Session 4: HTS for Children and Adolescents

Adherence for Children and Adolescents

ARVs have had a dramatic impact on the prognosis for children and adolescents living with HIV. Children and adolescents born with HIV or who have acquired it after birth are now growing up through adolescence and into adulthood. However, their survival is dependent on optimal adherence to the ARV medicines. In this section, we will focus on ART Adherence counselling for children and adolescents.

Learning Objectives

By the end of this section, you will be able to:

Describe the role of antiretroviral medicines in the management of children and adolescents living with HIV.
Develop strategies to address potential adherence challenges.
Demonstrate an understanding of adherence counselling for children, their caregivers, and adolescents.

Learning Activities

Knowledge Check (10 min)
1What are outcomes of poor adherence? Select all that apply.
1. Clinical progression of the disease
2. Emergence of resistant virus
3. Risk of spreading medicine resistant virus when adolescents become sexually active
4. Rashes and skin problems
5. Incomplete viral suppression
A, B, C, and E are correct. While rashes and skin problems may be side effects of ARV medicines, they are not outcomes of poor adherence. The risk of spreading medicine resistant virus can happen either through sexual contact or if an adolescent girl becomes pregnant.
2Rutendo is a 14-year-old girl who has just been given ARVs and has been sent to you for counselling. In your discussion with her you tell her some important things she should remember when on ARVs. Which of the following are things you would mention? Select all that apply.
1. Keep your medical appointment
2. Take medications on time
3. Stop taking your medicine if you don’t feel well
4. Follow food and nutritional guidelines
A, B, and D are correct. It is important to drive home the message that ARVs need to be taken in the right dose at the right time in the right way. You don’t want to ever suggest that someone stop taking their ARVs. Instead let him or her know to see the clinician if experiencing side effects. Remind the client that the doctor or nurse is the only one to change when or how the medicine is taken.
3When you are explaining why adherence is important, what are some of the messages you might share with Rutendo? Select all that apply.
1. Occasionally missing a dose is okay
2. Medication will keep you healthy
3. Missing doses of medication can cause the virus to build up drug resistance, which means the ARVs you are taking won’t work anymore
4. If you are adherent, you can live a healthy life
5. Adherence helps to decrease the amount of HIV in the body
B, C, D, and E are correct. The aim is for 100% adherence. It is important for Rutendo to understand how ARVs work and how adherence is crucial to her health and future.
4What are some of the reasons that adolescents lack motivation to adhere to treatment? Select all that apply.
1. Don’t want to be defined by HIV
2. Don’t want to be burdened by daily medications
3. Don’t want to be stigmatized
4. Religious beliefs
5. Depression
All of the answers are correct. Most adolescents have busy and often changing daily routines and competing priorities such as school work, socializing, and church and family commitments. This can make them reluctant to carry their medications with them, or they may not bother with taking the medications at all. They may not want to be seen with the medication because they fear stigma and discrimination.

If you see signs of depression, you will need to address that issue as it can lead to non-adherence.
5What are the steps you need to take to work with a child or adolescent to achieve adherence? Select all that apply.
1. Home visits
2. Education
3. Support group attendance
4. Readiness assessment
B and D are correct. The steps involved in achieving adherence are: readiness assessment, education, preparation, ongoing monitoring/assessment of adherence, support, and barrier assessment.
6During adherence counselling, you want to ensure that the adolescent or child and caregiver receive adequate education. What are the points you need to cover? Select all that apply.
1. Adherence definition
2. Who to disclose to
3. Lifelong treatment even when feeling well
4. Importance of strict adherence
5. Taking medicines at specific times
A, C, D, and E are correct. You should always make sure that before you hand over medications that proper education about adherence has taken place. It is your duty to explain and promote adherence.
7Assessing adherence includes which of the following? Select all that apply.
1. Tablet count
2. Biological and clinical markers
3. School attendance
4. Pharmacy records
A, B and D are correct. It is challenging to measure adherence perfectly, yet you can take actions by spending the time to assess adherence. You always want to emphasize the importance of honest reporting and you should take a multidisciplinary approach to monitoring. School attendance is not necessarily an indication of adherence as there are many other factors that are involved in going to school.
8What are some communication techniques that you should consider when discussing adherence? Select all that apply.
1. Use medical terms
2. Discuss the most important topics first and last
3. Repeat important information
4. Tell client to take notes
5. Use concrete examples
B, C, and E are correct. While discussing important issues, such as adherence, you want to use simple (nonmedical) terms. Give accurate information at an appropriate language level. When possible, give information in writing to clients and repeat the information more than once to be sure they have understood. Listen to feedback, pay attention to nonverbal cues (such as body language or tone of voice), and make the client interaction as positive as possible.
9What are some examples of good questions for probing ongoing adherence? Select all that apply.
1. “What seems to get in the way of taking your medicines?”
2. “How has it been going taking your medicines?”
3. “Which part of our last session did you not understand?”
4. “What was going on when you missed that dose you told me about?”
B, C, and D are correct. Remember that adherence to ART can be challenging, even for the most motivated clients. Your ongoing discussions about adherence are an important part of the treatment plan and provide an opportunity to uncover barriers and identify strategies to address them. Your ongoing relationship with the client is based on you being nonjudgmental and supportive.
10As long as a child or adolescent is adherent, there is no need to discuss adherence again.
1. True
2. False
False is correct. When a client is practicing good adherence you should acknowledge this and not miss the opportunity for positive reinforcement.
11HIV positive adolescents on ART often have lower viral suppression rates when compared to adults.
1. True
2. False
True is correct. Maintaining adherence to ART is one of the most significant challenges for adolescents living with HIV.
Soldier Game Part 2 (10 min)
Watch the video, “Soldier Game.” Think about the questions below.
Credit
I-TECH Zimbabwe based on Soldier Game from Africaid Zvandiri, Zimbabwe
1. What do you do differently when you are discussing adherence with adolescent or child clients?
2. How do you explain ARVs to children or adolescents?
3. How do you explain adherence to children or adolescents?
4. How will you apply what you learned in this video to adherence counselling?
Susan and Mary Part 4 (10 min)
Recall from earlier parts of this case, Susan is 8 years old and has tested positive for HIV. She has been brought to you by her 15-year-old sister, Mary, who has tested negative. Their parents are both late and they are living alone.

Susan began ART 8 months ago. She missed her last appointment, which was 1 month ago. You send a message with the village health worker for Mary to bring Susan back to the clinic. They have now returned to the clinic. Your review of the clinic record shows that Susan completed her TB treatment. Her weight had been steadily increasing and she was back in school. You also note that there have been a few times that the clinic nurse documented Susan’s adherence to her ART as fair and that Susan was “tired of taking medicine”. Her weight 2 months ago was down to 20kg from 22kg.
1Which of the following ways can be used to monitor children on ART?
1. Monthly pill count and growth and development markers quarterly
2. Clinical monitoring monthly and periodic laboratory monitoring according to national guidelines
3. Laboratory monitoring according to national guidelines
B is correct. Clinical and laboratory monitoring are good ways to monitor ART effectiveness. Monthly pill count is a good way to monitor adherence, but growth and development markers should be assessed at each monthly visit rather than quarterly. Laboratory monitoring should be done along with clinical monitoring, not on its own.
Upon reviewing the laboratory data in Susan’s chart, you notice that she had a CD4 count drawn at her 6-month visit but there is no record of the result. Before meeting with Mary and Susan you check with the clinic nurse, who tells you to look in a large folder where laboratory test results are stored when they come to the clinic. After several minutes, you find Susan’s result and note the following:
- Baseline CD4 count: 410/CD4 % 21.
- Month 6 CD4 count: 330/CD4 % 18.
You bring this result to the attention of the clinic nurse who is very busy referring another client for admission. She quickly looks at the result and clinic record and says “Looks like she is not taking her ART correctly. You better talk to her and her sister”.
2What is the best approach to take as the person who has the closest relationship with both Susan and Mary and has known them the longest?
1. Start with acknowledging how well Susan has done in the past, e.g., adherence to care by keeping scheduled appointments and adherence to medications, followed by exploring what challenges have occurred that may have led to a decrease.
2. Ask Mary why she has allowed Susan to miss doses of her medication and tell Susan that if she continues to miss any doses, her TB will return or she will get very sick with another type of infection.
3. Meet with them separately to find out why doses have been missed and then bring them together to compare their answers and develop corrective action.
4. Refer Susan and Mary to another staff member, if available. There are times when having a close relationship with a client or family members may not be an advantage.
A is correct. It is important for you to remember to praise clients for what they have accomplished in their care and treatment before discussing the challenges or problems. Even close relationships with clients or caregivers do not enable you to deliver negative messages or ones that make them feel guilty. Providing conflicting information to Mary and Susan will only create mistrust within their relationship as well as with you and other health care providers. While there may be situations where another staff member works better with certain clients, this does not seem like the case with Mary and Susan.
3What do you ask when you begin to explore why Susan missed her appointment? Select all that apply.
1. “Where were you last month? Didn’t I tell you that you cannot miss any appointments?”
2. “You have missed an appointment and we are worried about you. How are you feeling?”
3. “You know you will end up like your parents if you miss appointments and stop taking your medicine?”
4. “Can you tell me the reasons that made you fail to come in last month? Are you still staying in the same place?”
B and D are correct. The first question you ask when a client misses an appointment or is identified as having adherence issues will lay the groundwork. This will establish whether the client will be honest about what has happened and work to make sure the problem does not happen again. Using a question that conveys concern and offers support will provide you with valuable information and help keep the relationship positive. You don’t want to be accusatory, threatening, or judgmental. You should try to ask questions that don’t make the client defensive. You want to find out why they were unable to come in and if they are okay, as well as if they are adhering to medication. Never use threatening questions with children, adolescents, or adults!
4What are some possible barriers which Susan may be facing that caused her to miss her appointment and a month of medication? Select all that apply.
1. Susan was feeling better, especially when her TB was cured, so she thought she did not need the ART medicine.
2. Susan is angry that she is HIV positive and still grieving the loss of her parents. She is depressed and just does not feel like taking pills every day.
3. Susan has trouble swallowing pills. It started when she was taking the TB medicine and seems to be getting worse. She is afraid to tell Mary, you, or her nurse because then they will stick a needle in her to give her the medicine.
4. Susan sees how upset Mary gets with trying to manage the house, cooking, cleaning, keeping up with school, and taking her to the clinic every month. Susan decided that if she stopped the medicine and got sick again, maybe she would die and be with her parents and Mary would not have to take care of her.
All are correct. It is essential for you to explore all possible reasons for a client missing an appointment. This may require intensive, ongoing counselling that can be continued at home by ensuring that the village health worker is aware of the issues and the action plan you have developed.
5During your counselling session you find out from Susan that she didn’t want to take her medicine because she was “tired of drinking medicine”. Mary thought that since Susan was doing better, it would not hurt to stop for a while and then start again later. How do you respond to this information? Select all that apply.
1. Connect Susan to a community adherence treatment supporter (CATS) programme.
2. Review Soldier Game together to make sure there is an understanding of how ART works.
3. Discuss the consequences of poor adherence.
4. Remind them of what happened to their parents and say the same will happen if Susan does not pay attention to her adherence.
A, B, and C are correct. As part of your adherence counselling you want to ensure that Susan and Mary have an accurate understanding of what adherence means and how ARVs work. If possible, it would be good to link them with community support, like the CATS programme. You do not want to use fear or intimidation to address the issue.
Chenai (10 min)
Chenai is a 14-year-old HIV-positive adolescent who acquired HIV perinatally. Her auntie has raised Chenai after her mother passed on when she was 4 years old. Chenai does not know anything about her father.

She has been receiving care at the same clinic since she was born. In fact, she has had the same nurse! Over the years, the clinic has increased the number of children and adolescents who are HIV positive. They even started a peer support group that Chenai attends regularly. She likes going to the group. Everyone knows each other and what they are facing, unlike when she is at school and has to hide her diagnosis.

Chenai has been on ART since she was 6 years old and openly discusses the challenges she has had over the years with taking her medicines. She has been sick quite often and hospitalized for a variety of illnesses, most as a result of not taking her medicines correctly. But that all changed when she got older. Over the past 2 years she has not missed any doses and her laboratory test results have been good.

Living with her auntie has been good, but it seems like they are arguing a lot lately, especially about boys. Chenai wants to be like the other girls in her class who are dating and having sex. During one of the times that Chenai and her auntie were arguing, her auntie told her that she was going to send her to a boarding school where there are no boys. Chenai did not think she would really do it, but she did. Her auntie enrolled her in a school far away from her village. She arranged for a clinic near the school to get her medications and took her to meet one of the nurses before she moved into the school. Chenai cried when her auntie dropped her off and is very mad at her for sending her here. She misses her friends and thinks she will never find anyone she can be close to. She feels like she will have to be by herself and hopes the time goes by quickly.

You work at the clinic near the boarding school. You have several girls from the school who are HIV positive and today you are assigned a new girl, Chenai. You have a referral letter that provides a brief medical history, lists her most recent laboratory test results, and indicates that she was dispensed a two-month supply of antiretroviral medication. But according to the letter, she should have come to clinic a week ago for more medication.
1What approach will you take at this first meeting?
1. “I am happy to meet you. I see that you have been HIV positive for many years and doing very well. I am interested in how you have been able to stay healthy and how you have been taking your medications.”
2. “I am happy to meet you, but am very concerned that you have not come to clinic before today. According to the referral letter, you should have been here last week. Unless the referral letter is wrong, you have been out of your medication. Is the referral letter wrong?”
3. “I am happy to meet you. You can see that this clinic is very busy. I am glad you came today but make sure you always have an appointment. Otherwise you will wait a long time. In our clinic, we do not look kindly on HIV positive children who do not take their medication as they are told. I see you have stopped taking your pills. I need to have a reason you stopped to put on your clinic record and you will have to see the nurse.”
4. “I am happy to meet you. I will be examining you today but today. Since you have been out of your medication for a week, it means that your virus is out of control again. This is not the first time from what I have read on your referral letter.”
A is correct. This is the first meeting for an adolescent new to the clinic and new to the village. It is important for you to develop a relationship as quickly as possible, even if there may be challenges to discuss. You don’t want to have a negative or accusatory tone. It will only increase the tension that Chenai is already feeling. This will make her less likely to tell you what really happened with her medication.
Chenai tells you that she has not missed any doses of her medication. In fact, she came today since she took the last pills in her bottle yesterday. She tells you that she has always had pills left over and the pharmacist she had at her other clinic would give her a new supply on top of the ones left over.
2What are ways that you and the health care provider will know if Chenai is telling the truth and has not missed any doses of medication? Select all that apply.
1. Contact the pharmacist at her previous clinic to confirm that extra medication has been in Chenai’s bottles.
2. Have the clinic nurse do a clinical assessment to evaluate for any abnormalities.
3. Have the clinic nurse do a clinical assessment and, if available, draw blood for a HIV viral load.
4. Contact Chenai’s auntie to find out if Chenai had enough medication in her bottles to last until today’s visit.
A and C are correct. Communicating with the pharmacist at her previous clinic would be helpful and may provide an answer to the number of pills left over each month. A clinical assessment will alert the nurse of any abnormalities. If Chenai's HIV viral load is elevated, it will indicate that she has not been adherent. Even if the HIV viral load is undetectable, you and the health care provider must still monitor Chenai’s adherence closely if you suspect that she has been missing doses. Another indicator of treatment failure is a decrease in the client’s CD4 count. If viral load testing is not available, have Chenai’s CD4 count checked.

A clinical assessment alone will not indicate possible missed doses unless a previously asymptomatic client returns to the clinic with an opportunistic infection or other illnesses that may be caused by HIV. Contacting Chenai’s auntie may provide you with information, but it can also cause undue anxiety and worry for both of them. This is not an emergency, and it is best to work directly with Chenai, which will also help to strengthen the developing relationship.
The pharmacist was contacted. He gave the extra doses in the bottles back to her with a new supply. The pharmacist tells you that Chenai has had very good adherence for a long time. The laboratory tests confirm this.

Chenai has been sitting in the waiting area. When you bring her back to your office, she sits with her head down. She does not look at you when you ask her what is wrong. She tells you that she does not think she can continue to come to this clinic. She saw one of the girls in her school going in to see the nurse. “She saw me and I think she knows why I am here. I have been hiding my pills and do not want anyone at school to know I am HIV positive. I hear the older girls talking about not wanting to eat nor sleep near anyone who has any diseases. If they find out about me, I do not know what I will do.”
3How can you help Chenai maintain her confidentiality in the boarding school and if she sees her classmates at the health center? Select all that apply.
1. Explain that schools must have a policy against stigma and discrimination, which will allow Chenai to comfortably and safely keep her medication in her sleeping area without having to hide them. She should not be worried about seeing anyone she knows in the clinic.
2. Warn Chenai that hiding her medication and being worried about seeing other girls will affect her adherence and ultimately her health.
3. Ask Chenai to share past experiences of seeing someone she knows in the clinic or having to take medication during the school day.
4. Use role play exercises to assist Chenai with her responses to seeing other girls from her school at the clinic and provide her with information she can use to explain her daily medication, e.g., “the medication is to keep me healthy and help me grow”.
C and D are correct. You have a good opportunity to uncover how Chenai has managed disclosure in the past. It is important for you to remember that Chenai has been HIV positive since birth and has developed coping mechanisms for a variety of social situations. The difference here is that Chenai is now living with peers and not just her family. How you handle this situation will be critical to building a strong and positive relationship.

A is not correct because even if there is a policy and Chenai is told about that, it will not lessen her fears. Telling an adolescent “not to worry” in this situation avoids a very important discussion that needs to occur. It can also send a potentially negative message to an adolescent to not ask questions or share his or her concerns. B is ultimately true in that hiding and worrying about taking medication could lead to adherence issues, but warning an adolescent sends a message “do this OR…”. Adolescents may be struggling with adult authority, and being told “what to do and when to do it” can have the opposite effect of what is intended.
During the discussion, Chenai tells you that she felt the most comfortable when she was attending the peer support group sessions at her previous clinic. She was asked to be one of the co-facilitators for the group and found that she liked being able to share her experiences with living with HIV. Chenai asks when the peer support groups meet at this clinic and is told that they do not have such a group. You feel that individual counselling works the best with the adolescents coming to this clinic. Chenai is quiet again, and begins to think that this clinic is really not the right one for her. She feels more isolated than ever.
4What is known about peer support groups for adolescents living with HIV disease? Select all that apply.
1. Research shows that adolescents need support from their peers to assist with someone newly diagnosed or living with HIV disease.
2. Peer support groups can be a substitute for general counselling which will free you up to focus on providing intensive, individual counselling, especially on adherence.
3. School-based peer support groups can provide additional support specific to challenges within a boarding school atmosphere and be especially helpful to children dealing with other chronic diseases, such as diabetes.
4. Peer support groups can help adolescents to cope with fear, hopelessness, stigma and discrimination.
A, C and D are correct. Peer support groups should never be looked upon or recommended as a substitute for individual counselling. Peer support can be a good source of practical information, motivation and positive reinforcement for adherence to treatment, disclosure, SRH issues, and other concerns. The peer support workers are an extension of the health care team and should be included in periodic team meetings and changes in clinic procedures that would directly affect the adolescents treated at the clinic.
5Let’s return to the discussion about how Chenai has been managing her medications and her adherence. Since the referral form and pharmacist have said she has good adherence, it is not necessary for you to address this topic.
1. True
2. False
False is correct. You must include adherence assessment and counselling at every visit for adolescents and adults. Just because a client reports good adherence and has laboratory tests confirming this does not guarantee that the client will continue adhering to medication and treatment. Many things can happen between clinic visits that may alter a client’s adherence, such as a medical condition, psychosocial problems like depression, or problems at school.
Chenai tells you that her daily routine is to take her morning dose of medication right after her breakfast. But on school holiday days or the weekend, she likes to sleep late and so she moves her time to later in the morning or right after lunch. For the evening dose, she takes it right after dinner. During school holidays, she doesn’t have a set time when she eats dinner.
6Based on what Chenai has told you about her adherence, should you provide her with additional adherence counselling? If so, what should be addressed?
1. Yes, additional counselling is needed to address taking her antiretroviral medications on an empty stomach. All ARTs should be taken on an empty stomach.
2. Yes, additional counselling is needed, specifically asking her to keep a daily diary of exactly what time the doses are taken.
3. No, additional counselling is not needed.
4. Yes, additional counselling is needed to address altering the timing of the doses, especially during school holidays.
D is correct. Additional counselling is needed. Altering the timing of doses by a few minutes is not a problem. But it is not recommended to alter the timing by several hours. If the time between the doses is too short or too long, it can cause a drop in the level of medication needed to control the virus or can cause an increase in side effects, such as an upset stomach. ART must be taken regularly at approximately the same time every day. You can use client education tools to visualize the virus and what happens when the medication level is low in the body. The Soldier Game is also helpful when discussing the importance of consistent, good adherence.

While some ART medication does require taking it on an empty stomach, that is not necessary for all of them. Using a diary to record when medications are taken is a good idea but not necessarily one that an adolescent will be able or want to maintain.
Remember that when you are providing adherence counselling to an adolescent like Chenai, there are many topics to cover and techniques you can use. You want to empower Chenai to take control of her health and adherence. This is done through:
- Reinforcement of transmission routes
- Reinforcement of the importance of ARVs
- Reinforcement of the importance of adherence
- Illustration of the importance of adherence using the body mapping chart
- Sharing of testimonials from other teens (such as the book titled Red Ribbons and Roses, written by HIV positive adolescents)
Tendai Part 2 (10 min)
Tendai is a 17-year-old HIV-positive adolescent who has been on ART since he was 12. He loves to hang out with his friends, staying out late and socializing. He has been known to drink alcohol with his friends. Clinic staff have seen him drunk. One staff member who lives in the same village as Tendai knows that his family is worried about his drinking and behaviour. Tendai’s mother has told this health care worker that she does not know what to do with him—he has changed and is “hard to manage”.
1What are the possible issues that Tendai may face with regards to adherence? Select all that apply.
1. Peer pressure to drink or use substances
2. Forgetting to take medicines
3. Adherence fatigue
4. Lack of support from family
A, B, and C are correct. It appears that his mother and family are worried about him so there is no evidence that they are not providing support.
You have been managing Tendai for the past 6 months. According to his records, when Tendai first started ART, he faced many challenges including serious gastrointestinal side effects, elevated liver enzymes, and mild to moderate sleep disturbances. These were managed by changing some of the medications in his regimen, monitoring his laboratory results, and providing medication to relieve the side effects he was experiencing.

Other staff have told you that in the last 2 years Tendai has become increasingly upset by having to come to clinic. He has missed appointments and has been arguing with his mother about staying out with his friends and not doing well in school. There have been several times when Tendai came into clinic with flu-like symptoms as well as an outbreak of oral thrush, which was directly related to his poor adherence. His mother has come to the clinic to talk to the health workers, but you have not met the mother yet. You have talked to Tendai twice, but only for a short time since he was in a rush to get home.

Tendai is in the clinic early this morning and tells you that he needs to be seen. When asked if he is having a particular problem, Tendai tells you that he is “having a burning sensation when he goes to the bathroom and just doesn’t feel good”. You meet with him and give a prescription for antibiotics to treat a urinary tract infection. He appears upset as he is talking to you. “I don’t understand how this happened. I’ve been careful and have sex only with my girlfriend. I wear a condom when I’m inside of her. Could this happen from her kissing me down there? My friends all told me that oral sex was safe and the best way to avoid getting a girl pregnant. Maybe it happened when I had too many beers and the condom went on wrong. My girlfriend doesn’t know I am HIV positive and I can’t tell her that or she will leave me”.
2What is your response to what Tendai has just told you?
1. Tell Tendai that he is making bad decisions and he needs to listen to professionals or he will get really sick again and also get his girlfriend sick.
2. Tell Tendai that you are grateful that he has shared his questions and concerns. Use open-ended questions to explore his alcohol use and possible unprotected sex.
3. Since he seems upset, tell him to come back to see you in a few days with his girlfriend.
4. Tell Tendai that you are concerned that he is not telling you everything about his sexual activity and remind him that the only way counselling will work is if he is truthful.
B is correct. It is very important that you acknowledge the fact that Tendai was open about his current situation. You have an opportunity to explore three areas of concern: Tendai’s alcohol use, his unprotected oral sex and possibly vaginal sex activities, and disclosure. Counselling skills that include the use of open-ended questions are essential if you want to get as much information as possible while providing support and patient education.

You should address critical clinical or psychosocial issues during the session. Asking Tendai to return with his girlfriend delays important client education and risks the chance that he will not return. Confronting an adolescent with an accusation of not telling the truth will potentially lead to a significant communication barrier and weaken the relationship between you and Tendai.
3What are the priority areas that you will address during this session? Select all that apply.
1. Cover types of STIs, treatment, and long-term complications from STIs for males and females.
2. Review instructions provided by the clinic nurse, including antibiotic schedule, possible side effects, and importance of finishing all of the doses.
3. Assess the frequency, type, and amount of alcohol and substance use and provide risk reduction counselling.
4. Encourage Tendai to practice what he will tell his girlfriend about needing to come to clinic for an evaluation. Also inform him that you will help him with the next steps (disclosing his status). For now, it is important for him to make sure his girlfriend is evaluated and treated for the STI.
B, C, and D are correct. A is not correct because discussing specifics about STIs and long-term complications is not appropriate or beneficial to Tendai at this time. Discussing prevention of STIs is something that you can address in follow-up visits.
4What are the effects of a STI on HIV that you should discuss with Tendai? Select all that apply.
1. An additional infection like a STI can potentially have a negative affect on the immune system for someone living with HIV. This could cause a decrease in the CD4 cell count.
2. An additional diagnosis of a STI in a person living with HIV disease is only a problem if the individual is not taking ART.
3. STIs can be harder to treat for someone living with HIV disease.
4. STI treatment interacts with ART, potentially making the HIV medications less effective.
A and C are correct. STIs and many other infections can negatively affect the immune system. This can be a problem if the CD4 cell count is low, if the person is not on ART, or if there are other infections, such as pneumonia. A weakened immune system can also make treating a STI harder. Close follow-up will be needed to ensure that the STI is treated completely and does not reoccur.
5What are examples of questions to ask Tendai that will best assess his alcohol use? Select all that apply.
1. When was the last time you had more than 3 drinks in one day?
2. How many days a week do you drink alcohol?
3. Have you ever drunk so much alcohol that you passed out and when you woke up, you did not remember what happened?
4. Do you understand that drinking alcohol and being HIV positive puts you at an increased risk of dying young?
A, B, and C are correct. These types of questions will give you information that can be used to provide the risk reduction counselling Tendai needs at this time. Adolescents do not appreciate or necessarily listen to negative, consequence-framing messages. D is incorrect because this type of question will not provide the information you need to assess the amount of alcohol Tendai is consuming.
6How can you frame a message to Tendai that will alert him to the potential of a substance use problem?
1. Your drinking is concerning to me. It is more than what is considered medically safe for someone your age and for someone who is also HIV positive. Let’s talk about why you are drinking and how you might be able to cut down or stop altogether.
2. You are not an adult and you are HIV positive so you should not be drinking any alcohol. It will interfere with the medications you are taking and increase the risk of damage to your liver.
3. Your drinking is probably the reason why you forgot to use a condom and now have a STI.
4. I understand that you are probably being tempted to drink with your friend. But since you are HIV positive and at higher risk for damage to your body, I need to notify your parents so we can discuss your alcohol use.
A is correct. Tendai is engaging in high risk behavior, specifically consuming alcohol and possibly unprotected sexual activity. It is critical for you to balance acknowledging the high risk behavior while preserving your relationship. This is especially an issue with adolescent clients. You need to keep in mind some of the characteristics of adolescent growth and development and use appropriate counselling techniques, such as being nonjudgmental, respectful and give correct information.

Adolescents do not generally respond well to negative, consequence-framing messages. Family counselling may be indicated in the future, but that would have to be discussed with and agreed upon by Tendai.
7What is the best approach to correcting possible misinformation Tendai has about STI transmission and sexual and reproductive health? Select all that apply.
1. Tell Tendai that he could not have gotten his STI from oral sex only. Tell him that either the condom was not put on properly, it slipped off, or he did not wear one when he was having intercourse with his girlfriend.
2. Ask Tendai what he knows about STIs and how they are transmitted.
3. Tell Tendai not to listen to his friends. Correct health information must only be obtained from the clinic nurse or PC.
4. Explain that some STIs can be transferred by having oral sex either from a woman to a man or man to a woman. That is why condoms are recommended even for oral sex.
B and D are correct. It is important to engage Tendai in discussions about sex and sexual activity. This will provide you with valuable information about what he understands and what information he is hearing on the street. Adolescents want to believe that oral sex is safe and there is no risk for STIs, but this is not correct. Herpes, gonorrhea, syphilis, chlamydia, and HPV (genital warts) can all be transferred by oral sex.
When you ask Tendai about his adherence, he gives short answers, such as “I take my pills” or his adherence is “OK”. Tendai’s viral load tests in the past indicated that he was having adherence challenges.
8Given Tendai’s history and current situation, what approach should you take today to address his adherence? Select all that apply.
1. Remind him of the times when he became sick after poor adherence and how he has remained healthy when he has taken his medication as instructed.
2. Ask about his daily routine from the time he wakes up till the time he goes to sleep and where his medications fit into that schedule.
3. Ask Tendai how he has been successful in taking his medications. After he has shared that information, follow the discussion by asking him what challenges he faces in taking his medication regularly.
4. Provide Tendai with specific patient education about resistance and treatment failure, using age-specific information and pictures. Let him know that his treatment may already be failing.
B and C are correct. Successful adherence counselling starts with finding out what has worked for the client in the past even if he/she has never been on ART. Adherence is important when taking medications other than ART, such as taking an antibiotic for a respiratory infection. If clients share that they stop taking the medication after they feel better, you will know that they don’t understand the importance of continuing to take medication even after they feel better.

Acknowledging patient successes with past adherence tells them that you are interested in how they have done well. Also acknowledging that taking medication every day is hard shows that you understand and want to help.

Since you are building the relationship, it is harmful to use a warning, or a consequence-framing message, which an adolescent may not listen to or appreciate. It is important for an adolescent to understand resistance and treatment failure, but D is an example of a negative message, which potentially could scare a client.

Factors Affecting Adherence (5 min)

We know that there are many challenges and barriers that children and adolescents face around adherence. Below is a table that lists barriers, some examples of the barrier and some strategies that you can try to address them. You may have other strategies that you use so if you do not see it on this list, it doesn’t mean you should stop.

Type of Barrier	Examples	Strategies to Address Barriers
Health Service	Staff Attitudes Lack of information Transport costs Availability of medicines Transition from paediatric to adult services	Address stigma with other healthcare workers Provide education Work with the team to keep up-to-date documentation on client visits to ensure stock is available Link to community support
Individual	Lack of knowledge Delayed disclosure Orphanhood Desire for conformity with peers Fear of stigmatization Loss of purpose Forgetting Depression Drug or alcohol use	Recommend peer support groups, treatment buddies, support systems, and ongoing counselling Plan ahead for not being home Address any mental health issues, making sure that they understand to continue taking medication even when they feel well Use the Soldier Game to help understanding Give client choices
Family/Community	Changes of caregiver Absence of parental/caregiver support Cultural/religious beliefs Traditional medicines Lack of support Negative experiences of ART	Help with disclosure Provide education Link to community support/CATS Provide family counselling
Medication	Pill burden Side effects Drug fatigue Past experiences of medication Daily reminder of HIV status	Written and visual materials A daily schedule illustrating times and doses of medications Demonstrations on using syringes, medication cups and pill boxes Prepare them for possibility of side effects

It is important that you discuss barriers and ways to address them when you are conducting adherence counselling. It is a good idea to try implementing more than just one strategy and to provide positive reinforcement when your clients are doing well. Having an honest and trusting relationship with clients also has an impact on your ability to help them with adherence.

Key Points (5 min)
- Adherence to care is central to the appropriate management of children and adolescents with HIV.
- Adherence to ARVs is one of the major counselling issues in the follow up care and support for children and adolescents with HIV.
- Adherence to ARVs is key to successful outcomes by achieving viral suppression and preventing medicine resistance.
- There are many factors which make adherence to ARVs difficult for children and adolescents.
- Counsellors have a vital role to play in the provision of adherence counselling for children and adolescents and their families.