L.Bentz, M.Morin, C.Tourette-Turgis, M.Rébillon,

1. Maintaining counselling nurses for HIV patients treated by HAART at Nice University Hospital (France) : theory versus practice L.Bentz, M.Morin, C.Tourette-Turgis, M.Rébillon, P.Dellamonica, J.G.Fuzibet, J.P. Cassuto, J.P.Moatti, C.Pradier 13th international Conference on Health Promoting Hospitals (HPH) Dublin May 18-20th, 2005

2. Background • In 1998, effectiveness of HAART on mortality • In 1999 at Nice University Hospital, 2500 HIV infected patients followed yearly in 3 main departments

3. New problems concerning treatment adherence • Idea of an • intervention-research program, including counselling by professionals

4. Background (2) Principles of HIV counselling aiming at treatment adherence • An operational definition of adherence addressing the 4 components affecting adherence • A patient-centred intervention • Empathic approach based on active listening as well as acceptance of diversity of life styles • Active intervention

5. MOTHIV model : concept and strategies • Voluntary nurses • An intensive training for nurses, follow up and supervision. • A structured and brief counselling intervention (4 x 45 mn sessions) • Nurse’s tools : interview script and adherenceassessment sheet

7. MOTHIV : tool samples Intervention script N°1

8. Tool samples Adherence assesment sheet

9. Background (3) • The program was launched in June 1999 • On-going from 1999 to 2005 • Assessment of impact • Assessment of activity

10. Results Randomized study 310 patients offered participation 246 patients included (79%) M0 intervention group (IG) n=124 control group (CG) n=122 1 death 1 death M6 123 patients (IG) 121 patients (CG) 8 lost to follow-up 2 deaths 7 lost to follow-up 2 deaths M24 113 patients (IG) 112 patients (CG)

11. Results At M0 comparable patients in IG and CG : • Age • Gender • Mode of transmission • Education level • CDC stage • VL / CD4 • HAART • Average duration of HAART • % of treatment change

12. Results Assessment M0/M6 • Positive impact of counselling consultations on: adherence and VL at 6 months Pradier, Bentz et al, HIV Clinical Trials, 2003, 4, 121-131

13. Results Assessment M0/M24

14. Results Assessment M0/M24 Comparison of the average differences in VL (M0/M24) Deltas VL (log cp/ml) NS 0,12 -0,07 NS -0,12 -0,12 NS NS -0,22 -0,22 p=0,013 p=0,027 -0,36 p=0,002 -0,47 p<0,001 IG CG M6 M18 M24 M12

15. Results Medical consultations Overall population

16. Results Qualitative survey of patient satisfaction with counselling consultations : CG (n=9) : • Ambiguity between progress and constraints of new treatments • Deep questioning about adherence IG GI (n=9) : • Satisfaction with the information provided and the listening • Feeling of ability to handle the treatment • Development of a spirit of critical participation in treatment follow-up • The consultation appears as a social support

17. Results: counselling nurses’ activity 1999-2004 (1)

18. Results: counselling nurses’ activity 1999-2004 (2) 2 consultations/year/patient

19. Discussion (1) National factors encouraging this activity • Political support for treatment education of chronic diseases in general (Law 2004-806 relative to Public Health Policy) • Recent development of a « counselling culture » in France • Increase in counselling activities addressing HIV-infected patients, in spite of assessment gaps

20. http://www.counselingvih.org A Counselling, Health, Development & « Comment Dire » Project

21. Discussion (2) : Local factors in favour of this activity • Involvement of Nice University Hospital management to encourage health promotion and patient education activities. • Elaboration of a permanent program with on-going assessments by the Public Health Department • High degree of motivation on the nurses’part • Participation of physicians .

22. Discussion (3) : Positive assessment results for the patients • Positive impact on long-term viral load • Fewer medical consultations • Patients participate in a more active way in the managementof theirtreatment .

23. Discussion (4)Local difficulties • 2 of the 3 care units have diversified their recruitment in terms of pathology • Change in patient recruitment profile • HIV activity increasingly concentrated in a single care unit and nurse • Nurses ’ availability for counselling activities has decreased due to : • Reduced number of nurses available for patient education in favour of technical care • Recognition of nurses ’ skills : involvement in teaching and scientific communication tasks

24. Discussion (5) National difficulties No economic evaluation of counselling activity : • Time consuming activity • Need of an identification system, systematic data collection and processing of activity • Implementation of payment system based on diagnosis-related groups in French hospitals (2004) : no price setting from Health Ministry for educational activities

25. Conclusion • The program confirms its permanence and benefit for patients • A contextual fragility in spite of institutional involvement • Need for economic evaluation

26. Acknowledgments • To nurses in charge of counselling interventions G. Valentini, M. Borghi, P. Asplanato • To hospital care units :Pr P. Dellamonica, J. Durant, V. Mondain, I. Perbost, P. Pugliese,V. Rahelinirina, C.Rascle, Pr J.G. Fuzibet, F.Sanderson P. Heudier, E. Rosenthal, M. Pietri, Pr JP Cassuto, H. Vinti, C. Ceppi, J. Massiera, M.Chavaillon • To data managers:N. Oran, JN Mazza, S. Déric • To « How to say » : C.Tourette-Turgis, M. Rébillon • To the Health Direction :M. Rubolini, M. Mazard • To INSERM U 379 (JP Moatti, B. Spire, M. Souville) and to the laboratory of social psychology in Provence (M. Morin, J. Scherer) • To P. Touboul and B. Dunais, MD, for their availability

28. Results Assessment M0/M24