Transcript M4-Prep for ARVs-v1 Feb 2012

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 infant
2. testing child who turns out to be positive
3. testing a child who turns out to be negative
4. 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 criteria
Stages 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
The viral load
• Measures ability to
keep ahead of HIV
infection
• Predicts risk of
opportunistic infection
• Predicts risk of death
• Measures level of
infection
• Predicts CD4 decline
• Predicts risk of
opportunistic infection
& other complications
• Predicts risk of death
HIV/ART Card (Front Side)
10
REVIEW
Staging and ART Initiation
How is eligibility determined?
What are the new paedriatric eligibility
guidelines?
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?
ASSESS
Ask 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 Needs
ADVISE
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 truth
Caregivers:
– 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
AGREE
Caregiver & 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
AGREE
• These medicines must be taken EVERY DAY, just as the
directions say
Mon Tues
Wed
Thurs
Fri
Sat
Sun
• 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
Counselling for the Start of ART
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?
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 Doses
ADVISE
• 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 Adherence
ASSIST
• 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
That was
horrible!!!
OH NO!
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 nonjudgmental 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
Supporting Adherence
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?
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.