Readiness to Start/Maintain ART

Assessing PLWH's Readiness to Start and Maintain ART

ART of PLWH

This section provides an overview of the important aspects of the management of PLWH starting or established on ART. Recommendations are based on a range of evidence, in particular it is weighted towards randomised controlled clinical trials. Other data have been taken into account, including cohort studies, and where evidence is limited, the panel has reached a consensus around best clinical practice. The ART section is wide ranging and, with the change in starting therapy independently of CD4 count, there is an important section on readiness to start. Treatment recommendations are based on drugs licensed in Europe and range from initial therapy through to switching with or without virological failure. Two important areas of ART are highlighted: pregnancy and TB. Details on the use of PrEP, which is being rolled out across Europe, are also included.

Assessing PLWH's Readiness to Start and Maintain ART

Goal: to help persons start and/or maintain ART

(ix) Algorithm adapted from [11]

Starting ART is recommended for all PLWH regardless of CD4 count to reduce the morbidity and mortality associated with HIV infection, and to prevent HIV transmission (START trial, HPTN 052, PARTNER Study) [1-3]. Evidence is accumulating that starting ART on the same day after establishing a diagnosis of HIV infection is feasible and acceptable to PLWH. Nevertheless, assessment of the readiness to start ART is essential to enable the PLWH to express their preference and not feel pressured to start ART immediately, unless clinically indicated.

Given the need for lifelong treatment, successful ART requires a person's readiness to start and adhere to the regimen in a sustained manner. The trajectory from problem awareness to maintenance on ART can be divided into five stages. Knowing a person's stage, health care providers use appropriate techniques to assist them to start and maintain ART.

Identify the person's stage of readiness using WEMS(i)techniques, and start discussion with an open question/invitation:
“I would like to talk about HIV medicines.” [wait] “What do you think about them?”

Based on the person’s response, identify his/her stage of readiness and intervene accordingly(ii)

Immediate (i.e. same day) start of ART should be considered, especially in the following situations:

  • In the setting of primary HIV infection, especially in case of clinical signs and symptoms of meningoencephalitis (within hours). In this situation, the clinician may start ART immediately after a positive screening HIV test and before obtaining confirmatory HIV test results such as a HIV-VL
  • The wish of a PLWH to start ART immediately
  • In a setting where loss-to-follow-up is more likely if ART is not started the same day

Stages of Readiness to Start ART

   
Precontemplation:
"I don't need it, I feel good"
"I don't want to think about it"
Support: Show respect for the person's attitude. / Try to understand the person's health and therapy beliefs. / Establish trust. / Provide concise, individualised information. / Schedule next appointment
Contemplation: 
“I am weighing things up and feel 
torn about what to do about it”
Support: Allow ambivalence. / Support the person in weighing pros and cons. / Assess the person's information needs and support his/her information seeking. / Schedule the next appointment
Preparation: 
“I want to start, I think the drugs 
will allow me to live a normal life”
Support: Reinforce the person's decision. / Decide with the person which is the most convenient regimen. / Educate the person on adherence, resistance and side effects. / Discuss integration into daily life. / Assess self-efficacy
Ask: How confident are you that you can take your medicines as we discussed (specify) once you have started?
Consider skills training: 
  • Medicines-taking training, possibly Medication Event Monitoring System, e.g. electronic pill boxes 
  • Directly observed therapy with educational support 
  • Use aids: mobile phone alarm, pillboxes 
  • Involve supportive tools/persons where appropriate
Action: 
“I will start now”
‘Final check’: With a treatment plan established, is the person capable of taking ART and is ART available?

Maintenance: 
“I will continue” or ”I have 
difficulties continuing over 
the long run”

Caveat: A person can relapse 
to an earlier stage, even from 
“maintenance” to “precontemplation”

Assess: Adherence every 3-6 months(iii) 
Evaluate adherence: For persons with good adherence: show respect for their success
Assess: The person's own perception of ability to adhere to and continue treatment
Ask: In the next 3-6 months, how confident are you that you can take your medicines?
For a person without sufficient adherence: use mirroring techniques(iv) 
on problems, ask open questions to identify dysfunctional beliefs
Assess: Stage of readiness and provide stage-based support 
Assess: Barriers and facilitators(v)
Schedule next appointment and repeat support

Barriers

Several barriers are known to influence ART decision making and adherence to ART. Screen for and talk about problems and facilitators.

Consider systematic assessment of:

Consider talking about: 

  • Social support and disclosure 
  • Health insurance and continuity of drug supply 
  • Therapy-related factors
  • Recognise, discuss and reduce problems wherever possible in a multidisciplinary team approach

Footnotes

  1. WEMS: Waiting (> 3 sec), Echoing, Mirroring, Summarising [4]
  2. The person presenting in the clinic may be at different stages of readiness: precontemplation,  contemplation or preparation. The first step is to assess the stage, and then to support/intervene accordingly. In the case of late presentation (CD4 count < 350 cells/μL), the initiation of ART should not be delayed. The person should be closely followed and optimally supported. Schedule the next  appointment within a short time, i.e. 1-2 weeks
  3. Suggested adherence questions: “In the past 4 weeks, how often have you missed a dose of your HIV medicines: every day, more than once a week, once a week, once every 2 weeks, once a month, never?” / “Have you missed more than one dose in a row?” [5]
  4. Mirroring: reflecting back on what a person has said or non-verbally demonstrated (e.g. anger or disappointment) WITHOUT introducing new material by asking questions or giving information
  5. Adherence to long-term therapies [6]
  6. PHQ-2 or PHQ-9 [7]. Meta-analysis shows a consistent relationship between depression and ART non-adherence that is not limited to those with clinical depression. Therefore, assessment and intervention aimed at reducing depressive symptom severity, even at sub-clinical level is important. Ask: "Over the last two weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things; 2. Feeling down, depressed or hopeless." Answers: Not at all (0) / Several days (1) / More than half the days (2) / Nearly every day (3). If the person scores 2 or more, seven additional questions, see [8]
  7. Ask: “Do you feel having problems to concentrate in your daily life?” / “Do you feel slowed in your thinking?” / “Do you feel having problems with your memory?” / “Did relatives or friends express that they feel you have problems with your memory or difficulty concentrating?” [9]
  8. FAST-alcohol use, ask: How often have you had 6 or more units if female, or 8 or more units if male, on a single occasion in the last year? Never=0, Less than monthly=1, Monthly=2, Weekly=3, Daily or almost daily=4. Stop if the answer is 0 (Never). Ask more questions if the answer is 1, 2, 3 or 4. See [10]
  9. Algorithm adapted from [11]