“ASSESSING AND SUPPORTING PATIENTS’ READINESS TO START ART” (1)
Goal: Facilitate decision making and starting ART for patients who qualify according to international guidelines. |
Before initiating ART, screen for decision making and adherence barriers: |
Patient related factors:
A) Depression (2)
B) Harmful alcohol or recreational drug use (3)
C) Cognitive problems (4)
D) Low health literacy. |
System related factors:
E) Health insurance and drug supply
F) Continuity of drug supply
G) Social support and disclosure. |
Recognise, discuss and reduce problems wherever possible! |
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Assess patients’ readiness and support progress between stages (5):
“I would like to talk about HIV-medication” <wait> “what do you think about it?” (6) |
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- Set the agenda before every interview
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- use open questions whenever possible
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- use the WEMS-technique (7)
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Precontemplation:
“I don‘t need it, I feel good”
“I don‘t want to think about it” |
| Support: Show respect for patient attitude / Try to understand health and therapy beliefs / Establish trust / Provide individualised short information / Schedule the next appointment. |
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| Restage again |
Contemplation:
“I am weighing things up and feel torn about what to do about it” |
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| Support: Allow ambivalence / Support to weigh pros and cons together with patient / Assess information needs and support information seeking / Schedule the next appointment. |
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| Restage again |
Preparation
“I want to start, I think the drugs will allow me to live a normal life” |
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Support: Reinforce decision / Make shared decision on most convenient regimen / Educate: adherence, resistance, side effects / Discuss integration into daily life / Assess self-efficacy.
Ask: Do you think you can manage to take cART consistently once you have started?
Use: VAS 0-10 (8)
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| Patients presenting in the clinic may be at different stages of readiness: Precontemplation, contemplation or preparation [Transtheoretic model; Prochaska JO. Am Psychol 47:1102-1114, 1992]. The first step is to assess this stage, and then to support/intervene accordingly. An exception is if a patient presents late or very late, i.e. <200 or <50 CD4/μl. In this case the initiation of ART should not be delayed; the clinician should try to identify the most important adherence barriers which may be present, and support the patient to be prepared for prompt initiation
of ART.” |
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Consider skills training:
- Medication-taking training, possibly MEMS (2-4wk) (9)
- Directly Observed Therapy with educational support
- Use aids: Pill boxes, cell phone alarm, involve contact persons where appropriate
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START AND MAINTAIN ADHERENCE
Screen: For adherence problems in each meeting (10)
Support: Discuss side effects, educate about surrogate markers, discuss integration of drug taking schedule
Empower: Give positive feedback |
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Comments to the table Start of ART and patients’ readiness(1) |
- This table should facilitate the initiation of ART. Matters for consideration listed in this table, such as decision making or barriers to adherence, have to be judged clinically in their context. For instance the clinician has to judge whether ART has to be initiated immediately despite the detection of possible barriers to adherence or whether delaying initiation is justified. Consider patient's cultural background.
- Ask: “During the past month have you often been bothered by feeling down, depressed or hopeless?” “During the past month have you often been bothered by little interest or pleasure in doing things?” “Is this something with which you would like help?” If answers are positive, then sensitivity is 96%, specificity 89% (Arroll B et al. BMJ 327:1144-1146. 2003).
- Ask: “Have you thought about Cutting down?” “Have you ever become Annoyed when people talk to you about your drinking?” “Have you ever felt Guilty about your drinking?” “Do you ever have a drink first thing in the morning (Eye opener)?” An affirmative answer to more than two CAGE-questions means a sensitivity and specificity for problematic alcohol use of more than 90% (Kitchens JM. JAMA 272(22): 1782-1787. 1994.). Ask similar questions for recreational drug use.
- Ask: “Do you feel that you are having problems concentrating in your daily life?” “Do you feel slow in your thinking?” “Do you feel that you are having problems with your memory?” “Have relatives or friends expressed that they feel you are having problems with your memory or difficulty concentrating?”
- Patients presenting in the clinic may be at different stages of readiness: Precontemplation, contemplation or preparation [Transtheoretic model; Prochaska JO. Am Psychol 47:1102- 1114, 1992]. The first step is to assess this stage, and then to support/intervene accordingly. An exception is if a patient presents late or very late, i.e. <200 or <50 CD4/μl. In this case the initiation of ART should not be delayed; the clinician should try to identify the most important adherence barriers which may be present, and support the patient to be prepared for prompt initiation of ART.
- This is a suggested opening question to assess the patient’s stage of readiness. Further discussion will indicate which of the three initial stages the patient has reached: he/she might even be ready for therapy.
- WEMS: Waiting (>3sec), Echoing, Mirroring, Summarising (Langewitz W et al. BMJ 325:682-683. 2002).
- VAS (= Visual Analogue Scale; Range from 0 to 10 i.e. 0 = I will not manage, 10 = I am sure I will manage).
- Medication training/ MEMS training could be done with vitamins before starting ART.
- Suggested adherence questions: “In the past 4 wks how often have you missed a dose of your HIV medication: every day, more than once a wk, once a wk, once every 2 wks, once a month, never?” “Have you missed more than one dose in a row?” (Glass TR et al. Antiviral Therapy 13(1):77-85. 2008).
Adapted from: J. Fehr, D. Nicca, F. Raffi,
R. Spirig, W. Langewitz, D. Haerry, M.Battegay, NEAT, 2008. |
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