The National Operational and ServiceDelivery manual (OSDM) states that “AllHIV-positive clients, regardless of WHOClinical Stage or CD4 count, are eligibleto start ART. ART should be initiated assoon as possible after assessing clinicaland psychosocial readiness”. Yet, manyhealth care workers express concernsabout starting clients - in particularrelatively ‘healthy clients’ - citing issueswith adherence, patient readiness, andmobility.

HIV Treatment will only improve thehealth and well-being of people livingwith HIV (PLHIV) if they are successfullyprepared to adhere to treatment andretain in HIV care.

ART counselling prior to ART initiationand health care worker evaluation of aclient’s readiness to adhere to treatmentare the foundation of successfultreatment outcomes.

ART Counselling and Patient Preparedness

This tool provides tips on how ART counselling can be optimized to support clientpreparedness for HIV treatment.

1. Always provide quality pre- and post-test counselling.

2. Link clients immediately to care, treatment and support programs.

3. Support client readiness before ART initiation.

4. Emphasize importance of adherence and retention in care for treatment success atevery visit.

5. Provide enhanced adherence counselling to clients who have detectable viral load.

Adequately prepare clients for ARTinitiation, adherence and retention

Tool 5

“Getting into care and on treatment has helped us learn more aboutHIV and how to live well with the virus. This has not only helped uslive longer but gave us an opportunity to live a healthier life.” –Ishamael and Patricia Mupesa

1. Always provide quality pre- and post-testcounselling

It can be a shock for a client to find out that they are HIVpositive. Newly diagnosed HIV-positive clients will havemany questions and experience diverse emotions. Thesupport, counselling and written information providedimmediately after a diagnosis is critical for preparing theclient to adhere to treatment.

Quality pre- and post-test counselling is a key for supportinga client’s readiness and acceptance of their result andtreatment.

Whether the client is tested in the facility, work-place,community or at home, health care workers need to providequality counselling and available written material that followsthe principles of the 6Cs.

ART Counselling and Patient Preparedness

2. Link clients immediately to care, treatment and support programs

Receiving an HIV positive test result only benefits HIV positiveclients if they are successfully linked to HIV care, treatment andsupport. These linkages should be made as soon as the diagnosisis made.

RemembeR: Clients will react differently when they find outthey have HIV. Some will experience shock, anger, fear or sadness.Some will be alone and afraid. Recognising this, health careworkers need to build systems to retain the client from diagnosisthrough treatment and beyond.

The Treat All Learning Phase highlighted that a small proportion of clients fail to link to HIV care and treatment afterbeing diagnosed. Strong linkages between testing and treatment will ensure we ‘leave no one behind’ and reach90-90-90 goals.

To ensure linkage of all PLHIV to care, treatment and support Health Care workers should:

4 Ensure accurate, comprehensive contact details are documented (full name, address, phone number, nextof kin) - in HTS register and the Pre-ART register.

4 Ask for clients’ consent to be followed up at home (and document consent given in the HTS register).

4 Introduce the concept of a ‘treatment buddie’- someone with whom the client can discuss their status.

4 Introduce client to a clinic referral facilitator (an HIV-positive lay-counsellor within the facility). The clinicalreferral facilitator can walk (or navigate) them to treatment services and provide additional peer educationand counselling.

4 The clinic referral facilitator, as a person living with HIV, can also link them to other facility and communitybased services that provide psycho-social support.

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RemembeR: Rapid ART initiation does NOT mean reduced quality of care or reduced efforts to ensure clinical and psychosocial readiness before ART!

Guidelines and job aides provided by MOHCC are intended to assist health care workers to ensure all PLHIV receive supportive,high quality counselling.GO TO

6Cs Guiding Principles• Consent - clients should have sufficient

information to agree to be tested• Confidentiality - discussions between health

care worker and client should not be disclosedwithout permission of the client

• Counselling - all clients should receive highquality pre- and post-test counselling

• Correct and accurate test results - sites toensure testers are trained and proficientthrough internal and external quality assurance

• Connection to HIV care - linkages to prevention,treatment, care and support services need to bein place

• Comfort - testing should be offered in a spacethat is clean and comfortable for the client

ART Counselling and Patient Preparedness

3. Support client readiness before ART initiation

Treatment for HIV is a life-long commitment. HIV Treatment will onlyimprove the health and well-being of people living with HIV (PLHIV), if theyare successfully prepared to take their ARVs as prescribed- at the right time,in the right amount (adherence) for life, and stay in HIV care (retention).

Research evidence indicates individual-level factors leading to poor ART adherence include a poor understanding ofHIV and ART; and difficulty managing practical demands of ART. Psychological factors such as adherence self-efficacyand beliefs/concerns about ART are being increasingly demonstrated to be critical for ART adherence. Good clientpreparedness should address all of these factors.

With Treat All, ART initiation should be done as soon as possible following an HIV positive test result. Assessmentsconducted during the Treat All learning phase demonstrated a great deal of variability in the amount, content anddocumentation of counselling received by clients prior to ART initiation. Health care workers need to determine individual patient readiness for ART based on the following factors:

4 Understanding of HIV (transmission, effect on the body if untreated)

4 How HIV treatment works in the body (increase CD4, decrease VL)

4 Belief in treatment efficacy and possible side effects

4 Importance of starting treatment early and staying on treatment for life

4 Myths and misconceptions about efficacy and safety of ART

4 Emotional readiness to accept their diagnosis and adhere to treatment

4 Disclosure and social support available

4 Vulnerabilities (poverty, gender based violence, cross-border work,stigma and discrimination, depression, use of harmful substances) thatmight act as barriers to treatment adherence and problem solving howto overcome barriers.

4 Patient preparedness therefore requires patient and family-centred careand patient-provided trust and rapport.

4. emphasize importance of adherence and retention in care for treatment successat every visit

The goal of HIV Treatment is to achieve sustained viral suppression.The third 90 aims to have 90% of all those on treatment to be virallysupressed.

Sustained adherence to first line ART regimens is a patient’s best chanceto avoid development of resistance and experience treatment failure.

Health care workers should be

committed to creating a supportive and nonjudgmental

atmosphere. Building rapport and taking time

to listen, facilitates honesty and trust

between patients and providers. Patients

should feel free to ask questions and talk openly about their

concerns.

“Being HIV-positive does not stop you living a full and healthy life. With the right treatment and care, you canexpect to live just as long as someone who does not have HIV”.

The Ministry of Health and Child Care, AIDS & TB Program, provides clear and detailedguidance on the minimum package for preparing individuals for ART in Section 2.3Differentiated ART Initiation of the Operational Service Delivery manual for thePrevention Care and Treatment of HIV in Zimbabwe (OSDM Manual).

Supporting patient readiness is more than just going through a counselling checklist.Health care workers need to determine individual patient readiness for ART, andsupport the client to plan for a lifetime on treatment.

GO TO

How do we define

‘treatment success’?

SUSTAINED VIRALSUPPRESSION

5. Provide enhanced adherence counselling to clients who have detectable viralload

MOHCC and implementing partners are rapidly increasing access to viralload monitoring.

Evidence suggests that receiving adherence counselling alone is not apredictor for viral suppression. However, targeted adherence supportsuch as enhanced adherence counselling for clients with detectableviral load has been shown to be effective for achieving suppression atnext VL test. Viral load monitoring is an opportunity to provideenhanced counselling and support to clients for ongoing preparednessto problem solve barriers to maintaining retention and adherence.

4 All clients should receive VL monitoring in accordance withMOHCC guidelines on monitoring patients on ART.

4 Clients with high viral load should be supported with enhanced Adherence Counselling. The counsellingsessions should be well documented.

ART Counselling and Patient Preparedness

CHAPTeR 8: monitoring Patients on Antiretroviral Therapy in the 2016 Guidelines for Antiretroviral Therapy for the Preventionand Treatment of HIV in Zimbabwe and Section 2.6 Differentiated ART delivery for clients with high viral load in the OSDM forMOHCC guidance on how to provide care to clients with high viral load in line with MOHCC guidance.

Tool 8: Viral Load monitoring for tips for optimizing viral load monitoring. To accompany these tools, VL monitoring job aideshave been created.

During ART Initiation Counselling and Patient Preparedness activities it should be emphasized that the ultimate goalof HIV treatment is to achieve viral suppression. The only way this goal can be achieved is through adherence toART and retention in HIV care.

Treatment success is co-produced between health care workers and clients:

l Clients must adhere to treatment, attend HIV care appointments, and lead a healthy, positive lifestyle tokeep their immune system strong.

l Health care workers must provide accurate, easy to understand information about adherence and retention,and ensure timely viral load testing to monitor clinical success. Health care workers must involve clients intheir treatment process to enhance adherence.

l Community and family support are required to assist PLHIV to adhere to ART and be retained in care.

Good quality counselling will seek to problem-solve barriers to adherence and retention before they occur.

GO TO

GO TO

Tool 7: Adherence and Retention and Tool 8: Viral Load monitoring for more tips to optimize support provided to clients to adhereto treatment, retain in care and meet the goal of viral suppression.GO TO

What is enhanced Adherence Counselling?

Intensive sessions given to patients withunsuppressed viral load (which may bedue to suspected treatment failure) to:

Identify possible causes and addressadherence related issues before makingthe decision to switch the patients to2nd line.

RemembeR: Lifelong HIV treatment means that clients will experience life changing social, emotional andphysical events that may influence their ability to adhere to treatment. Viral load monitoring is an effective startingpoint for additional adherence counselling and providing compassionate patient-centred care.

Acknowledgements: We gratefully acknowledgesupport from the President’s Emergency Plan forAIDS Relief (PEPFAR) through USAID to Families andCommunities for Elimination of HIV in Zimbabwe(AID-613-A-12-00003, FACE HIV)

For more information contact:Organization for Public Health Interventionsand Development20 Cork Road, Belgravia, Harare, Zimbabwewww.ophid.co.zw/