PATIENTS’ EDUCATION ON ARV TREATMENT ADHERENCE AND MONITORING OF ARV THERAPY

• To guide pharmacists in providing appropriate education and drug related information to patients and to discuss the role of treatment adherence in the success of ART.

Objectives

·         To understand the importance of imparting education and drug related information to patients

·         To appreciate that providing information about prescribed medicines promotes appropriate use, increases compliance and leads to effective and successful therapy

·         To  discuss the importance of patient adherence to first line ART

·         To understand patient barriers to adherence

·         To determine ways of promoting patient adherence

·         To list methods of assessing adherence

·         To illustrate relevant drug related patient information pertaining to ART and OIs medicines

Among various tasks assigned under Pharmacist’s role in the Operational Guidelines for ART Centers (March 2008), three specific tasks related to patients’ education on ARV medicines and monitoring of ARV therapy are:

·   

     Advise the patients and family about importance of adherence during each visit

·         Advise the patient on possible drug toxicities and reporting of the same if significant

·         Do Pill count and report any adverse effects of drugs or any OIs.

Why Adherence is needs to be Different in HIV disease?

About 80% adherence may be sufficient to achieve therapeutic goals in many chronic disease states (e.g. hypertension, etc.). However, this level of adherence is inadequate in treatment of HIV. A more than 95% adherence is necessary to achieve a viral load of <400 copies/ml in 81% of patients. A 10% reduction in adherence is associated with a doubling of HIV RNA level. HIV multiplies rapidly in the absence of ARVs, or when there are sub-therapeutic levels of ARVs. With the increasing viral load in the presence of ARVs, more mutations may occur, causing resistance to the ARVs. Once resistance develops, the ARVs are no longer effective and viral replication increases, CD4 counts drops, and clinical illness develops. The very short life cycle of ARV (1-2 days) means that whenever there is any non-adherence, viral load increases very quickly within 3-7 days, and sometimes even faster. In a prospective observational study of therapy of 950 naive patients treated with triple-combination therapy it was found that for every 10% decrease in adherence there was a 16% increase in HIV-related mortality.

Non-adherence

It affects specially children, working adults and patients in acute and chronic stages of the disease. This is a global problem which may exceed 50%, leading to even life-threatening situations, some of causes are: (i) Inappropriate attitude and poor communication skills of the providers; (ii) Patient's fear of asking questions; (iii) Inadequate consulting time; (iv) Inadequate dispensing time: (v) Lack of access of printed information in simple language (e.g. patient leaflets or adequate labels); (vi) Inability to pay for prescribed drugs; (vii) Complexity and duration of treatment, particularly in chronic disease; (viii) side effects; (ix) poor labelling (x) nature of medication (xi) social isolation (xii) mental illness (xii) deliberate deviation (xiii) in appropriate packaging. Common types of non-compliance are (i) failure to take prescribed medication; (ii) not having prescription filled (or re-filled); (iii) self-discontinuation of medications; (iv) taking incorrect doses (over or under); (v) taking medicine at wrong time (vi) skipping doses. (vii) Side effects, (viii) poor labeling (ix) nature of medication (x) inappropriate packaging. Incorrect medication leads to prolongation of illness, avoidable side effects, drug interactions, increased hospitalization, work absences, over use of health care facilities and even death.

Compliance vs. Adherence

Compliance is acting in accordance to a command. The doctor/nurse tells the patient what to do and he/she must do it without any question. Adherence is a mutual decision making. The patient understands and, together with the healthcare worker, agrees to make behavior changes to improve health outcomes. Barriers for Adherence could be patients related (simply forgetting, financial constraints, fear of disclosure, having a co-existing substance addiction, inability in understanding treatment instructions, co-existing diseases or illnesses and physical disability, etc.), beliefs about medication (side effects and toxicities, complicated drug schedules, doubts in the effectiveness of ART, feeling fine or healthy / sense of well being, decreasing quality of life while on ART and feeling too sick, et.) and inconvenient daily schedules (difficulty in incorporating work and family responsibilities with ART schedules, traveling long distances to receive ART, being too busy or engaged otherwise, being away from home, etc). Therefore, for improving care by better adherence, special attention is made to ensure high quality of counseling on all visits with focus on ART issues- adherence, consequences of side effects, positive living and psycho social aspects. Adequate preparedness for ART shall be done for all patients (2-3 sessions before ART is initiated). Remember ART is never an emergency intervention and initiate it only when patient is ready for it. In order to keep a full track on patient receiving ART, the documentary “Address Proof” is mandatory for registration of patients at ART Centres. In case a patient does not have address proof on the first visit, he / she should still be attended to and asked to bring address proof on the next visit. In case the person does not have a valid address proof, he / she can get a certificate from local Panchayat / Sarpanch. In case of footpath dwellers and others, who do not have any residence, a certificate from DLN or NGO supported / funded under NACP, who takes the responsibility of tracing them in case they are lost to follow up (LFU), will suffice. All ART centres should put up a notice board at the centre giving the contact details of the local network of positive people. Treatment adherence over time is a big challenge in ART as aadherence declines over the time (Treatment Fatigue).

Box 11.1

Reasons for Treatment Default	Adherence %
Long Distance	36
Finance Problem	32
Sickness	11
Social Problem	6
Adverse Weather	5
Others	10
Total	100

Factors facilitating Adherence Counselling

Taking sufficient time to reinforce information and counselling to discuss issues pertaining to therapy is very important. Educate the patient relevant to his level of understanding. A team approach by physician, nurse, counselor, and pharmacist can lead to better appreciation of adherence by the patient. If required, arrange a session with psychiatrist in specific situations. Encourage use of peer counselors and group counseling. At every subsequent visit or follow up reinforce information and administer adherence counseling. Factors facilitating adherence counselling are of three kinds:

Patients related

1. Self-Belief in living and living well
2. Accepting HIV result and accepting life-long treatment
3. Improved quality of life when adhering to ART (Experiencing it to believe)
4. ART taking priority over substance use

Beliefs about medication

1. Belief in the efficacy of ART and “having faith” in the treatment
2. Understanding the need for strict treatment adherence
3. It is a simple regimen, feasible to follow (First line ART)

Daily Scheduling

1. Learning to balance ART with daily schedules as a facilitator of adherence. Having a routine in which taking antiretrovirals could be easily incorporated
2. Making use of reminder tools (Tailor made for each patient)

Role of Patient information on use of medicine

Adequate information on medicines enables patients to use them in an appropriate, safe and judicious way. Incomplete and inadequate information leads to serious health and economic consequences. Pharmacist can provide information either verbal or written. Information and counseling can be provided at the time of dispensing medicines. Information provided could be vital/essential viz. dose, frequency, duration, how medicines should be stored and supplementary information viz. side effects, concomitant medicines, purpose of each medicine, how to take each medicine- dose, time, frequency, before or after meals, specific precautions to be taken, what side effects can be expected, when to report to the doctor, what to do if a dose is missed and how to use devices: MDI, rotainhalers, etc.

GOOD COMPLIANCE AND ADHERENCE TO ANTIRETROVIRALS

The therapeutic outcome of any treatment is largely based upon the good compliance by the patient. Non compliance (or non-adherence), not only include for drug therapy, but also the failure to obey instructions on other aspects of health care, such as dietary advice, exercise, smoking or drinking habits and life style modification. As per Current Medical, Diagnosis and Treatment (CMDT) and Guidelines for HIV Diagnosis and Monitoring of Anti-retroviral therapy (WHO 2004) encompassing scaling up of HIV/AIDS treatment and WHO 3 by 5 Initiative, the treatment for HIV infection can be divided into four categories; therapy for opportunistic infections and malignancies, anti-retroviral treatment, administration of hematopoietic stimulating factors and prophylaxis for opportunistic infections. Antiretroviral (ARV) therapy has proven to be effective in: (i) Decreasing viral load, (ii) Increasing CD4 counts, (iii) Preserving immune functions, (iv) prolonging survival, (v) Decreasing the incidence of opportunistic infections, (vi) Preventing disease progression, (vii) Prolonging survival, (viii) Enabling the patient to lead a productive life, e.g. resuming job and (ix) Improving quality of life. Monitoring of ARV therapy is necessary to achieve two goals. Laboratory evaluation of toxicity depends upon the specific drugs in the combinations, but generally should be done approximately every 3-6 month once a patient is on stable regimen. The second aspect of monitoring is to regularly measure objective markers of efficacy (CD 4 cell counts, HIV viral load and microbiological studies).

Rapidly increased the availability of ARV treatment in line with 3 by 5 targets has lead to more people knowing their HIV status and more openness about AIDS. Individuals on effective treatment are also likely to be less infectious and less able to spread the virus. Good treatment programme will make more people come forward for testing of HIV/AIDS status and can therefore; contribute to the rapid acceleration of prevention. However, there are many difficulties associated with the use of antiretroviral therapy, such as; treatment is lifelong and is associated with many side effects, patients often find it difficult to adhere to antiretroviral treatment. Certain antiretrovirals, such as the protease inhibitors, have complex restriction regarding food intake. There are many pills to be swallowed per dose, and dosing is often on a twice/thrice-daily basis.

Drug interactions: The protease inhibitors most frequently exhibit drug interactions with each other, and also with other drug, e.g. anti-TB drugs, antifungals. This poses a problem for treating the HIV positive patient, because there are common opportunistic infections, especially in our country. The NNRTI class of drugs also exhibits some drug interactions. The NRTI class is not associated with clinically significant drug interactions. For details refer module on Drug-drug interactions with special reference to ARV & OI drugs.

Long-term side effects: The protease inhibitors are associated with some of the most severe long-term side effects. These include: (i) Lipodystrophy (the arms, legs and face appear to lose weight, whereas the central portion of the body accumulates fat and become obese); (ii) Diabetes, (iii) Increased cholesterol and triglycerides levels; (iv) Hypertension; (v) Osteoporosis; (vi) Gynaecomastia; (vii) Kidney stones and loss of renal function; (viii) Myocardial infarction. The non-nucleoside reverse transcripts inhibitor (NNRTI) class of drugs is not associated with significant long-term toxicity, but certain patients may develop a rash or elevated liver enzymes during the first few weeks of therapy. The nucleoside reverse transcriptase class of drugs may be infrequently associated with lactic acidosis or peripheral neuropathy. For details refer module on Adverse Drug Reactions and Pharmacovigilance with special reference to ARV and OI drugs.

Access: The patient should be able to get antiretroviral therapy for an indefinite period of time. However, the Government of India under 3 by 5 initiative has made the HIV/AIDS treatment free of cost at all designated ART centers, and elsewhere, there are good number of international and national NGOs/Foundations trying to support ARV treatment.

Patient Information, Education and Communication (IEC) - Importance of IEC

Patient information, education and communication including counseling (IEC) leads to not only increased knowledge and better compliance by the patients but also makes an improvement in the quality of care. It has been established by various studies that in informed group of patients including knowledge of potential side effects, there was better compliance and safety. Communication is now recognized as a core clinical skill and a challenge in medicine in general and in HIV/AIDS/and cancer in particular. Pharmacists must communicate with depressed and anxious patients and their relatives. Before initiating antiretroviral therapy, it is essential to discuss and clarify the following points with the patient and their relatives.

§  AIDS is not an immediate death warrant. Induce and encourage hope.

§  Therapy available today is suppressive, and not curative. But treatment helps the patient to lead a more productive life. The treatment would not only add years to the life but also a quality of life to the years. The patient may continue to acquire other illness associated with AIDS, including opportunistic infections. Therefore, patients should always remain under physician's care during the therapy. Periodic lab test monitoring from a reliable lab is also necessary.

§  The duration of therapy is lifelong. HIV may be regarded as a chronic illness, just like diabetes or hypertension.

§  Although treatment is expensive, the prices of antiretrovirals have now been reduced and opportunities for free treatments exist through various sources.

§  Long-term adverse events may occur, but there are drugs to manage these side effects.

§  There is a potential for drug interactions with other concomitant medications.

§  There may be a number of pills to be swallowed per day, depending on the antiretroviral regimen chosen. However some of the new regimens entail taking a total of only 4-6 tablets per day.

§  Adherence is critical, else the virus quickly develops resistance. Take medicines regularly as prescribed.

§  ARVs may interact with some drugs; therefore, advise patient to report to the doctor the use of any prescription or non-prescription/OTC medication, herbal products.

§  It is important to inform the patients that even if they are receiving therapy they should not donate blood and should practice protected sex, since the patient is still capable of infecting others.

§  Maintenance of a regular life, exercise, personal hygiene and avoidance of infections is very important. The patient must have nutritious food, regular exercise, proper rest and sleep and avoid smoking, tension, alcohol and intoxicating drugs and contact with pets. Woman patients may avoid pregnancy.

Counseling facilitates rational and compliant behaviour by the patient. The basic and most common cause of the non-compliance is that the patient does not fully understand what is expected. Helping the patient to understand what is expected is the prime motive of counseling. Facilitating characteristics for effective communication are empathy, respect and warmth. Exploration improves both insight and understanding of problems and helps in building a professional relationship between the pharmacist and the patient. Unfortunately in India, these aspects are yet to be seen in the community pharmacist. Factors that may contribute to the pharmacist's ineffectiveness in helping the patient to take medicine appropriately are: (i) they do not know what to tell about their medicine. Communication, if at all it takes place, is often one-way communication and there is hardly any element of feedback. (ii) Attitude towards medication to patient while dispensing prescription or OTC drugs, and (iii) lack of communication skills. Often there are false assumptions about compliance such as physician must have already discussed with the patient the medicines prescribed (study shows physicians frequently omit to pass on critical information); the patient understands all the given information; the patient understands what is required (non-medical advice, diet, exercise, etc.); non-compliance is because the patient "doesn't care" or is not motivated or lacks intelligence or can't remember (esp. elderly); patients would ask if they have any problem.

Techniques that assist in compliance are: (i) Maintain a friendly, caring (rather than impersonal) relationship with the patient, for which prerequisites are rapport building, assured confidentiality, privacy, easy accessibility and empathy; (ii) emphasize the key points; (iii) give reasons for key advice; (iv) give definite, concrete and explicit instructions; (v) supplement and reinforce the spoken words with written information; (vi) ensure feedback.

Drug related patient information

General (for all antiretroviral drugs)

Inform the patients that the given medication is not a cure for HIV infection, which they may continue to acquire illnesses associated with AIDS, including opportunistic infections. Medicines may not reduce the incidence of frequency of such illnesses. Tell the patients that the long-term effects of some of these newer drugs are unknown at this time. Advise them that the therapy have not been shown to reduce the risk of transmission of HIV to other through sexual contact (safe sex) or blood contamination.

Drug-specific patient information

Drug-specific patient information is usually based on when to use (indications) and not to use (contraindications) a particular medicines, warnings, special precautions and side effects associated with the medicine, drugs and foods to be avoided during the medications (Drugs and Food Interaction) and specific storage conditions, if any. Usually detailed information about these aspects is available in the printed packaged leaflets/information supplied with the medicines by the manufactures and a pharmacist is expected to synthesize key information in simple understandable language as relevant “Patient Information”. The “Patient Information” should be communicated in such a subtle manner so as to not cause a fear, but, promote compliance and adherence. It should specifically convey what are usual side effects which patient must tolerate or must report to doctor for review of the treatment. A brief summary about commonly used antiretroviral drugs, including some second line ARVs are discussed here under following groups:

1. NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITOR ANALOGUES (NRTIs)

ZIDOVUDINE (Azidothymidine, AZT, Compound S)

The major toxicity of Zidovudine is neutropenia and anemia that may require transfusion or dose modification including possible discontinuation. Frequency and severity of the toxicity are greater in patients with more advanced disease and in those who initiate therapy later in the course of their infection. It is extremely important to have blood counts followed closely while on therapy, especially patients with advanced symptomatic HIV disease.

Warn the patients about the use of other medications (eg. ganciclovir, interferon) that may exacerbate the toxicity of zidovudine.

Advise the patients to contact their physician if they experience shortness of breath, muscle weakness, symptoms of hepatitis or pancreatitis, or any other unexpected adverse reaction. Inform patients that nausea and vomiting may also occur. Advice pregnant women considering use of the drug to prevent maternal fetal transmission of HIV and that transmission may still occur in some cases despite therapy. Long-term consequences on uterus and infant exposure are unknown. HIV infected women should not breastfeed.

Take the dose exactly as prescribed. Do not share the medication and do not exceed the recommended dose.

LAMIVUDINE (3TC)

Advise patients of the importance of taking Lamivudine exactly as it is prescribed. Advice parents to monitor pediatric patients for symptoms of pancreatitis (like abdominal pain, nausea and fever). Advise patients to discuss any new symptoms or concurrent medication with their physician.

STAVUDINE (d4T)

Inform and counsel patients that the most common toxicity of Stavudine is peripheral neuropathy Symptoms include tingling, burning, pain or numbness in the hands or feet. Advice them to report these symptoms to their physician and that dose changes may be necessary. They should also be cautioned about the use of other medications that may exacerbate peripheral neuropathy.

Inform patient of the importance of early recognition of symptoms of symptomatic hyperlactemia or lactic acid acidosis, which include unexplained weight loss, abdominal discomfort, nausea, vomiting, fatigue, dispense, and motor weakness and seek immediate medical attention.

It should not be combined with Zidovudine.

2. NON-NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NNRTI)

EFAVIRENZ

To improve tolerability of nervous system side effects, bedtime dosing is recommended during the first 2-3 weeks of therapy and in those patients that continue to experience these symptoms. High fat meals should be avoided.

Inform patient that serious psychiatric symptoms including severe depression, suicide attempt, aggressive behaviour, delusion and psychosis like symptoms also have been infrequently reported in patients receiving efavirenz.

Inform patient that one of the most common side effect is rash, which usually goes away without any change in treatment.

NEVIRAPINE

Hypersensitivity characterized by rash (which may lead to fatal situation if ignored) may occur, inform treating physician immediately.

Loss of appetite, unusual tiredness, yellowness of eyes/skin may occur in some cases in first few weeks of initiation of therapy (hepatotoxicity), inform doctor immediately).

3. PROTEASE INHIBITORS (Pls)

RITONAVIR

Take with meals. Do not alter the dose or discontinue. It should be stored in the refrigerator as directed.

Box 11.2  Assessing Adherence and Monitoring of ARV Therapy

Assessing Adherence
Assessment  Tool	Effectiveness / Reliability
Patient self-report	•      Counsellor interview, MO examination, Entries in white card and patient’s record (Green book) •      Convenient, routine and inexpensive •      Less accurate; assessments over time improve  the accuracy
Pill counts	•      May be more accurate than self-report •      Already incorporated in the system
Pharmacy records /prescription refill monitoring	•      Objective measure, but presumptive; collection of drugs does not necessarily mean that they are consuming them correctly •      May serve to improve adherence when combined with telephone prompts on due visit dates

Box 11.3

Simple Drug Adherence: Calculation
> 95% Treatment Adherence	Less than 3 doses missed in a period of 30 days
80 - 95% Treatment Adherence	3 to 12 doses missed in a period of 30 days
< 80 % Treatment Adherence	12 or more doses missed in a period of 30 days

Treatment Adherence Calculation for Individual Patient

The simplest method to assess adherence percentage is by pill counts. Fractions generated by the following formula when multiplied with 100 would give “Adherence %”.

A = (Number of tablets/ doses actually taken by a patient for a particular time period) ÷   (Number of tablets/ doses the patient should have taken during this same time period)

A = (Number of tablets remaining with the patient during the previous refill/ visit + Number of tablets given to the patient during the previous refill/ visit – Number of tablets remaining with the patient during the present refill/ visit) ÷  (Number of  days between the previous refill/ visit and the present actual visit  ×  Number of doses per day).

This fraction “A”, when multiplied by 100, gives the adherence percentage

LFU & MISS patients

In order to avoid default, the Operational Guidelines requires that the data manager should prepare a daily “due list” which indicates all PLHA due to visit ART centre on that day. All those patients in this list who fail to collect drugs on that day must be followed up within 48 hours through phone calls or through home visit by ORW of TCC/CCC or ICTC counselors / DLN members. The team should also hold a meeting with linked CCC manager/ ICTC/ DLN to explain the process of tracking LFU / MISS cases to ensure the operationalisation of this system. In the same meeting the referrals between ICTC to ART centre should be line listed and reviewed. In tracing LFU & missed cases of large ART centres who belong to neighboring states, the mother SACS should play a vital role in coordination with these neighboring SACS.

Continuous monitoring and supervision of all activities carried out at all the ART centers (Government, PSUs, Non-Government Sector) are important for monitoring effectiveness and quality of services. To facilitate a uniform and systematic monitoring, it is necessary to develop common monitoring tools and systems. A set of registers and reporting formats have been developed by NACO and should be used uniformly by all the ART centers as per the Operational Guidelines for ART Centers March 2008 (section 2.8). Treating doctor and counselor have been assigned most activities pertaining to monitoring treatment and reporting in the following prescribed formats:

ART Code								ART
1. ART Centre CMIS Code					Schedule Code
Please do not create any other file, use only this file for data entry and sending to NACO.
Monthly Input Formats for ART
2. Name of ART Centre
3.&4. Address :
City:				Pin Code:		District:	Satara
5. Reporting Period:			Month		Year	2009
6. Name of Officer
6a.Contact Details of ART Center incharge				Phone		Email
7. PLHA seeking care at the treatment center (Registering in HIV Care)
Indicator			Adults			Children		Total
			Male	Female	TS/TG	Male        <15 Years	Female        <15 Years
7.1 Cumulative number of persons ever registered in HIV care at the beginning of this month								0
7.2 Number of new persons registered in HIV care during this month								0
7.3 Cumulative number of persons registered in HIV Care at the end of this month			0	0	0	0	0	0
7.4 Out of 7.2, the number of pregnant women registered in HIV care this month			0		0	0		0
7.5 Number of persons newly started on CPT  (CTX) this month								0
8. Enrolment in ARV treatment
8.1 Cumulative number of patients ever started on ART (Number at the beginning of this month)								0
8.2 Number of new patients started on ART during this month								0
8.3 Number of patients on ART "transferred in" during this month								0
8.4 Cumulative number of patients ever started on ART (Number at the end of this month) = 8.1+ 8.2 + 8.3			0	0	0	0	0	0
8.5 Cumulative Number of  patients who re-entered into ART (after LFU) during this month								0
9. Treatment Status of Patients on ART
9.1 Cumulative number of patients who died since the beginning of the programme								0
9.2 Cumulative number of patients  "transferred out"								0
9.3 Number of all patients whose treatment status in this month is “stopped treatment”								0
9.4 Cumulative Number of patients who are lost to follow-up (LFU)								0
9.5 The number of patients who did not return to the ART center whose treatment status is “MIS” in this month								0
9.6 Total number of patients alive and on ART (OT) at the end of this month = 8.4 - (9.1+9.2+9.3+9.4+9.5)			0	0	0	0	0	0
9.7a  Out of 9.6, the number of patients on ART initiated on DOTS this month								0
9.7b Out of 9.6, the number of patients on ART initiated on non-DOTS anti-tuberculosis treatment this month								0
9.7c Out of 9.6, the total number of pregnant women on ART this month								0
10. Treatment adherence 10.1 Of all patients who are on treatment this month (9.6) the number who have NOT been assessed for adherence (refer guideline) 10.2 Of all patients on ART (9.6) this month and who have been assessed for adherence, how many had 95% adherence or better (refer guideline) 10.2a)  Number 10.2b)  Percentage 11. Regimen used during the reporting month Adult Regimen Number of Patients alive and on ART on this regimen (i)  AZT+3TC+NVP (Ia)  d4T30+3TC+NVP (II) AZT+3TC+EFV (Iia) d4T30+3TC+EFV (III) TDF+3TC+NVP (IIIa) TDF+3TC+EFV (IV) AZT+3TC+LPV/r (Iva) d4T+3TC+LPV/r Others Total number of Adult patients Paediatric Regimen Number of Patients alive and on ART on this regimen d4T6+3TC+NVP d4T10+3TC+NVP d4T30+3TC+NVP d4T6+3TC+EFV d4T10+3TC+EFV d4T30+3TC+EFV AZT+3TC+NVP AZT+3TC+EFV AZT60+3TC30+EFV ABC60+3TC30+NVP50 ABC60+3TC30+EFV Others Total number of Paediatric patients Total patients

15 Key side effects to ARV drugs/IRIS.
Side effects	No. of  Patients who were diagnosed with a side-effect this month		Side effects	No. of  Patients who were diagnosed with a side-effect this month
1. AZT Induced Anaemia			6. Pancreatitis
2. Preipheral Neuropathy			7. Skin Reaction
3. Hepatitis			8. CNS Side Effects
4. Lipoatrophy			9. IRIS
5. Lactic Acidosis			10. Others
16. DETAILS OF OPPORTUNISTIC INFECTIONS
16.1 Total Number of patients having one or more OIs this month:
16.2 OI types and episodes
OI's	16.2a) No. of  patients who were diagnosed with OIs this month	16.2b) Total no. of episodes this month for all patients	OI's	16.2a) No. of  patients who were diagnosed with OIs this month	16.2b) Total no. of episodes this month for all patients
1. Tuberculosis			7. Cryptococcal Meningitis
2. Candidiasis			8. Toxoplasmosis
3. Chronic Diarrhea			9. CMV Retinitis
4. PCP			10. MAC
5. Herpes Zoster			11. Other (Specify)
6. Bacterial Infections (Respiratory)			12. Other (Specify)

Pharmacists have been assigned monitoring related tasks pertaining to supply, store management and dispensing. As pharmacists are required to advise the patients and family about importance of adherence during each visit and advise the patient on possible drug toxicities and reporting of the same if significant, the pharmacists can play a significant role in monitoring by doing Pill counts during re-fill and report any adverse effects of drugs or any OIs.

Optimal adherence requires full participation by the health-care team, with goal reinforcement by more than 2 team members. Supportive and nonjudgmental attitudes and behaviors will encourage patient honesty regarding adherence and problems. Improved adherence is associated with interventions that include pharmacist-based adherence clinics, street-level drop-in centers with medication storage and flexible hours for homeless persons, adolescent-specific training programs, and medication counseling and behavioral intervention. Monitoring can identify periods of inadequate adherence. Evidence indicates that adherence wanes as time progresses, even among patients whose adherence has been optimal, a phenomenon described as pill fatigue or treatment fatigue. Thus, monitoring adherence at every clinic encounter is essential.

Key Learning Points •         Providing education and information is a key element in the success of ART •         Patient must be prepared before initiation of the ART with clear understanding that treatment is not cure, lifelong and side effects should not encourage patient to quit medication. •         High rates of adherence are vital to ensuring continued efficacy of ART •         Taking time for education and support to the patient is essential •         All members of the healthcare team should be involved •         Adherence must be reinforced at every visit •         Self reporting and Pill count are low cost effective ways of assessing adherence •         There is “No Magic Bullet” for effectiveness of ART •         Providing education and information about prescribed treatment and making patients aware about the role of therapy promote appropriate medicine use, increases compliance and leads to effective therapy •          Patient be encouraged to cooperate for the monitoring of the therapy