Homework/Recap

• Review the flipchart for the whole process of pre and post testing (pink section).

• Write down exactly which pages you would go to for counselling in these sitatuations:1. testing HIV exposed infant2. testing child who turns out to be positive3. testing a child who turns out to be negative4. testing an adolescent who tests HIV positive and

needs SRH counselling

Module IV: Preparing to Start ARVs and

Supporting Adherence

In this module, we will discuss:•Unit 1: Understanding Staging and ART Initiation Process•Unit 2: Counselling for the Start of ARVs•Unit 3: Supporting Adherence

Counselling to Start ARVs and Supporting Adherence

• Who is this counselling for?– Patients who have received a positive HIV test,

have been staged and are eligible to start ART

• Goals:– Explain the process of staging and ARV initiation– Determine if the patient is able to adhere to ARVs– Help the patient understand what to expect during

the first weeks on treatment– Provide ongoing counselling to support adherence

Module IV: Preparing for ART

Unit 1: Understanding the Staging and ART Initiation Process

By the end of this unit, participants should be able to:•Explain how eligibility is determined.•Explain the new paediatric ART eligibility guidelines.

Understanding Staging

A clinician will determine eligibility by:

1. Using WHO criteriaStages I (asymptomatic), II (mild), III (advanced) and IV (severe). ARVs are usually started in Stage III or IV.

2. By doing a CD4 cell count (or CD4 %)

Understanding CD4 and Viral Load

The CD4 count• Measures ability to

keep ahead of HIV infection

• Predicts risk of opportunistic infection

• Predicts risk of death

The viral load• Measures level of

infection• Predicts CD4 decline• Predicts risk of

opportunistic infection & other complications

• Predicts risk of death

10

HIV/ART Card (Front Side)

REVIEW

How is eligibility determined?What are the new paedriatric eligibility

guidelines?

Staging and ART Initiation

Module IV: Preparing for ART

Unit 2: Counselling for the Start of ARVs

By the end of this unit, participants should be able to:•Describe the benefits of good adherence•Counsel caregivers to anticipate adherence challenges that many children and adolescents face•Describe several symptoms of side effects that require the counsellor to refer the client to a clinician.

What is Adherence?

ARV adherence means....– the right drug, in the right dose – at the right time, – with the right frequency and– in the right way

• Adherence is an informed choice–a joint decision. Children have a right to participate in issues that affect their lives.

Key Determinants of Patient Readiness to Start ARVs

ASSESS• Do the caregiver and child understand what it means to be

HIV infected?• Do the caregiver and child understand the importance of

taking ARV and how they work• Can the caregiver and child demonstrate how to take them?• Can the caregiver and child explain what to do if the child

experiences side effects of ARVs?• Have the caregiver and child both agreed to an adherence

plan and are able to address barriers?

What are the Benefits of ARVs?

ASSESSAsk clients: What do you see as the benefits of taking

ARVs?– Slow HIV multiplication in the body– Keep your body’s natural defenses strong– Ensure good health and continued growth– Reduce HIV-related illnesses (OIs)– Ensure proper growth and development– Improve the quality of life– ability to play, go to school and

enjoy life

Counselling Process: Explaining ARVs to Younger Children

ADVISE• Most caregivers and

HCWs struggle with how to explain complex concepts to children

• This is an opportunity for the HCW to model a good, clear, complete explanation of HIV

How To Say It:Explaining ARVs to Younger Children

ADVISE• Our body has many CD4 cells. These are the most

important part of our defense system.• When HIV enters the body, it uses the CD4 cells to

make more HIV. This kills the CD4 cells.• When CD4 cells are few, the body becomes weak

and a person may become sick. Having lots of CD4 cells will help you to stay healthy.

• These medicines (ARVs) help to slow down HIV multiplication, keeping CD4 cells strong and many.

Case Study– Counselling Juma

ADVISE• Juma, a boy of 6 yrs, is HIV positive. Both parents died

of AIDS when he was 3 yrs– he was taken for testing by his aunt, who is his primary caregiver. Juma comes to the clinic frequently with recurrent infections. The aunt has not told Juma about his HIV status. Now, the clinician has told Juma’s aunt that he soon needs start ART. He refers her to a counsellor to talk more about ART for children.

• Role Play: With the aunt in the room, explain to Juma that he needs to start ART.

Different NeedsADVISE

Children:– Have unique needs; they are not just small adults – Are constantly developing; new issues emerge– Should be involved through age-appropriate language in

their care: tell them the truthCaregivers:– Must understand how to give medications to children,

including liquid forms– Need to know that 100% adherence is important for

treatment success

Different Needs

ADVISE

Caregivers need to understand:• When treatment will be started• What it means to be “eligible” for ART• What side effects to watch for• When to bring the child back to the clinic

Case Study–Counselling Juma’s Aunt

ADVISE• Juma, a boy of 6 yrs, is HIV positive. Both parents

died of AIDS when he was 3 yrs– he was taken for testing by his aunt, who is his primary caregiver. Juma comes to the clinic frequently with recurrent infections. The aunt has not told Juma about his HIV status. Now, the clinician has told Juma’s aunt that he soon needs start ART. He refers her to a counsellor to talk more about ART for children.

• Role Play: What do you need to discuss with Juma’s aunt? Refer to flipchart to answer this question

Case Study Practice

ADVISE• Form 6 teams— review

the side effects chart

• For each case study presented, identify the key counseling messages

Support Clients to Understand and Anticipate Side Effects

ADVISE• ARVs are strong drugs—sometimes people have

negative effects when they first start• It will take a child’s body about 4-6 weeks to get

used to the effects of ARVs• If any health problems occur within the first few

weeks, it is important to return to the clinic right away

• Continue taking your drugs unless the clinician tells you to stop taking them

Nabatanzi, 7 months

ADVISE• Nabatanzi is a 7 month old girl who was started on

ART tablets 6 days ago. Her grandmother returns today to see you because Nabatanzi has developed an itchy rash on her neck and back last evening.

• She has no fever, and the rash has not formed any blisters. Her neighbour, who also has a child with HIV, has told her the rash is a sign that the drugs make the child sicker and asked her to stop them. She is confused.

What would you tell her grandmother?

Mbabazi, 5 years

ADVISE• Mbabazi is a 5 year old boy who has been on ART for

10 days. • His concerned mother brings him to see you because

he has developed peeling on his skin • His mother says his condition began as a rash all over

the body and has steadily gotten worse over the last 2 days

• She says that he has not been burned

What would you tell his mother?

Acayo, 4 years

ADVISE• Acayo is a 4 year old child who has been on

ART for 4 months • Her mother brought her for a routine

monitoring visit. You notice that she tires easily when she runs around your office. You also notice her hands and inner eyes are pale

What would you tell her mother?

Determining Readiness: AGREE

AGREECaregiver & child should agree on

a plan for how to:• Achieve excellent adherence• Keep regular clinic appointments• Identify and seek treatment for

possible side effects• Secure needed support for the

child’s treatment from family, school, community

How to Say It: Adherence Planning With Children

Mon Tues Wed Thurs Fri Sat Sun

AGREE• These medicines must be taken EVERY DAY, just as the

directions say

• What happens if you forget to take your medicine? HIV can multiply and your CD4 cells can go very low.

• Do you think you can take your medicine every day? How can you be sure to remember? Who will help you?

Adherence Planning includes Disclosure

ASSIST• Probe disclosure with the

caregiver—encourage discussions with the child starting at 5 years old

• Ideally, children should be fully disclosed by 10 years.

• Disclosure can take place little by little.

Closing: ARRANGE

ARRANGE• If the caregiver and child are ready, arrange for

them to visit the clinician on the same day for ARVs to be prescribed

• Schedule follow-up counselling sessions, which should be on the same days as clinical follow-up

• Document the counselling session on the patient’s HIV Care/ART card (blue)

Reviewing the Process

• Review the Counselling Observation Tool– Preparing for the Start of ART

REVIEW

What are the benefits of good adherence?What challenges do children commonly face

with adherence? Adolescents?What are some of the symptoms of serious

side effects that require the client to be referred to a clinician?

Counselling for the Start of ART

Module IV: Preparing for ART

Unit 3: Supportive Adherence Counselling

By the end of this unit, participants should be able to:•Explain 3 methods for measuring adherence for children and adolescents•Identify reasons why adherence might become more challenging over time•Explain strategies for helping families address adherence challenges

Brainstorm: Measuring Adherence

ASSESS• How will we know if a child

or adolescent misses doses of ART?

• How do we measure adherence for adults? Is it the same for children?

Assessing Adherence

ASSESS• Adherence from pill counts:– May be announced or unannounced (home visit)

• Adherence from self report:– Ask the child and caregiver about missed doses

• Assessing missed clinic appointments• Checking pharmacy records to determine if

clients have picked up their drugs

Calculating Adherence: John

ASSESS• John is a 1 year old child. His last

clinic visit which was 28 days ago. He was given 60 tablets of the drug. He takes 1 tablet twice daily. He returns today and has a balance of 8 tablets.

• Calculate his adherence.

Supportive Adherence Counselling

ASSESS• Regular discussions with child, caregiver on

any problems faced taking medication— school, peer pressure, side effects etc.

• Open-door policy for child to see counsellor• May need to offer specific strategies for

encouraging child to take meds• Recognize that the child may go through

periods where it is harder to adhere

Addressing Missed DosesADVISE• If a child misses one dose, give the next dose as normal• If the child vomits before 30 minutes, give the full dose again• If the child vomits after 30 minutes, do not give the dose again AGREE• Develop a plan to address adherence challenges• Emphasize to the child and caregiver that they should

continue to take ARVs despite feeling unwell• See the clinician for an evaluation of symptoms

Children and AdherenceASSIST• Support identification of strategies to

overcome adherence challenges• What do you think are the most

common challenges that children and caregivers face with ART adherence?– Child factors– Caregiver factors– Medication factors– Provider factors

OH NO!

That was horrible!!!

Closing: ASSIST and ARRANGE

ASSIST• Ask about sources of community support, suggest

involvement in support groups• Review disclosure plan and probe barriers

ARRANGE• Referrals• Follow-up visits to the counsellor and/or clinician• Document the session on the HIV Care/ART card

Reviewing the Process

• Review the Counselling Observation Tool– Starting and Supportive Adherence Counselling

Macdot Video Clip

Adolescent Adherence

Discussion:– What questions does the counsellor ask to better

understand Macdot’s challenges with adherence?– How does she probe adherence in a non-judgmental

way?– What were the issues that Macdot struggled with?– How did the counsellor support Macdot to improve his

adherence?

Discussing Adherence– Case Studies

• In your 6 groups, read the case studies (Vincent, Tom, Mary)

• Discuss the following:– What are the barriers to adherence?– How can we promote adherence in each case?– What would you emphasize to the child? To the

caregiver?

REVIEW

What are 3 methods for measuring adherence in children and adolescents?

Why might adherence become more challenging over time?

How can counsellors encourage families to better support ART adherence?

Supporting Adherence

Key Messages from this Module

• Eligibility criteria for starting ART varies by age. All HIV+ children under 2 years start ARVs right away.

• Readiness criteria includes whether or not the client has an adherence plan and the support mechanism to adhere.

• Disclosure is important for good adherence, since children are more cooperative if they understand their situations.

Key Messages (2)• Counsellors need to screen for side effects and

refer patients to the clinician because adherence might be affected if clients feel unwell.

• When clients are on ARVs they need ongoing counselling to support their treatment and solve problems that arise over time.