PhD, who conducted the original research and developed content on which much of this manual is based. SMART Couples is one of four HIV medication ...
SMART CoupleS ShARing MediCAl AdheRenCe ReSponSibiliTieS TogeTheR HIV MEDICATION ADHERENCE STRATEGY IMPLEMENTATION MANUAL ACKNOWLEDGMENTS John Snow, Inc. (JSI) acknowledges the support provided by the Centers for Disease Control and Prevention (CDC) through Task Order 200-2009-30955-0004 for the funding to develop the SMART Couples e-learning training toolkit and implementation package and by Robert Remien, PhD, who conducted the original research and developed content on which much of this manual is based. SMART Couples is one of four HIV medication adherence strategies which make up the Every Dose Every Day toolkit. This toolkit features e-learning tutorials on four evidence-based strategies, implementation resources, consumer materials, and a medication adherence mobile application. Every Dose Every Day is designed to encourage HIV prevention and care providers to adopt evidence-based strategies to help people living with HIV attain optimal adherence to antiretroviral therapy (ART) in order to keep their virus under control and reduce transmission. Every Dose Every Day is sponsored by the CDC Division of HIV/AIDS Prevention Capacity Building Branch. The e-learning tutorials and their related materials can be found on the Medication Adherence homepage of the High Impact Prevention website. The research that underlies the SMART Couples strategy was published in AIDS: Remien RH, et. al. Couple-focused support to improve HIV medication adherence: a randomized controlled trial. AIDS. 2005 May 20;19(8):807-14. We are grateful for the input and assistance of Dr. Remien as we adapted the strategy for application in today's clinics and community-based organizations. Special thanks to CDC Technical Monitor, Rhondette L. Jones, MPH and Behavioral Scientist, Kathleen Green, PhD for their continuous support and thoughtful input into all aspects of the development of the Every Dose Every Day toolkit. We extend special sincere appreciation and gratitude to the people living with HIV whose images grace the Every Dose Every Day posters and consumer fact sheets. Acknowledgment and thanks are also due to the dozens of providers of HIV care around the United States who tested, reviewed, and provided feedback and suggestions that improved each of the e-learning tutorials and their supporting materials. The efforts of JSI staff members who played key roles in developing the SMART Couples e-learning tutorial and its implementation materials are also recognized: Elizabeth Costello, Janet Van Ness, Lisa Hirschhorn MD, Frances Marshman, Bisola Ojikuto MD, Michelle Samplin-Salgado, Allison Power, Juli Powers, Courtney Winger, and Diana Zuskov. TABLE OF CONTENTS SMART Couples Overview ......................................................................................................1 Working with Couples ...........................................................................................................3 How to Use this Manual.........................................................................................................4 Session 1: ART and the Importance of Adherence ...............................................................6 Session 2: Identify and Address Adherence Barriers.........................................................14 Session 3: Cope with Stressful Situations ..........................................................................22 Session 4: Make a Commitment to Adherence...................................................................28 Worksheets .........................................................................................................................33 SMART COUPLES OVERVIEW SMART Couples is a couple-focused strategy for HIV-discordant couples with poor medication adherence in the HIV-positive partner. This strategy helps the HIV-positive client improve medication adherence by cultivating social support from the HIV-negative partner. SMART Couples also addresses sexual transmission concerns within the couple. Social support has been shown to enhance treatment adherence. Family-oriented and couple-based interventions have demonstrated effectiveness in improving health outcomes in chronic diseases such as diabetes, heart disease, and mental illness. The goals of the SMART Couples strategy are to: 1. Improve medication adherence among HIV-positive patients by fostering active support from their HIV-negative partners 2. Help couples address issues of sex, intimacy, and transmission risk behaviors Structure and Duration In SMART Couples, an HIV provider works with a couple for four sessions. A health care provider (i.e., nurse practitioner, nurse, licensed social worker, licensed psychologist, HIV counselor) facilitates the sessions in a clinical setting. Each session lasts 45 to 60 minutes and occurs in oneto two-week intervals. This strategy was originally implemented in a clinical setting, but can be delivered in an AIDS service organization or community-based organization that has a strong formalized partnership with a clinical site. Strategy Components Educate couples about the importance of adherence to avoid viral resistance and maintain health Include patients' partners in discussions of treatment decisions and adherence Teach skills to identify patterns of non-adherence Develop communication and problem-solving strategies to overcome adherence barriers Optimize partner support for adherence Build confidence for achieving and maintaining improved adherence SMART Couples Implementation Manual 1 Key Findings From the Randomized Controlled Trial SMART Couples is the first couple-focused intervention for heterosexual and same-sex couples supporting ART adherence to be tested in a randomized controlled trial. The study included 215 heterosexual and same-sex HIV-discordant couples in which the HIV-positive partner had <80% adherence at baseline. Participants were randomized to either the SMART Couples intervention (n=106) or usual care (n=109). The intervention was administered by a nurse practitioner within an HIV outpatient clinic. SMART Couples participants showed higher mean medication adherence post-intervention compared to participants receiving usual care whether adherence was defined as proportion of prescribed doses taken (76% versus 60%) or doses taken within specified time windows (58% versus 35%). Figure 1 shows significant group differences at the primary outcome time-point (week 8) in the percentage of participants who took >80%, >90%, and >95% of doses. Figure 2 shows significant group differences in the percentage of participants who took >80%, >90%, and 95% of doses within specified time windows. The proportion of participants achieving these three adherence levels was significantly higher among SMART Couples participants. In addition, at 6 months post-completion of intervention, the proportion of prescribed doses taken within a specified time window, as measured by MEMs caps, was significantly greater among intervention participants than comparison participants (data not shown). Results of Randomized Clinical Trial: Adherence at 8 Weeks SMART Couples Implementation Manual 2 WORKING WITH COUPLES When engaging a couple and developing rapport, it is important to assess their current concerns and priorities. In SMART Couples, the partners address their concerns by discussing ways they can take care of and support each other. Throughout the strategy, remind the couple that the focus is to acheive optimal medical adherence for the HIV-positive partner. Priorities and concerns that go beyond adherence issues should be acknowledged, but this strategy will not address them in depth. Your agency or clinic should consider referrals to other professionals for issues that go beyond the scope of the strategy. Strategy Session Policies If one partner does not show up for the session: Spend a few minutes talking to the partner who is present to determine why the other partner did not attend. Discuss the importance of them coming in and participating together. Reschedule the session for a time when both partners can attend. If the HIV-negative partner tests HIV-positive: Receiving a positive test result may occur at any point during the delivery of the strategy as HIVnegative partners may take an HIV test and seroconvert at any time. The newly diagnosed individual should receive appropriate medical care once he/she tests positive. The sessions should continue with an emphasis on caring for each other, and all session activities should be conducted as usual. In this case, apply the steps and session activities to the newly diagnosed partner. SMART Couples Implementation Manual 3 HOW TO USE THIS MANUAL This manual is intended for use by SMART Couples providers. For each of the four sessions, we have provided an overview, objectives, worksheets, and steps. Each session is further detailed to include the associated purpose, procedures, suggested scripts, and provider notes. Example step: SESSION 1, STEP 1 Orient the couple to the program; establish rapport; address their concerns. Purpose: Set ground rules for session attendance; establish rapport and acknowledge the current priorities and concerns of the couple before focusing more directly on adherence issues. PROCEDURES Orient the couple to the program. SUGGESTED SCRIPTS Welcome to our first session. It's good to see you here. And it's nice to see you both together. As we know, you're here because one of you is HIV-positive and the other one is not. And I know that presents different challenges for you. As we meet over the coming weeks, we will solve problems and increase your ability to support each other and work together. We will meet for four sessions that will each last between 45 minutes and 1 hour. We will plan to meet over the next five to eight weeks. The suggested scripts can be used as written, but should be tailored to the specific couple as appropriate. Many of the suggested scripts include a series of questions. Allow the script to guide your dialogue with the couple. Sensitivity to culture, language, and educational background is essential. It is important to maintain fidelity to the strategy goals and to cover the content of each session. SMART Couples Implementation Manual 4 Session Titles Session 1: ART and the Importance of Adherence Session 2: Identify and Address Adherence Barriers Session 3: Cope with Stressful Situations Session 4: Make a Commitment to Adherence Strategy Worksheets These worksheets are available as appendices to this manual. Some can be used in multiple sessions. The chart below indicates the applicable session for each worksheet and the number of sheets to print per couple. The provider should keep these worksheets in a folder between sessions. Worksheet Name My Medication Tracker* Pros and Cons of ART Goal Tracking 4 A's of Problem-Solving Challenges and Solutions Triggers and Early Warning Signs Applicable Sessions All sessions Session 1 Sessions 2, 3, 4 Sessions 2, 3, 4 Session 2 Session 4 # to Print per Couple As needed 1 1 3 1 1 *Provider Note: Mobile applications to support medication adherence may be used to keep track of medication doses and medical care visits. SMART Couples Implementation Manual 5 SESSION 1: ART AND THE IMPORTANCE OF ADHERENCE The first session aims to introduce the couple to the importance and components of treatment regimen adherence and set the ground rules for session attendance. The session underscores the importance of adherence by discussing its relationship to health outcomes and the development of drug resistance. The session also clarifies the behaviors that constitute adherence by reviewing information about the medication regimen, medical appointment schedules, and prescription plan. The session introduces the role that the partner can play in promoting adherence, and it aims to begin building motivation, commitment, and mutual support regarding adherence behaviors. Objectives 1. Set ground rules for session attendance. 2. Establish rapport and discuss current priorities and concerns. 3. Increase amount and clarity of information about the medication regimen, medical appointment schedules, and prescription plan. 4. Increase amount and clarity of knowledge about the importance of adherence regarding medical concepts such as viral resistance, bioavailability, absorption, viral load, and CD4 count. 5. Increase commitment to medical adherence, including maintaining a steady supply of medications and keeping medical appointments. 6. Increase couple-level support for medical adherence. Session Steps Step 1: Orient the couple to the program; establish rapport; address their concerns. Step 2: Refocus attention on adherence. Step 3: Explain ways to monitor medication effectiveness and adherence. Step 4: Explain how the partner can play a role in adherence. Step 5: Review the HIV-positive client's medication regimen. Step 6: Review the HIV-positive client's appointment/prescription schedule for the next month. Step 7: Ask questions to determine how well both partners know and understand the medication, appointment, and prescription refill schedules for the next month. Step 8: Inquire about the couple's knowledge and management of side effects. Step 9: Answer questions about the information provided. Step 10: Have the couple list advantages and disadvantages of the medication regimen. Step 11: End the session with a goal to complete before the next session. Worksheets My Medication Tracker Pros and Cons of ART Goal Tracking SMART Couples Implementation Manual 6 SESSION 1, STEP 1 Orient the couple to the program; establish rapport; address their concerns. Purpose: Set ground rules for session attendance; establish rapport and acknowledge the current priorities and concerns of the couple before focusing more directly on adherence issues. PROCEDURES SUGGESTED SCRIPTS Orient the couple to the program. Welcome to our first session. It's good to see you here. And it's nice to see you both together. You're here today because one of you is HIV-positive and the other is not. And I know that presents different challenges for you. As we meet over the coming weeks, we will solve problems and increase your ability to support each other and work together. We will meet for four sessions that will each last between 45 minutes and 1 hour. We will plan to meet over the next five to eight weeks. Establish rapport and ground rules. First, we need to cover ground rules for our meetings. This program is for couples, so it is important that you both attend each session. If only one of you shows up, we'll have to reschedule. At each of our appointments, it is important that you bring any materials, like a journal, calendar, pillbox, cell phone, or anything else that helps you remember to take your medications and attend your appointments. It may also help to bring your medication bottles with you. Address their concerns. Finally, you should feel free to ask me questions about anything. Do you understand these ground rules? Are you both okay with them? What questions do you have for me? Great. So, let me start by asking: What are your most important issues and concerns right now, given the fact that you, as a couple, are living with HIV? Provider Note: Allow the couple to present their concerns. If necessary, remind them to focus on things related to HIV. Acknowledge the importance of their concerns and let the couple know which things you will be able to talk more about and which things you will not have time to address in the few sessions you have together. Remind them that they can talk to others in the clinic/at the agency. SMART Couples Implementation Manual 7 SESSION 1, STEP 2 Refocus attention on adherence. Purpose: Increase knowledge about the importance of adherence and related medical concepts such as viral resistance; increase commitment to medication adherence. PROCEDURES SUGGESTED SCRIPTS After addressing general concerns, orient the couple to medical adherence issues if necessary. So although you face many challenges, we want to focus on doing everything necessary to help you maintain the best health possible. This is going to require ongoing commitment and attention from both of you. Note the spectrum of tasks necessary for proper adherence to medical treatments, acknowledge that adherence can be challenging. Explain the importance of staying adherent. This includes instruction on issues of bioavailability/absorption and potential for drug resistance. This includes keeping your regular clinic appointments and getting regular viral load tests and CD4 cell counts, maintaining a constant supply of medications, and following a strict schedule to ensure you are taking them as you should. Doing all of these things consistently is difficult. In addition to the schedules, you may have to deal with unpleasant side effects from the medications. But staying on top of your treatment is so important it can contribute to optimal health, improved quality of life, and a longer life. It is essential you take your medication as it is prescribed with food or without food and at the right time. This is important because the medication needs to be in your system to keep the virus down. We talk about how much drug is available in your body, and how much is actually absorbed by your body. We also want to decrease any opportunity to develop resistance to your medication. If the virus becomes resistant to the drugs you are taking, it is likely that other medications in that same class will not work either. So you become more vulnerable to illness. A person living with HIV needs all of the help he/she can get to maintain the best health possible. Involving your partner can lead to increased support and assistance. Provider Note: Bioavailability is physiological availability of a given amount of a drug, as distinct from its chemical potency. Absorption is the process of the drug moving from the muscle, digestive tract, or other site of entry into the body toward the circulatory system. SMART Couples Implementation Manual 8 SESSION 1, STEP 3 Explain ways to monitor medication effectiveness and adherence. Purpose: Increase knowledge about the importance of adherence in relation to concepts such as viral load and CD4 cell count. PROCEDURES Explain how to know the medications' effects, whether they are being taken as prescribed (implications for CD4 counts/viral load), and discuss the use of lab data during future sessions. SUGGESTED SCRIPTS We can find out how well the medications are working and how well you are taking them in a few different ways. Lab results will help us look at their effects in your body. Our discussions, information the two of you provide, and any records you keep will focus us on how well you have been able to take your medications as prescribed. CD4 cell counts tell us how your immune system is functioning, and viral load tells us how much HIV is in your system. If the medications are working, the level of virus in your blood will drop to below the level we can detect. This does not mean the virus is gone; it will continue to grow and multiply again if you stop taking your doses every day. A low viral load also does not rule out the possibility of infecting your partner. Also, if the medications are working, we will see your CD4 cell count get higher as your immune system gets stronger. However, if you do not take your doses as prescribed, your CD4 count will drop, telling us that your immune system is not working as well as it should. SESSION 1, STEP 4 Explain how the partner can play a role in adherence. Purpose: Increase couple-level support for medical adherence. PROCEDURES Explain how the HIV-negative partner can play a key role in adherence. SUGGESTED SCRIPTS Let's talk about how your partner can support you with taking your medications. You already know that following the medication regimen means changes in your life. These changes affect your partner's life as well. So, we need to find ways to make it easier on both of you. Your partner can help you meet your schedule of medications and appointments, and provide you with emotional support and encouragement. SMART Couples Implementation Manual 9 SESSION 1, STEP 5 Review the HIV-positive partner's medication regimen. Purpose: Increase knowledge and understanding of the medication regimen. Worksheet: My Medication Tracker PROCEDURES SUGGESTED SCRIPTS Review the HIV-positive partner's medication regimen and introduce the tracker. Let's start by going over your medication schedule: which pills are you taking, when, and under which conditions? You can use this tracker to record your medication schedule, noting whether you've taken your dose each day. If you miss a dose, take notes on what caused you to miss that dose. SESSION 1, STEP 6 Review the HIV-positive partner's appointment/prescription schedule for the next month. Purpose: Increase knowledge and understanding of appointment schedules and the prescription plan. Worksheet: My Medication Tracker PROCEDURES SUGGESTED SCRIPTS Review the HIV-positive partner's appointment and prescription schedule for the next month and record them on the tracker. Now let's look at the appointments you need to keep for the next month. When is your next clinic appointment? Who will you see at that visit? Will you be getting any laboratory tests, such as a viral load or CD4 count? When will you be running out of your medications? When is the next prescription refill? You can also use the tracker to write down your appointments for the next month and when you will need to refill your prescription(s). SMART Couples Implementation Manual 10 SESSION 1, STEP 7 Ask questions to determine how well both partners know and understand the medication, appointment, and prescription refill schedules for the next month. Purpose: Review and reinforce information about the medication regimen, medical appointment schedules, and prescription plan with the couple. PROCEDURES SUGGESTED SCRIPTS Ask questions to determine how well both partners know and understand the medication, appointment, and prescription refill schedules for the next month. It is important to know and understand these schedules. I will ask you some questions and I want you to work together to answer them. · Which pill(s) do you take on an empty stomach? · Which pill(s) do you take twice a day? · How long after a meal should you take _______? · What appointments do you have next week? · When will you get your next viral load? · When is your next prescription refill? For which drug? Provider Note: Customize these questions as necessary. SESSION 1, STEP 8 Inquire about the couple's knowledge and management of side effects. Purpose: Increase knowledge about medication and its side effects. PROCEDURES SUGGESTED SCRIPTS Inquire about the couple's knowledge and management of side effects. Provide consultation regarding the management of them. Provide prescriptions and referrals as needed. What are the side effects of taking these medications? How many can you list and what can you do about them? Have you talked to your doctor about your side effects and ways to manage them? Do you have any concerns about other effects of the medications? Provider Note: The couple may raise the issues of lipodystrophy and diarrhea. SMART Couples Implementation Manual 11 SESSION 1, STEP 9 Answer questions about the information provided. Purpose: Review and reinforce information provided during the session. PROCEDURES SUGGESTED SCRIPTS Answer questions about the information provided. We've gone over a lot of information in a short time. What questions do you have? Provider Note: If there are questions you cannot answer, assure the couple that you will have the answers at the next appointment (or before if necessary). SESSION 1, STEP 10 Have the couple list advantages/disadvantages of following the medication regimen. Purpose: Increase motivation and commitment to medication adherence. PROCEDURES Have the couple list the advantages and disadvantages of following the medication regimen. Give the Pros and Cons of ART worksheet to the couple to complete. Ask them to take it home and review. SUGGESTED SCRIPTS You have heard a lot about medications and how to take them. To summarize our discussion today, I would like you to think about the advantages and disadvantages of taking these medications and doing it exactly as prescribed. Write your responses on this worksheet. SMART Couples Implementation Manual 12 SESSION 1, STEP 11 End the session with a goal to complete before the next session. Purpose: Introduce couple communication skills and begin building couple-level support for adherence. PROCEDURES SUGGESTED SCRIPTS End the session by having the couple establish a goal to complete before the next session. The objective is for the couple to commit to a goal to complete on their own. I want you to select a goal that you can achieve as a couple between now and the next time we meet. The goal should focus on the two of you taking care of one another in some way. The goal should be clear, reasonable, not too big or too small, and easy to check if it was completed. For example, a goal might be for the two of you to review the medication schedule at the beginning of the week and then see how well you did at the end of the week. Or you can make a list of the kind of support you would like from each other. It can be an activity that you don't usually do together, such as going for a walk or preparing a healthy meal. Take a moment to decide together. What goal would you like to complete as a couple before our next session? I look forward to seeing you again on (date) at (time). Next time we'll look more closely at what gets in the way of always taking your medication on time. We will also look at how well you've been doing taking your medication and review your goal from this week. Provider Note: Provide the couple with the Goal Tracking worksheet and have them record their goal. They may either take the sheet with them to remind them of the goal, or you may keep it with their other worksheets. You will refer to and add to this worksheet again in the following three sessions. Depending on the client's schedule, you may ask him/her to bring his/her pill box, medication bottles, or any adherence records to the next session. Let them know you will review labs in the next visit. SMART Couples Implementation Manual 13 SESSION 2: IDENTIFY AND ADDRESS ADHERENCE BARRIERS Session 2 focuses primarily on identifying barriers to adherence and developing problem-solving skills to address these challenges. The couple will choose an adherence barrier to work through the problem-solving process and identify a solution to this barrier. The session also includes an activity to enhance the couple's communication skills. Objectives 1. Identify barriers to adherence. 2. Increase problem-solving skills. 3. Apply problem-solving skills to an identified barrier. 4. Increase couple communication skills. Session Steps Step 1: Welcome couple back; review the between-session goal; find something to praise. Step 2: Review any new CD4 count, viral load tests, and medication adherence records; discuss what these results means. Step 3: Review the past week(s) to identify what made things easier and the couple's emotional and behavioral adherence barriers. Step 4: Review steps in the problem-solving process. Step 5: Model problem-solving. Step 6: Conduct an example of a brainstorming activity. Step 7: Select a problem and apply the problem-solving steps. Step 8: Practice communication skills by having each partner tell the other how he/she finds him/her supportive. Step 9: Consider use of reminder devices to promote adherence. Step 10: End session with a between-session goal. Worksheets Goal Tracking My Medication Tracker Challenges and Solutions 4 A's of Problem-Solving SMART Couples Implementation Manual 14 SESSION 2, STEP 1 Welcome couple back; review the between-session goal; find something to praise. Purpose: Review the between-session goal and encourage development of couple communication and collaboration on specific tasks. PROCEDURES Welcome the couple back; review the between-session goal; find something to praise (reframe if necessary). SUGGESTED SCRIPTS Let's hear how the two of you did in reaching your goal. What did you do, and how did that feel? "The way you two worked together was really good..." "You are saying that you have a ways to go, but don't you think you did well by remembering to take food to work with you?" SESSION 2, STEP 2 Review any new CD4 count, viral load tests, and medication adherence records and discuss what these results mean. Purpose: Provide feedback on medication adherence. Worksheet: My Medication Tracker PROCEDURES SUGGESTED SCRIPTS Review any new CD4 count, viral load tests, and medication adherence records and discuss what these results mean. Let's take a look at your tracker and see how you've been doing. What updates do you have about taking your dose at the same time every day since we last met? Provider Note: At this time, give the couple the Challenges and Solutions worksheet. SMART Couples Implementation Manual 15 SESSION 2, STEP 3 Review the past week(s) to identify what made things easier and the couple's emotional and behavioral adherence barriers. Purpose: Identify barriers to and facilitators of adherence. PROCEDURES SUGGESTED SCRIPTS Review what worked since the last session to increase adherence, and talk about the cognitive, emotional, and behavioral barriers. Provider Note: Allow time for the couple to respond and reflect back on what they've said. Provide affirmation. Let's talk about your experiences since we last met. First, what worked well for you? Good, glad to hear that you were able to... So what got in the way of taking your medications as intended? In other words, what were your barriers to medication adherence since our last session? Remember that barriers include your own attitudes, such as "These medications will never work," or "This schedule is too hard," or "I am never going to get better." These beliefs will make it much harder to keep taking your medications as prescribed. Do you ever find yourself thinking this way? Provider Note: Prompt client if If Yes: the couple is having a difficult time Tell me about it. What do you do when you think this way? describing any barriers. How do you overcome it? (Inquire of both partners.) If No: Well, if such a thought were to pop into your head, how would you counter it? I'm going to write down the barriers you've already mentioned on the Challenges and Solutions worksheet. You have already said... Did I understand that correctly? Provider Note: Summarize what the couple has said, confirming that you have understood their barriers. Okay now, what are some of your other barriers? What else makes it hard for you to get to all of your appointments or keep a steady supply of medication? I am writing these down, so we can see what we are dealing with. SMART Couples Implementation Manual 16 SESSION 2, STEP 4 Review the steps in the problem-solving process. Purpose: Increase problem-solving skills. Worksheet: Problem-Solving PROCEDURES SUGGESTED SCRIPTS Review the steps in problem-solving. In a minute we will take one of your barriers and work on it together. First, it will help to go over the problem-solving method called "The 4 A's." There are four steps. Provider Note: Provide the couple with the 4 A's of Problem-Solving worksheet. 1. ASK: What is the problem? 2. AIM: What is the goal? 3. ALTERNATIVES: What are some solutions? 4. ACTION: How will we proceed? Each of these steps is important. Do you have any questions about the 4 A's? SMART Couples Implementation Manual 17 SESSION 2, STEP 5 Model problem-solving. Purpose: Apply problem-solving skills to an identified barrier. PROCEDURES Model the problem-solving process. SUGGESTED SCRIPTS Now let me give you an example. We're going to walk through the 4 A's and practice applying them to a problem that doesn't really have to do with medication adherence. But you will be able to see how we use these steps to come up with potential solutions to the problem. So first, you will ASK: What is the problem? In this case, we'll say that I am HIV positive. Now my mother fusses over me and keeps bringing me food that I don't want. I want her to stop, but I don't want to hurt her feelings. So following with the second A for AIM, I determine what it is I do want. What is the goal? In this case, I think - I wouldn't mind if she visited every two weeks and didn't bring food. So next we have ALTERNATIVES. I ask - what are some potential solutions? Some may be (1) have my sister tell her to stop; (2) grin and bear it; (3) tell her my doctor says I can't eat the food; (4) make sure I am not home when she usually comes; (5) write her a letter explaining things; (6) tell her how I feel. So what do I do next? I take a look at the alternatives, decide which one is going to work for me, and ACT on it. So I think, well, I don't want to drag my sister into it, and I don't want to lie to my mom or hurt her. So, I'll go over to her place and talk to her. This might go more smoothly if I visited her there. I'll call and see if she is at home on Tuesday after the holidays. She should be in a good mood. And finally, how did it go? So in this example, I could say: Well, I did it. I tried hard not to hurt her feelings. I think she felt relieved. Bringing me food was getting to be a pain for her. She loves the idea of visiting her. It worked out pretty well. SMART Couples Implementation Manual 18 SESSION 2, STEP 6 Conduct an example of a brainstorming activity. Purpose: Conduct an example of a brainstorming activity. PROCEDURES Apply brainstorming and problem-solving skills to an identified barrier. SUGGESTED SCRIPTS Now let's look at a medication barrier. In this problem-solving process, it is helpful to keep an open mind and try to think of alternatives that you could choose to act on. Let's practice this. So what if a person asked, what is the problem (our first A) and responded: "I keep forgetting to take my pills on time." Our second A (AIM) is to take the medication on time. Provider Note: Possible strategies for taking medications on time include: · Have a friend call as a reminder · Post reminders around the house · Set an alarm So let's think about the alternatives. What are some possible solutions to taking your medications on time? For example, you might say, "use an alarm." What else can you think of? Good, so the next step in the process would be to review the possible solutions and select one to ACT on. SESSION 2, STEP 7 Select a problem and apply the problem-solving steps. Purpose: Apply problem-solving skills to an identified barrier. PROCEDURES Select a problem and apply the problem-solving steps using the 4 A's of Problem-Solving worksheet. SUGGESTED SCRIPTS Now let's apply these same problem-solving steps to one of your barriers. Select one from your Challenges and Solutions worksheet that we can work on together. Now that you have found a barrier, let's see what you might do to change the situation. We'll use the 4 A's of ProblemSolving worksheet. First, ask what is the problem? How can you tell there is a problem? Remember, these are problems that I want you to work on together. We discussed that this is important to both of you, and I'm sure you have some good ideas. Use the selected barrier to walk the couple through the remaining problem-solving steps. What is the aim? What do you want to accomplish? What are some alternatives? Now looking at the possible solutions, which one would you select to act on? How will you proceed? SMART Couples Implementation Manual 19 SESSION 2, STEP 8 Practice communication skills by having each partner tell the other how he/she finds him/her to be supportive. Purpose: Increase couple communication skills. PROCEDURES SUGGESTED SCRIPTS Practice communication skills by having each partner tell the other how he/she finds him/her to be supportive. There are times when each of us can benefit if we worked on improving our own communication skills and communication in our relationships with friends, family, or colleagues. It is difficult to establish a helping and supportive relationship when communication between partners needs improvement. I don't know you well enough to know your patterns, but let's try something that encourages you to put yourself in the other person's shoes. I want each of you to tell your partner what you like about the way he/she supports you particularly when it comes to taking care of yourself. Ask what they would like their partners to do differently. Now I want each of you to share what you would like your partner to do differently. Listen without interrupting or asking questions. When you are done, I want each partner to state what he/she heard. In other words, tell me what your partner likes about the way you help and what would he/she like to be different. Give each partner some time How did you feel when you were communicating? How has your to share and listen. point of view changed? SESSION 2, STEP 9 Consider use of reminder devices to promote adherence. Purpose: Assist with improving medication adherence. PROCEDURES SUGGESTED SCRIPTS Consider use of devices to promote adherence. Have you considered using a medication reminder device? Provider Note: Based on the couple's problem-solving and brainstorming exercises in today's session, ask the couple if they would like a medication reminder device or pillbox. If so, download the CDC Every Day, Every Dose mobile app to the client's smart phone to assist him/her with setting medication and medical visit reminders. You can also provide the HIV-positive partner with a weekly or monthly pill box. SMART Couples Implementation Manual 20 SESSION 2, STEP 10 End the session with a between-session task. Purpose: Foster couple communication and caring for each other. Worksheet: Goal Tracking PROCEDURES SUGGESTED SCRIPTS End the session with a betweensession task. Provider Note: Record the betweensession task on the Goal Tracking worksheet. We are at the end of the session. Here is what I want you to do before the next session. Each of you should treat your partner "royally" sometime this week -- do something special for each other. It doesn't really matter what it is, but try to think of something you've never done for your partner, or something you haven't done in a long time but would be appreciated. Confirm the date and time of the next session. I suggest giving a massage, taking care of household chores, getting flowers, making a nice dinner, and so on. How does that sound? See you both at our next session on (date) at (time). We'll do more of what we've been working on today, and we will have another opportunity to look at how well you've been doing with your medication schedule. SMART Couples Implementation Manual 21 SESSION 3: COPE WITH STRESSFUL SITUATIONS The third session reinforces some previously-covered issues and expands upon others regarding relationship coping and sexual risk-taking. The session uses a review of patient CD4 and viral load tests over time as an opportunity to reinforce knowledge about these health indicators. Data are reviewed again with an eye toward identifying continued barriers to adherence, and the couple will again practice problem-solving as applied to one of these barriers. The session also aims to help the couple consider the many ways that they can take care of one another. The session therefore provides an opportunity to discuss sexual risk taking from the perspective of protecting the health of the HIV negative partner (just as the program's focus on adherence aims to protect the health of the HIV positive partner). Objectives 1. Solve a problem by applying problem-solving skills. 2. Increase relationship coping skills, including the ability to deal with issues of sexual risk-taking. 3. Explore what it means to care for each other. Session Steps Step 1: Review the between-session task. Step 2: Review recent CD4 counts/viral load tests and discuss what these results mean. Step 3: Discuss adherence barriers since the last session; look for any patterns or problems. Step 4: Have the couple select a barrier to work on and apply problem-solving skills. Step 5: Discuss issues of sexual risk-taking in the context of the many dilemmas of HIV- discordant relationships. Step 6: Have the couple identify what it means to take care of each other. Step 7: End the session with a between-session goal. Worksheets Goal Tracking My Medication Tracker Challenges and Solutions 4 A's of Problem-Solving Blank sheet of paper SMART Couples Implementation Manual 22 SESSION 3, STEP 1 Review the between-session goal. Purpose: Review the between-session goal and further encourage couple communication and caring for each other. Worksheet: Goal Tracking PROCEDURES SUGGESTED SCRIPTS Review between-session task of giving each other "the royal treatment." How did it go doing something special for each other this week? How did you feel doing it? How did it feel being on the receiving end? Provider Note: Refer to the Goal Tracking worksheet. SESSION 3, STEP 2 Review recent CD4 counts and viral load tests and discuss what these results mean. Purpose: Reinforce knowledge of these health indicators and underscore the importance of adherence. PROCEDURES SUGGESTED SCRIPTS Review recent CD4 counts and viral load tests and discuss what these results mean. How has it gone taking your dose at the same time every day since we last met? Let's take a look at your medication schedule and see how you've been doing. Let's review your CD4 cell count and viral load test results. Tell me your understanding of what these results means. How do you think things are going? Provider Note: If possible, use the clinic software to display a graph of the patient's health indicators over time. Reinforce correct knowledge. Clear up any misunderstandings. Provide as much education as required for a basic understanding of the significance of these markers. SMART Couples Implementation Manual 23 SESSION 3, STEP 3 Discuss adherence barriers since the last session, and look for any patterns or problems. Purpose: Provide direct feedback on medication adherence. PROCEDURES SUGGESTED SCRIPTS Discuss the barriers to adherence since the previous session and look for any patterns or problems. Remember that our goal is for you to do your best to take your medication and attend appointments. So let's talk about how you've been doing. Reinforce the appropriate pilltaking behaviors and identify barriers that lead to missed doses or taking pills off schedule. Last time we made a list of all the things you could think of that make it harder for you to take your medication on time and keep your appointments. Which of these challenges explain why you missed a dose or took your medication late since our last session? Was there something that got in the way that wasn't on your list? Provider Note: Use the Challenges and Solutions worksheet to reference adherence barriers discussed during the last session. SESSION 3, STEP 4 Have the couple select a barrier to work on and apply problem-solving skills. Purpose: Solve a problem by applying problem-solving skills. PROCEDURES Have the couple select a barrier to work on and apply problemsolving skills. SUGGESTED SCRIPTS Okay, let's work on one of the barriers that you think is important. First, let's review the problem-solving steps, and then let's see if we can make changes to fix the problem. 1. ASK: What is the problem? 2. AIM: What is the goal? 3. ALTERNATIVES: What are some solutions? 4. ACTION: How will we proceed? Provider Note: Use the 4 A' of Problem-Solving worksheet to walk through the problem-solving steps with the barrier the couple has selected. SMART Couples Implementation Manual 24 SESSION 3, STEP 5 Discuss issues of sexual risk-taking in the context of the many dilemmas of HIVdiscordant relationships. Purpose: Increase relationship coping skills and the ability to deal with issues of sexual risk-taking. PROCEDURES Discuss issues of sexual risktaking in the context of the many dilemmas of HIV-discordant relationships. SUGGESTED SCRIPTS Living with HIV, taking medication, and dealing with the problems that it creates are not easy tasks for a couple. It's not like coping on your own. Each partner has to find ways to do what is best for himself/herself, what is best for his/her partner, and what is best for the relationship. That is not easy, but the rewards are great. Being HIV-positive and taking ART affects many areas of the couple's life. We discussed a few weeks ago that a low viral load does not rule out infecting your partner. So, what are your thoughts and what do you do about safer sex? Provider Note: Invite and address questions and concerns about risk behaviors for HIV and other sexually transmitted diseases (what is and isn't risky, etc.). Acknowledge and normalize the desire for unprotected sex while reinforcing the importance of not allowing HIV to be transmitted in this couple. If there are significant problems around risk behaviors, consider a referral to a mental health provider. SMART Couples Implementation Manual 25 SESSION 3, STEP 6 Have the couple identify what it means to take care of each other. Purpose: Explore what it means to care of each other and increase relationship coping skills. Materials: Blank sheet of paper PROCEDURES Have the couple identify what it means to take care of each other. SUGGESTED SCRIPTS There are many ways that two people can take care of each other. As we just talked about, one of them is protecting your partner from HIV. We've also been talking a lot about helping the HIV-positive partner stick to a challenging medication regimen. What are the other ways that you take care of each other? I want each of you to try to finish this sentence: To take care of my partner means... Provide the couple with blank pieces of paper. Take a moment to think about it. You can write down your thoughts, if you like. Don't worry about grammar and punctuation; I want you to be able to express your deepest feelings to your partner. You don't have to share this list unless you want to. Give them time to reflect and If you feel like it, tell your partner some of what you thought think about what they want to say. or wrote. SMART Couples Implementation Manual 26 SESSION 3, STEP 7 End the session with a between-session goal. Purpose: Encourage couple communication skills, caring, and coping. Worksheet: Goal Tracking PROCEDURES End the session with a betweensession goal. SUGGESTED SCRIPTS Our session is about over. Between now and the next meeting, I want you to complete another goal. Pick a time each week when the two of you can meet for about 20 minutes. During this meeting, each of you will share your thoughts and feelings. Talk about anything that affects your relationship. Begin by saying something positive about your partner. Provider Note: Record the between- During the meeting, spend time monitoring how well you session goal on the Goal Tracking have been following the medication regimen and keeping worksheet. appointments. I will see you again in (number) weeks. SMART Couples Implementation Manual 27 SESSION 4: MAKE A COMMITMENT TO ADHERENCE The final session will primarily work to build the couple's commitment and self-efficacy for the maintenance of adherence behaviors. The session includes a final review of ongoing barriers to adherence and the steps to problem-solving. To prepare for the future, the session prompts the couple to consider "triggers" of poor adherence and ways to avoid them. The couple will also build self-efficacy by discussing strategies that have worked in the past, with an eye toward using them in the future. The session concludes with activities aimed at reinforcing the couple's commitment to adherence and caring for each other. Objectives 1. Increase monitoring skills. 2. Increase problem-solving skills. 3. Increase commitment to following the medication regimen and keeping appointments. 4. Increase self-efficacy. Session Steps Step 1: Review the between-session goal that involved sharing with each other on a regular basis through a weekly communication meeting. Step 2: Review any new results of viral load tests, CD4 counts, and medication adherence. Discuss their meaning. Step 3: Select a problem or barrier and apply problem-solving skills. Step 4: Identify triggers and early warning signs for poor adherence and discuss ways to avoid them in the future. Step 5: Review adherence strategies that worked and link them to self-efficacy. Step 6: Having the couple share what they value in each other, and reinforce a commitment to adherence. Step 7: End the session with positive reinforcement for the couple's dedication and commitment to each other and to addressing the challenges of adherence to HIV medical care. Have the couple commit to a goal for the next month. Step 8: End the session with a summary of the couple's new skills and knowledge to support medication adherence. Worksheets Goal Tracking My Medication Tracker 4 A's of Problem-Solving Triggers and Early Warning Signs SMART Couples Implementation Manual 28 SESSION 4, STEP 1 Review the between-session goal. Purpose: Encourage couple communication skills, caring, and coping. Worksheet: Goal Tracking PROCEDURES SUGGESTED SCRIPTS Review the between-session goal of holding a weekly communication meeting. How did the weekly sharing go? What impact did the sharing have on anything else in your life? How did sharing help with the challenge of taking care of yourself, taking care of your partner, and maintaining the relationship? Provider Note: Refer to the Goal Tracking worksheet. Use open-ended questions as much as possible. SESSION 4, STEP 2 Review any new results of viral load tests, CD4 counts, and medication adherence. Discuss their meaning. Purpose: Reinforce knowledge of these health indicators and provide direct feedback on medication adherence. Worksheet: My Medication Tracker PROCEDURES Review any new results of viral load tests, CD4 counts, and medication adherence. Discuss their meaning. Reinforce the appropriate pilltaking behaviors, especially improvements from last time. Identify barriers that lead to missed doses or taking pills off schedule. SUGGESTED SCRIPTS Let's review any new results of your viral load test or CD4 count. How has it gone taking your dose at the same time every day since we last met? Let's take a look at your tracker to see how you've been doing. What do you think of these results? How do you plan to deal with them? Are you continuing to address the barriers that affect your ability to take your medications regularly, on time, or to keep your appointments? SMART Couples Implementation Manual 29 SESSION 4, STEP 3 Select a problem or barrier and apply problem-solving skills. Purpose: Increase problem-solving skills. Worksheet: 4 A's of Problem-Solving PROCEDURES Select a problem or barrier and apply problem-solving skills. Use the 4 A's of Problem-Solving worksheet. Probe if needed. Evaluate potential solutions and next steps. SUGGESTED SCRIPTS Which barrier would you like to work on? Let's apply the problem-solving steps as we've been doing each session. Walk me through the 4 A's. What is the problem? What is the goal? What are the alternatives? Which solution would you like to go with? What steps are you going to take to implement the solution? SESSION 4, STEP 4 Identify triggers and early warning signs for poor adherence and ways to avoid them in the future. Purpose: Increase monitoring skills. Worksheet: Triggers and Early Warning Signs PROCEDURES SUGGESTED SCRIPTS Identify triggers and early warning signs for poor adherence and discuss ways to avoid them in the future. Were there any early warning signs or triggers in the past that told you that keeping up with your medication would be harder than usual? For example, it might be harder over the holidays when there are lots of parties, when cash is running short at the end of the month, when people pressure you, when certain unpleasant people come around, or when you start to get a cold. Using the worksheet, discuss triggers and early warning signs and ways to avoid them. What are some of your warning signs or triggers? Let's make a list on this worksheet. One of the best ways to deal with triggers is to avoid them. What can you do to avoid them? How can you cope if they cannot be avoided? SMART Couples Implementation Manual 30 SESSION 4, STEP 5 Review adherence strategies that worked and link them to self-efficacy. Purpose: Increase self-efficacy. PROCEDURES SUGGESTED SCRIPTS Review the adherence strategies employed by the couple that worked for them and link them to self-efficacy. Believing you can handle the medication and keep appointments does not just depend on the attitude of the person who is HIVpositive. Believing you can do it depends on your partnership. It is okay to depend on your partner or let your partner do something for you. Interdependence means you give to each other. We have been meeting now for a couple of months. What strategies have you used that worked for you? What has made a significant difference? With these strategies in mind and the strength of your relationship, how confident are you that you can keep your medication schedule and your appointments? SESSION 4, STEP 6 Have the couple share what they value in each other, and reinforce a commitment to adherence. Purpose: Increase relationship coping skills and commitment to following the medication regimen and keep appointments. PROCEDURES Connect the couple by having them share what they value in the other person, and reinforce commitment to adherence. SUGGESTED SCRIPTS We are getting close to the end of the session. Before you go, I want to give you a chance to tell each other what you value in each other. Go ahead and tell your partner what you value. Now complete this sentence: Taking the medication as scheduled is important to us because... SMART Couples Implementation Manual 31 SESSION 4, STEP 7 End the session with positive reinforcement for the couple's dedication and commitment to each other and to addressing the challenges of adherence to HIV medical care. Have the couple commit to a goal for the next month. Purpose: Increase commitment to following medication regimen and to keeping appointments. PROCEDURES End the session with positive reinforcement for the couple's dedication and commitment to each other and to addressing the challenges of adherence to HIV medical care. Have the couple commit to a goal for the next month. SUGGESTED SCRIPTS It has been great working with you. You are both caring and committed to each other and we've seen many ways that you take care of each other. I applaud your commitment to meeting all of the challenges that HIV introduces into your lives, not the least of which is meeting all the treatment demands. I want you to continue to commit yourselves to communicating regularly with each other and to continue acknowledging the ways that you take care of each other. As a way of continuing this process, what goal could you set for yourself for the next month? Remember the goal should be clear, realistic, not too big or too small, and easy to see if it is completed. What goal would you like to set together? From now on it is up to you to monitor your progress. Keep at it; this requires continued commitment on both of your parts. SESSION 4, STEP 8 End the session with a summary of the couple's new skills and knowledge to support medication adherence. Purpose: Remind the couple of the new strategies they have developed to address the challenges to following the HIV treatment schedule together, including problem-solving skills and thinking ahead to identify problems before they happen. PROCEDURES SUGGESTED SCRIPTS End the session with a recap of the couple's new skills and knowledge to support medication adherence. Before you go, let's review the strategies you have developed to address the many challenges of HIV medication adherence. Provider Note: Encourage the couple to support each other in their commitment to adherence. Let them know how to reach you if they need to discuss adherence challenges in the future. SMART Couples Implementation Manual 32 WORKSHEETS Worksheet Name My Medication Tracker Pros and Cons of ART Goal Tracking 4 A's of Problem-Solving Challenges and Solutions Triggers and Early Warning Signs Applicable Sessions All sessions Session 1 All sessions Sessions 2, 3, 4 Session 2 Session 4 # to Print per Couple As needed 1 1 3 1 1 SMART Couples Implementation Manual 33 SMART Couples My Medication Tracker WEEK OF: ________ MON TUE WED THU FRI SAT SUN MY MEDICATIONS Place an "X" on the chart when you take your medication each day as prescribed. Dose 1 Dose 2 Leave blank if no Dose 2 MY CHALLENGES If you missed or were late for a dose, what was the reason? WEEK OF: ________ MON TUE WED THU FRI SAT SUN MY MEDICATIONS Place an "X" on the chart when you take your medication each day as prescribed. Dose 1 Dose 2 Leave blank if no Dose 2 MY CHALLENGES If you missed or were late for a dose, what was the reason? SMART Couples Implementation Manual 1 WEEK OF: ________ MON TUE WED THU FRI SAT SUN MY MEDICATIONS Place an "X" on the chart when you take your medication each day as prescribed. Dose 1 Dose 2 Leave blank if no Dose 2 MY CHALLENGES If you missed or were late for a dose, what was the reason? WEEK OF: ________ MON TUE WED THU FRI SAT SUN MY MEDICATIONS Place an "X" on the chart when you take your medication each day as prescribed. Dose 1 Dose 2 Leave blank if no Dose 2 MY CHALLENGES If you missed or were late for a dose, what was the reason? SMART Couples Implementation Manual 2 For all SMART Couples sessions SMART Couples The Pros and Cons of ART List the advantages (pros) and disadvantages (cons) of antiretroviral therapy. PROS CONS SMART Couples Implementation Manual 3 For SMART Couples session 1 SMART Couples Goal Tracking Record your between-session goals at the end of each session, and write down your progress at the beginning of the next session. GOAL HOW DID IT GO? SESSION 1 SESSION 2 SESSION 3 SESSION 4 SMART Couples Implementation Manual 4 For all SMART Couples sessions SMART Couples The 4 A's of Problem-Solving Ask: What is the problem? Aim: What is the goal? Alternatives: What are some solutions? Action: How will we proceed? ASK AIM ALTERNATIVES ACTION SMART Couples Implementation Manual 5 For SMART Couples sessions 2, 3, and 4 SMART Couples Challenges and Solutions List some of the challenges that make it more difficult for you to take your medication as prescribed, get to your medical appointments, and maintain a steady supply of medication. Then list potential solutions to address these challenges. CHALLENGE SOLUTION SMART Couples Implementation Manual 6 For SMART Couples sessions 2 and 3 SMART Couples Triggers and Early Warning Signs List any triggers and early warning signs that let you know it will be more difficult to take your medication. TRIGGERS EARLY WARNING SIGNS SMART Couples Implementation Manual 7 For SMART Couples sessions 2, 3, and 4 Blank Back PageAdobe PDF Library 11.0