COUNSELING IN HIV/AIDS MANAGEMENT IN UGANDA

COUNSELING IN HIV/AIDS MANAGEMENT

1. Counselling in hiv /aids management BY MUTEGEKI ADOLF

2. COUNSELING IN HIV MANAGEMENT Counseling plays a crucial role in HIV prevention, treatment, and care . It helps individuals cope with their diagnosis, adhere to treatment, make informed decisions, and live positively . HIV counseling should be confidential, client-centered, and supportive to promote emotional well-being and behavior change.

3. Types of HIV Counseling A. Pre-Test Counseling 🔹 Provides information before an HIV test to prepare individuals emotionally. 🔹 Explains testing process, meaning of results, and possible next steps . 🔹 Discusses risk factors, prevention strategies, and confidentiality . B . Post-Test Counseling 🔹 Helps individuals understand their results (HIV-positive or HIV-negative). 🔹 For HIV-positive individuals , it provides emotional support, linkage to care, and treatment initiation . 🔹 For HIV-negative individuals , it emphasizes risk reduction strategies ( PrEP , condoms, safe sex, etc.) .

4. C. Adherence Counseling 🔹 Encourages consistent ART use to suppress the virus and prevent resistance. 🔹 Educates on the importance of viral load monitoring . 🔹 Identifies barriers to adherence (stigma, side effects, forgetfulness) and provides solutions. D . Disclosure Counseling 🔹 Helps individuals disclose their status to partners, family, or caregivers . 🔹 Guides on safe disclosure to reduce stigma and violence risks. 🔹 Encourages partner testing and family support .

5. E. Psychosocial Support Counseling 🔹 Addresses mental health challenges (depression, anxiety, stigma). 🔹 Promotes positive living strategies for emotional resilience. 🔹 Provides referrals to peer support groups and mental health professionals . F . Sexual and Reproductive Health Counseling 🔹 Helps PLHIV make informed family planning decisions . 🔹 Supports safe conception options for HIV-positive couples . 🔹 Educates on STI prevention and dual protection (condoms + contraception) .

6. G. Prevention Counseling 🔹 Educates on risk reduction (condoms, PrEP , PEP, safe injection practices) . 🔹 Encourages safe sex, reducing multiple sexual partners, and avoiding risky behaviors . 🔹 Promotes PMTCT services for pregnant women . H . Couple and Family Counseling 🔹 Strengthens communication between partners and family members . 🔹 Supports discordant couples (one partner HIV-positive, the other negative) . 🔹 Helps families understand and support loved ones living with HIV .

7. I. Intensive Adherence Counseling (IAC) Intensive Adherence Counseling (IAC) is a structured approach used to support people living with HIV (PLHIV) who have High viral loads despite being on antiretroviral therapy (ART) . The goal of IAC is to identify adherence barriers, provide tailored support, and help clients achieve viral suppression .

8. Importance of HIV Counseling Reduces fear and anxiety associated with HIV testing and diagnosis. Encourages ART adherence , preventing drug resistance and improving health. Reduces stigma and discrimination , promoting social support. Helps individuals make informed decisions about disclosure and relationships. Supports mental health and emotional well-being . Prevents new HIV infections through education and behavior change.

9. Who should provide counseling ( PSS ) 14 1 Multidisciplinary Team PSS service provision to PLHIV Pharmacist Counselor/ Social worker Family / Friends Clini c i a n/ Doctor Expert Clients Nurse/ mid w i v es CHWs Supp o rt groups Medical social worker/counselor should take lead in coordinating PSS services at facility level 9 PHO

10. Service package for children <10years 14 2 Common issues PSS Service Package Non-adherence N o n - di s clo s ure Loss and bereavement Stigma and di sc ri m in ation Screening for PSS issues Encourage supported age-appropriate HIV serostatus disclosure HIV Testing Services. Treatment education for caretaker Adherence support Bereavement counselling through play therapy Screen and manage child abuse including; violence and sexual abuse e.g PEP Referral and linkage to education, nutrition and legal support OVC Assessment 10

11. Screening for psychosocial issues among adolescents (1) 1 48 Home Education/Eating/Exercise Activities Drugs/Depression Sexuality Suicidality/Safety (HEADSS) Home situation and family Who lives with the young person? Where? Do they have their own room? What are relationships like at home? What do parent and relatives do for a living? Ever institutionalized? Incarcerated? Recent moves? Running away? New people in home environment? Have you disclosed your HIV status? If yes, with whom? If not, what are the reasons? May use the Genogram/Family tree Education and e m p l o y m ent School/grade performance-any recent changes? Any dramatic past changes? Favourite subjects-worst subjects? (include grades) Any years repeated/classes failed, suspension, termination, dropping out? Future education/employment plans? Any current or past employment? Relations with teachers, employers-school, work attendance? 11

12. Screening for psychosocial issues among adolescents (2) 1 49 Home Education/Eating/Exercise Activities Drugs/Depression Sexuality Suicidality/Safety (HEADSS) Activities On own, with peers (what do you do for fun? where? when?) With family? Sports, regular exercise? Church attendance, clubs, projects? Hobbies, other activities? Reading for fun: what? TV: how much weekly, favourite shows? Favourite music? Does young person have car, use seat belts? History of arrests, acting out, crime? Drugs Use by peers? Use by young person? (include tobacco, alcohol) Use by family members? (include tobacco, alcohol) Amounts, frequency, patterns of use/abuse, and car use while intoxicated? Source: how paid for? 12

13. Screening for psychosocial issues among adolescents (3) Home Education/Eating/Exercise Activities Drugs/Depression Sexuality Suicidality/Safety (HEADSS) Sexuality Experience with sex Number of partners? Degree and types of sexual experience and acts? Masturbation? (normalize) History of pregnancy/abortion? Sexually transmitted diseases: knowledge and prevention? Contraception? Frequency of use? Comfort with sexual activity, enjoyment/pleasure obtained? History of sexual/physical abuse? Suicide and Depression Use SRQ-20 and sad person scale screening tool 1 50 This is aimed at screening clients for possible depressive disorders. Health workers should screen all clients at every visit. Clients found to be eligible for further assessment should be referred for psychiatry services. Use: The PHQ-2 is not to establish a final diagnosis or to monitor depression severity, but rather to screen for depression as a “first-step” approach. 13

14. Key messages during pre-ART adherence counseling (3) Questions Answers Why should I start ART when I don’t feel sick? HIV causes harm inside the body even when it is not seen on the outside. It destroys cells that help the body fight diseases. Eventually one may start falling sick often Taking ARVs early, reduces the amount of HIV in the blood allowing the body to fight diseases better, prevent TB, heart disease, HIV-related cancer and other infections that may occur if immunity is low Improved health will permit continued economic activity, continued school attendance and fewer hospital visits Children and adolescents will not fall sick often, will grow and develop well ARVs (used together with other prevention methods e.g condoms) will significantly reduce the chances of transmitting HIV among sexually active adults and adolescents ARVs given to pregnant women will reduce the chances of transmitting HIV to their babies Benefits of adhering to ARVs Suppresses the multiplication of the virus in your body The CD4 count will increase, and you will be protected from other illnesses Reduces the risk of developing ARV drug resistance The risk of transmitting HIV to your HIV-uninfected sexual partners may be reduced Reduces the risk of infecting your born or unborn baby Children and adolescents remain healthy, grow and develop better C o n se qu e n c es of not adhering to ARVs The virus will multiply in the body and continue to destroy the immune system CD4 count will decrease, increasing the risk for opportunistic infections and development of more severe disease The virus in the body may also become resistant to ARVs The options for treatment may become limited and require more costly ARVs for treatment which may not be readily available in the country Lower productivity resulting in loss of economic activity May develop life-threatening conditions of AIDS which can lead to death Increased chances that pregnant and breastfeeding women will transmit HIV to their born and unborn babies 15 6 14

15. 5As for adherence preparation support (1) Guide Components Assess Knowledge, myths and misconceptions about HIV and ARVs Potential barriers to adherence Patient psychosocial concerns and needs that may hinder adherence to ART Patient readiness, willingness and commitment to take medicines correctly and attend appointments for treatment support Patient’s support systems at family and community level Disclosure status and implications Advise (i n for ma ti o n giving) Give information about HIV and ARVs improved quality of life while on ART. Provide information on adherence to ART (The 5 Rs) Demonstrate how the ARVs are taken Provide information about side effects of ARVs Explain the benefits of disclosure and support systems to adherence Explain how treatment will be monitored Emphasize the importance of attending clinic appointments for review and support Discuss the Positive Health, Dignity, and Prevention package Explain the implication of not adhering to ARV treatment Explain what VL test is and the meaning of suppressed and unsuppressed viral load 15 7 15

16. 5As for adherence preparation support (2) G u i de Components Assist the client to Evaluate possible barriers to adherence and how to overcome them Identify systems that will support ART adherence and clinic attendance (e.g support groups) Disclose to a trusted person/people Develop an individual adherence plan Document the agreed-upon options on the ART card Agree on An adherence plan Family and community support systems (e.g expert client in the community) Possible home visits and consent Possibility of testing of other family members including sexual partner and children Assess client’s readiness to start ART Arrange for  Clinician review for ARV prescription if they are ready to start ART Follow-up adherence counseling and psychosocial support sessions At one month for patients who have initiated ART At agreed time but probably a week for those who were not ready for ART at the initial visit Enrolment with PSS groups Follow-up appointments (home visiting where appropriate, phone call reminders and text messages where appropriate) Counselling sessions for drug adherence Review of action plans at every encounter HIV testing of other family members Supported disclosure where it has not happened 158 16

17. 5As Psychosocial and Counseling Framework 15 3 17

18. Adherence Counseling Adherence counseling is crucial in ensuring that people living with HIV (PLHIV) take their antiretroviral therapy (ART) correctly and consistently . Proper adherence leads to viral suppression, reduced transmission, and improved health outcomes .

19. Importance of Adherence Counseling Prevents HIV progression by keeping the virus under control. Reduces the risk of drug resistance , ensuring ART remains effective. Improves quality of life and prevents opportunistic infections. Reduces the risk of HIV transmission (U=U: Undetectable = Untransmittable ). Ensures long-term treatment success , preventing treatment failure

20. Monitoring adherence to ART 16 2 Determining adherence levels from self-report and pill count and recommended action Missed doses per months Percent a dher e nce A d h er e nce ranking Recommended Action Once daily dosing Twice daily dosing <2 doses ≤ 2 doses ≥95% Good Review adherence plan Support to continue adhering well. 2-4 doses 4-8 doses 85–94% Average Address the causes of average/poor adherence Review adherence plan ≥5 doses ≥9 doses <85% Poor Note: Adherence >105% could imply potential drug sharing or other inconsistencies in dosing and should be investigated. Question guide for reviewing an adherence plan Question 1. How many times do you take drugs in a day? 2. What time do you take it? 3. How many doses have you missed in the past month? 4. What are the reasons for missing your drugs? 20

21. Providing Intensive Adherence Counseling and support (IAC) to clients with non-suppressing viral load (VL) 16 3 Definition of IAC : Intensive adherence counseling (IAC) refers to a targeted structured counseling and support intervention offered to patients with a non-suppressed viral load (patients with viral load >1000 copies/ml). IAC is offered systematically and routinely as per scheduled appointments. Multi-Disciplinary IAC Team Adherence messaging to NS client Su p p o rt groups Pharmacist Counsellor Social worker Family / Friends Clinician Expert Cli e nts Nurse/ mi d w i v es 21 Public health officer

22. IAC Flow Chart for VL non-suppressed clients 16 4 Prepare Client for Repeat VL test & Link to Lab for bleeding Conduct First IAC Session when client presents to the facility (Record Adherence score and consider as baseline) Conduct Third IAC Session Assess and record adherence score for 2 ND IAC Conduct Second IAC Session Assess and record adherence score for 1st IAC Continue IAC until 3 consistent sessions of >95% Adherence are recorded (Focus on addressing adherence barriers) VIRAL LOAD >200 Copies/ml PLASMA OR >400 Copies/ml DBS ( N O N S U PP R E SS E D ) Recall Client Immediately (within 1 week) Client not suppressing? Prepare client for 2 nd or 3 rd line Rx; whichever applies Month 1 Month 2 Client suppressing? Continue routine adherence counseling Assess and record adherence for 3rd IAC session Client at >95% (Good) adherence at 3 consecutive IAC sessions 2 wks NO YES Month 3 Visit 1 Visit 2 Visit 3 Visit 4 22

23. Conducting IAC session (1) 16 5 Task Step What to do Assess Explain purpose of session Disclose VL test results to client and explain the meaning of suppressed and non-suppressed VL Explain reasons for non-suppressed VL results (non- adherence to drugs or drugs may not be working well) Discuss implications of non-suppressed results to the client Determine adherence levels Calculate the adherence score using the adherence percentage formula. Assess client’s barriers to adherence Use the adherence assessment checklist to ascertain client’s adherence practices. Identify barriers to client’s adherence (arising from the assessment) Advise Identify information gaps from assessment Educate client in relation to specific barriers identified 23

24. Conducting the 1 st IAC session (2) 16 6 Task Step What to do Advise Review benefits of good adherence Assess client’s knowledge of benefits Provide correct and complete information Discuss consequences of non-adherence Assess clients knowledge on the dangers of non-adherence Educate client on the consequences of non- adherence Assist Evaluate the underlying causes of the identified barriers Prioritize the barriers Identify possible root causes of each barrier (where applicable) Identify client specific strategies to overcome identified barriers Discuss possible options to address key barriers Provide information about available support systems e.g. CBOs, peer support groups etc Discuss the pros and cons of each strategy/option 24

25. Conducting the 1 st IAC session (3) 16 7 Task Steps What to do Agree Agree on client’s action points to address the key barriers Identify appropriate strategies Provide relevant and necessary information Evaluate each action point using the 5 Ws and 1H What , where, when, who, which , how? Document agreed upon action points on the IAC session form Develop and document a new adherence plan on the IAC session form Arrange Summarize the session Review the action points Review the new adherence plan Arrange for ART refill Explain the schedule for IAC intervention Explain the number of sessions Emphasize appointment keeping Schedule the 2 nd IAC session Document the next appointment date on the IAC session form Remind client to bring remaining pills at next visit Refer and link to other services as appropriate 25