Adherence Counseling and Treatment Preparation Sop

Adherence Counseling SOPs, October 2014
ADHERENCE COUNSELING AND TREATMENT PREPARATION SOP
OCTOBER 2014
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Table of contents
Introduction.... 3
Skills required.. 3
Training package. 3
List of contributors. 3
Pediatric 1st line TPS 5
Adolescent 1st line TPS.. 11
Adult 1st line TPS. 17
Pediatric 2nd line TPS. 24
Adolescent 2nd line TPS 28
Adult 2nd line TPS 31
Pediatric 3rd line TPS.. 35
Adolescent 3rd line TPS . 37
Adult 3rd line TPS.. 40
1st line adherence counseling checklist 44
2nd and 3rd line adherence counseling checklist . 46
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ADHERENCE PREPARATION STANDARD OPERATING PROCEDURES

Introduction
This document will outline the HAART preparation requirements for different category of clients.
It will look at the process and the content that each preparation session is expected to
competently deliver in order to promote informed decision making for the client and at the same
time promote treatment literacy which is key to sustaining adherence. The different group
specific preparation process will target: Pediatric clients (2-9 years), Adolescents (10-19 years),
ART nave adult clients (freshers), Clients transitioning to second line and clients transitioning to
3rd line or salvage.
Adherence Counselors
For effective adherence preparation, service providers (Social Workers, Peer educators, Nurses,
Clinical Officers, etc) need specific knowledge, skills and attitudes. In order to acquire the
requisite competencies, the Psychosocial sub TWG recommended that ART adherence service
providers need to go through the NASCOP prescribed adherence training (5 days curriculum) and
certified by NASCOP.
Training package
The service providers that have not been trained on NASCOP Adherence training will need to go
through the same under support of accredited NASCOP ART Adherence Training TOTs. The
training duration is five days. For those trained in the past but requiring updates, partners/MOH
will need to carry out a 5 days refresher training using the same curriculum and the training TORs.
The trainees will then be followed up at the clinical sites for supportive supervision and
mentorship.
Contributors
This document was developed by the psychosocial support team drawn from all CDC partners in
care and treatment as indicated below:
Name Designation Organization
George Osoo Psychosocial Support component Lead KCCB-KARP
Beryl Audi Community Activities Coordinator KEMDR/CDC
Kevin Ooro Social worker KEMRI/CDC-JOOTRH
Faith Oriwo Community Liaison Officer EGPAF
Kizito Mukhwana HP and Community Services Lead CARE
Josphat Deya HIV Integration Program Officer EGPAF
Moses Kidi Prevention Officer ICAP
Christine Osula Community Liaison Officer FACES
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Section 1:
1st line ART Adherence preparation SOPs
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Adherence SOP I: Treatment preparation for Pediatric clients (2-9 years)
Requirements:
Service provider who has undergone NASCOP pediatric psychosocial and NASCOP
adherence trainings.
A well ventilated confidential place.
Adequate seats for the health worker, the child and the caregiver/s
Counseling in progress door tags
Safe drinking water
Pediatric Psychosocial assessment form
Clients file
Job Aids: TPS SOPs, Timer, literacy flip charts, PwP flip charts, Dummy pills,
Penile/vaginal models, male and female condoms.
Adherence counseling Register
Pediatric TPS 1
Approach: individual one to one
1. Service provider facilitates climate setting:
Greet and welcome the clients: the child and the caregiver
Make the child and the caregiver comfortable (provide seats and reassure)
Service provider does self-introduction
Service provider then invites the caregiver to introduce self and the child
Service provider invites the clients to clarify their reason for coming to the clinic.
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Service provider and the clients harmonize expectations: explain objectives for the
session, duration, and the norms of the session.
2. Service provider does psychosocial assessments
Fill in psychosocial assessment questionnaire to gather intake data for evaluation of
possible psychological, emotional and social adherence boosters and barriers.
Carry out checklist driven milestone assessment for the child to rule out retardation,
developmental challenges such as autism, deafness and any other physical challenge.
3. Health worker interprets the findings and makes decision to proceed or not as follows:
If the child manifests any developmental challenge (s), refer for appropriate care but proceed
with preparations as indicated below.
If the child is less than 6 years of age then only focus on the proxy (the caregiver)
If the child is >6 years then focus on the proxy but engage the child in bits that he or she can
understand.
For children under 6 years: if the caregiver has mental condition (s), then refer for psychiatric
management and reschedule TPS 1 to the time when the caregiver is stable enough to go
through the literacy component.
o But if the management of the mental condition is likely to take longer than 1 month
then seek for an alternative caregiver and do the same assessment then use the
same algorithm to make decision.
If the caregiver has no mental condition then proceed to TPS 1:
Pediatric TPS 1 contents:
o Clarify the meaning of being HIV positive with the client.
o Clarify modes of transmission of HIV in children of different age groups
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o In lay mans language explain HIV disease progression to AIDS and explain effects of
HIV on the health and growth of children.
o Explain the ARVs eligibility criteria for children.
o Discuss the benefits of ARVs
o Discuss ARV adherence: requirements, measurements, benefits and risks of non-

adherence
o Explain the investigations that the child will need and in what frequency (HB, renal
function, liver function, CD4, viral load, crag, etc).
o Show the caregiver (and the child if able to understand) the dummy ARVs
o Discuss the common side effects that they need to watch out for.
o Discuss benefits of disclosing to the child his or her status.
o Explore if there are any concerns of the caregiver and then formulate disclosure plan
if not disclosed to and the child is above 6 year (NASCOP 2014).
o Explain how pediatric support group (kids club) operates and formally link the child
and care give to the coordinator of Kids club at the clinic
o Invite the child and caregiver to ask any questions or to express any fears and address
such concerns.
o Document all procedures, findings and intervention appropriately in the childs file.
o Introduce treatment contract and discuss contents.
o Conclude the session with reassurance and link the client to appropriate department
if further services are needed or discharge home with a confirmed to come again date
(TCA).
(NASCOP, 2011:117-119; NASCOP, 2014: 7)
Note: being listed among the priority clients, children do not need to wait for all the three TPS
sessions to be initiated. They can be initiated after pediatric TPS 1 but mop up the pending
adherence preparation sessions during the subsequent visits.
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Pediatrics TPS 2
Interval: 1 week after TPS 1
Approach: either individual or group
1. Welcome the child and the caregiver and make them comfortable.
2. Assess for retention of the contents of the last session (TPS 1).
3. If partially remembered or not remembered then go through the TPS 1 agenda again and assess
for retention immediately the discussion topics are over.
4. If the caregiver remembers the basic facts (discussed during the initial or make up TPS 1) then
proceed to TPS 2.
Pediatric TPS 2 contents:
a. Discuss when and why ARV treatment can fail
b. Explain the manifestation and consequences of treatment failure.
c. Explain why opportunistic infections attack, why they should be managed promptly and
risks of delayed management of Opportunistic infections.
d. Re-emphasize the types, rationale and frequency of lab investigations.
e. Revisit benefits of disclosure, when and how to do it.
f. In a lay mans language, explain any other clinic procedures like ICF, anthropometrics and
what happens when the child qualifies for IPT.
g. Provide diet and nutritional information. Also explain the conditions in which a child can
get nutritional supplements from the clinic.
h. Examine the progress regarding enrollment in Kids club, if not yet reemphasize the benefit
and encourage the child to be supported by caregiver to join and participate in the group.
i. Explore if the child and caregiver have any concerns or questions and address
appropriately.
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j. If there are no more concerns then conclude the session by linking them to the next
service point if further services are needed, or discharge home with a confirmed TCA.
(NASCOP, 2011 and 2014)
Pediatric TPS 3
1. Welcome the child and the caregiver and make them comfortable.
2. Assess the treatment literacy levels for the caregiver based on content of TPS 1 and TPS 2.
3. If partially or not remembered, review TPS1 and TPS 2 content in summary, assess caregivers
understanding then proceed to the next stage even if there is minimal content recall.
4. Revisit the samples of pediatric ARVS and explain how ARVS work
5. Revisit reasons for treatment failure and its consequences
6. If well remembered then agree on medication hours and clarify reminders available for the client.
7. Explore hopes of both the child and care giver and capitalize on this to emphasize how ARVs can
help them to achieve that hope.
8. Invite clarifications, questions, and concerns from the child and caregiver and address them
appropriately
9. Complete the final treatment contract and discuss contents with the caregiver who then commits
to implement it fully by signing (informed consent for treatment).
10. Conclude the session with reassurance on the benefits of ARVs if well adhered to and emphasize
that a child can make it in life even with HIV.
11. Document the interventions and outcomes of the session in a checklist in the clients file.
12. Link to the clinician for HAART initiation.
(NASCOP ART Adherence notes Module 4)
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Pediatric Booster adherence counseling

Interval: 6 monthly
Approach: individual
1. Welcome the child and the caregiver.
2. Re-assess knowledge on contents of TPS 1 and 2.
3. If partially or not remembered then re-explain both TPS 1 and TPS 2 contents in summary.
4. If reasonably understood then congratulate and emphasize adherence and consequence
of non-adherence. Remember to re-emphasize any gaps observed.
5. Evaluate participation of the child in Kids club (from self-report). If wanting then explain
the benefits and encourage the caregiver to help the child to attend.
6. Explore any concerns, questions and challenges and address them appropriately
7. Remember to do psychosocial assessments annually.
8. Document booster adherence counseling activities in a checklist in the patients file.
(NASCOP, 2011; NASCOP Pediatric psychosocial training notes, mod 4 and 8)
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Adherence SOP II: Adherence preparation for adolescent clients (10-19yrs)
Requirements:
Service providers trained on peds psychosocial and adherence counseling (NASCOP)
A well ventilated and confidential place
Adequate seats for the health worker, the adolescent and the caregiver/s
Safe water for drinking
Adolescent Psychosocial assessment form
Clients file
Job Aids: laminated Tanner staging charts, penile and vaginal models, female and male
condoms, PwP flip charts, adherence flip charts, PwP Manual.
Adolescent TPS 1
Greet and welcome the clients: the adolescent and the caregiver
Make the adolescent and the caregiver comfortable (provide seats and reassure)
Service provider invites the caregiver (If adolescent) to introduce self and the
adolescent.
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A mature minor (>15 years with evidence of sexual activity) to have both private and
joint session with caregiver.
Service provider invites the caregiver or the adolescent to clarify their reason for
coming to the clinic.
Service provider joint with the caregiver and adolescent harmonize expectations and
proceeds to the next step.
2. Service provider does psychosocial assessments (using individual approach):
Fill in adolescent psychosocial assessment questionnaire to gather intake data for
evaluation of possible adherence boosters and barriers.
Carry out milestone assessment for the adolescent to rule out retardation,
developmental challenges and any other physical challenges.
3. Health worker interprets the assessment findings, advises the clients on the meaning of the
findings then makes a decision to proceed or not as follows:
If the adolescent manifests any developmental challenge, refer for appropriate care but
proceed with preparations as indicated below if caregiver is available.
If no caregiver accompanied the adolescent who is less than 15 years of age, ask him or her
to come with the caregiver for psychosocial support in one weeks time or ASAP.
If the adolescent is above 15 years but below 18 years then proceed with TPS but ask him or
her to come with a guardian during the next visit. If it is not possible to get a caregiver, seek
the help of childrens department. Only proceed when there is a caregiver to give written
consent for ART initiation.
Encourage caregiver to disclose to the adolescent the HIV status if not yet done.
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If the adolescent has mental condition refer for psychiatric management but if he is
accompanied by caregiver/treatment buddy, proceed with the TPS 1 but focusing on the
caregiver.
If the caregiver of the adolescent has mental condition and the adolescent does not qualify
for preparation alone (below 18years), seek alternative caregiver and then proceed with TPS
1.
Adolescent TPS 1 contents:
o Clarify the meaning of being HIV positive
o Clarify modes of transmission of HIV in children/adolescents of different age groups
HIV on the health of adolescent.
o Explain indications for ARVs in adolescents.
o Discuss adherence: requirements, measurements, benefits and risks of non-
adherence
o Explain the investigations that the adolescent will need and in what frequency (HB,
renal function, liver function, CD4, viral load, crag, etc).
o Show the adolescent and or caregiver the dummy ARVs
o Discuss disclosure benefits and any concerns of the caregiver and formulate
disclosure plan.
o Explain how adolescent support group (adolescent club) operates and formally link
the adolescent and caregiver to the coordinator of adolescent club at the clinic
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o Invite the adolescent and caregiver to ask any questions or to express any fears and
address such concerns.
o Document all procedures, findings and interventions appropriately in the clients file.
o Conclude the session and link the client to appropriate department if further services
are needed or discharge home with a confirmed to come again date (TCA).
Adolescent TPS 2
1. Welcome the adolescent and the caregiver and make them comfortable.
2. Assess for retention of the discussion contents of the last session (TPS 1).
4. If the adolescent and or caregiver have the basic facts (discussed during the initial or make up TPS
1) then proceed to TPS 2.
TPS 2 contents:
a. Discussion when and why ARV treatment can fail
b. Explain the manifestation and consequences of treatment failure.
c. Explain why opportunistic infections attack, why they should be managed promptly and
d. Re-emphasize the types, rationale and frequency of lab investigations.
e. Revisit benefits of disclosure if not yet done, when and how to do it.
f. In a lay mans language, explain any other clinic procedures like ICF, anthropometrics and
what happens when the adolescent qualifies for IPT.
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g. Provide diet and nutritional information. Also explain the conditions in which the
adolescent can get nutritional supplements from the clinic.
h. Examine the progress regarding enrollment in adolescent club, if not yet reemphasize the
benefit and encourage the adolescent to be supported by caregiver to join and
participate.
i. Explore if the adolescent and caregiver have any concerns or questions and address
appropriately.
j. If there are no more concerns then conclude the session by linking them to the next
Adolescent TPS 3 (competency assessment and HAART initiation):

1. Welcome the adolescent and the caregiver and make them comfortable.
2. Assess the treatment literacy levels for adolescent and the caregiver based on content of TPS 1
and TPS 2.
3. If partially or not remembered, review TPS1 and TPS 2 content in summary, assess the
understanding of adolescent and caregivers understanding then proceed to the next stage even
if there is minimal content recall.
4. Revisit the samples of ARVS and explain how they work.
7. Explore hopes of both the adolescent and care giver and capitalize on this to emphasize how ARVs
can help them to achieve that hope.
8. Invite clarifications, questions, and concerns from the adolescent and caregiver and address them
appropriately
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9. Conclude the session with reassurance on the benefits of ARVs if well adhered to and emphasize
that adolescent can make it in life even with HIV.
11. Link to the clinician for HAART initiation.
Adolescent Booster adherence counseling

Interval: 6 monthly
1. Welcome the adolescent and the caregiver.
4. If reasonably understood then congratulate and emphasize adherence and consequence of non-
adherence. Remember to re-emphasize any knowledge gaps or negative attitudes observed.
5. Evaluate participation of the child in Kids club (from self-report). If wanting then explain the
benefits and encourage the caregiver to help the child to attend.
7. Remember to do psychosocial assessments annually.
8. Document booster adherence counseling activities in a checklist in the patients file.
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Adherence SOP III: Adherence preparation for ART nave adult
Requirements:
Service providers trained on adherence counseling (NASCOP)
Adequate seats for the health worker, the client and treatment buddy.
Adult Psychosocial assessment form
Clients file
Job Aids: penile and vaginal models, female and male condoms, PwP flip charts,
adherence flip charts, PwP Manual.
ART Nave adult TPS 1

Greet and welcome the client
Make the client comfortable (provide seats and reassure)
Service provider invites the client to introduce self.
Service provider invites the client to clarify his or her reason for coming to the clinic.
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Service provider with the client harmonize expectations and proceeds to the next
step.
5. Service provider does psychosocial assessments (using individual approach):
Fill in adult psychosocial assessment questionnaire to gather intake data for
evaluation of possible adherence boosters and barriers.
6. Health worker interprets the assessment findings, advises the clients on the meaning of the
findings then makes a decision to proceed or not as follows:
If the client manifests any mental challenge, refer for appropriate care but proceed with
preparations as indicated below if there is a treatment buddy.
If there is no treatment buddy then defer TPS 1, encourage the client or family to find a buddy
and then re-schedule the meeting to include buddy as the client is mentally incapacitated.
If the caregiver is mentally sound or mentally challenged with a buddy then proceed to the
next step TPS1
Contents of ART nave adults TPS 1:
o Clarify the meaning of being HIV positive
o Clarify modes of HIV transmission of HIV in in adults.
HIV on the health of a person.
o Explain eligibility criteria for ARVs in adults.
o Discuss adherence: requirements, measurements, benefits and risks of non-
adherence
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o Explain the investigations that the client will need and in what frequency (HB, renal
function, liver function, CD4, viral load, crag, etc).
o Show the client and or treatment buddy the dummy ARVs
o Discuss disclosure benefits and how to disclose.
o Invite the client to seek any clarifications and address any concerns of the client or
the buddy and formulate disclosure plan if client needs to extend disclosure.
o Explain how adult support group operates and formally link the client to the
coordinator of adult support group at the clinic
o Invite the client and or the buddy to ask any questions or to express any fears and
appropriately address such concerns.
o Document all procedures, findings and interventions appropriately in the clients file.
o Conclude the session and link the client to appropriate department if further services
are needed or discharge home with a confirmed to come again date (TCA).
Caution: HIV positive Pregnant/lactating mothers, TB HIV co-infected clients, Hepatitis B
HIV co-infected clients, HIV positive clients in discordant relationships and HIV positive
children below 10 years are priority clients and their ART initiation should not be delayed.
Link them to clinician for initiation after TPS 1 but complete the pending tasks in TPS2 and
TPS3
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1. Welcome the client and make him or her comfortable.
2. Assess for retention of the contents of the last session (TPS 1).
4. If the client and or buddy have the basic facts (discussed during the initial or make up TPS 1) then
proceed to TPS 2.
ART nave adults TPS 2 contents:
a. Discuss how immune system works and how HIV affects it.
b. Discussion when and why ARV treatment can fail
c. Explain the manifestation and consequences of treatment failure.
d. Explain why opportunistic infections attack, why they should be managed promptly and
e. Re-emphasize the types, rationale and frequency of lab investigations.
f. Revisit benefits of disclosure to sexual partner if not yet done: emphasis on when and
how to do it.
g. In a lay mans language, explain any other clinic procedures like ICF, anthropometrics and
what happens when the client qualifies for IPT.
h. Provide diet and nutritional information. Also explain the conditions in which the client
can get nutritional supplements from the clinic.
i. Examine the progress regarding enrollment in support group, if not yet reemphasize the
benefit and encourage the client to join and participate.
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j. Explore if the client and or the buddy have any concerns or questions and address
appropriately.
k. If there are no more concerns then conclude the session by linking them to the next

1. Welcome the client and make him or her comfortable.
2. Assess the treatment literacy for the client and or buddy, based on content of TPS 1 and TPS 2.
3. If partially or not remembered, review TPS1 and TPS 2 content in summary, assess the
understanding of client and or buddy then proceed to the next stage even if there is minimal
content recall.
4. Revisit the samples of ARVS and explain how they work.
7. Explore hopes of both the client and or buddy and capitalize on this to emphasize how ARVs can
help them to achieve that hopes.
8. Invite clarifications, questions, and concerns from the client and address them appropriately.
9. Conclude the session with reassurance on the benefits of ARVs if well adhered
11. Link to the clinician for HAART initiation or reassure if he or she is a priority client initiated after
TPS 1
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ART nave adult Booster adherence counseling

Interval: 6 monthly
9. Welcome the adolescent and the caregiver.
12. If reasonably understood then congratulate and emphasize adherence and consequence of non-
adherence. Remember to address any knowledge or attitudes gaps observed.
13. Evaluate participation of the client in the support group (from self-report). If wanting then explain
the benefits and encourage the client to join the group and attend the meetings.
15. Remember to do psychosocial assessments annually to determine if there are any changes in
psychosocial dynamics of the client.
16. Document booster adherence counseling activities in a checklist in the patients file and then link
to the next service point or discharge home with a clear TCA is adherence is the last station visited.
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Section 2:
2nd line ART Adherence preparation SOP
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Adherence SOP IV: Adherence preparation for pediatrics transitioning to 2nd line
Requirements:
Service providers trained and certified on pediatric psychosocial and adherence
counseling (NASCOP)
Adequate seats for the health worker, the client and treatment buddy.
Clients file
Job Aids: adherence flip charts pictorial illustrations of immunity and immune damage
by HIV virus.
Pediatric 2nd line adherence Counseling

Step 1: Service provider facilitates climate setting:
Service provider invites the caregiver to introduce self and the child.
Service provider invites the client/caregiver to clarify his or her reason for coming to
the clinic.
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Service provider with the client harmonize expectations and proceeds to the next
step.
Step 2: Service provider carries out pediatric 2nd line adherence counseling 1
Revisit pediatric TPS 2 with the caregiver if child is less than 6 years but if above 6
years go through pediatric ART TPS 2 step by step with both the child and the
caregiver:
Explore possible reasons for treatment failure in the clients context.
Explain how viral load test works.
Discuss how immune system works and how HIV affects it.
Discussion when and why ARV treatment can fail
Explain the manifestation and consequences of treatment failure.
Explain why opportunistic infections attack, why they should be managed promptly and risks
of delayed management of Opportunistic infections.
Re-emphasize the types, rationale and frequency of lab investigations.
Revisit benefits of disclosure to the child if not yet done: emphasis on when and how to do it.
Provide diet and nutritional information to the caregiver.
Explore if the child and the caregiver have any concerns or questions and address them
appropriately.
Explains when and why repeat viral load will be done. Book for this test.
If there are no more concerns then conclude the session with reassurance and link the client
(s) to the next service point if further services are needed, or discharge home with a confirmed
TCA.
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Step 3: Service provider carries out pediatric 2nd line adherence counseling 2
Assess clients understanding of contents of 2nd line adherence session1.
Invite client to ask questions and clarify any concerns.
Explain the need for 2nd or confirmatory viral load test (done 3 months post adherence
intervention NASCOP, 2011).
Send the client to the sample room for viral load sample collection.
Link to an appropriate service point if further services are needed or discharge home to
await results if no more services are pending.
Step 4: Service provider carries out 2nd line adherence counseling 3
When the results have been received, discuss the findings in MDT meeting and agree on
a course of action.
Trace the client and invite back to the clinic for results.
Explain the results in a simple language and allow the client to ask questions.
If less than 1000 copies per milliliter of blood, reassure the clients then re-emphasize the
importance of adherence for better treatment outcomes in future.
If the result documents more than 1000 copies per ml of blood, prepare for switching by:
o Explaining what second line ARVs mean and why the clients require it.
o Explaining the consequences of not switching to second line.
o Discussing the consequences of not adhering to ARVs.
o Allowing the client to seek clarifications and addressing those concerns.
Confirm clients and caregivers readiness for switching to 2nd line.
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After the above preparations, link the client to clinician for switching to second line.
Re-schedule for a review after 1 week to rule out side effects and monitor progress.
Service provider to carry out monthly progress follow-up and adherence
monitoring/counseling.
Service providers carries out quarterly booster adherence counseling (using step 2
contents and re-emphasize knowledge, attitudes and skills gaps)
(NASCOP, 2011; NASCOP, 2014)
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Adolescent 2nd line adherence Counseling

Approach: either individual, group or both
Service provider invites the caregiver and or adolescent to introduce self.
Service provider invites the client(s) to clarify his or her reason for coming to the clinic.
Service provider, with the client, harmonize expectations and proceeds to the next step.
Step 2: Service provider carries out adherence counseling 1
Revisit adolescent TPS 2 with the caregiver and or adolescent (refer to adolescent TPS 2).
Explore sexual practices: if sexually nave move to the next step but if sexually active
explain the concept of re-infection, benefits of condom use, provide condoms to the client
and introduce the need for pregnancy prevention (between client and sexual partner).
Explain how viral load test works.
Explain why opportunistic infections attack, why they should be managed promptly and risks of
delayed management of Opportunistic infections.
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Revisit benefits of disclosure to the adolescent if not yet done: do assisted disclosure in
the facility, at this point, before proceeding to the next.
Provide diet and nutritional information.
If there are no more concerns then conclude the session by linking the client (s) to the next service
point if further services are needed, or discharge home with a confirmed TCA.
Step 3: Adolescent 2nd line adherence counseling 2
Assess clients understanding of contents of adolescent 2nd line adherence session1.
Explain the need for 2nd viral or confirmatory viral load test (done 3 months post
adherence intervention NASCOP, 2011).
Link to sample room for viral load sample collection.
Link to an appropriate service point if further services are needed or discharge home to
await results.
a course of action.
If the result reports less than 1000 viral copies per mls of blood, reassure, re-emphasize
the importance of adherence for better treatment outcomes and link to the next service
point if some services are still pending or discharge home if no pending service.
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If viral load result is more than 1000 copies per mls of blood, prepare for switching to 2nd
line:
Explain what second line ARVs mean and why the client need it.
Explain the consequences of not switching to second line.
Discuss the consequences of non-adherence on future treatment
outcomes.
Allow the client to seek clarifications and address concerns.
Confirm clients readiness for 2nd line switch.
Link to the clinician for switching to second line if ready.
Re-schedule for a review after 1 week to rule out side effects and to monitor adherence.
Re-emphasize adherence.
Service provider to carries out monthly follow up and adherence counseling.
Service providers carries out quarterly booster adherence counseling (using step 2
contents and addressing knowledge, attitudes and skills gaps using group approach for
general clients but individual approach for clients with unique needs)
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Adult 2nd line adherence Counseling

Approach: individual or group
Greet and welcome the client (s)
Make the client(s) comfortable (provide seats and reassure)
Service provider invites the client to introduce self.
Service provider invites the client to clarify his or her reason for coming to the clinic and
clients expectation.
Service provider with the client harmonize expectations and then proceed to the next
step.
Step 2: Service provider carries out adherence counseling 1
Based on identified gaps re-visit ART nave adult TPS 2 contents with the client (refer to
ART nave adults TPS 2).
Explore sexual practices: if sexually inactive move to the next step but if sexually active
explain the concept of re-infection and benefits of condom use, supply condoms to the
client and discuss the need for dual contraception for the client/sexual partner to prevent
unintended pregnancies.
Explain how viral load test works and its role in clients management.
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Explain why opportunistic infections attack, why they should be managed promptly and
Re-visit benefits of disclosure to sexual partner if not yet done and develop disclosure
plan (to be executed within 3 months).
Provide diet and nutritional information.
If there are no more concerns then conclude the session by linking the client to the next service
point if further services are needed, or discharge home with a confirmed TCA.
Step 3: Adult 2nd line adherence counseling 2
Assess clients understanding of contents of 2nd line adherence session1.
Explain the need for 2nd viral or confirmatory viral load test (done 3 months post
adherence intervention NASCOP, 2011).
Reassure and link to sample room for viral load sample collection.
Reassure and link to an appropriate service point if further services are needed or
discharge home to await results.
a course of action.
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If result is less than 1000 copies per ml of blood, reassure, re-emphasize the importance
of adherence for better treatment outcomes and discharge home. Re-enforce the need
for safer sex.
If viral load result is more than 1000 copies per ml of blood, prepare for switching:
Explain what second line ARVs mean and why the client needs it.
Explain the consequences of not switching to second line.
Discuss the consequences of not adhering.
Allow the client to seek clarifications and address concerns.
Confirm readiness for switching to second line.
Reassure and link to clinician for switching to second line if ready for switch.
Re-schedule for a review after 1 week to rule out side effects and re-emphasize
adherence.
Monthly follow up and monitoring: emphasize adherence.
Carry out quarterly booster adherence counseling: use step 2 contents and re-enforce
knowledge, attitudes and skills gaps using group approach for general clients but
individual approach for clients with unique needs
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Section 3:
3rd line ART Adherence preparations
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Pediatric 3rd line adherence Counseling

Approach: one to one
Step 1: Present confirmed 2nd line failure to MDT for a discussion and process mapping.
Step 2: Invite the client to come to the clinic for the results and review.
Step 3: Service provider facilitates climate setting during clients visit.
Step 4: Service provider carries out pediatric 3rd line adherence counseling
Explore possible reasons for clients failure to 2nd line treatment.
Identify and agree on adherence reminders that the client will use.
Re-emphasize adherence (drug timing, dosage compliance, appointment keeping, safer sex
and implementation of all clinical instructions) as the only key to better and sustained
treatment outcomes.
Support client to identify treatment buddy if he or she does not have any.
Discuss with the client and caregiver how immune system works and how HIV affects it.
Discuss how ARVs work and how poor adherence affects outcomes.
Explain to the care giver that this is the last option and has to be ordered from Nairobi when
clients readiness is established.
Allow client to seek clarification and address concerns and questions.
Jointly construct with the client an adherence plan.
Discuss the 3rd line treatment contract and invite client to commit to it by signing.
Invite client to ask any question, express concerns or to seek clarifications.
Reassure the client and ask him or her to diligently continue with the old regimen until new
regimen is available.
35 | P a g e
Link to clinician for review and requisition of regimen from NASCOP - Nairobi.
Step 5: When 3rd line regimen is confirmed available at the facility
Trace the client and invite him or her to visit facility with treatment buddy or caregiver
for review.
Assess clients understanding of the meaning and behavioral expectations while on 3rd
line.
Review the earlier developed adherence/treatment plan and reconstruct it if there are
gaps.
o Confirm locator details with working phone number and clear map on how to get
to the clients residence. Ensure that the current (updated in the month of activity)
locator form is in the file.
o Confirm the types of drugs to be given and if the order has been placed from
NASCOP/Nairobi.
o Confirm venue for the ART DOT in readiness for treatment.
o Confirm and introduce (to the client) the CHW/health worker who will administer
the DOT for the initial 3 months.
o Confirm the monthly home visits schedule for moral support and for assessing
psychosocial support mechanism and other support dynamics in the family.
If all arrangement have been done and necessary paperwork complete then link to
clinician for switching to 3rd line.
Carry out adherence gaps assessment and gaps based booster adherence counseling
every month during the clinic visits.
(NASCOP, 2011; MOH, June 2014)
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Adolescent 3rd line adherence Counseling

Step 2: Invite the client to come to the clinic for the results and review.
Step 4: Service provider carries out adolescent 3rd line adherence counseling
Re-emphasize adherence (drug timing, dosage compliance, appointment keeping, safer
sex and implementation of all clinical instructions) as the only key to better and sustained
treatment outcomes.
Explain to the care giver that this is the last option and has to be ordered from Nairobi
when clients readiness is established.
Jointly construct with the client an adherence plan.
Discuss the 3rd line treatment contract and invite client to commit to it by signing.
Invite client to ask any question, express concerns or to seek clarifications.
37 | P a g e
Reassure the client and ask him or her to diligently continue with the old regimen until new
regimen is available.
Explore practical drugs acquisition, storage and use for adolescents in boarding schools
(solicit for a school based treatment buddy).
If all details are adequate, link to clinician for review then discharge home to await
availability of the 3rd line regimen but with emphasis on the need for adherence to the
current regimen, CTX and any other prescribed medications.
The clinician makes requisition of regimen from NASCOP - Nairobi.
Trace the adolescent and invite him or her to visit facility with treatment buddy or
caregiver for review.
Assess adolescents understanding of the meaning and behavioral expectations while on
3rd line.
gaps.
o Confirm that there is an MDT report recommending 3 rd line for this client in the
file.
o Confirm the types of drugs to be given and if the order has been placed from
NASCOP/Nairobi.
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o Confirm the monthly home/school visits schedule for moral support and for
assessing psychosocial support mechanism and other support dynamics for clients
on 3rd line in the family/school.
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Adult 3rd line adherence Counseling

Step 2: Invite the client to come to the clinic for the results and review with a treatment buddy.
Step 4: Service provider carries out adult 3rd line adherence counseling
Re-emphasize adherence as the only key to better and sustained treatment outcomes.
Explain to the care giver that this is the last option and has to be ordered from Nairobi when
clients readiness is established.
Explore clients sexual activities: if sexually inactive then move to the next task. If sexually
active then review clients RH plans/pregnancy intentions/safer conception.
Link to clinician for review and requisition of regimen from NASCOP - Nairobi.
40 | P a g e
Trace the client and invite him or her to visit facility with treatment buddy or caregiver
for review.
Assess the clients understanding of the meaning and behavioral expectations while on 3rd
line.
gaps.
o Confirm that there is an MDT report recommending 3 rd line for this client in the
file.
o Confirm availability of 3rd line drugs from NASCOP.
o Confirm the monthly home visits schedule for moral support and for assessing
psychosocial support mechanism and other support dynamics for clients on 3 rd
line at the family level.
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References
Ministry of Health (June 2014). Guidelines on use of Antiretroviral Drugs in Treating and
Preventing HIV infection. Unpublished.
National AIDS STIS Control Programme - NASCOP (2008). HIV Prevention for People Living
with HIV/AIDS: Tools for Health Care Providers in HIV Clinical Settings, 1st Edi. Nairobi:
NASCOP.
National AIDS STIS Control Programme - NASCOP (2011). Guidelines for Antiretroviral
Therapy in Kenya, 4th edi. Nairobi: NASCOP.
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Section4:
Forms and checklists
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1st line Adherence Preparation Checklist
Section 1: Patient demographics

Name of the client___________________________________CCC No______________Phone contact___________
Facility name____________________________________MFL code__________________County_______________
DOB _______________Date diagnosed_________________Date enrolled__________________ Marital status____
Occupation (specific)_________________________________
Client classification at enrollment: ( ) Pediatric (2-9yrs) ( ) Adolescent (10-19yrs) ( ) Adult (>19 yrs.)
Section 2: Treatment Preparation Services:

1. TPS 1 date: ______________Done by(Name):_____________________Designation:______________________
Successfully completed TPS 1: ( ) Yes ( ) No
TPS 1 Comments:
2. TPS 2 date: ______________Done by(Name):_____________________Designation:____
Successfully completed TPS 2: ( ) yes ( ) No
TPS 2 Comments:
3. TPS 3 date: ______________Done by(Name):_____________________Designation:____
Successfully completed TPS 3 ( ) Yes ( ) No

TPS 3 Comments:
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Clients name________________________________CCC No________________________
Section 3: Booster counseling

Booster adherence counseling sessions: done 6monthly for 1st line, 3 monthly for 2nd line
and monthly for 3rd line.
Session Date done Done by Brief comments Sign
description (name)
Booster1
Booster 2
Booster 3
Booster 4
Booster 5
Booster 6
Booster 7
45 | P a g e
2nd and 3rd line adherence counseling checklist
Section 1: Patient demographics

Name of the client___________________________________CCC No______________Phone contact___________
Facility name____________________________________MFL code__________________County_______________
DOB _______________Date diagnosed_________________Date enrolled__________________ Marital status____
Occupation (specific)_________________________________Date initiated on ART__________________________
Client classification at enrollment: ( ) Pediatric (2-9yrs) ( ) Adolescent (10-19yrs) ( ) Adult (>19 yrs.)
Section 2: 2nd line adherence counseling

Client classification at 2nd line preparation: ( ) Pediatric (2-9yrs) ( ) Adolescent (10-19yrs) ( ) Adult (>19 yrs.)
4. 2nd line adherence counseling date: ______________Done by(Name):___________________Designation:____
Successfully completed 2nd line adherence counseling ( ) Yes ( ) No

2nd line adherence counseling Comments:
Section 3: 3rd line adherence counseling

5. 3rd line adherence counseling date: ______________Done by(Name):___________________Designation:____
Successfully completed 3rd line adherence counseling ( ) Yes ( ) No
3rd line adherence counseling Comments
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Clients name_______________________________________CCC No_________________
Section 5: Booster counseling

Booster adherence counseling sessions: done 3 monthly for 2nd line and monthly for 3rd line.
Session Date done Done by Brief comments Sign

description (name)
Booster i
Booster ii
Booster iii
Booster iv
Booster v
Booster vi
Booster vii
Booster viii
Booster ix
Booster x
47 | P a g e

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Adherence Counseling and Treatment Preparation Sop

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Adherence Counseling SOPs, October 2014

ADHERENCE COUNSELING AND TREATMENT PREPARATION SOP

ADHERENCE PREPARATION STANDARD OPERATING PROCEDURES

1st line ART Adherence preparation SOPs

Adherence SOP I: Treatment preparation for Pediatric clients (2-9 years)

A well ventilated confidential place.

Counseling in progress door tags

Safe drinking water

Pediatric Psychosocial assessment form

Penile/vaginal models, male and female condoms.

Adherence counseling Register

1. Service provider facilitates climate setting:

Service provider does self-introduction

session, duration, and the norms of the session.

2. Service provider does psychosocial assessments

Fill in psychosocial assessment questionnaire to gather intake data for evaluation of

possible psychological, emotional and social adherence boosters and barriers.

with preparations as indicated below.

through the literacy component.

If the caregiver has no mental condition then proceed to TPS 1:

Pediatric TPS 1 contents:

o Clarify the meaning of being HIV positive with the client.

o Clarify modes of transmission of HIV in children of different age groups

o Explain the ARVs eligibility criteria for children.

o Discuss the benefits of ARVs

o Discuss ARV adherence: requirements, measurements, benefits and risks of non-

o Discuss benefits of disclosing to the child his or her status.

o Introduce treatment contract and discuss contents.

(NASCOP, 2011:117-119; NASCOP, 2014: 7)

adherence preparation sessions during the subsequent visits.

for retention immediately the discussion topics are over.

Pediatric TPS 2 contents:

a. Discuss when and why ARV treatment can fail

b. Explain the manifestation and consequences of treatment failure.

risks of delayed management of Opportunistic infections.

d. Re-emphasize the types, rationale and frequency of lab investigations.

e. Revisit benefits of disclosure, when and how to do it.

what happens when the child qualifies for IPT.

get nutritional supplements from the clinic.

(NASCOP, 2011 and 2014)

5. Revisit reasons for treatment failure and its consequences

help them to achieve that hope.

to implement it fully by signing (informed consent for treatment).

that a child can make it in life even with HIV.

12. Link to the clinician for HAART initiation.

(NASCOP ART Adherence notes Module 4)

Pediatric Booster adherence counseling

1. Welcome the child and the caregiver.

2. Re-assess knowledge on contents of TPS 1 and 2.

4. If reasonably understood then congratulate and emphasize adherence and consequence

of non-adherence. Remember to re-emphasize any gaps observed.

7. Remember to do psychosocial assessments annually.

8. Document booster adherence counseling activities in a checklist in the patients file.

(NASCOP, 2011; NASCOP Pediatric psychosocial training notes, mod 4 and 8)

Adherence SOP II: Adherence preparation for adolescent clients (10-19yrs)

Service providers trained on peds psychosocial and adherence counseling (NASCOP)

A well ventilated and confidential place

Counseling in progress door tags

Safe water for drinking

Adolescent Psychosocial assessment form

Adherence counseling Register

condoms, PwP flip charts, adherence flip charts, PwP Manual.

1. Service provider facilitates climate setting:

Service provider does self-introduction