1. Enhanced Adherence Counseling (EAC) for Adults

2. Learning Objectives
To be able to conduct counselling sessions for patients with a high viral load through the identification of barriers to adherence and strategies to overcome them.

3. Why do EAC?
70.5% have a re-suppressed viral load after an adherence intervention
(CI 56,6%- 84,4%)
Bonner, 2013
Varied range of interventions
What is an optimal and feasible intervention in resource limited settings?
EXPLAIN A recent systematic review – looking at different studies - showed that on average 70,5% have a re-suppressed viral load after a targeted adherence intervention . However these studies looked at in this review are hard to compare as they used different definitions of re-suppression, different thresholds to trigger an intervention and different times on ART. They also used very different adherence interventions ranging from a once off session, to multiple sessions, use of pillboxes, home visits and even directly observed ART.
So what remains is the question of what is an optimal and feasible intervention in a resource limited setting; taking into account issues of workload as well as the burden of any intervention on patients.

4. Adherence interventions
Different interventions developed for resource limited settings
Variations according to context:
Programme location (high volume versus low volume sites)
Available HR (doctors, nurses, professional or lay counsellors)
All in common:
Structured intervention
Supported by implementation tools like session guide, patient file and register
EXPLAIN Re-suppression rates for different interventions vary from 30% to 60%

5. How to do EAC Attitudes: Non-judgmental attitude:
“What have you done wrong?” versus “What makes it challenging for you to take drugs every day?”
Empower patients:
“You should take your drugs every day as I tell you to do.” versus “Well done, your viral load is suppressed, keep up the good adherence.”

6. How to do EAC (contd.) Skills: Use open-ended questions
“Did you take your drugs last night?” versus “Can you tell me how you have been taking your drugs over the last days?”
Work on realistic solutions
“You should never stop taking drugs when you travel” versus “Let’s see how we can ensure you do not run out of drugs when you travel. What do you think about coming to the health facility for a longer supply before you leave for your trip to see your family?”

7. Individual Session plan - overview
EAC Sessions
Individual Session plan - overview
1st EAC
High VL result given
1 month refill given
2nd EAC
3rd EAC M4
2nd VL taken
Adapt this slides and following slides according to context or according to session guides chosen (see tools: individual or individual + group sessions)
Give overview of when these sessions will happen
Handout the actual session guides to the participants and review main content, while relating it to what we have seen in this session already
To facilitate each session and ensure you address the different topics needed, a counselling session will help you in delivering a counselling session of good quality. In the beginning you may need to refer to these counselling session guides often, while once you are more experienced you may only still need to look at them now and then to refresh your mind. These tools are there to help you.
Examples of such counselling session guides can be found in annex … / tool …. Getting familiar with these tools is a perfect preparation to perform you first EAC sessions.

8. EAC Session 1 Welcome and introduction Explain the viral load result
Explain the EAC procedure
Assess previous and current adherence
Explore barriers to adherence and identify ways forward (behavioral, soco-economical, emotional)
Conclude the session

9. EAC Session 2 Welcome and introduction
Assess patient’s adherence since last visit
Assess patient’s knowledge regarding treatment failure
Review adherence barriers and implementation of solutions
Conclude the session

10. EAC Session 3 Welcome and introduction
Assess patient’s adherence since last visit
Review adherence barriers and implementation of solutions
Explain that a 2nd VL will be taken at their next visit
Conclude the session

11. Documenting EAC High VL & EAC register
To check if all patients with high viral load are receiving EAC
To check if all patients with a high viral load receive a 2nd viral load
Document whether patients have been switched to 2nd line
Any other additional comments
Explain the tools and tell how this will be practised during the role plays
Several tools should be used to document the EAC sessions.
First we need to register attendance of EAC sessions in the enhanced adherence counselling register. Each health centre should have such a register. All patients with a high viral load will be marked in this register as well as their date of attendance of the EAC session. This will allow to check if all patients with a high viral load are receiving EAC and if a second viral load was done.

12. Documenting EAC Referral Form for patient with High Viral Load
To document adherence of patient with each EAC session
To communicate with and inform clinician (MA, CO, or Nurse)
Should be in each high VL patient’s mastercard
More detailed information on what was discussed during the EAC session such as barriers identified and what solutions were defined, will go in the high viral load form. This form should be kept in the patient’s mastercard.
EAC attendance and session outcomes could also be marked in the patient’s health passport
This will allow counsellors to be able to remember what was discussed in previous sessions and will enhance communication with health care worker
Explain how they will practice this during role play

13. Exercise
Adherence Roleplay

14. Roleplays
Subgroups of 5 with participants taking turns as observer, patient or counsellor
Handout for patient & counsellor of role play, session guides, patient file and EAC register
Debriefing questions after every role play
How did this role play feel for the counsellor?
How did the role play feel for the patient?
How did the role play feel for the observers?:
what were the good points about this counselling session
what would you suggest to do differently
What will you record in the patient file and in EAC register?
Wrap up main points

15. Role play 1: Handout for counsellor
You are seeing a 33 years old woman who has been on ART for 4 years with a viral load of 6000 copies/ml.
She always attends for her appointments or drug refills on time.

16. Role play 1: Handout for patient
You are a 33 year old woman and have never heard about viral load before.
You know that sometimes they take a blood sample to measure the amount of soldiers in your blood.
You often forget to take your drugs when you are out of the house as you don’t want others to see you are taking drugs (e.g. at church, at the market)
You always come to your appointments on time.

17. Role play 2: Handout for counsellor
You see a 35 year old man who often fails to attend for his appointments with a viral load of copies/ml.
In his file you see he travels often which makes it impossible for him to come to his appointments.

18. Role play 2: Handout for patient
You are 35 years old man who often fails to take his treatment due to running out of drugs.
You get your treatment at a health centre in a village in Malawi, yet you live in Mozambique. You only come to the village once every few months, so sometimes you run out of drugs if you do not have enough money to travel back in time for your appointments.

19. Role play 3: Handout for counsellor
A 48 year old man who started ART 3 years ago comes to you with a viral load of 9500 copies/ml.
The nurse did a first viral load which was detectable.
In the first EAC session he told you that he often drinks and that’s why he forgets to take this treatment.
As a way forward the patient wants to ask a friend to remind him to take the drugs when out.
You see this patient now for a second EAC session.

20. Role play 3: Handout for patient
You are a 48 year old widowed man who lives alone in his house. You started ART 3 years ago
Your nurse has told you that your viral load was too high.
You often go out drinking with your friends and that makes you forget to take your meds. You’ve told this to the counsellor the other time. Since then you have been thinking about your health, but you do not see a way to improve your adherence. You did not dare to ask a friend to remind you of taking drugs when out.
You are now attending a 2nd EAC session.

21. Role play 4: Handout for counselor
A 27 year old woman who is pregnant comes to you with a viral load of 8600.
She has been HIV+ for some time, but has only started ART during her second pregnancy. Her first child is HIV+ as well.
You see this patient now for a first EAC session.

22. Role play 3: Handout for patient
You are a 27 year old woman who is pregnant with her second child. You started ART 6 months ago.
You did not take ART during your first pregnancy, even though you knew your were HIV+. Your first child is HIV+ as well.
You are now attending your 1st EAC session.

23. Key messages
Enhanced adherence counselling is put in place to support patients with a high viral load with the aim of resuppression.
EAC explores the patients’ barriers to adherence and identifies together with the patient a way forward
These sessions happen in a structured way, with the support of a session guide and registration in a patient file and register