Module 4: Role Playing and Case Discussions

Case 1 A 35 year old man was diagnosed one year ago at a community testing venue. He has had difficulty accepting this diagnosis because he had few lifetime sexual partners and has been in good health. He arrives today at the clinic and agrees to start ART. 5 MINUTES – ROLE PLAY find the relevant section of the flipchart and role play Use card 1 for ART initiation

Case 1 He is now back at the ART clinic 6 months after ART initiation. He is clinically doing well and has come on time for all scheduled appointments and drug pick-ups. VL test will be sent today. 5 MINUTES – ROLE PLAY find the relevant section of the flipchart and role play Use card 2 for explaining & sending VL

Case 1 He is back in clinic for next scheduled visit. VL result is 140 copies/ml. 5 MINUTES – ROLE PLAY find the relevant section of the flipchart and role play Use card 3 to explain low VL and reinforce messaging

Case 2 A 23 year old woman on ART for 4 years presents to ART clinic which now has routine viral load testing available. She has no VL results in the last 6 months. What is your next step? 3 MINUTES – ROLE PLAY Prompt participants to switch roles of patient & provider. find the relevant section of the flipchart and role play Use card 2 for sending VL

Case 2 Results return in one week and VL is 200,000 copies/ml. What are your next steps? 3 MINUTES – ROLE PLAY Call her to come to clinic immediately - role play the telephone call Ask group what they came up with. Did they give the actual results over the phone? Who would you give the results over the phone to? When would you not? *Highlight that you should only give results to the patient. If this patient is not well known to you and you think best to wait to discuss the results until the patient returns, can just tell them over the phone the need for the immediate visit. __ RECAP FROM ROLE PLAY: During the phone call tell her something like – as we discussed at your last visit when we sent the VL, we would contact you to come to the clinic before the next scheduled visit if needed. We have your VL result and it is elevated, and we need you to come back in to talk about next steps.

Case 2 She returns to clinic a week after your phone call. What are your next steps? 10 MINUTES – ROLE PLAY Find the relevant flipchart cards, 4-8, to explain high VL, assess adherence, and look for barriers – be sure to document on tool. Prompt participants – do not move on to providing tips yet, we will cover that next.

Case 2 Adherence assessment reveals that she has been nauseous when taking ARVs and as a result has been missing some doses (>4 doses per month, adherence assessed as poor). She also reports that her cousin started ART and died one month later so she has been afraid to take her ARVs. 10 MINUTES – ROLE PLAY Use cards 9-side effects & knowledge deficit, 10, - health beliefs, and 14-understanding your ARVs (and any early cards such as 1&2 about how ARVs work and VL monitoring) to provide tips to address

Case 2 You and she agree to take ARVs with a small, bland snack which has helped nausea and you review how ARVs work. Document on tool. Did anyone come up with other ideas?

Case 2 She returns for her third adherence session (was doing well at second session and adherence was assessed as good at that time). You find she has missed 1 dose over the last month. How do you rate her adherence using the table? Look at card 16 – ask a volunteer to say how they would categorize this patient’s adherence

Case 2 Since her adherence is assessed as good, she now has 2 months of good adherence. When should repeat VL be done? Tell her that her repeat viral load is due in one month (has had 2 months of good adherence, needs a 3rd before sending repeat viral load) as long as she remains adherent Remind her it’s important to continue to take ARVs as instructed. Also explore what has been working well for her for taking ARVs and encourage that these continue. Assess any potential barriers. Don’t forget to document on the tool

Case 2 She returns to the clinic one month later, adherence is assessed and still good, VL is sent and you tell when her next scheduled appointment will be but that you will call sooner if needed. Repeat VL results return at 256 copies/ml. She comes back to the clinic at her scheduled visit. 3 MINUTES - ROLE PLAY Use card 17 to review results When would you plan for her next viral load? In 6 months (or according to national guidelines if different)

Case 3 31 year old man on ART for several years, VL becomes available for routine monitoring and returns at 12,000 copies/ml. 10 MINUTES – ROLE PLAY Prompt participants to switch roles of patient & provider. Call him to come to clinic immediately Use cards 4-8 to explain high VL, assess adherence, and look for barriers Document on tool

Case 3 You find that he is forgetting to take doses because he is working late into the evening. He also reveals that he has not disclosed to this wife and he is afraid she will find the medications. 10 MINUTES – ROLE PLAY Use cards 9,10, 13, and 15 to provide tips to address her identified barriers

Case 3 You and he discuss the fears around disclosure and explore potential benefits. He ultimately agrees it is important for his own health as well as his wife’s to disclose to her, and accepts the offer to have her come in for couples counseling and testing. In addition, he agrees to set an alarm on his phone to remind him to take his ARVs prior to going to sleep. Document on tool

Case 3 Over the course of 4 months of enhanced adherence counseling, he achieves 3 months of good adherence and repeal VL is sent Results come back at 9,000 copies/ml What is your interpretation? 10 minutes role play Use card 18 to explain treatment failure and next steps for switching