Counseling Roles

Counseling was available at all 15 of the ATC clinics in the study, covering four basic topics: taking medications, recognizing and managing side effects, general health, and safer sex behaviors. While only the five provincial hospitals had trained counselors, all ATC nurses had received training in counseling and provided most of the counseling at the ten district hospitals.

During the preparation phase, nine of 12 hospitals reported that they provided clients with counseling or information two weeks before starting HAART; the other three hospitals started this on the same day that clients began their treatment. Counseling during this phase lasted an average of 26 minutes for individual counseling and 40 minutes for group counseling.

But confidence in providing individual counseling varied by topic and type of health provider. About two-thirds of the nurses, counselors, and pharmacists involved in counseling felt very confident about providing general health counseling. But nearly half did not feel confident about providing safer sex counseling. While 70 percent of pharmacists expressed confidence about counseling patients about the side effects of antiretroviral drugs, only a third of the nurses and none of the counselors did.

Over the course of the first month of treatment, counselors played less of a role than did nurses and pharmacists, largely because the focus of counseling shifted to discussing reactions to the medications and difficulties with adherence. After the first month of treatment, care providers reported that far fewer clients needed counseling because many had worked out problems with dosages and side effects. By this stage, professional counselors had generally stopped working directly with clients; nurses and pharmacists were responsible for most of the counseling.

Quality of Counseling

The researchers also assessed the quality of counseling by observing one-on-one counseling sessions between clients and doctors, nurses, and pharmacists that took place after the preparation stage. These were generally quite short, seven minutes on average. In two-thirds of the observations, service providers started the session by asking clients about problems they were having, but the researchers found that few attempted to draw out details of these problems or to provide information. Care providers tended to ask questions that required simple yes/no answers, and if the client was not forthcoming, the discussion ended quickly. Researchers noted that little effort was made to motivate clients to continue to adhere to medication.

The experience was quite different during a group counseling session observed in a provincial hospital moderated by an NGO representative that focused on the practical problems clients face when taking antiretrovirals. With the help of a nurse, a health worker, and a pharmacist, who each contributed to the discussion from the perspective of their expertise, the two-hour session examined issues and problems in considerable detail, and the clients appeared comfortable about discussing their feelings with the group.

Despite the inconsistency in quality of counseling observed by the research team, an overwhelmingly high percentage of clients expressed satisfaction with all of the counseling services—both one-on-one and group—that they had received. Nearly all of the clients (98 percent) felt that they had had an opportunity to talk about their problems, and 95 percent expressed satisfaction that their problems had been solved.

“One important cultural factor to consider when analyzing quality of counseling is that Thais do not have the same tradition of counseling found in Western nations, or even a strong understanding of the concept,” said Dr. Baker. “Health providers often ‘talk at’ clients or provide information rather than engage in an interactive discussion of personal issues that is key to good counseling.”

Supporting Adherence

To encourage adherence to HAART, the ATC program implemented follow-up procedures—including letter or phone reminders and home visits—to help clients follow medication regimens and remember clinic appointments. But less than half of current clients and dropouts reported that they had been reminded by letter or phone call of an upcoming appointment.

The rate of home visits was quite low. Among clients receiving HAART, 20 percent reported that a health care provider visited them at home in the first month of starting HAART, and 11 percent reported that a volunteer from a support organization for HIV-positive people had visited them. After the first month, home visit rates for clients dropped to 5 percent. Among treatment dropouts, the home visit rate was 30 percent for the first month and 25 percent after the first month, higher percentages that likely reflect the greater problems experienced by dropouts.

The researchers also found several patterns of nonadherence to HAART that included missing tablets (13 percent had missed a tablet within the last four days), not taking the medication on time (28 percent), and not following instructions (25 percent). Clients reported different reasons for their nonadherence. “Busy with other things” and “away from home” were the major reasons ATC clients gave for forgetting to take medication.

Overall, ATC client records revealed a high dropout rate of 30 percent after six months among all of the hospitals in northern Thailand. The primary cause for this was the severity of side effects that clients experienced. Among clients interviewed in this study who were receiving HAART, 15 percent reported severe side effects and 43 percent reported moderate side effects in the first month. Among dropouts, though, the rate of severe side effects in the first month was 40 percent and of moderate side effects was 20 percent. After the first month, none of the clients who adhered to HAART reported severe side effects, compared to 29 percent of those who dropped out.

Clients who adhered to their HAART regimen reported marked improvements in their health. Ninety-seven percent reported improved physical health, while 90 and 96 percent reported that their mental health and general outlook on life, respectively, had improved. In addition, 78 percent said that their ability to work had also improved.

Community Involvement

All 15 hospitals in the study had support groups for clients. Ten of the hospitals included representatives of groups for HIV-positive people in establishing selection criteria for clients to receive HAART. At eight hospitals, organizations of people living with HIV/AIDS helped follow up HAART clients; eight hospitals also invited HIV-positive individuals to talk about their own HAART experiences to those starting therapy. People living with HIV/AIDS also undertook home visits, as requested, but this was informally arranged. During these visits, they provided physical and emotional support, offered information on taking medication, encouraged clients to adhere to their medication schedules, and made referrals to other services. Half of the representatives of organizations for HIV-positive people surveyed for the Situation Analysis reported that they had received training in antiretroviral medication from international NGOs.

Fifteen representatives of support organizations for HIV-positive people were interviewed for the study, and several made suggestions about how to improve the ATC program. These included strengthening procedures for follow-up and for home visits, giving organizations of people living with HIV/AIDS a more active role in client monitoring and follow-up, and offering them more training in counseling and health education.

Most health providers agreed that members of these organizations could play an important role in monitoring patients’ medication adherence at home, and also felt that they should moderate group counseling sessions because they understand what clients are experiencing as they begin and continue HAART treatment.

The study also found that NGOs involved in HIV/AIDS treatment, care, and support provided a wide range of services to ATC clients. During home visits, NGO outreach workers provided physical and mental support and health care education, made referrals, and accompanied clients who were unable to get to health care facilities by themselves. They sometimes also provided education and counseling on taking antiretroviral medication. Some of the NGOs were involved in strengthening the capacity of HIV-positive volunteers to undertake outreach activities and provided technical and financial assistance to newly established groups of people living with HIV/AIDS.

Next Steps

According to Dr. Baker, the Situation Analysis has been well received by ATC program managers and public health officials in Thailand, who have used its findings to consider how to improve provider skills and confidence; patient counseling, monitoring, and follow-up; and involvement of local resources to strengthen adherence to HAART and reduce the dropout rate.

“The study has been a useful tool to help health officials in northern Thailand identify where they need to put resources and energy to make ATC even better,” he said. “Even program managers whose clinics were not involved in the study are familiar with the study’s results and use them to advocate for improvement.”

With support from the Ministry of Health and hospital officials, Horizons and its study partners have used the insights gained from the Situation Analysis to design an intervention study. The research evaluates the use of practical guidelines and a strengthened clinic counseling intervention with and without a peer-based component to reduce dropout rates and promote short- and long-term HAART adherence.

To date, health providers have been trained to provide HAART counseling and to use practical guidelines detailing how to provide antiretroviral medication, and HIV-positive volunteers have been trained to provide peer education to individuals taking these medications. In Chiang Mai, Chiang Rai, Lampang, and Lampoon provinces, 45 hospitals have been assigned to one of three study arms. In Arm 1, the health providers will provide HAART counseling and use the practical guidelines. Arm 2 will be the same as Arm 1, except that HIV-positive volunteers will provide peer education, counseling, and support at the hospital and at clients’ homes. Arm 3, the control arm, will provide the standard of care that is currently offered in the ATC program. Findings from this research will be used to help strengthen and scale up the ATC program throughout Thailand.

This article was written by Margaret Dadian in conjunction with the study team, which includes Dr. Simon Baker, Horizons/Population Council, and Dr. Ratana Panpanich, Community Medicine Department, Chiang Mai University. For more information about this study, please contact Dr. Philip Guest at Philip@popcouncil.th.com or Dr. Panpanich at rpanpani@mail.med.cmu.ac.th. To receive e-mail notice when new publications about this research and other studies are available, sign up at www.popcouncil.org/horizons/signup.html.