Homework/Recap

1. 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

3. 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

4. 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

5. Module IV: Preparing for ARTUnit 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.

6. 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 %)

7. Understanding CD4 and Viral Load The CD4 count The viral load Measures level of infection Predicts CD4 decline Predicts risk of opportunistic infection & other complications Predicts risk of death • Measures ability to keep ahead of HIV infection • Predicts risk of opportunistic infection • Predicts risk of death

10. HIV/ART Card (Front Side)

11. Staging and ART Initiation How is eligibility determined? What are the new paedriatric eligibility guidelines?

12. Module IV: Preparing for ARTUnit 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.

13. 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.

16. 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?

23. 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

24. 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

25. 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.

26. 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.

27. 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

28. 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

30. 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

32. Case Study Practice ADVISE • Form 6 teams— review the side effects chart • For each case study presented, identify the key counseling messages

33. 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

34. 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.

35. What would you tell her grandmother?

36. 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

37. What would you tell his mother?

38. 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

39. What would you tell her mother?

40. 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

41. How to Say It: Adherence Planning With Children • 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? Mon Tues Wed Thurs Fri Sat Sun

42. 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.

45. 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)

47. Reviewing the Process • Review the Counselling Observation Tool– Preparing for the Start of ART

48. 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?

49. Module IV: Preparing for ARTUnit 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

50. 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?