Ministry of Health

Toolkit for Third Line

Antiretroviral Therapy

April 2015
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Table&of&Contents&
Acknowledgements...................................................................................................................2!
Introduction................................................................................................................................3!
Multidisciplinary.Team.Composition.and.Roles.............................................................4!
Viral.Load.Algorithm................................................................................................................6!
Clinical.Summary.Form...........................................................................................................8!
Adherence.and.Retention.Assessment.and.Support..................................................10!
Introduction.......................................................................................................................................10!
Objectives............................................................................................................................................11!
Case.Manager.....................................................................................................................................11!
Adherence.assessment.and.enhanced.adherence.counselling.........................................11!
Morisky!Medication!Adherence!Scales:!MMAS 8!........................................................................!13!
Adherence!sessions!in!details!.................................................................................................................!15!
Mental!Health!Screening!...........................................................................................................................!18!
Enhanced.Adherence.Counseling.Sessions.Documentation..............................................20!
Adherence.Counseling.for.Adolescents....................................................................................21!
3rd.line.ART.client.education.and.counselling.sessions......................................................23!
Key!Messages!on!Treatment!Failure!and!Use!of!Viral!Load!.......................................................!23!
Adherence.support.systems.........................................................................................................24!
Patient.Management.Protocol............................................................................................29!
Clinical.Encounter.Form.......................................................................................................31!
Commodity.Management.Standard.Operating.Procedures.....................................32!
Requesting.for.Third.Line.Medicines.for.New.Patients.......................................................32!
Documenting.the.Dispensing.of.Third.Line.Medicines........................................................33!
Reporting.Consumption.and.Resupply.Requests.for.Patients.on.Third.Line.
Treatment...........................................................................................................................................35!
Third.Line.ARV.Drug.Information....................................................................................41!
RALTEGRAVIR.(Integrase.Inhibitor).........................................................................................41!
DARUNAVIR.(WITH.RITONAVIR)YProtease.Inhibitors........................................................43!
ETRAVIRINE.(NonYNucleoside.Reverse.Transcriptase.Inhibitor)...................................45!
Medication.Use.Counseling.(MUC)....................................................................................47!
Pharmacovigilance.................................................................................................................48!
Quarterly.Reporting.Tool....................................................................................................49!
List.of.Contributors................................................................................................................50!
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1!
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Acknowledgements&
.
The! development! of! the! Toolkit! for! 3rd! Line! Antiretroviral! Therapy! is! a! result! of!
various! efforts! by! the! 3rd! Line! ART! working! group,! drawn! from! different!
organizations!and!coordinated!by!NASCOP.!The!package!was!developed!to!build!the!
capacity!of!healthcare!workers!at!facilities!providing!3rd!line!ART!for!patients.!
!
Special!and!sincere!appreciation!goes!to!the!NASCOP!Care!and!Treatment!team!for!
spearheading!this!process!and!working!tirelessly!to!develop!this!tool!kit,!under!the!
leadership!and!coordination!of!the!ART!Program!Manager.!
!
Special! and! sincere! appreciation! also! goes! to! our! partners,! NGOs,! technical!
organizations,!individuals!and!all!members!who!participated!in!many!meetings!and!
workshops!to!share!useful!ideas!towards!the!development!of!this!document.!!
.
.
.
.
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2!
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Introduction&
.
As!of!January!2015,!Kenya!had!763,859!patients!on!ART!of!whom!697,647!are!adults!
and!66,212!are!children.!There!are!32,579!on!second!line!regimens!and!21!patients!
who! will! immediately! access! 3rd! line! ART! through! the! national! program.! However!
we!are!in!the!process!of!strengthening!systems!to!identify!additional!patients!who!
qualify!for!3rd!line!ART.!
!
Kenya! has! recently! obtained! the! third! line! ARV! medications! for! patients! and!
developed!a!tool!kit!to!provide!guidance!to!health!care!workers!and!health!facilities!
in!order!to!provide!3rd!line!ART.!
!
This!tool!kit!provides!guidance!on!diagnosis!of!second!line!treatment!failure,!patient!
preparation! for! treatment! and! adherence! support! for! 3rd! line! ART,! medication!
information,!commodity!management!and!reporting.!
!
We! recognize! that! there! are! limited! treatment! options! for! patients! beyond! the! 3rd!
line! regimen! and! as! such! recommend! that! health! care! workers! and! patients! work!
together!and!strengthen!systems!to!preserve!this!regimen.!
!
We!anticipate!that!this!tool!kit!will!be!useful!to!you!as!clinicians!and!welcome!your!
feedback!on!it!at!ulizanascop@gmail.com.!
. .

3!
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Multidisciplinary&Team&Composition&and&Roles&
.
Every&facility&providing&3rd&Line&ART&should&have&a&Multidisciplinary&Team&(MDT)&whose&
role&is&to&ensure&that&the&patient&receives&the&highest&quality&of&care&available&through&a&
team&approach&to&care&and&in&applying&quality&improvement&initiatives.&
Members&of&the&MDT&
• Clinical&care&provider&(medical&officer&and/or&clinical&officer/consultants)&
• Pharmacy&
• Adherence&counselor&&
• Nutritionist&&
• Laboratory&personnel&
• Social&worker&
• Health&Records&Officer&&&
• Case&manager&
Objectives&of&the&MDT&
• To&improve&the&capacity&and&skills&of&HCW&to&offer&quality&health&services&and&
strengthen&the&health&systems&at&facility&level&
• Improve&treatment&standards&and&decision&making&
• Identify&gaps&in&service&provided&and&plan&how&to&address&those&identified&needs&
&
Running&an&MDT&Meeting&&
• Appoint&a&chair&and&secretary&for&each&meeting&
• Review&the&agenda&(see&example&of&standing&agenda)&
• Conduct&meeting&&
• Summary&of&action&items,&persons&responsible,&timelines&and&follow&up&plan&
• Date&of&next&meeting&(recommend&weekly)&&
&

Suggested&Standing&Agenda&
• Review&of&previous&minutes&and&matters&arising&&
• Care&and&Treatment:&&
o Review&the&care&and&ART&history&of&the&patients&suspected&to&be&failing&
ART&&
o Discuss&factors&contributing&to&treatment&failure&&
o Review&adherence&for&the&client&and&propose&adherence&support&plan&
o Complete&clinical&summary&form&
• Commodity&Management&&
• Laboratory&Issues&
• Quality&of&Care&
o Support&Continuous&Quality&Improvement&through&review&of&plans,&
implementation&progress,&developing&action&plans&

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o Do&peer&chart&reviews&and&chart&audits&and&give&feedback,&develop&action&
plans&&&follow&up&plan&
o Conduct&mortality&review&
o Develop&data&quality&audit&feedback&and&action&plans&
• Signing&off&of&Clinical&Summary&Forms&
NB:&Good&documentation&is&critical&for&the&MDT&
&
Requirements:&
• Reference&materials&&
• Teaching&aids&
• SOPs&
• Book&for&MDT&minutes&
• Clinical&Summary&Form&
• Stationery&
&

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5!
Indications for Viral Load:
st nd rd
1) All!HIV'infected!children,!adolescents!and!adults!initiating!ART!(1 ,!2 !or!3 !line!ART!regimens)!should!receive!a!viral!
!
load!test!6!months!following!ART!initiation,!at!12!months!and!annually!
2)!Confirmation!of!treatment!failure!for!those!with!VL>1000!copies/ml!!
!
3)!All!HIV'infected!women!who!become!pregnant!while!on!ART!and!have!not!had!a!viral!load!test!in!the!preceding!6!
months!
4)!Before making any single-ARV drug substitution if the patient has been on ART for more than 6 months!!

Collect a sample for viral load testing

Viral load >1,000 copies/ml Viral load <1,000 copies/ml

Adherence assessment and intervention in all treatment

failure patients; assess for, treat &/or stabilize
opportunistic infections; review drug interactions; assess
for other possible causes of treatment failure

!
Repeat viral load after 3 months of excellent adherence

Viral load >1,000 copies/ml Viral load <1,000 copies/ml

Confirms treatment failure, continue

adherence review, preparation and
intensive follow-up plan
If first line ART failure switch to second
line ART as per guidelines.
No treatment failure.
Do not switch ART
Continue with the current regimen and adherence
support, manage drug toxicities as appropriate

*If 2nd line ART failure, summarize case

and email to ulizanascop@gmail.com

NB:
! Plasma remains the preferred specimen type for viral load testing. Facilities in close proximity and
easy access to a testing laboratory should use plasma samples. Facilities with poor access or in remote
areas should use DBS.

Guidance for second line ART failure

• *Patients confirmed to have failed 2nd line ART treatment failure: Summarize case in the clinical summary
form provided by NASCOP and submit to ulizanascop@gmail.com for approval of Drug Resistance Testing
• NASCOP ART Therapeutics TWG will determine need for DR testing and advise the facility. Results of
HIV DR testing should be submitted to this TWG to determine ART regimen
• Meanwhile continue with current regimen

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Viral.Load.Algorithm:.Additional.Notes.
.
.
! Always!consider!all!possible!causes!of!suspected!treatment!failure:!
• Poor!adherence!(consider!stigma,!disclosure,!side!effects!of!medications,!
alcohol!or!other!drugs,!mental!health!disorders,!religious!beliefs,!inadequate!
treatment!preparation,!etc.)!!
• Inadequate!dosing/dose!adjustments!(particularly!for!children)!!
• Impaired!absorption!(e.g.!chronic!severe!diarrhea)!!
• Drug`drug!interactions!!
• Drug`food!interactions!!
!
! If!2nd!viral!load!is!still!≥1,000!copies/ml!after.3.months.of.optimal.adherence,!
fill!in!the!Clinical!Summary!Form!and!send!it!within.one.week.via!email!to!
ulizanascop@gmail.com!for!consultation!
!
! National/Regional!Clinical!TWG!will!review!and!provide!feedback!for!next!steps!
in!patient!management!within.one.week!of!the!receipt!of!the!Clinical!Summary!
Form!
!
.
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7!
 MINISTRY OF HEALTH
NATIONAL AIDS AND STI CONTROL PROGRAMME
CLINICAL SUMMARY FORM
Name of MFL
Facility Code
Patient CCC Date
no.
(do not write name)
Patient Details Date of Birth : Enrollment Date:

Gender: Current Weight (Kg): Height (cm):

Clinician’s
Name
Facility Tel: Email:
Contacts
What is the primary reason for this consultation:

Clinical Evaluation: history, physical, diagnostics, working diagnosis (excluding the information in the table below)

Complete the table below chronologically, including all ART regimens and laboratory results (and any
previous history available for transfer-in patients)
Date CD4 HB CrCl/ Viral Weight (z- ARV Regimen Reason for Switch New OI or other
eGFR Load score/BMI clinical event
for children)

Completely filled forms should be sent to ulizanascop@gmail.com

8
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Adherence and Treatment Failure Evaluation

Parameters of Evaluation Findings

Number of adherence counseling/assessment sessions done in the

last 3-6 months

Number of home visits conducted in last 3-6 months, and findings

Support structures (e.g. treatment buddy, support group

attendance, caregivers) in place for this patient?

Evidence of adherence concerns (e.g. missed appointments, pill

counts)

Number of DOTS done in last 3-6 months

Likely root cause/s of poor adherence for this patient (e.g. stigma,
disclosure, side effects, alcohol or other drugs, mental health
issues, caregiver changes, religious beliefs, inadequate
preparation, etc.)

Evaluation for other causes of treatment failure, e.g.:

• Inadequate dosing/dose adjustments (particularly for

children)
• Drug-drug interactions
• Drug-food interactions
• Impaired absorption (e.g. chronic severe diarrhea)

Other Relevant ART History

Comment on treatment interruptions, if any
Has Drug Resistance/Sensitivity Testing been done for this
patient? If yes, state date done and attach the detailed results
Has facility multidisciplinary team discussed the patient’s case? If
yes, comment on date, deliberations and recommendations
(indicate how treatment failure was established and confirmed,
proposed regimen and dosage, current source of drugs if patient
already on 3rd line)

MDT members who participated in the case discussion (names and

titles)

Summary of Recommendations from the Regional/National Clinical Technical Working Group:

Date of Feedback:

Completely filled forms should be sent to ulizanascop@gmail.com

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Adherence&and&Retention&Assessment&and&Support&
Introduction&
!
Adherence!counseling!support!and!patient!retention!is!an!extremely!important!
component!of!third!line!ART!in!the!management!of!clients!with!HIV.!It’s!importance!
is!emphasized!and!made!all!the!more!important!because!usually!they!have!already!
been!through!basic!ART!adherence!counseling!and!will!therefore!have!progressed!
through!from!1st!line!to!second!line!and!now!in!need!of!third!line!counseling.!Critical!
reasons!leading!to!this!development!poor!adherence!to!second!line!treatment!
independently!as!well!as!the!development!of!resistance!through!virological!
processes!of!the!virus!itself!regardless!of!their!adherence!practices!to!ART.!This!
therefore!requires!a!guidance!protocol!in!the!implementation!of!the!adherence!
counselling!support!to!ensure!optimal!compliance!to!the!third!line!ART.!A!further!
challenge!is!that!this!is!currently!the!last!line!of!defense!as!well!as!being!a!very!
expensive!undertaking.!In!order!to!ensure!adherence!is!carried!out!to!the!most!
efficient!and!effective!levels!there!is!need!to!address!concerns!of!the!actually!
capacity!of!the!providers!in!terms!of!training!and!experience,!the!requisite!intensity!
of!the!sessions!and!the!specialization!required!to!provide!this!support!at!this!level!
and!the!need!for!more!professional!oversight!of!this!service.!
!
This!module!sets!out!to!provide!guidance!on!the!adherence!and!adherence!support!
systems!to!ensure!client!adherence!to!3rd!line!ART.!
!
Purpose.
The!purpose!of!this!section!on!adherence!guidance!is!to!act!as!support!for!the!health!
care!provider!in!terms!of!highlighting!training,!experience!and!oversight!needs!for!
the!service!providers!as!well!as!guideline!on!delivery!of!services!to!ensure!provision!
of!quality!patient!education!and!counseling!for!patients!in!need!of!3rd!line!regimens.!
.
For.all.clients.on.third.line.regimen..

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Stress!that!this!treatment!options!remain!as!the!only!last!option!and!hence!need!to!
increased!effort!and!support!by!a!multidisciplinary!team!is!necessary.!Patient!
should!complete!three!adherence!sessions!and!develop!a!treatment!plan!prior!to!
initiating!third!line!treatment!
!!

Objectives&

The!three!(3)!main!objectives!of!drug!adherence!counselling!are,!to:!

(a)!Support!patients!in!making!informed!choice!on!HIV!3rd!line!treatment!according!
to!individual!needs!

(b)!Assist!patient!in!adopting!drug!adherence!behavior!

(c)!Enhance!patient's!ability!in!managing!and!maintaining!the!treatment!

!
Case&Manager&
Role.of.case.manager:!

Plans!MDT,!identifies!files!to!be!discussed,!presents!the!case!to!the!MDT,!coordinates!

multidisciplinary! management,! follows`up! on! respect! of! scheduled! appointments,!

assign!roles!to!the!team!members,!organizes!client!reminders!(SMS,!calling)!the!day!

before,!prepares!patient!files,!lead!in!defaulter!tracking,!plans!and!coordinates!home!

visits!(schedule!visits,!transport,!staffing!and!other!logistic).!

Adherence&assessment&and&enhanced&adherence&counselling&&
o To! avoid! 2nd! line! failure! and! need! to! switch! to! 3rd! line,! it! is! key! to! have! an!

adherence!support!strategy!in!place!from!the!start!of!ART!initiation,!with!means!

and! ! activities! adapted! to! the! different! stages! (initiation,! suspected! 1st! line!

failure,…)!Prevention!of!2nd!line!failure!starts!at!initiation.!!

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o Initial! adherence! assessment:! there! are! existing! adherence! scales,! e.g.! Morisky!

Medication! Adherence! Scale! (see! annex! 1! MMAS`8)! evaluating! self`reported!

adherence.!They!are!however!not!very!reliable!in!routine!practice!with!patients!

most! often! over! reporting! self`adherence.! For! patients! with! suspected! 2nd! line!

treatment!failure!it!is!important!to!have!an!in!depth!adherence!assessment!done!

by! an! experienced! counsellor! as! part! of! the! Enhanced! Adherence! Counselling!

Sessions.!!!

o Enhanced! Adherence! Counselling! Sessions:! The! goal! of! enhanced! adherence!

counselling! is! to! assess! possible! barriers! to! adherence.! It! is! important! not! to!

focus! only! on! knowledge! of! HIV/AIDS! and! ARV! treatment! (cognitive! factors)!

but! to! asses! also! emotional,! socio`economical! and! behavioral! factors.! In!

addition!exploring!the!client’s!motivation!for!taking!medication!often!highlights!

reasons!for!non`adherence.!Barriers!to!adherence!should!be!explored!in!a!non`

judgmental! way! and! the! goal! of! the! sessions! is! to! construct! jointly! with! the!

patient!an!adherence!plan!with!concrete!objectives.!!!

o The!set!standard!recommends!three!Enhanced!Adherence!Counselling!sessions!

organized! on! a! monthly! basis,! but! more! often! if! needed.! If! the! adherence! is!

evaluated! as! adequate,! a! repeat! viral! load! will! be! done! after! three! months! of!

good! adherence.! Followed! by! a! fourth! counselling! session! to! conclude! on! the!

way!forward!based!on!viral!load!result.!!If!adherence!problems!persist,!further!

Enhanced!Adherence!Counselling!sessions!would!be!organized.!

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Morisky&Medication&Adherence&Scales:&MMASI8&
Adherence.MMASY4.Score.MMASY8.ScoreMMASY4.MMASY8.
1) Do!you!sometimes!forget!to!take!your!pills?!
!
2)!People!sometimes!miss!taking!their!medications!for!reasons!other!than!
forgetting.!Thinking!over!the!past!two!weeks,!were!there!any!days!when!you!did!not!
take!your!medicine?!
!
3)!Have!you!ever!cut!back!or!stopped!taking!your!medicine!without!telling!your!
doctor!because!you!felt!worse!when!you!took!it?!
!
4)!When!you!travel!or!leave!home,!do!you!sometimes!forget!to!bring!along!your!
medicine?!
!
5)!Did!you!take!all!your!medicine!yesterday?!
!
6)!When!you!feel!like!your!symptoms!are!under!control,!do!you!sometimes!stop!
taking!your!medicine?!
!
7)!Taking!medicine!every!day!is!a!real!inconvenience!for!some!people.!Do!you!ever!
feel!hassled!about!sticking!to!your!treatment!plan?!
!
8)!How!often!do!you!have!difficulty!remembering!to!take!all!your!medicine?!
___A.!Never/rarely!
___B.!Once!in!a!while!
___C.!Sometimes!
___D.!usually!
___E.!All!the!time!

!
!
High!Adherence! 0!
! Medium!Adherence! 1!`!2!
Low!Adherence! 3!`!8!
!

!
!
!
Ref:!Morisky!DE,!Green!LW,!Levine!DM.!Concurrent!and!predictive!validity!of!a!self`reported!measure!
of!medication!adherence.!Med!Care.!1986;24:67–74.!
!

! !

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Table!1:!Enhanced!Adherence!Counselling!sessions!content!!

Session!1! " VL! education! review! and! discuss! with! patient! why! VL!
high!
" Review!treatment!literacy!
" Review! behavioral,! emotional! and! socio`economic!
barriers!to!adherence:!!
" Review!medication:!dosage,!timing,!storage!
" Mental!Health!screening!(screen!for!depression!using!
PHQ9!–!session!3)!
" Discuss!risk!reduction!(e.g.!substance!abuse)!
" Discuss!patient’s!support!system!
" Referrals!and!networking!
" Make! an! adherence! plan! with! the! client! based! on!
identified!issues!
Session!2!! " Review!plan!of!the!first!session!and!discuss!problems!
" Review!if!new!issues!emerging!
" Referrals!and!networking!!
" Make! an! adherence! plan! with! the! client! based! on!
identified!issues!!
Session!3! " Review!plan!of!the!first!and!second!session!!and!discuss!
problems!
" Identify!other!possible!gaps!and!issues!emerging!
" Make! an! adherence! plan! with! the! client! based! on!
identified!issues!
" Re`assess!adherence:!
" If! the! adherence! is! good! `! plan! next! VL! testing! after!
three! months! of! good! adherence! and! explain! possible!
ways! forward,! emphasizing! role! of! the! client! and! the!
health!facility!
" If! adherence! problems! persist:! plan! further! Enhanced!

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Adherence!Counselling!Sessions!
Session!4! " Discuss!VL!result!
" Plan!the!way!forward!!!!
!
!

Adherence&sessions&in&details&
Enhanced.Adherence.Sessions..1,.2,.3.and.4.
Target.group. All!2nd!line!patients!with!viral!load!>!1000!copies/ml!
Timing. On! the! day! the! patient! comes! for! scheduled! clinic!
appointment,!on!a!monthly!basis!
Duration. 15`30min!!!
Mode. Individual!–!with!patient!!and!counsellor!
SESSION.1.
Introduce.yourself.to.the.patient.and.provide.the.viral.load.result.
• Provide!VL!result!and!explanation!of!result.!You$have$a$detectable$viral$load.$This$means$your$
ART$is$not$effective$and$HIV$continues$multiplying$in$the$blood.$If$viral$load$is$detectable,$it$is$
important$ to$ determine$ whether$ the$ treatment$ is$ failing$ due$ to$ drug$ resistance$ or$ poor$
adherence.!

• How!does!the!client!feel!concerning!the!result?!

• Explain!the!process!of!enhanced!adherence.!Aim!of!the!session!is!to!identify!what!barriers!the!
client!has!to!adherence!and!find!solutions!

Assess.possible.barriers.to.adherence.
FIRST.ASK:!What!do!you!think!is!the!reason!for!your!high!viral!load?!!
Sometimes!the!patient!already!knows!why!his/her!Viral!Load!is!going!up.!Here!you!can!give!them!a!
chance!to!give!their!own!explanation.!Often!they!will!already!tell!you!at!this!point!that!they!are!
struggling!with!their!adherence.!!
If!they!really!don’t!know!why!their!Viral!Load!is!high!you!can!say:We$notice$that$when$people$sometimes$
forget$to$take$their$ARVs$everyday$it$gives$the$virus$a$chance$to$grow,$do$you$think$that$you$sometimes$
forget?!
Cognitive.barriers.(ART/HIV.knowledge).
• What!is!HIV?!What!is!AIDS?!

• What!is!immune!system!and!CD4!cells?!

• What!are!ARVs!and!how!do!they!work?!

• What!should!you!not!do!when!taking!ARV?!What!are!the!side!effects?!

• Why!is!it!important!to!be!adherent?!And!How?!

• Why!do!you!have!to!come!on!review!dates?!What!to!bring?!

Behavioural.barriers:.
• Review!how!client!takes!drugs!

o How!does!treatment!fit!in!daily!routines?!!

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E.g.!Establish!with!the!patient!whether!the!time!they!are!meant!to!take!their!medication!is!appropriate!
or!whether!the!time!is!a!problem.!For!example!if!the!patient!has!chosen!9pm,!but!is!already!asleep!in!
bed!by!9pm,!then!that!is!not!a!good!dosing!time.!!If!the!time!is!a!problem!then!determine!a!new,!more!
appropriate!time!with!the!patient!based!on!their!schedule.!
o What!reminder!tools!do!you!use?!(!e.g!mobile!phone!alarm)!

o What!do!you!do!in!case!of!visits,!travel,!side`effects?!

Travelling!is!always!risk!for!poor!adherence!or!default!of!treatment.!Encourage!patient!to!plan,!to!make!
sure!they!have!enough!medication!on!hand!before!and!to!remember!to!pack!it!!
Make!sure!that!all!relevant!information!is!on!the!patients!appointment!card!and!explain!to!that!if!they!
are!ever!away!from!home!and!they!run!out!of!medication!that!they!must!go!to!the!closest!ARV!clinic!and!
show!their!appointment!card!!
o What!do!you!do!in!case!of!side!effects?!
!
Ask!patient!if!he!sometime!find!difficult!to!take!ARV!because!of!the!side!effects.!Ask!him!how!does!he!
manages!side!effect!and!if!it!does!influence!the!way!he!take!his!drugs.!
o What!are!the!most!difficult!situations!for!you!to!take!drugs?!

• How!is!your!life!style!:!e.g!smoking,!exercises!!

• Check!for!alcohol!or!drug!use!
Ask!the!patient!in!a!casual!way!(not!in!an!accusing!way)!if!they!sometimes!use!substances;!emphasize!
treatment!planning!in!case!they!do:!!“Taking$alcohol$or$drugs$sometimes$makes$it$difficult$for$us$to$
remember$to$take$treatment.$If$possible$it$is$best$to$limit$your$use,$$but$if$you$are$planning$to$take$any$
alcohol$or$drugs,$it$is$important$to$plan$ahead$so$that$you$don’t$forget$to$take$your$treatment”!!
“If$you$feel$your$alcohol$or$drugs$use$is$affecting$your$adherence,$would$you$feel$ready$to$be$referred$to$
some$professionals$that$may$help$you$to$work$on$that$problem?”$(refer$this$patient$to$your$version$of$
Alcoholics$Anonymous).$!
Emotional.barriers:.. .
• How!do!you!feel!about!taking!drugs!every!day?!

• What!are!your!ambitions!in!life?!!.
E.g.!Use!motivation!cards:!Ask!the!patient!to!think!of!their!own!personal!goals!/!dreams!for!their!future.!!!!!!!!!!!!!!!!!!!!!!!!!!!!!.
What!are!the!3!most!important!things!they!still!want!to!achieve!in!their!future.!Have!them!write!it!in!their!
own!language!on!a!notecard.!Encourage!the!patient!to!read!the!notecard!every!day!preferably!right!before!
they!take!their!medication.!!!!! ! !
• Mental!health!screening:!!
Depression!is!an!important!reason!of!non`adherence.!If!the!patient!is!reporting!loss!of!
interest!or!pleasure,!feeling!down!or!depressed!it!is!advised!to!screen!the!patient!using!PHQ9!
(session!3).!
! !

SocioYeconomical.barriers..
• Disclosure!to!partner!/!family!/!friends!or!co`workers!
Do$you$have$any$people$in$your$life$who$you$can$talk$to$about$your$HIV$and$ARVs?$
Suggest!to!the!patient!that!they!enlist!the!support!of!their!family,!friends,!and!coworkers!in!reminding!
them!to!take!their!medication!if!they!have!not!already!done!so.!
• Support!from!treatment!buddy!

o If!client!came!with!treatment!buddy,!assess!input!of!relative!

o If! client! did! not! come! with! treatment! buddy,! explain! the! role! on! treatment! and!
encourage!client!to!come!with!a!person!they!trust!next!visit.!

• Support!in!family/community/support!group!

16!
!

• Profession,!income!generating!resources!

• Specific!barriers!to!come!to!health!centre!on!regular!basis!(transport,…)!

• Stigma!and!discrimination!

• Religious!beliefs!

Referrals.and.networking!
• Confirm!in!the!patient!file!if!the!patient!has!been!referred!to!other!services.!This!includes!
referrals!to!social!services,!psychology!services,!nutrition!services,!medical!clinics,!substance!
abuse!groups,!etc.!
Ask!patient!if!they!attended!the!appointments,!check!in!on!their!experience!with!the!referral!
services!and!re`organize!referral!if!necessary!!
Elaborate. an. adherence. strategy. with. the. client. to. overcome. identified. difficulties.! For!
example:!
• Behavioural!barriers:!use!of!reminder!tool,!pill!box,!daily!planning,!change!routines!

• Socio`economical!barriers:!move!on!in!disclosure!process,!identify!treatment!buddy,!refer!to!
support!group,!refer!to!CBO/NGO!to!learn!about!income!generating!activities!

• Emotional!barriers:!emotional!support!or!refer!to!clinician!for!mental!health!management!

SESSION.2.–.four.weeks.after.session.one.
Review.plan.of.the.first.session.and.discuss.problems.
• Review! the! client’s! barriers! to! adherence! documented! during! the! first! session! and! if!
strategies!identified!have!been!taken!up.!If!not`!why!not!and!make!a!concrete!plan.!

Review.if.new.issues.emerging!
Referrals.and.networking!
• Follow`up!on!referrals!to!other!services!(social!services,!psychology!services,!nutrition!
services,!NCD!clinic,!substance!abuse!groups,!etc.)!
o Identify!patients!needing!home!visits!!
!
Review.adherence.strategy.with.the.client.to.overcome.identified.difficulties.!
o Give!another!short!motivational!speech!on!how!you!believe!in!the!patient!!You!know!they!can!
do!this!!Together!you!will!make!sure!that!they!suppress!their!viral!loads!!!
o Agree!on!follow!up!date!
.
SESSION.3.–.four.weeks.after.session.two.
Review.plan.of.the.first.and.second.session.and.discuss.problems.
• Review! the! client’s! barriers! to! adherence! documented! during! the! first! session! and! if!
strategies!identified!have!been!taken!up.!If!not`!why!not!and!make!a!concrete!plan.!

Review.if.new.issues.emerging!
Re`asses!adherence!
" If!the!adherence!is!adequate!`!plan!next!VL!testing!after!three!months!of!adequate!adherence!
and! explain! possible! ways! forward,! emphasizing! role! of! the! client,! the! support! systems! and!
the!health!facility.!
" If!adherence!problems!persist:!plan!further!Enhanced!Adherence!Counselling!Sessions!
Plan.a.way.forward.
Start!discussing!what!might!happen!if:!

17!
!

“If$your$results$come$back$and$your$VL$is$less$than$1000$–$you$will$continue$with$same$ARTs”.$Adapt$to$
individual$patient$/$context$
“If$your$viral$load$is$still$elevated$we$will$repeat$your$viral$load$again$in$3$months,$or$we$can$also$do$a$
genotype$test$to$check$if$your$HIV$has$become$resistant$to$your$current$ARVs”.$Adapt$to$individual$
patient$/$context$
SESSION.4.–.to.be.done.the.month.after.viral.load.was.repeated.
Step.1:..Discuss.viral.load.results.
.
If.suppressed.VL.<.1000,!!CONGRATULATE!the!patient!!!!
• Explain!the!way!forward!–!will!continue!with!same!ART!and!have!next!VL!according!to!
national!guidelines.!
!
If.not.suppressed.then:!
• Refer!to!Viral!Load!flowchart/national!guidelines!to!assess!next!steps!
• Patient!to!be!discussed!in!MDT!meeting!and!case!to!be!referred!to!regional!/!national!TWG!
!

Mental&Health&Screening&
Patient.Health.Questionnaire.(PHQ9).
NAME:._____________________.......Date:.____________.
*.
Over$the$last$2$weeks,$How$often$have$you$been$ ! ! ! !
bothered$by$any$of$the$following$problem?$

! Not!at!all! Several! More!than!half!the! Nearly!

days! days! every!day!
!1.!Little!interest!or!pleasure!in!doing!things! 0. 1. 2. 3.

2.Feeling!down,!depressed,!or!hopeless! 0. 1. 2. 3.

If$one$of$the$above$symptoms$are$present$more$ . . . .
than$half$of$the$time,$go$on$with$the$following$
questions$:$
3.Trouble!falling!or!staying!asleep,!or!sleep!so! 0. 1. 2. 3.
much!
4.Feeling!tired!or!having!little!energy! 0. 1. 2. 3.

5.!Poor!appetite!or!overeating! 0. 1. 2. 3.

6.Feeling!bad!about!yourself!or!that!you!are!a! 0. 1. 2. 3.
failure!or!have!let!yourself!or!your!family!down!

7.Trouble!concentrating!(on!things!linked!with! ......0. ......1. 2. 3.

patient’s!usual!activities)!

8.Moving!or!speaking!so!slowly!that!other!people! 0. 1. 2. 3.
could!have!noticed!.Or!the!opposite`!being!so!
fidgety!!or!!restless!that!you!have!been!moving!
around!a!lot!more!that!usual!

18!
!

9.Throughts!that!you!would!be!better!off!dead!or! 0. 1. 2. 3.
of!hurting!yourself!in!some!way!
Add!columns!!!:!!! ! ! ! !

TOTAL.:.. ! ! ! !

!
10:!If!you!checked!off!any!problems,!how!difficult!have!these!problems!made!it!for!you!to!do!your!
work,!take!care!of!things!at!home,!or!get!along!with!other!people?!
Not!difficult!at!all:!_____!
Somewhat!difficult:!_____!!
Very!difficult:!_________!
Extremely!difficult:!_________!!!
if!you!faced!any!difficulty,!did!it!occur!for!two!years!or!more!?!______!
!
A.patient.is.considered.as.having.signs.of.depression.if:.
PHQ9..score. Provisional.diagnosis. recommendation.
5`9! Minimal!symptoms! Support!and!educate!to!call!if!worse!
10`14! Minor!to!mild!depression.. Support!and!watchful!waiting!
or## Reassess!in!one/two!weeks!
chronic.depression! !
(symptoms!lasting!for!two! Consider!starting!treatment!
years)!
15`19! Major!depression! Refer!to!clinical!officer!/!psychologist!(need!for!
specific!treatment)!
>!20! Severe!depression! Major!impairment,!need!for!active!treatment!
!
• For.major,.severe.and.chronic.depression,.treatment.and.follow.up.consists.on.:.
1. regular.supportive.counselling.
1. Reassure!patient!about!his!(her)!symptoms,!build!a!trustful!and!confidential!
relationship!
2. Evaluate!depression!(when!did!it!start,!release!context,!etc…)!!!
3. Asses!functional!impairment!:!ask!for!question!10,!be!sure!all!symptoms!are!
lasting!for!more!than!two!weeks!
4. Reassess!patient!after!one!week!(counselling!session!and!PHQ9)!if!PHQ9!
<17.!
5. provide!regular!counselling!sessions!during!medical!treatment!!
!
2. Refer.to.clinical.officer/medical.doctor.(++.if.score.>.17).who.will.consider.a.
treatment.of.depression...
.
Note:$Grieving$is$a$personal$process$that$has$no$time$limit,$nor$one$“right”$way$to$do$it$(Axelrod$2015).!

The! patient! may! be! in! any! of! the! five! stage! of! the! Kbuller! loss! stage! of! grief! (denial! and! isolation,!

anger,! bargaining,! depression! and! acceptance)!! which! in! most! cases! recur! ! from! time! to! time! and!

need!to!be!handled!before!the!client!get!worse.!!

Ref:!Axelrod.!J.!(2015).The!five!stages!of!loss!and!grief!http://psychcentral.com/lib/the`5`stages`of`

loss`and`grief/000617!!!

19!
!

Enhanced&Adherence&Counseling&Sessions&Documentation&
The!adherence!counseling!session!should!be!documented!on!recto`verso!patient!

form!(see!the!form!(Session!4)!below).!It!is!important!to!write!up!information!

collected!during!the!sessions!in!the!patient’s!file!in!order!to!ensure!good!follow`up!

and!communication!between!the!MDT!members.!It!is!also!necessary!to!have!a!

systematic!planning!and!follow`up!of!the!Enhanced!Counseling!Sessions;!this!will!be!

followed!up!by!the!case!manager!appointed!by!the!MDT.!!

NB:!It!is!preferable!clients!with!suspected!2nd!line!failure!to!be!attended!by!the!same!

counselor!in!order!to!ensure!continuity.!

Adherence&Counseling&for&Caregivers&and&Children!
The!main!aim!is!to!support!the!caregiver!through!collaboration!with!the!MDT,!to!
address!the!concerns!which!are!barriers!to!adherence.!The!baseline!in!preparation!
to!3rd!line!treatment!should!be!based!on!the!reason!of!what!were!the!causes!of!the!
child!failure!on!2nd!line.!Working!with!direct!caregiver!is!the!best!so!that!their!
worries!and!concern!can!be!address!directly.!
The!social!worker!or!nurse!counsellor!should!assist!caregivers!to:`!
• Address!the!child’s!needs!
• Develop!a!plan!addressing!those!needs!
• Link!up!with!community`based!services!for!children!
• Disclose!the!child’s!status!gradually!in!an!age!appropriate!way!

In!providing!support!for!adherence,!the!social!worker!or!nurse!counsellor!should!
assess:`!
• The!caregivers!level!of!comfort!with!the!medication!
• Caregiver’s!cognitive/psychological!capabilities!
• Caregiver’s!awareness!of!the!risk!to!the!child!as!a!result!of!inadequate!adherence!
• Involvement!of!other!caregivers!in!the!child’s!therapy!
• The!understanding,!level!of!comfort!and!capabilities!of!other!caregivers.!

Preparation.
• Explain!about!the!expected!changes!in!physical!wellbeing!to!the!care!giver.!
• Importance!of!adherence!despite!improvement.!
• !It!should!be!well!understood!that!on!other!treatment!option!available.!
• Regular!visits!to!clinic!to!monitor!physical!and!psychological!status.!

20!
!

• Importance!of!regular!laboratory!check`ups!to!monitor!biological!markers(!eg!
various!lab!test,!CD4!and!viral!load)!with!ART.!
• Recap!on!adherence!promotion!for!positive!living!e.g.!nutrition,!positive!behavior!
change!etc.!
• Family!to!identify!the!most!appropriate!adherence!promotion!strategy.!
• Address!important!pending!issues!e.g.!appropriate!care!giver!to!support!adherence.!
• Get!assent!from!child!(10!years!and!above)!and!consent!from!the!care!giver/s!to!
commence!3rd!line!ART.!
• Start!3rd!line!ART!if!criteria!has!been!met!
• Make!a!follow!up!plan!

The!adherence!counseling!process!should!follow!the!4!adult!adherence!counseling!
sessions!but!always!consider!the!above!points!when!dealing!with!a!child!and!a!
caregiver.!

Adherence&Counseling&for&Adolescents&
Follow!the!4!sessions!for!adult!counseling!and!pay!special!consideration!in!the!
following:`.
1. Their!developmental!stages!and!their!emotional!state..
2. Their!cognitive!understanding!and!self`perceptions..
3. Stigma&!discrimination..
4. Social!support!system.!(family!and!peers).
5. Goals!and!motivation!in!life..

. .

21!
!

Enhanced&Adherence&Counselling&Form.(to.be.filed.by.the.counsellor).
For#each#session,#assess#major#barriers#to#adherence#(cognitive,#behavioural,#emotional,#socio7
economic)#
Date.of.1st.session:.. ARV!intake!demonstration!by!patient/caretaker!done?!Yes!□! !No!□!
! MMAS`8:!!
Summary:..
.
.
.
Treatment!motivation:!______________________________________________________________________________________!
Adherence!plan:!____________________________________________________________________________________________.
.
Your.impression.about.patient’s.adherence:.
□!Likely!to!be!adequate! □!Likely!to!be!NOT!adequate!(relevant!barriers!identified)! ! !
□!Clearly!inadequate!(defaulter).
.
Date.of.2nd.session:.. . Summary:.
_____________________________________________________________________.
__________________________________________________________________________________________________________. .
Adherence!plan:.____________________________________________________________________________________________.
.
.
Date.of.3rd.session:. . Summary:.
____________________________________________________________________.
___________________________________________________________________________________________________________.
Adherence!plan:.____________________________________________________________________________________________.
Did.the.client.attend.all.three.appointments?.Yes!□! !No!□.. .
If!no,!any!reason?!________________________________________.
Impression.about.patient’s.adherence:..
□!Likely!to!be!adequate! □!Likely!to!be!NOT!adequate!(relevant!barriers!identified!and!not!cleared)! !
□!Clearly!inadequate!(defaulter)!
Major.remaining.barriers.identified.
• Cognitive.. . Yes!□! !No!□! If!yes:!_______________________________________.
• Behavioural.. Yes!□! !No!□! If!yes:!_______________________________________.
• Emotional. . Yes!□! !No!□! If!yes:!_______________________________________.
• SocioYeconomic. Yes!□! !No!□! If!yes:!_______________________________________.
If$adherence$is$likely$to$be$adequate:$plan$repeat$viral$load$$
If$adherence$is$likely$to$be$not$adequate:$$repeat$viral$load$should$be$deferred$and$Enhanced$Adherence$
Counselling$$extended.$Discuss$with$MDT$team$
.
Date.of.extra.session.(if.any):.. . Summary:.
______________________________________________________________.
___________________________________________________________________________________________________________.
Adherence!plan:!____________________________________________________________________________________________.
.
.
Date.of.extra.session.(if.any):.. . Summary:.
______________________________________________________________.
___________________________________________________________________________________________________________.
Adherence!plan:._____________________________________________________________________________________________.

22!
!

3rd&line&ART&client&education&and&counselling&sessions&&
Figure!2:!Overview.3rd.line.ART.client.education.and.counselling!NB:!It!is!

important!for!patient!on!3rd!line!to!be!attended!by!the!same!counsellor!in!order!

to!ensure!continuity.!Ideally!it!should!be!the!counsellor!who!has!done!the!

enhanced!adherence!counselling!sessions.!It!is!also!important!to!involve!the!

clinician!and!good!to!have!the!counsellor!and!clinician!address!the!patient!

together.!

Key&Messages&on&Treatment&Failure&and&Use&of&Viral&Load&
!
Topic. Messages. .
You! are! taking! ARVs! on! a! daily! basis! to! fight!
HIV!in!your!body.!Due!to!the!ARVs!the!number!
What! is! the! goal!
of!HIV!copies!will!decrease!in!your!body,!while!
of!ART!therapy?!
your!soldiers!(CD4s)!will!increase!and!protect!
you!from!diseases.!
A! viral! load! test! measures! the! number! of! HIV!
viruses! in! your! blood.! The! test! is! done! by!
What! is! a! viral!
taking!a!sample!of!blood!by!a!finger!prick!or!by!
load!test?!!
drawing! blood! and! sending! to! the! laboratory!
for!testing.!!
All! those! on! ART! treatment! will! be! offered! a!
viral!load!test!as!part!of!your!routine!follow`up!
at! 6! months,! 12! months! and! then! yearly! on!
ART!or!according!to!your!health!condition.!You!
can! always! remind! your! health! worker! for!
When! to! have! a!
your! need! to! get! a! viral! load! test! or! ask! them!
viral!load!test?!
for!the!results!of!your!test.!!
It! is! important! not! to! miss! your! appointment!
date!for!your!viral!load!test!and!to!come!for!the!
results! on! time! as! instructed! by! your! health!
care!worker.!
Undetectable! viral! load! means! that! you! have! !
less!HIV!in!your!blood.!
Undetectable! viral! load! in! the! blood! does! not!
mean!you!no!longer!have!HIV,!but!the!amount!
What! does! an!
of! HIV! in! your! blood! is! ! too! low! to! be!
undetectable!viral!
measured.!
load!result!mean?!
Undetectable! viral! load! means! your! treatment!
is! working! well,! because! your! ARV’s! are!
fighting! HIV! and! thus! reducing! the! amount! of!
HIV!in!your!blood.!
!
!
!
! !

23!
!

Topic. Messages. .
Detectable! viral! load! means! that! there!
is!a!lot!of!HIV!in!your!blood.!!
What! does! a! When! your! viral! load! is! detectable,! the!
detectable! a! health! worker! will! suspect! treatment!
viral! load! failure.! Treatment! failure! means! your!
>1000! HIV!treatment!is!no!longer!working!as!it!
copies!result! should:!HIV!is!multiplying!in!your!body!
mean?! while! your! soldiers! (CD4)! reduce! in!
number!and!you!become!more!likely!to!
develop!opportunistic!infections.!!
You! have! problems! taking! your!
treatment! on! a! regular! basis:! stopping!
to! take! your! pills! for! a! while,! skipping!
many!doses.!
What! could!
You! have! developed! resistance! to! the!
explain! a!
treatment! which! means! that! the! HIV! in!
detectable!
your! blood! has! changed! and! your!
viral!load?!
treatment! is! no! longer! able! to! fight! the!
changed!HIV.!!The!resistant!HIV!is!now!
multiplying!rapidly!in!your!blood.!!
! !
Together! with! the! counsellor! you! will!
identify! the! reason! for! your! detectable!
What! to! do! viral! load! and! look! at! ways! to! address!
when! you! possible!adherence!problems.!!
have! a! If! your! viral! load! continues! to! be!
detectable! detectable! and! there! is! no! longer! any!
viral!load?! treatment! adherence! problem,! you!
might! be! changed! to! another! type! of!
drug!treatment.!
How! to! Adhere!to!your!ARV!treatment!in!order!
avoid! to! maintain! undetectable! viral! load,! a!
resistance! strong!immune!system!and!a!long!life.!!
and!
treatment!
failure?!
!!

Adherence&support&systems&
!

Adherence!support!systems!will!need!to!be!adapted!to!patient’s!specific!needs!and!

the! context.! Special! attention! needs! to! be! given! to! adolescents,! mental! health!

patients!and!patients!with!substance!use.!!

Figure!3:!Adherence!support!systems!

24!
!

treatment!
buddy!

MDT! home!visit!

client!

support!
DOTs!
group!

!!

Figure!3:!Adherence!support!systems!

a. Support.client.to.identify!a.treatment.buddy.

" Discuss! with! the! client! the! importance! and! the! role! of! a! treatment! buddy! or!

caregiver.! This! a! person! who! should! be! able! to! provide! the! needed! moral! and!

social!support!and!!even!remind!the!client!to!take!medication.!!

" They! may! also! assist! them! back! to! the! clinic! when! they! are! very! sick! or! convey!

information! to! the! clinic! when! they! are! admitted! or! bedridden! at! home! and!

provide!support!at!home!when!they!are!very!weak.!Having!the!names!and!contacts!

The!treatment!buddy!or!caregiver!should!be!invited!to!at!least!one!of!the!3rt!line!

education!and!counselling!sessions.!!

b. Provide.Directly.Observed.therapy.(DOTS)!!

25!
!

The!Multidisciplinary!team!determines!how!and!by!whom!direct!observed!
therapy!would!be!carried!out!
" DOTs!providers!include:!health!care!provider,!CHW!or!peer!educators,!caregivers!
or!family!members!
" Steps:!
.

• confirm&venue&for&3rd&line&ART&DOTs&in&readiness&for&
step&1& treatment&&

• Build&capacity&of&the&DOT&providers&
step&2&

• Confirm&and&introduce&to&the&client&the&CHW&or&health&
step&3& worker&who&will&administer&the&dots&

• Develop&data&capture&mechanism&to&inform&MDT&
step&4&

!
2. Enroll.the.client.to.a.support.group.

" Support!groups!give!confidence!and!provided!emotional!support!for!the!patients!on!

3rd!line.!

" Support! may! improve! patient’s! experience! of! HIV`status! disclosure! and! possibly!

even!promote!disclosure.!!

" Provide!platform!for!education!sessions!by!specialists!and!clients!sharing!amongst!

themselves.!

" Provides!social!support!to!group!members!

3. Home.visits.

" Home!visit!team!of!two!to!be!formed!by!MDT!(nurse/counsellor,!social!worker,!peer!

educator/CHW)!!

" All! patients! on! 3rd! line! require! a! home! visit! to! enhance! psychosocial! support! and!

enhance!adherence!!

" Steps:!

26!
!

STEP&1& STEP&2& STEP&3& STEP&4&

•  Confirm&locator& • Ensure&that&the& • Develop&a&home& • The!home!visit!team!
details&with& current&and&updated& visits&schedule&for& will!determine!the!
working&phone& informa[on&is&in&the& moral&support&and& frequency!of!home!
number&and& file& for&assessing& visits!depending!on!
psychosocial&support& the!clients!status&
clear&map&on& mechanism&and&
how&to&get&to& other&support&
the&client’s& dynamics&in&the&
residence.&& family.&(Use&home&
visit&checklist&]&
session&6)&

NB:!Provide!referrals!for!services!that!address!factors!that!may!impede!adherence,!

such! as! lack! of! health! insurance! or! other! resources! to! cover! ART! costs,! drug! and!

alcohol!use!rehabilitation,!and!mental!illness.!

.
.
.
.
. .

27!
!

.
Client$Name:#################################################Tel$No#######################################Sex:$M$$$$$$$$$F#
Family$Member:$ Tel$No$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$File$no.$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$$
Physical$landmark:$
This!checklist!is!not!all!inclusive!but!highlight!critical!areas!specific!which!can!affect!
3rd!line!ART!adherence.!
! Critical.areas.for.clients.to.enhance.on.third.line. A! B!
1! Current!Status!of!the!client:!assess!the!activities!of!daily!living!e.g! ! !
feeding!grooming,!toileting…..!
2! Availability!of!basic!needs!.e.g.!clothing,!shelter,!food!(!observe!&! ! !
Discuss)!
3! Disclosure`!Assess!and!Supported!disclosure!as!required!(!Discuss)! ! !
4! Adherence`!Assess!for!common!condition!which!affect!adherence!e.g.! ! !
pain!
5! !Immediate!Social!support`!Available!social!support!structures!e.g.! ! !
stable!and!supportive!family!(observe,!discuss)!
6! Community!support!system!e.g.!community!leaders,!community! ! !
support!groups!
7! Facilities!for!linkage!for!required!service!which!are!not!provided!like! ! !
Spiritual,!legal!or!nutrition!(inquire!,!observe,!Link)!
8! Emotional!problems!`!Screen!and!support!for!mental! ! !
health/emotional!problem(!observe/discuss)!
9! Drug!toxicity`!side!effects,!ADRs!(observe!&!discuss)! ! !
10! In!case!of!stress!full!situation!such!as!loss!through!death!of!loved,! ! !
offer!or!refer!for!grief!counselling!
!
Key:!A:!Absent!!B:!Present!

For!each!section!1`!7!if!absent,!counsel,!educate!and!refer!the!client!appropriately.!
!For!each!section!8`10!if!present!counsel!and!refer!the!client!accordingly.!
!
The!visiting!team!should!be!able!to!handle!at!least!three!identified!issues!based!
priority!and!refer!other!needy!issues!which!are!not!dealt!with.!This!also!forms!the!
basis!for!the!frequency!of!home!visit!!!
.
.
. .

28!
 Patient Management Protocol
(These are minimum standards for management of a patient on 3rd line ART and do not replace
the essential package of services for PLHIV)

Pre-initiation MDT Meeting

Confirm what ARV regimen is prescribed, its availability and the management plan
Assign a case manager to the patient

Initiation of 3rd Line ART

Triage
o Record vital signs and take action as needed

Adherence Support
o Conduct patient education on the new ART regimen; treatment goals, dosing,
drug interactions and potential side effects and adverse events
o Conduct adherence assessment and counseling
o Link patient to adherence support systems

Clinical Assessment
o Take history and conduct physical examination
o Complete Clinical Encounter Form and MOH 257 (blue card)
o Manage any co-infections and co-morbidities
o Review for potential drug interactions and contraindications
o Conduct adherence assessment and review adherence support systems
o Reinforce patient education messages on new regimen
Currently no further treatment options
Need for perfect adherence (>95%)
Dosing
Potential side effects and what the patient should do
o Prescribe new regimen for 2 weeks
o Confirm dosing as per the weight (for 18 years and below)
o Continue other medication e.g. CPT, IPT

Dispensing
o Confirm ARV dosing as per the weight
o Conduct medication use counseling
o Dispense 3rd line ARVs for 2 weeks

Community Follow up
o Link all patients to support group, CHW/CHEW
o Plan for home visits as required

29
Patient Follow Up After Treatment Initiation
Frequency
o First follow-up should be within 2 weeks of initiation of 3rd line ART
o Subsequent visits should be monthly (or more frequent) until confirmed viral
suppression at 6 months
o Thereafter, follow-up can be 1-3 monthly
Triage
Record vital signs and take action as needed
Adherence Support (adherence should be reinforced during every clinic visit, in
addition to enhanced adherence counseling sessions)
o Review and address knowledge deficits on new regimen
o Confirm understanding of adherence, conduct adherence assessment, and
reinforce key adherence messages
o Document reasons for missed doses and manage obstacles to perfect adherence
o Review and reinforce adherence support systems
Clinical Assessment
o Take history and conduct physical examination
o Complete Clinical Encounter Form and MOH 257 (blue card)
o Manage any co-infections and co-morbidities
o Evaluate for potential drug interactions
o Evaluate for and manage any drug side effects and adverse events
o Conduct adherence assessment and review adherence support systems
o Reinforce patient education messages on new regimen
Review and address knowledge gaps on ART regimen
Need for perfect adherence (>95%)
Dosing
Potential side effects and what the patient should do
o Prescribe 3rd line ARVs
Laboratory Monitoring
o Baseline and routine monitoring should be based on clinical symptoms
o Hb should be done at baseline because RAL and ETR may rarely cause anemia
o ALT should be monitored quarterly in mild to moderate underlying chronic liver
disease or Hepatitis B/C co-infection
o Creatinine should be monitored quarterly in mild to moderate Kidney Disease
o Blood Sugar and lipid profile should be monitored at baseline and annually
o Creatinine Kinase should be done in suspected rhabdomyolysis
o Viral load should be conducted at month 6, 12 and annually thereafter
Dispensing
o Confirm ARV dosing as per the weight
o Conduct medication use counseling
o Dispense 3rd line ARVs
Community Follow up
o Review linkage to community adherence support systems
o Conduct home visits as required
o Continue DOTS

30
 Clinical Encounter Form Date:_____/______/_______
DD MM YYYY
Name: Clinic Number: Facility Name:

MFL Code:

Sex: O Male O Female Birthdate: ____/____/_______ Marital status:

DD MM YYYY
Presenting Complaints:

History of Presenting Illness:

Known comorbidities:

Current Medications
ARVs (specify): TB treatment (specify):
Food By Prescription (specify): Treatment type: O 1st line TB
CTX O 2nd line TB (MDR)
Antibiotic (specify): Other (specify):
Adherence support systems in place (specify):_________________________________
Adherence assessment: O Good ( 95%) O Fair (85-94%) O Poor ( 84%)
ARV Adherence
Has the patient defaulted in the past 3 months? O Yes O No
Adherence counseling conducted today: O Yes O No
Any suspected side effects/toxicities related to third line ARVs?
Drug Toxicities
O Yes (specify): O No
TB Screening & TB screening outcome: O Positive O Negative
Prophylaxis On IPT? O Yes O No (specify reason):________________________________________
Vitals Examination Comments/Description
General Appearance
Temp: _____ o C
Eyes, Ears, Nose, Throat
Pulse: ______b/min Lymph Nodes
BP: ___/___mmHg Respiratory
Cardiovascular
Today’s weight: ____kg
Gastrointestinal
Height: ______cm Neurological
BMI / Z-Score: _________ Musculoskeletal
Genitourinary
Resp. rate: ____breaths/min
Skin
Other
Investigations Most Recent Investigation Results (Date, Value)
Ordered Today None
Viral load: Blood Sugar:
Creatinine: Total Cholesterol:
ALT: Other (specify):
HB:
Impression (including any new WHO condition):

Plan:

Medications Prescribed Today

ARVs (specify): TB treatment (specify):
Food By Prescription (specify): Treatment type: O 1st line TB
O 2nd line TB (MDR)
CTX
Antibiotic (specify): Other (specify):
Referrals/Hospitalization:

Follow up issues for next visit:

Next Appointment Form completed by: Name:

(print name clearly) Signature:
_______/________/_________
DD MM YYYY Title:
Page 1 of 1 Clinical Encounter Form Revised: 9 April 2015
31
!

Commodity&Management&Standard&Operating&Procedures&

Requesting&for&Third&Line&Medicines&for&New&Patients&

Objective: To describe the procedure for requesting third line ARVs for new patients.

Responsible persons:
• Comprehensive!Care!Centre!in`charge.
• Pharmacist/Pharmaceutical!technologist!responsible!for!making!requests!for!
ARVs!and!OI!drugs!!

Tools needed:
• Clinical Summary Form
• DST/DRT report (where available)

Procedure:
• A duly filled patient clinical summary form, with drug dosages for the proposed
regimen should be submitted by the facility to NASCOP using the email
ulizanascop@gmail.com
• Patient (s) to continue on failing 2nd line with intensified adherence efforts
(adherence counseling, Directly Observed Treatment Support (DOTS) and home
visits)
• Regimen proposed by facilities to be reviewed by the National Clinical Technical
Working Group (TWG)
• Facility to be notified by NASCOP on approved regimen, medicines to be
supplied and expected date of delivery
• The initial medicine supply to be for 3-months for each patient identified
• Subsequent resupplies to be based on consumption and request reports submitted
monthly to KEMSA

32!
!

Documenting&the&Dispensing&of&Third&Line&Medicines&

Objective: To describe the procedure for documenting the dispensing of third line
medicines

Responsible persons:
• Pharmacist/Pharmaceutical technologist or other health providers responsible for
dispensing ARVs and OI Drugs

Tools needed:
• MOH 367A: DAR for ARVs and OI Drugs (Version September 2014)
• Electronic ART dispensing tool, where available

Figure 01: Cover page of Version September 2014 DAR for ARVs and OI Drugs

33!
!

Procedure
• Each dispensing event for third line medicines should be documented using the
DAR for ARVs and OI (Version September 2014) or where available, an
electronic ART dispensing tool
• All fields should be duly filled for each dispensing event
• Each page of the manual DAR for ARVs and OI should be summarized once all
the rows have been filled

34!
!

Reporting&Consumption&and&Resupply&Requests&for&Patients&on&Third&Line&
Treatment&

Objective: To describe the procedure for reporting consumption and resupply requests
for patients on third line treatment.

Responsible persons:
• Pharmacist/Pharmaceutical! technologist! in`charge! of! making! requests! for!
ARVs!and!OI!Drugs!

Tools needed: (Version September 2014, manual or electronic)

• MOH 730B (F-CDRR) and MOH 730A (D-CDRR)
• MOH 729A (D-MAPs) and MOH 729B (F-MAPs)

Procedure
• Facilities with patients on 3rd line to request for 3rd line ARVs monthly using D/F-
CDRR and D/F-MAPS (Version September 2014, manual or electronic)
• The correct adult or paediatric third line regimen code to be reported. Third line
regimen codes for adults and pediatrics are defined as:

ADULT ART Third-Line Regimen Codes

RAL + 3TC + DRV +
AT1A Raltegravir + Lamivudine + Darunavir + Ritonavir
RTV
RAL + 3TC + DRV + Raltegravir + Lamivudine + Darunavir + Ritonavir +
AT1B
RTV + AZT Zidovudine
RAL + 3TC + DRV + Raltegravir + Lamivudine + Darunavir + Ritonavir +
AT1C
RTV + TDF Tenofovir
ETV + 3TC + DRV +
AT2A Etravirine + Lamivudine + Darunavir + Ritonavir
RTV
All other 3rd line Adult Total of ALL OTHER Adult patients on 3rd line
AT2X
regimens regimens not listed above (coded and uncoded)

PAEDIATRIC ART Third-Line Regimen Codes

RAL + 3TC + DRV +
CT1A Raltegravir + Lamivudine + Darunavir + Ritonavir
RTV
RAL + 3TC + DRV + Raltegravir + Lamivudine + Darunavir + Ritonavir +
CT1B
RTV + AZT Zidovudine
RAL + 3TC + DRV + Raltegravir + Lamivudine + Darunavir + Ritonavir +
CT1C
RTV + ABC Abacavir
ETV + 3TC + DRV +
CT2A Etravirine + Lamivudine + Darunavir + Ritonavir
RTV
All other 3rd line Total of ALL OTHER Paediatric patients on 3rd line
CT3X
Paediatric regimens regimens not listed above (coded and uncoded)

35!
!

• Quantity ordered for resupply to be calculated using the formula:

Quantity ordered for resupply= (AMC * 3) – physical stock at the end of

the reporting month
Where!AMC!=average!monthly!consumption!
!
• Both D/F-CDRR and D/F-MAPS to be submitted to KEMSA by the 5th of the
month

36!
!

Figure 02: Cover page of Version September 2014 F-CDRR (standalone sites)

37!
!

Figure 03: Cover page of Version September 2014 F-MAPS (standalone sites)

38!
!

Figure 04: Cover page of Version September 2014 D-CDRR

39!
!

Figure 05: Cover page of Version September 2014 D-MAPS

40!
!

Third&Line&ARV&Drug&Information&

RALTEGRAVIR&(Integrase&Inhibitor)&
A. DOSAGE FORMS, STRENGTH AND PACKAGING

Description Strength Packaging

Film-coated tablet 400 mg 60s

Chewable, scored tablet 100 mg 60s

Chewable tablet 25 mg 60s

Oral suspension 100 mg Single use packet

B. DOSING RECOMMENDATIONS

1. For children ≥ 4 weeks old and weighing 3 kg to < 20 kg, use oral suspension, if
available
2. Children aged 2 to < 12 years or < 25 kg, use the chewable tablet as per dosing table
below
3. Patients ≥ 12 years or ≥ 25 kg: 400 mg film-coated tablet twice daily

Note: The film-coated tablet is the recommended formulation for patients weighing ≥ 25
kg (regardless of age); if unable to swallow a film-coated tablet, the chewable tablet
regimen should be considered.

Raltegravir Chewable Tablet Dosing

Body Weight (kg) Dose

10 to < 14 75 mg twice daily

14 to < 20 100 mg twice daily

20 to < 28 150 mg twice daily

200 mg twice daily (only if unable to swallow
28 to < 40
film-coated tablet)
300 mg twice daily. This is the maximum dose
≥ 40 for the chewable tablet. Use only if unable to
swallow film-coated tablet.

41!
!

Raltegravir Oral Suspension Dosing

Body Weight (kg) Dose

3 to < 4 1 mL (20 mg) twice daily

1.5 mL (30 mg) twice daily
4 to < 6

2 mL (40 mg) twice daily

6 to < 8

8 to < 11 3 mL (60 mg) twice daily

11 to < 14 4 mL (80 mg) twice daily

5 mL (100 mg) twice daily (This is the

14 to < 20
maximum dose for the oral suspension)

C. SPECIAL INSTRUCTIONS
" Can be given without regard to food
" Avoid use of aluminum and magnesium-containing antacids (they reduce Raltegravir
plasma levels)
" Chewable tablets may be chewed or swallowed whole. Film coated tablet should be
swallowed whole.
" DO NOT interchange film-coated tablets, chewable tablets and oral suspension
(the three formulations are not bioequivalent)
" Chewable tablets should be stored in the original package with desiccant to protect from
moisture
" Close monitoring of weight required at every visit to prevent underdosing or overdosing
" Oral suspension is contraindicated in neonates.

D. SELECTED ADVERSE EFFECTS

" More common: Nausea, fever, headache, dizziness, diarrhea, fatigue, itching and
insomnia (can be treated symptomatically or can resolve spontaneously)
" Less common: Abdominal pain, vomiting. Patients with chronic active HBV and/or
HCV are more likely to experience worsening AST, ALT, or total bilirubin than non
co-infected patients
" Rare: Creatine phosphokinase elevation, muscle weakness, rhabdomyolysis, rash/SJS,
thrombocytopenia

42!
!

E. MANAGEMENT OF ADVERSE EVENTS

Consult senior clinician or National HIV Clinical Support Center if any concerns about
adverse drug reactions.

F. DRUG INTERACTIONS

Rifampicin: It is a strong Inducer of uridine diphosphate glucuronosyltransferase (UGT) 1A1

that metabolizes Raltegravir. Therefore, the dose for adults should be increased to 800 mg
twice daily during co-administration with Rifampicin. Alternatively, use Rifabutin instead of
Rifampicin in such cases.
There are no data to guide co-administration of Raltegravir with Rifampicin in patients below
18 years of age.

Note: For more information on drug interactions, visit online resources such as;
www.medscape.com/drug-interactions or www.drugs.com/drug-interactions.

DARUNAVIR&(WITH&RITONAVIR)IProtease&Inhibitors&&
Darunavir is a Protease Inhibitor and is not currently available as a co-formulation
with ritonavir. It should always be co-administered with ritonavir. Ritonavir is
available as a tablet or liquid formulation.
A. DOSAGE FORMS, STRENGTH AND PACKAGING

Description Strength Packaging

Darunavir oral suspension 100 mg/ml 200 ml
Darunavir film-coated tablets 75 mg 480s
Darunavir film-coated tablets 150 mg 240s
Darunavir film-coated tablets 600 mg 60s
Darunavir film-coated tablets 800 mg 30s
Ritonavir oral suspension 80 mg/ml 90 ml
Ritonavir film-coated tablets 100 mg 30s

B. DOSING RECOMMENDATIONS
1. Adult dosing (≥ 18 years): Darunavir 600 mg twice daily + Ritonavir 100 mg
twice daily
2. Adolescent and pediatric dosing (< 18 years): as per dosing chart below

DARUNAVIR PAEDIATRIC DOSING

43!
!

Weight (Kg) Dose (Oral Suspension or Tablet formulation)

10 to < 11 Darunavir 200 mg twice daily + Ritonavir 32 mg twice daily
11 to < 12 Darunavir 220 mg twice daily + Ritonavir 32 mg twice daily
12 to < 13 Darunavir 240 mg twice daily + Ritonavir 40 mg twice daily
13 to < 14 Darunavir 260 mg twice daily + Ritonavir 40 mg twice daily
14 to < 15 Darunavir 280 mg twice daily + Ritonavir 48 mg twice daily
15 to < 30 Darunavir 375 mg twice daily + Ritonavir 48 mg twice daily
30 to < 40 Darunavir 450 mg twice daily + Ritonavir 60 mg twice daily
Darunavir 600 mg twice daily + Ritonavir 100 mg twice daily
≥ 40
(adult dosage)

C. SPECIAL INSTRUCTIONS

" Co-administer with ritonavir and food to enhance Darunavir plasma levels and
efficacy
" Tablets should be swallowed whole with a drink (e.g. water or milk)
" Consider oral suspension if patient is unable to reliably swallow tablets whole
" Close monitoring of weight required during dosing to prevent under dosing or
over dosing
" Dose should not exceed the recommended adult dose
" Oral suspension should not be frozen or refrigerated and should be stored in
original container
" Renal dose adjustments: No adjustment recommended in moderate renal
dysfunction. Consult if severe or end-stage renal dysfunction
" Liver dose adjustments: No adjustment recommended in mild to moderate
liver dysfunction. Not recommended in severe liver dysfunction

D. SELECTED ADVERSE EFFECTS

" More common: Nausea, diarrhea, rash, hypercholesterolemia, hyperglycemia
" Less common: Headache, fatigue, dyspepsia, increased liver enzymes
" Rare: Acute renal failure, pancytopenia, toxic skin rash/SJS.

E. MANAGEMENT OF ADVERSE DRUG REACTIONS

Consult senior clinician or National HIV Clinical Support Center if any concerns
about adverse drug reactions.
F. DRUG INTERACTIONS

44!
!

Rifampicin: It induces darunavir metabolism. This may result in loss of antiviral

efficacy and/or development of viral resistance. Avoid co-administration.

Oral contraceptives: Darunavir decreases plasma levels of oral contraceptives by

enhancing their metabolism.

Carbamazepine and phenobarbitone: Both affect hepatic/intestinal enzyme

CYP3A4 metabolism. Significant interaction possible, monitor closely.

Note: For more information on drug interactions, visit online resources such as;
www.medscape.com/drug-interactions or www.drugs.com/drug-interactions.

ETRAVIRINE&(NonINucleoside&Reverse&Transcriptase&Inhibitor)&&
A. DOSAGE FORMS, STRENGTH AND PACKAGING

Description Strength Packaging

Etravirine scored tablet 200 mg 60s
Etravirine scored tablet 100 mg 120s
Etravirine scored tablet 25 mg 120s
B. DOSING RECOMMENDATIONS
1. Adult dosing (≥ 18 years): 200 mg twice daily after a meal
2. Pediatric dosing (6 to < 18 years), AND weighing ≥ 16 kg: as per
dosing chart below

Weight (kg) Dose (Tablets)

16 to < 20 100 mg twice daily after a meal
20 to < 25 125 mg twice daily after a meal
25 to < 30 150 mg twice daily after a meal
≥ 30 200 mg twice daily after a meal
C. SPECIAL INSTRUCTIONS
" Tablets are dispersible in 5ml water, orange juice, or milk. Do not mix with
grapefruit juice, warm liquids, or carbonated beverages.
" Store tablets at 15-30 °C in a tightly closed container to protect the tablets from
moisture
" Efficacy and safety and have not established in children < 6 years old

D. SELECTED ADVERSE EFFECTS

" More common: Rash, nausea, dyslipidemia, hyperglycemia
" Less common: Diarrhea, peripheral neuropathy, increased liver enzymes,

45!
!

increased Creatinine
" Rare: Anemia, diabetes, hepatic failure, toxic rash/SJS
E. MANAGEMENT OF ADVERSE DRUG REACTIONS
Consult senior clinician or National HIV Clinical Support Center if any concerns
about adverse drug reactions.

F. DRUG INTERACTIONS

Rifampicin, Rifabutin: May decrease levels or effect of etravirine by inducing its

metabolism.
Ritonavir and Atazanavir: May also decrease effects of etravirine.
Isoniazid: It increases the level or effect of etravirine by affecting hepatic/intestinal
enzyme CYP3A4 metabolism. Significant interaction possible, monitor closely.
Artemether-Lumefantrine: Etravirine will decrease the level or effect of
artemether/lumefantrine by affecting hepatic/intestinal enzyme CYP3A4 metabolism.
Never use in combination.
Carbamazepine: It affects hepatic/intestinal enzyme CYP3A4 metabolism. May
decrease the level or effect of etravirine. Possible serious or life-threatening
interaction, monitor closely or use alternatives.

Note: For more information on drug interactions, visit online resources such as;
www.medscape.com/drug-interactions or www.drugs.com/drug-interactions.

46!
!

Medication&Use&Counseling&(MUC)&
!

MUC!refers!to!counseling!offered!by!pharmacists!and!other!health!professionals!at!
the!dispensing!point!regarding!use!of!medicinal!products.!It!is!recommended!for!all!
patients!initiating!antiretroviral!therapy!(ART)!and/or!switching!ART!regimens.!

MUC!is!essential!in!order!to:!

• Educate!patient!&!promote!adherence!!

• Improve!patient’!s!confidence!in!the!health!care!system!

• Assess!patient’s!understanding!of!their!treatment!!

• Get!feedback!from!the!patient!

(For.more.information,.refer.to.the.National.Integrated.HIV.Training.
Curriculum.(NHITC),.Module.23Y.Pharmaceutical.CareYsection.on.MUC).
.
. .

47!
!

Pharmacovigilance&
• Health!professionals!should!actively!look!for!adverse!drug!reactions!(ADRs)!
• Any!suspected!ADR!to!be!reported!to!PPB!(can!be!done!electronically)!!
• Facilities!should!conduct!monthly!reviews!of!all!reported!ADRs!and!discuss!
in!Multidisciplinary!Teams!(MDTs)!and!Medicines!and!Therapeutics!
Committees!(MTCs)!
• However,!it!is!worth!noting!that!ADRs!are!not!easy!to!identify,!as!some!may!
mimic!new!illnesses!e.g.!an!opportunistic!infection!or!co`morbidity!
• Good!clinical!practice!is!therefore!important!for!identification!and!
management!of!ADRs!
!
(For.more.information,.refer.to.the.NHITC,.module.23Y.Pharmaceutical.care.–.
section.on.pharmacovigilance)..
.
!
!
!
.
.
. .

48!
 Ministry of Health
National AIDS and STI Control Programme
Third Line ART Reporting Form

Date: _____/______/_________DD/MM/YYYY Facility name:________________________ MFL code:_______________

Patient clinic number: Sex: O Male O Female Weight (kg): Height (cm):
Medications & Adherence
Date initiated on third line regimen (first report only): _____/______/_________DD/MM/YYYY

Any suspected side effects/toxicities related to third line ARVs? O Yes (specify):___________________________ O No

Third Line ARVs Dosage & frequency Any other medications

DRV/r ___________ ____________ CTX

LPV/r ___________ ____________ IPT
ATV/r ___________ ____________ Anti-TBs (other than INH alone)
RAL ___________ ____________ O 1st line TB
ETR ___________ ____________ O 2nd line TB (MDR)
3TC ___________ ____________ Other, specify: ____________________________
TDF ___________ ____________
AZT ___________ ____________
ABC ___________ ____________
Other, drug:____________ ___________ ____________
Has the patient defaulted in the past 3 months? O Yes O No

Current adherence score: O Good (≥95%) O Fair (85-94%) O Poor (≤84%)

Sources of adherence support (tick all that apply): Treatment buddy Support group (actively attending)
Peer supporter (DOT) Relative (DOT) CHW/CHEW (DOT) Other DOT, specify: ________________
Home visit in past 3 months SMS reminders Other, specify: ____________________

Do you have regional mentor/mentorship team providing support? O Yes O No

If yes, name, email address & phone number of contact person:

WHO Staging Conditions

New WHO condition since last report? O Yes O No If yes, indicate all

Lab Results within past 3 months Sample Draw Date (DD/MM/YYYY) Value
Viral load
Creatinine
ALT
HB
Blood sugar
Total cholesterol

Page 1 of 1 Third Line Reporting Form Revised: 10 April 2015

49
!

List&of&Contributors&
.
Dr.!Irene!Mukui!NASCOP!
Dr.!Shobha!Vakil!NASCOP!
Dr.!Evans!Imbuki!NASCOP!
Dr.!Susan!Njogo!NASCOP!
Dr.!Caroline!Olwande!NASCOP!
Dr.!Linda!Misiko!NASCOP!
Dr.!Laura!Oyiengo!NASCOP!
Patricia!Macharia!NASCOP!
Lenet!Bundi!NASCOP!
Mohamud!Mohammed!NASCOP!
Dr.!Sarah!Masyuko!NASCOP!
Dr.!Maureen!Kimani!NASCOP!
Prof.!Jeremy!Penner!UCSF!
Dr.!Reson!Marima!UMB!
Dr.!Michelle!Ogolla!LVCT!
Dr.!Angela!Mcligeyo!CHS!
Dr.!Alexandra!Vandenbulcke!MSF`!France!
Dr.!David!Bukusi!K.N.H!
.
. .

50!
!

!
!
!
Copyright.Statement.
!
This!Toolkit!is!under!copyright!of!the!National!AIDS!and!STI!Control!Programme!
(NASCOP),!Ministry!of!Health,!Kenya.!
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All!reasonable!precautions!have!been!taken!by!NASCOP!to!verify!the!information!in!
this!publication.!
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For!clarifications!and!enquiries!please!contact:!
National!AIDS!and!STI!Control!Programme!(NASCOP)!
P.O.!Box!19361,!Nairobi,!Kenya!
Tel:!254!20!2729502,!2714972!
Email:!info@nascop.or.ke!
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