Transcript Tarisai-ICASA-2015-T.. - Society for AIDS in Africa

Presented by
Tarisai Bere
The TENDAI Study:
Treatment for depression and non-adherence to ART in people
living with HIV in Harare, Zimbabwe
Background:
Depression and non-adherence
Gonzalez 2011:
-Meta-analysis, 95 independent samples, depression significantly associated with
non-adherence (r = 0.19; P < 0.0001)
-Relationship between depression &HIV treatment non-adherence is consistent
across samples.
Importance of adherence
• High levels of adherence are necessary to achieve
viral suppression, prevent resistant strains, and
reduce disease progression
• The cut-off for sufficient ART adherence usually
ranges from 90% to 95% (Orteg0, 2011)
Adherence in Zimbabwe
• In Zimbabwe, data on early warning indicators for
drug resistance from a national sample of sites
prescribing ART to adults shows that only 21%
(22/103) of the sites managed to meet the target for
on-time pill pick up suggesting that adherence
remains a national public health problem (Zimbabwe
Ministry of Health and Child Welfare, 2015).
Other Measurement of adherence
• No gold standard
• Self-report by
questionnaire/
interview
• Pill count
• Electronic
• Hair levels
Langebeek et al, 2014 systematic review of
studies assessing predictors/correlates of ART
adherence
Meta-analysis of global predictors
for poor adherence (Langebeek et al, 2014)
• Low adherence self-efficacy
• Current substance use
• Depressive symptoms
• HIV stigma
• Low social support
• Concerns about adverse effects of ART
• Low levels of trust in HIV care providers
• Beliefs that ART is unnecessary
Tendai Qualitative Work
predictors results
Interventions for adherence in Sub Saharian
Africa
• Barnighausen et al (2011)
– Directly observed therapy (DOT), text-messaging
reminders, diary cards, treatment supporters, food
rations
– Can be effective but some unlikely to produce
large or lasting results
– Not generalizable to all settings
Interventions for adherence (WHO, 2013)
- Program level approaches: decentralise care to
community-based delivery models, reduce costs for
patients, simplify regimens and ensure drug supply.
- Individual level approaches:
SMS
real time monitoring
peer support,
treating co-morbid
mental disorders,
psychosocial support,
Interventions for adherence – Centre
for disease control recommendations.
• Problem solving, motivational and collaborative
approaches
• Texting reminders
• Directly Observed therapy for intravenous drug
users
AIMS OF THE STUDY
• To select and adapt an evidence-based intervention
for adherence and depression in people living with
HIV (PLWH) at risk of treatment failure
• To test feasibility and acceptability of the intervention
• To run a pilot trial
ADAPT ITT
Wingood & DiClementte (2008)
Focus groups, 47 in-depth interviews & observation
ASSESMENT
(Kidia et al Trop Med Intl Health, 2015)
DECISION
Life Steps used in the USA, China & South Africa
ADMINISTRATION &
PRODUCTION
TOPICAL
EXPERTS
Translation, metaphors, visual aids &
video
Senior medical practitioners, education
Experts ART counselors & psychologists.
INTERGRATION &
TRAINING
TESTING
Five day training & master class
Pretested in 100 patients,
observed fidelity
Life Steps structure of Nzira Itsva
•
•
•
•
Set the agenda
Identify motivation for taking medication
Identify goal for adherence
Psycho-education, information on
HIV and ART using video
•Review 2-week adherence
• Problem Solving
- Identify barriers to adherence
- Identify a plan to overcome
barriers
• 5 minutes on other issues e.g.
unprotected sex
Common Barriers
Case Example
Barrier: A widowed teacher had to provide her
deputy head with a letter from the clinic to
confirm her reason for missing work. This
caused her to miss appointments as she was
worried about the stigma of revealing she had
HIV.
Solution
Motivated by the educational film, she
“problem-solved” to find a solution which was
asking her doctor’s permission to switch
medication pick-up to the day she leaves work
early to collect her salary
Differences from standard counselling
• More emphasis on visual aids
• Trains client to problem-solve
• Uses collaborative approach
to problem-solve around
barriers to adherence and find
pill-taking strategies that suit
the client
• Use of technology, low-cost visual reminders and
personal alarms
• Extra support for clients with depression
Pilot RCT
Inclusion Criteria:
• 18 years of age or above
• On antiretroviral therapy for at least 4 months – pharmacy
records
• Score above cut-point for depression on a locally validated
scale for depression
• Indicator of poor adherence via any one of: 1) missed
clinic appointments; 2) falling CD4 count; 3) self-reported
adherence problems; 4) detectable viral load
Baseline data
N
Gender
Viral
suppression
Age
Mean (SD) (<=200
copies/ml)
Number of participants
scoring above cut-point
on locally validated
scale for depression
Intervention
Group
22 13 female
(59%)
39.5 (11.2) 5 (24%)
100%
Control
Group
20 13 female
(65%)
34.9 (10.7) 0 (0%)
100%
Some preliminary results for intervention
participants
Adherence
Measured over a 14 day period using Wisepills electronic adherence
monitors
N
Mean
% pills
taken on
time
SD
Range
Number of participants
with good adherence
(>90%)
Baseline
12 84
21
43 to 100
7 (58%)
Follow Up
12 98
3
92 to 100
12 (100%)
* On time is defined as +/- 1 hour from target time
Conclusion
• CBI intervention appears to be feasible, acceptable
and improves pill-taking in those with adherence
problems.
• Lay health counsellors can be trained to deliver the
intervention at low cost.
What’s next for our work on CBIs for adherence
and ‘depression’
• Supplement to validate tools for depression,
cognition and barriers to adherence
• Randomized Controlled Trial, NIMH R01, in progress
• Medical Research Council (MRC-UK) Pilot trial in
South Africa (with Alan Stein, Oxford and Africa Centre KZN)
• PMTCT study – with College of Medicine, Malawi
Acknowledgements
Tendai Zimbabwe Team: Dixon Chibanda, Ronald
Munjoma,Khameer Kidia, Debra Machando, Emily Saruchera
Tariro Makadzange, Rati Ndlovu, Nomvuyo Mthobi, OI clinic
nurses and adherence counsellors
Tendai London team: Kirsty Macpherson, Lucy Potter,
Ricardo Araya, Liam Morton, Melanie Abas.
Tendai Harvard Team : Steven Safren, Conall O'Cleirigh,
Jessica Magidson
UZ Dept of Psychiatry/IMHERZ: Walter Mangezi, Alfred
Chingono, Frances Cowan, Shamiso Jombo, NECTAR
Research grants management team
NIMH Division of AIDS
TATENDA, THANK YOU