HTS for Children and Adolescents

Week 5: Adherence Counselling for Children and Adolescents

Notes: Content in this week covers Module 7 Session 2 (pages 117-127) in the HTS for Children and Adolescents manual. Keep in mind that everyone has their own style of counselling. Some of the questions will ask you to write down your thoughts about different topics in your workbook and then “compare answer”. We have provided sample responses from experts. You may find that you have written something that is not listed. This does not necessarily mean your response is wrong.

Learning Objectives

Upon completion of this week, you will be able to:

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

This week pay attention to principles, skills, techniques, and strategies for counselling children and adolescents with regards to adherence. You will have an opportunity to reflect, share an experience with your WhatsApp partner, and commit to making a change about the way you provide adherence counselling. Use your Action Plan to document your challenges and plans related to this week’s topic.

Learning Activities

  • Podcast: Adherence (5 min)
    Instructions

    Listen to this podcast from the book Red Ribbons and Roses, created by a group of HIV positive youth. In your workbook, write down your answers to the question below.

    Credit: Africaid Zvandiri, Zimbabwe
    Questions
    1. Are you familiar with the terms “juice card” or “makabi”?
    2. What are the different words for ARVs that you have heard in your community?
  • Check Your Knowledge: Adherence Counselling for Children and Adolescents (15 min)
    Instructions

    Complete these quiz questions to check your knowledge on the principles, techniques, and skills of counselling children and adolescents on adherence.

    1.What are outcomes of poor adherence? Select all that apply.

    2.Rutendo 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.

    3.When you are explaining why adherence is important, what are some of the messages you might share with Rutendo? Select all that apply.

    4.What are some of the reasons that adolescents lack motivation to adhere to treatment? Select all that apply.

    5.What are the steps you need to take to work with a child or adolescent to achieve adherence? Select all that apply.

    6.During 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.

    7.Assessing adherence includes which of the following? Select all that apply.

    8.What are some communication techniques that you should consider when discussing adherence? Select all that apply.

    9.What are some examples of good questions for probing ongoing adherence? Select all that apply.

    Answer true or false to the following questions.

    10.Adherence to medicines is more important for children than adherence to care (going to appointments and tests as scheduled, modifying lifestyles as needed).

    11.Adherence and compliance are the same.

    12.As long as a child or adolescent is adherent, there is no need to discuss adherence again.

    13.HIV positive adolescents on ART often have lower viral suppression rates when compared to adults.

    14.When counselling a caregiver and a child, it is not necessary to involve the child in the discussion about adherence. It is only important that the caregiver understands.

  • Video: Soldier Game - Understanding Adherence (10 min)
    Instructions

    Watch the video, “Soldier Game.” In your workbook, write down your answers to the questions below.

    Credit: I-TECH Zimbabwe based on Soldier Game from Africaid Zvandiri, Zimbabwe
    Questions
    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?
  • Case Study: Susan and Mary, Part 4 (10 min)
    Instructions

    Complete the case to learn more about counselling children on adherence.

    Background

    As you recall from Parts 1-3 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.

    1.Which of the following ways can be used to monitor children on ART?

    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”.

    2.What is the best approach to take as the PC who has the closest relationship with both Susan and Mary and has known them the longest?

    3.What do you ask when you begin to explore why Susan missed her appointment? Select all that apply.

    4.What 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.

    5.During 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.

  • Video: Tanaka (5 min)
    Instructions

    View the following short video of a 20-year-old adolescent girl living with HIV who is talking about staying healthy by taking medication. In your workbook, write down your answers to the questions below.

    Credit: United Nations Development Programme (UNDP)
    Questions
    1. What are the key messages that come out of this video?
    2. Tanaka talks about faith healers in a very strong way. How do you discuss adherence with your clients when they want to stop taking their medicine because of faith healers?
  • Case Study: Chenai (15 min)
    Instructions

    Complete the case to learn more about adherence counselling for adolescents.

    Background

    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 are the PC 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.

    1.What approach will you take at this first meeting?

    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.

    2.What 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.

    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.”

    3.How 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.

    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.

    4.What is known about peer support groups for adolescents living with HIV disease? Select all that apply.

    5.Let’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.

    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.

    6.Based on what Chenai has told you about her adherence, should you provide her with additional adherence counselling? If so, what should be addressed?

    7.What are the topics and techniques you would cover in your adherence counselling with Chenai? List 3-4 topics/techniques in your workbook and then click the compare answer button.

    Compare Answer

  • Podcast: Together Let’s Adhere (5 min)
    Instructions

    Listen to these podcasts from the book Red Ribbons and Roses, created by a group of HIV positive youth. In your workbook, write down your answers to the question below.

    Credit: Africaid Zvandiri, Zimbabwe
    Questions
    1. In what ways do you think it takes courage to live life healthy as an adolescent who is HIV positive?
    2. What are some ways that you encourage young HIV positive clients to stay healthy?
  • Case Study: Tendai (15 min)
    Instructions

    Complete the case to learn more about adherence counselling for adolescents.

    Background

    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”.

    1.What are the possible issues that Tendai may face with regards to adherence? Write your responses in your workbook and then click compare answer button.

    Compare Answer

    You have been Tendai’s PC for the past 6 months. His previous PC discussed his case with you when you began. 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.

    His previous PC told you that over the past 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 previous PC, 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 see the nurse. 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”. Tendai is seen by the nurse and returns to your office. He has been given 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. The nurse told me I have to tell my girlfriend to come to clinic for medication. I’ll do that but she doesn’t know I am HIV positive and I can’t tell her that or she will leave me”.

    2.What is your response to what Tendai has just told you?

    3.Where are the priority areas that you will address during this session? Select all that apply.

    4.What are the effects of a STI on HIV that you should discuss with Tendai? Select all that apply.

    5.What are examples of questions to ask Tendai that will best assess his alcohol use? Select all that apply.

    6.How can you frame a message to Tendai that will alert him to the potential of a substance use problem?

    7.What is the best approach to correcting possible misinformation Tendai has about STI transmission and and sexual and reproductive health? Select all that apply.

    Prior to today’s meeting, you have reviewed Tendai’s large clinic record. The previous PC did not provide good documentation of counselling she gave Tendai. Most of her notes are about what a difficult client Tendai was.

    She also didn’t list specific adherence strategies. When you asked 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.

    8.Given Tendai’s history and current situation, what approach should you take today to address his adherence? Select all that apply.

  • Video: Adherence (15 min)
    Instructions

    View the following video of a group of teens discussing adherence. In your workbook, fill in the worksheet to identify more strategies to address barriers to adherence that children and adolescents face.

    Credit: Africaid Zvandiri, Zimbabwe

    After you have completed the worksheet in your workbook, click on the compare button.

    Compare Answer

  • Action Plan (30 min)
    Instructions

    In your workbook, fill in the Action Plan for this week. There are three parts to fill in.
    Part 1: Describe a challenging case. The worksheet will help you to develop the details.
    Part 2: Create a strategy. From the ideas generated above to address the challenge, choose one and create a strategy to apply in your workplace.
    Part 3: Putting your learning into action. Using the worksheet, you will list out what you learned this week and how you will apply it to your job.

  • Partner Discussion (30 min)
    Instructions

    Using WhatsApp, send your response to the following discussion topic to your partner before midnight on Thursday. By midnight on Saturday, please post thoughtful responses to your partner’s posts. To get credit, forward the discussion to the administrator before midnight on Sunday.

    Discussion Topic: Looking back at this week’s material:

    1. Share one of the challenges that you face in counselling adolescents about adherence.
    2. Share a specific strategy that you have or plan to use to overcome this challenge.
  • Case Presentation Preparation (45 min)
    Instructions

    Reviewing your Action Plans from each week, choose one case that you will present to the group during the in-person session next week. Using the outline provided in your workbook, prepare information for your case presentation.