Better patient communication gets more people admitting adherence issues
A pilot that saw health workers adopt ‘patient-centred’ communication at an HIV clinic in rural Tanzania led to a three-fold increase in the number of people openly reporting treatment adherence problems.
Health workers from an HIV clinic serving the districts of Kilombero and Ulanga in Tanzania were trained on how to encourage patients on antiretroviral treatment (ART) to talk about adherence problems and find ways to tackle these issues.
The intervention was found to have significant benefits in empowering people to discuss adherence issues, with self-reporting on non-adherence rising from 3.3% to 10.7%.
Healthcare workers were trained in a two-day workshop and seminar, and adopted an assessment checklist for use during patient consultations. Around 300 people living with HIV (71% female, 29% male) were included in the trial, which ran from October 2013 to September 2014.
Patients were assessed during three visits: the first was conducted just before the training, with the second and third visits carried out between one and three months, and six and nine months after it. All participants entering the study had been on ART for at least six months, with the median treatment length 3.5 years. A quarter had experienced at least one episode of non-adherence before the study.
During each visit, the vast majority of participants (81%) completed a clinical and self-reported adherence assessment, and underwent a CD4 cell count, viral load measurement and therapeutic drug monitoring (TDM).
Only a small minority of participants (3.3%) disclosed any adherence problems to health workers during their first visit, despite TDM indicating a non-adherence rate of 6.9%. By the second visit, non-adherence self-reporting had risen three-fold. The most common reasons given for missing doses were running out of pills (64.3%), forgetting to take pills (10.7%), travel problems (7.1%) and feeling depressed (3.6%).
But self-reported non-adherence dropped to 5.7% at the third visit, indicating the effect of the communication training declined over time. Should this approach be adopted elsewhere, the authors suggest refresher sessions are delivered as part of the intervention to ensure its benefits are sustained. These can be delivered either online or in-house to keep costs down.
The study found participants’ median CD4 cell count also increased significantly over time, rising from 413 cells/mm3 at first visit to 504 cells/mm3 at the third. This resulted in the immunological failure rate, when someone is unable to achieve and maintain an adequate CD4 count, decreasing from 14.4% to 8.7%.
However, the study found the virological failure rate, when consistently high and increasing levels of HIV are detected, remained unchanged throughout the study. As the virological failure rate was relatively low during the first visit, the fact that it remained unchanged may be due to only the most adherent patients – i.e. those on treatment for more than six months – being selected for the study.
A further limitation of the study is that it was designed without a control group, that is, patients treated by healthcare providers not trained in adherence communication skills. This decision was taken by the study’s authors in view of ethical considerations and the risk of a contamination bias, as all of the clinic’s healthcare providers worked closely together.
Despite the study’s limitations, it has shown how patient-centred communication can feasibly be delivered in low-cost settings, with significant benefits for adherence.
Interventions such as this one will be critical for the continued effective scale-up of ART to meet UNAIDS’ 90-90-90 testing and treatment goals, which will see millions more people living with HIV on treatment by 2020, most of them in sub-Saharan Africa.