1. ART/TB Initiation Counseling
Patient-centered ART Initiation and Adherence counseling model

2. Objectives At the end of the training you will be able to:
Know the structure of the adapted ART/TB Initiation counseling model
Know what all the tools are, and use them appropriately
Understand the importance of the Adherence Plan and how to complete it with the client
Apply the 14 steps to assist the client to complete the counseling sessions
Perform ART/TB initiation counseling and PMTCT counseling

3. How many squares do you see?
Notes for presenter:
There is no one right answer.
This activity is called Perspective Squares.
It shows you how we all see things differently.
This shows us also that we as healthcare workers may see things differently to how our patients see them.
We are all a product of our own life experiences and lessons. Understanding that everyone experiences and sees things differently is important. It can help you have an open mind when dealing with different people. This is the approach we want to keep in mind through the training, and as we offer counseling.

4. Rationale for a adapted counseling model
Think about your counseling at the moment:
What counseling support do your patients need?
Post-initiation support
Challenging social circumstances
Problem-solving
Co infection with HIV/TB (or other conditions)
What do you think are the qualities of a good counselor?
NOTE this is an animated slide
Have participants brainstorm answers to questions

5. Overview of adapted model with a new approach toward patients, putting them at centre in order to find solutions to their problems
Structure
Approach
Tools
Training
Mentoring

6. Overview Assist in integrating treatment into their lives
Focus on encouraging patient ownership of treatment process
Supportive not prescriptive
Acknowledges practical barriers to adherence
Assist patient in addressing barriers to adherence
Take home messages clear
Wanted to create a model that shifts the way we think about being on treatment,
A model that is SUPPORTIVE, that it focused on…. (give overview of each point)
Lets understand how each of the 5 key areas have been revised…

7. Structure Allows for fast tracking without compromising content
Limit number of preparation sessions
Strengthen post-initiation support (active learning on treatment)
Allows for fast tracking without compromising content
We kept 4 sessions,
Limited preparation sessions
Strengthened post initiation support
Allowing for fast tracking without compromising content

8. Adherence counselling Standard track
Clinical Management
Day of diagnoses
HIV testing and
counselling
CD4 count
4 to 7 days
Day of eligibility
Consultation
By MA/CO for
TB screening &
Staging
Session 1A-B-(C)
Pre-ART
3 to 7 days
Session 2:
ART initiation
Day of initiation
ART
Initiation
30 days
Session 3:
1st adherence FU
Month 1
on treatment
ARV Refill
We kept 4 sessions
The timing of the sessions is different – less pre ART prep and more post ART initiation support
We wanted to improve post initiation support
Encourage active learning while on treatment
Above diagram is an example of timing between the sessions in this model – adapt to suit your setting.
M2/M3/M4/M5
Session 4:
2nd adherence FU
Month 6
on treatment
ARV Refill
Detectable VL
Enhanced
Adherence
Counseling
Viral Load (6M)

9. Approach 14 simple specific adherence support steps to address
Limit time spent on repeated treatment literacy
Patient centered readiness to initiate
14 simple specific adherence support steps to address
We are now going to review the approach adopted in this counseling model – a patient centered approach
This model introduces a more structured approach to cover 14 of the most common adherence challenges patients face while integrating treatment into their life –
NOT going to go through each content point now.

10. Approach: ABC’s of adherence
Identify the GOAL
Identify the BARRIERS to achieving the goal
Work on making a PLAN to overcome the barriers
How do we adopt this NEW approach to counseling?
We are using an updated strategy to look at adherence
Trying to shift the thinking about being sick and on treatment to investing in health and well-being.
We use the ABCs of adherence – Goal, Barriers, Plan
Aim is to empower the patient by encouraging them to create their own solutions/plans

11. ABC’s of adherence in practice
Adherence Step 7 - Storing medication and extra doses
Review
adherence
goal
“It is important to identify a convenient place to store medication so that you have easy access and are easily reminded”
Identify
barriers
“Where could you keep your medication at home?”
“How could you carry your medication when you go out?”
Make
a concrete plan
Identify safe and convenient place to store drugs at home or at place where patient usually takes his/her drugs
Identify a place to carry extra doses of drugs, what to keep them in - in case patient does not make it in time to usual storage place
(e.g. envelope in pocket of woman’s bag, plastic bag in man’s backpack or jacket he usually wears)
Use an example like “storing medicines” to show how ABCs of adherence – Goal, Barriers, Plan – can be used to aid adherence planning

12. Tools Simplified flipchart (HIV/ART, TB, PMTCT)
Session guide (for lay counselors)
Adherence plan (put in patient file)

13. ARV Patient Education Flipchart
Not to go through details now – just to show the tool
Simplified flipchart for group/individual educational session
Limited to treatment literacy for Session 1A only

14. TB Flipchart Not to go through details now – just to show the tool
Provides simplified messages for patients initiating TB treatment

15. Flipchart for PMTCT ART Initiation
Covers general PMTCT information in addition to routine ART adherence messages
For group/individual educational session
1min - Not to go through details now – just to show the tool

16. Adherence Plan For patient file
Not to go through details now – just to show students where they can find the tool in their training pack

17. Session guide for counselors
Step by step guide
Structured in ABC approach (goal, barrier, plan)
Not to go through details now – just to show students where they can find the tool in their training pack

18. Adherence steps
Adherence steps are associated with 3 reasons to stay healthy and alive
Move away from treatment focus, but rather on why…
I want to be alive for my children
I need to be able to earn
I want to see my children grow older
Activity: close your eyes, think about what is important in your life – think about the goals you would want to achieve, people who you’d like to support. When you think of these things, put together 3 reasons why you would want to stay healthy and alive.

19. Mentoring tools Counselor observation tool
Who is responsible for this?
MSF Patient Support Officers are responsible for providing mentorship to the lay counselors at the facilities
How is this completed?
Observation of sessions
Feedback on sessions
Develop goals with counselor to strengthen/improve counseling

20. Overview complete!
Stop here for Counseling Model Overview Prestentaion

21. ART/TB Initiation and Adherence Counseling Model
Building Session 1A
ART/TB Initiation and Adherence Counseling Model

22. Brainstorm!
What is the most important information a patient should learn and know about HIV?
Definition of HIV, CD4, viral load, healthy living, adherence, etc. Let’s see if all that information fits into our literacy session…

23. Session 1 3 parts to session 1 (A + B + C - All done on same day)
Education session (A)
Individual session (B)
Non readiness session (C)
Content covers: Adherence Steps 1-4
Notes for presenter:
Ask class to go to the overview of counseling sessions table in their Counseling Manual
Show how Session 1 has 3 parts
Take class through the content of session 1 (main headings) in the detailed session plan section of their Counseling Manual

24. Review flipchart In pairs read through Flipchart together
Notes for presenter:
Split class into pairs with one ART/TB flipchart between 2 – Ask each pair to review the flipchart together and ask questions to facilitators as required – 2 facilitators go round the room to answer queries and check teams are progressing
Instruction for students:
Remember to start from the very cover page – overview of the colours and what they stand for – this is your first introduction to the components of the flipchart AND the patients learning
Encourage the class to just focus on carefully reading through the information on the flipchart for this exercise – to ensure they don’t miss any new/updated information and to familiarize themselves with the details before they have to do it in front of patients.

25. End of Building Session 1A
Next time to Role Play Session 1A
Stop here

26. Session 1 A: Review When do we do Session 1A? What tools are needed?
As soon as eligible patient referred to counseling
What tools are needed?
Flipchart
Remember to start from the cover page.
Start with overview of the colours/images and what they stand for – this is your first introduction to the components of the flipchart AND the patient’s learning
Notes for the presenter:
Remind the participants to READ READ READ! They must try for the training, to just focus on reading, we know they know the information, but we want them to give the training a chance.

27. Role play Session 1A: What tools do you need?
Introduction (intro facilitator, explain objectives, confidentiality)
Work through flipchart
Notes for presenter:
60 minutes – 5mins for instructions, 40mins for role play, 15mins for feedback and discussion on session1A
Instruction to the class:
Go into pairs
Tools you will need to complete this session: flipchart, counseling manual.
Turn to the page in your counseling manual with the detailed session plan for session 1A - You will see instructions on use of the flipchart throughout this session.
Remember the use of the flipchart in this session ends BEFORE the Viral Load part. Viral Loads are not discussed in session 1A – this is discussed in Session 4.
In your pairs, decide who will be the counselor and who will play the patient for this exercise.
Take your time to read through the steps in your session plan
Role Play:
Facilitators go round the room to answer queries and check teams are progressing
Feedback session:
Ask each group in turn to share what they found helpful/not with Session 1A
As you move from group to group for feedback ask for additional points – to avoid repetition
Ask class to comment on each feedback given – does anyone agree or disagree

28. End of Role Play Session 1A
Next Building Session 1B
Stop here

29. ART/TB Initiation and Adherence Counseling Model
Building Session 1B
ART/TB Initiation and Adherence Counseling Model

30. Brainstorm!
What should a patient know or learn about their treatment journey? What are the most common challenges that a patients faces when learning to take their treatment?
Notes for presenter:
Encourage the group to all participate
Exercise is designed to help the class build the adherence steps included in session 1B
Encourage participation by asking:
What do you think is important to know about taking your own treatment (no matter what its for)?
Write all points on the board

31. Overview of Adherence Plan
Notes for presenter
Present the Adherence Plan sections applicable to Session 1B - My 3 reasons to stay healthy and alive & Session 1 after ART education session
Tick off each point the group raised that coincides with the topic covered in the Adherence Plan
Congratulate and thank the class for their participation - Now you have ‘built’ the Adherence Plan

32. End of Building Session 1B
Next time to Role Play Session 1B
Stop here

33. Session 1B Role Play When do we do Session 1B? What tools do you need?
Immediately after 1A
What tools do you need?
Adherence Plan, guide
Introduction (intro facilitator, explain objectives, confidentiality)
Work through session with your partner (each person has a turn at being the counselor)
Use your manual -READ, READ, READ !!
Notes for presenter:
60 minutes – 5mins for instructions, 40mins for role play, 15mins for feedback and discussion on Session1B
Same as with Session 1A role paly
Tools: Adherence plan, counselor session guide
Role play working through the session
Encourage the class to simply read the manual at this stage – do not go “off script” – familiarize yourself with the manual 1st, once you know it, you can then improvise.

34. End of Role Play Session 1B
Next Session 1C Discussion
Stop here

35. Session 1C
How soon after patient says ‘they are not ready to start ART’ do we do Session 1C?
Immediately
Why do we need session 1C?
Give the patients time and space to share the reasons why they are not ready to start treatment
Allows us to better understand their reasons for non-readiness
Notes for presenter:
Explain that Session 1C is for patients that say they are not ready to start ART
Give 1-2 mins for students to offer answers to the questions before presenting them
Main points to stress:
Never allow the patient to leave after they say they are not ready – go immediately into session 1C
If after the session they say they still need time to decide, try to fix an appointment for them to come to you again

36. Session 1C How do we do this? Allow the patient to share
Give a listening ear to the patient
Share other patients stories (testimonies) of having overcome barriers to starting treatment
Work together to make a plan to overcome their reasons for non-readiness
Notes for presenter:
Encourage discussion around each of these points
Ask class:
do you agree or disagree
Can you give examples of how you would do this

37. Session 1C GROUP or INDIVIDUAL : why?
Tools: session guide, testimonies,
Overview of session:
Invite the patient to share why they don’t feel ready
Choose the testimony that best fits their needs/reasons
Read the testimony
Discuss the way forward to overcoming these reasons
Notes for presenter:
Discuss the reasons for individual or group sessions:
if you put two or more people in a group they often have compatible traits (same reasons for non readiness, age, gender, language etc.).
commonalities help people share openly

38. Day 1 complete!

39. Welcome to Day 2

40. Recap of Day 1 How many sessions are in the model?
What is the order of the sessions?
Name 4 adherence steps
What are the ABCs of Adherence?
Name tools!

41. Recap of Day 1 ART/ TB Treatment Counseling Model contains:
Sessions: 4 sessions
1 education session, 1 day initiation, 2 post initiation follow-up
Tools: flipchart (2), counselor session guide, adherence plan
Approach: patient-centered, supportive, address the common adherence challenges, focus on reasons to be healthy and alive
ABCs of Adherence: Goals, Barriers, Plans

42. ART/TB Initiation and Adherence Counseling Model
Building Session 2
ART/TB Initiation and Adherence Counseling Model

43. Session 2 When do we do Session 2? On the day of treatment initiation
Which tools are needed?
Session guide, Adherence Plan
Review all content covered in: Adherence Steps 5-9
Medication schedule
Managing missed doses
Reminder strategies
Storing medication
Dealing with side effects
Notes for presenter:
60min Exercise
Take class through the content of Session 2 as detailed in the Counseling Manual – Read out the steps
Emphasize use of Adherence ABCs (Goal, Barriers, Plan) in each step
Update the counselors on new information
Medication schedule – if taking BD meds, the duration between the doses doesn’t have to be 12hrs – can simply pick morning and evening times that suit your schedule best
Managing missed doses: regardless of when you remember – take your treatment, why? Its about having enough ARVs in your body to prevent multiplication of virus – no calculation of hours needed
Reminders strategies: do the activity, ask counselors where would THEY put the stickers to remind them – (stickers can be replaced by a piece of fabric or any item readily available in your setting)
Storing medication – plan for energencies
Dealing with side effects: important thing to remember is, communicate with your treatment team at facility, DON’T stop your treatment

44. Session 2 Role Play Introducing Observation and Feedback (discussion)
In groups of 3 role-play the session:
1 counselor
1 patient
1 observer
Observer asks counselor: how did the session go? What went well, what could improve?
Observer report back: give your own feedback, make goals with the counselor to work on progress.
90 minutes
5mins for instructions
60mins for role play (each student gets 30mins)
20mins for feedback and discussion on Session 2 (10 mins after each round out role play)
Instruction to the class:
Go into pairs (different from pairs used in day 1)
Tools you will need to complete this session: Counseling manual and Adherence Plan – ideally use same adherence plan as you used in day 1
Turn to the page in your counseling manual with the detailed session plan for session 2
Each person should get a chance to be the counselor with session 2 lasting 25mins
Role Play:
Facilitators go round the room to answer queries and check teams are progressing
Feedback session:
Ask each group in turn to share what they found helpful/not with Session 2
As you move from group to group for feedback ask for additional points – to avoid repetition
Ask class to comment on each feedback given – does anyone agree or disagree
Discuss the value of feedback and its importance for counselor professional development and quality assurance in counseling

45. End of Role Play Session 2
Next Building Session 3
Stop here

46. Session 3 When is session 3 completed? Which tools are used?
First adherence follow-up appt.
Which tools are used?
Session guide, Adherence Plan
Content covered in: Adherence Steps 10-12
Planning for trips
Dealing with substance use
Communicating with Treatment Team
Notes for presenter:
60min exercise
Take class through the content of Session 3 as detailed in the Counseling Manual – Read out the steps
Point out use of Adherence ABCs (Goal, Barriers, Plan) in each step
Main points to stress:
Planning for trips: planned and unplanned travel. You (patient) can prepare to ensure you remain on treatment while travelling
Dealing with substance use: remember the difference between substance USE and substance ABUSE. We are talking about USE – there is no interaction between alcohol and ARVs, the issue is about remembering to take your treatment and to making a plan to ensure you take your treatment when you plan on using substances. BUT if you asses the patient to have a problem or suspect ABUSE, seek out resources to available in your setting to support these patients - refer and talk to clinicians at facility
Communicating with team: we want to enable the patients to ask anyone in their treatment team the questions they have

47. Session 3 Role play Go into pairs Different pairs from those in Day 1
Each person should get a chance to be the counselor – Session 3 lasts approx. 20mins
90 minutes
5mins for instructions
60mins for role play (each student gets 30mins)
20mins for feedback and discussion on Session 3 (10 mins after each round out role play)
Instruction to the class:
Go into pairs (different from pairs used in day 1)
Tools you will need to complete this session: Counseling manual and Adherence Plan – ideally use same adherence plan as you used for Session 2
Turn to the page in your counseling manual with the detailed session plan for session 3
Each person should get a chance to be the counselor with session 2 lasting 20mins
Role Play:
Facilitators go round the room to answer queries and check teams are progressing
Feedback session:
Ask each group in turn to share what they found helpful/not with Session 3
As you move from group to group for feedback ask for additional points – to avoid repetition
Ask class to comment on each feedback given – does anyone agree or disagree

48. Day 2 Feedback
What are your overall thoughts on the sessions practiced today (session 2 and 3)?
Did you like the structured session plan?
What would you do differently?
Notes for presenter:
Congratulate class for their participation so far
Now time to have an informal discussion on how they found the day
Facilitators take notes for their own learning – can be applied to adapting the course/counseling in the future

49. Day 2 complete!

50. Welcome to Day 3

51. Recap of Day 2
30mins
Open up to the class to shout out what they remember from day 2.
Write points on the white board and clarify any errors or points of confusion
Key points to recall:
Medication schedule
Managing missed doses
Reminder strategies
Storing medication
Dealing with side effects
Planning for trips
Dealing with substance use
Communicating with Treatment Team

52. Session 4 When is session 4 completed? Which tools are required?
Final adherence follow-up appt.
Which tools are required?
Session guide, Adherence Plan, Flipchart
Content covered in: Adherence Steps 13-14
Preventing any future problems with taking treatment
Education on Viral Load
Continuation Phase (TB)
Notes for presenter:
Take class through the content of Session 4 as detailed in the Counseling Manual – Read out the steps
Point out use of Adherence ABCs (Goal, Barriers, Plan) in each step
Main points to stress:
Preventing future problems: its normal to have negative feelings and thoughts when you make a mistake or forget to take your treatment, how would you work through those feelings to try again
Viral load section has accompanying pages in the ART/TB Flipchart

53. Session 4 Role play Go into pairs Different pairs from those in Day 1
Each person should get a chance to be the counselor – Session 4 lasts approx. 20mins
90 minutes
5mins for instructions
60mins for role play (each student gets 30mins)
20mins for feedback and discussion on Session 4 (10 mins after each round out role play)
Instruction to the class:
Go into pairs (different from pairs used in day 1)
Tools you will need to complete this session: Counseling manual and Adherence Plan – ideally use same adherence plan as you used for Session 2
Turn to the page in your counseling manual with the detailed session plan for session 3
Each person should get a chance to be the counselor with session 2 lasting 20mins
Role Play:
Facilitators go round the room to answer queries and check teams are progressing
Feedback session:
Ask each group in turn to share what they found helpful/not with Session 3
As you move from group to group for feedback ask for additional points – to avoid repetition
Ask class to comment on each feedback given – does anyone agree or disagree

54. Feedback
What are your overall thoughts on the sessions practiced today (session 4) ?
Did you like the structured session plan?
What would you do differently?
30mins
Congratulate class for their participation so far
Now time to have an informal discussion on how they found the day
Facilitators take notes for their own learning – can be applied to adapting the course/counseling in the future

55. Recap! How many sessions are in the model?
What is the order of the sessions?
Name 4 adherence steps
What are the ABCs of Adherence?
Name tools!

56. Recap: patient flow How are they referred to counseling
Counseling is IMPORTANT
How do patients move in your facility?
How are they referred to counseling
What can we do to make sure they come to counseling?

57. Adherence counselling Standard track
Clinical Management
Day of diagnoses
HIV testing and
counselling
CD4 count
4 to 7 days
Day of eligibility
Consultation
By MA/CO for
TB screening &
Staging
Session 1A-B-(C)
Pre-ART
3 to 7 days
Session 2:
ART initiation
Day of initiation
ART
Initiation
30 days
Session 3:
1st adherence FU
Month 1
on treatment
ARV Refill
We kept 4 sessions
The timing of the sessions is different – less pre ART prep and more post ART initiation support
We wanted to improve post initiation support
Encourage active learning while on treatment
Above diagram is an example of timing between the sessions in this model – adapt to suit your setting.
M2/M3/M4/M5
Session 4:
2nd adherence FU
Month 6
on treatment
ARV Refill
Detectable VL
Enhanced
Adherence
Counseling
Viral Load (6M)

58. Role Play Session 1 to 4 60mins
Opportunity for class members to role play on front of others and receive constructive feedback
Options for how to structure this session:
Have class split into groups of 3 – one is the observer, one is the patient, and one is the counselor. After each session is complete, the group gives feedback to the person playing the counselor role in that session.
Class members volunteer to role paly the session in front of the rest of the class. Whole class gives feedback on their session on completion.
Facilitators stage an ‘ideal counseling session’ for the class – class gives critical feedback and asks questions on completion of the session
Encourage the class to give feedback to each session by answering the following:
How do you think it went?
What was good? What was challenging?
Ways it can be improved?

59. Day 3 complete!

60. Welcome to Day 4!

61. Brainstorm! What is the most important information a pregnant patient
should learn and know about HIV?

62. Review our PMTCT Guidelines
Replace with PMTCT Guidelines for your setting as required
Review our PMTCT Guidelines

63. Key messages for PMTCT Start ART early!
Breast is still best! Exclusive breastfeeding for first 6 months
Give your baby ARVs after birth
Deliver in a health facility
Stay on ART for life to protect mom, baby and partner!

64. Questions?
Allow the class to ask questions – clarify points of confusion