (III B). 2 intervention studies specifically evaluated Frick et al 2006 No difference in pharm-refill adherence Sig difference in VL and change in VL at 12 months [adj] Levy et al 2004 Sig difference in adherence (phone based self-report) No difference in VL or CD4 at ~20 weeks

  15. Multidisciplinary education and counselling intervention approaches are recommended (III B) From this evidence base… • Use of multidisciplinary teams • NOT the same as having multiple team members duplicate efforts or content concerning adherence. • Each team member had clearly delineated roles and covered content specific to their particular areas of expertise.

  16. Multidisciplinary education and counselling intervention approaches are recommended (III B) Implementation challenges? • Need to have a team • Can teams be created? • Time (coordination of care team meetings) • Need to clearly identify who does what • How to coordinate the systems • What unmet needs will be addressed • How to conduct process and outcome monitory Over half of respondents of IAPAC web survey (64%) reported coordination of care across disciplines

  17. Offering peer support may be considered (III C). 9 intervention studies 5 generally + effects on adherence 3 generally + effects on biomarkers

  18. Offering peer support may be considered (III C) From this evidence base… • Diversity in type of peer-based approach • 4 studies monitored administration of ART • 4 targeted peer support • 1 Peer included psycho-education • Similar to other intervention approaches there was diversity in…. • Type, length, location or content of peer delivered intervention

  19. Offering peer support may be considered (III C) Implementation challenges? • Who serves as peers • Training and supervision requirements • Resources to compensate peers • Who will coordinate peer services • What approach will be adopted or developed • How to ensure confidentiality/privacy • How to conduct process and outcome monitory 27% overall reported use of peers; 67% of respondents located in Africa reported use of peers in IAPAC’s web survey

  20. APPROACHES REPRESENTED IN EVIDENCE BASE…BUT NOT EMERGING INTO A GUIDELINE (YET) • Dyad/couples counseling • Contingency management • Technology

  21. Guidelines ARE FIRST OF SEVERAL STEPS General Guideline Evidence Base • One on One • Education • Counselling • Multidisciplinary support • Peer support • Group • Education • Counselling • Peer support

  22. Guidelines ARE FIRST OF SEVERAL STEPS General Guideline IMPLEMENTATION OF Evidence Based Approaches Evidence Base • Not specified • When to provide • Who to involve • What to target/include • How long • Over what period of time • How to support • How to sustain • How to monitor • How to adapt • One on One • Education • Counselling • Multidisciplinary support • Peer support • Group • Education • Counselling • Peer support

  23. THE GREY AREAS ARE NEEDED IN BEHAVIORAL GUIDELINES… • Opportunities to incorporate and reflect • Local/community/cultural needs • Identify and address unmet needs • Local (clinic, organizational) resources • Building/leveraging capacities for implementation and monitoring of outcomes Targeting and tailoring increases chances of implementing something effective for a given person, at a given time, in a given context

  24. PROCESS APPROACH TO INTERVENTION DEVELOPMENT

  25. Suggestions for implementation of education and counseling guidelines: • Needs assessment (drivers of adherence) • Identification of needs not presently met (intervention targets) and resources available • Identification/development of intervention approach(theory, models) to use (packaged, general strategies) • Identification of how to disseminate approach to interveners (manuals, workshop) • Identification of how to support approach (sustainability) (opinion leaders, champions) • A monitoring and evaluation plan • Plan for modifications and adaptation

  26. Suggestions for existing education and counseling practices: • What does the intervention in place target? What pathways to adherence are promoted? Does that match with community work, theories, or evidence base? • How does the intervention try to change, promote, reduce or influence adherence or behaviors on the pathway to adherence? Does each strategy have support from community work, theories, or evidence base? • Is there good uptake/acceptability of intervention? • Are implementers satisfied? • What are the costs of implementation presently? • Process and outcomes monitoring!

  27. THE SCIENCE OF DISSEMINATION AND IMPLEMENTATIONExtensive area of scientific inquiry

  28. THE SCIENCE OF DISSEMINATION AND IMPLEMENTATION

  29. CDC Manuals and resources for specific packaged approach available

  30. RESOURCES ALREADY AVAILABLE

  31. “Making a difference in practice means listening to what those doing the work and those affected by the work have to say." Jim Dearing

  32. Thank you! • The IAPAC guidelines reviewed were the result of sustained efforts from numerous individuals including: • Panel Members • The authors, research teams, supporting agencies and participants directly responsible for the evidence available to date.

  33. Acknowledgements • Funding was provided by the US National Institutes of Health, Office of AIDS Research and IAPAC • Cindy Lyles, PhD: CDC Prevention Research Synthesis database • IAPAC: Jose Zuniga, PhD, MPH; Angela Knudson • Systematic reviews: Laura Bernard, MPH, Kathryn Muessig MPH, Jennifer Johnsen, MD • Editorial assistance: Anne McDonough

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