Introduction
Patients with mental health disorders should be considered candidates for highly active antiretroviral therapy (HAART) if they meet the medical eligibility criteria for HAART and demonstrate readiness to begin therapy. Clinicians should determine treatment readiness on a case-by-case basis, weighing such factors as whether the patient attends the majority of his/her appointments and whether he/she expresses an interest in receiving antiretroviral (ARV) therapy.
Key Point:
The most effective means of promoting adherence in patients with mental health disorders is through adequate stabilization of their mental health and integration of mental health treatment into the comprehensive treatment plan.
Coordination of Care
Primary care clinicians should refer patients to licensed mental health providers when:
- Initial mental health treatment by the primary care clinician is ineffective
- Complex mental status evaluations become necessary or a patient's behavior jeopardizes effective treatment
- The patient has co-occurring mental health and substance use disorders
Primary care clinicians and mental health care providers should collaborate to develop a step-by-step treatment plan. The treatment plan should delineate the frequency of follow-up visits with both providers as well as the frequency of team meetings to reevaluate effectiveness of the overall medical and mental health treatment.
Primary care clinicians should initially consult with a psychiatrist when managing patients with mental health disorders who refuse mental health care. Throughout the patient's care, the clinician should communicate with a psychiatrist or a licensed mental health professional who can provide consultation.
Primary care clinicians should notify the mental health care provider when there is a change in medical or mental health treatment.
Predictors of and Barriers to Adherence
Key Point:
Patients with mental health disorders may have learned skills related to adherence to psychiatric medications that they can use to help them adhere to HIV treatment.
See the original guideline document for lists of predictors of and barriers to adherence.
Identifying and Addressing Potential Barriers to Adherence before Initiating HAART
Clinicians should carefully assess each patient to evaluate his/her ability to adhere to HAART.
Clinicians should identify and address potential barriers to adherence before initiating HAART. If clinicians elect to defer HAART while addressing potentially modifiable barriers to adherence, they should discuss this decision with the patient and document it in the medical record.
Clinicians should discuss the following with patients before initiating HAART:
- Clinician and patient treatment goals
- Patient's concerns about treatment and ability to adhere
- Potential side effects of ARV therapy and potential interactions with psychotropic and other medications, as well as how the side effects and interactions will be managed should they occur
Clinicians should use translator or sign language services when language barriers exist.
Primary care clinicians should refer patients with mental health disorders to specialized adherence services when adherence barriers cannot be resolved, particularly if the patient has acquired immunodeficiency syndrome (AIDS) or is at risk for advanced progression of HIV.
Refer to Table 1 in the original guideline document, "Assessment and Approaches to Potential Barriers to Adherence".
Initiating, Measuring, and Monitoring Adherence to ART Therapy
Clinicians should assess adherence at every routine monitoring visit by verifying that patients are taking the correct medications, correct number of pills per dose, and correct number of doses per day.
Clinicians should use finite time intervals when inquiring about and quantifying the patient's self-report. Clinicians should calculate an average response rate based on information obtained at multiple visits to determine a more accurate estimate of adherence.
Clinicians should reassess potential barriers to adherence at least every 3 to 4 months and whenever adherence problems are identified.
When clinicians find it necessary to speak with the patient's friends or family to assess adherence, permission should be obtained from the patient and the patient should be involved in these discussions.
Strategies to Improve Adherence
Patient-Provider Interaction Strategies
Clinicians should encourage patients to state in their own words what they understand about treatment instructions and to ask questions when additional information is needed.
Clinicians should encourage patients to be honest by responding in a nonjudgmental, supportive manner when patients report non-adherence.
Key Point:
A strong patient-provider relationship, including trust and engagement with the provider, has been associated with improved ARV adherence.
| Table. Communication Strategies for Clinicians Treating Patients with Mental Health and/or Substance Use Disorders |
- Proceed slowly; repeat key points; have patients repeat back instructions in their own words.
- Teach science in simple terms.
- Allow honest reporting of non-adherence.
- Use translator or sign language services when language barriers exist.
- Use pictures and/or written material.
|
Health Education Strategies
Clinicians should provide adherence information in an organized manner, both orally and in written form, with easy-to-understand brief statements.
| Table. Health Education Points for Enhancing Adherence |
- The treatment regimen and treatment options
- Drug side effects, with special attention to psychiatric side effects—how to address or avoid
- Drug-drug interactions—how to determine whether interactions are occurring and what to do about them; which drugs do not have any known risks for or lack of likelihood for drug-drug interactions with prescribed and alternative medications, methadone, recreational drugs, and/or alcohol
- The importance of treating comorbid disorders, such as mental health and substance use disorders
- The possible impact of HIV on mental health symptoms
|
Motivational Strategies
Table. Key Components of Motivational Interviewing
| Component |
Involves |
| Expressing empathy |
Understanding and being aware of and sensitive to the feelings, thoughts, and experiences of another. Accomplished through reflective listening. |
| Supporting self-efficacy |
Supporting the patient with the sense that an individual can identify and meet one's needs and goals. |
| Avoiding argumentation and rolling with resistance |
Listening to the patient's resistance to change. Working collaboratively with the patient to develop his/her input regarding the treatment plan. |
| Discovering discrepancies |
Helping patients identify discrepancies between their current behavior and desired future behavior. |
See the original guideline document for information on cognitive-behavioral strategies and directly observed therapy.
