CASE STUDY ON HOW ART INITIATION AND FOLLOW UP OF A CLIENT.

INTRODUCTION
Jane Kainda (not her real name)is a middle aged lady 33 years,
separated and lives at matundu village, kiamucii, sub location, gitareni
location, meru south district, Kenya. She has been married but
separated one month ago. She is a mother of 3year old son. The son
lives with her at her parents home. The father is her next of kin and
her sister in law is her treatment buddy.
Before initiation of ART the health worker visited her home twice to
prepare the patient psychological for readiness and also assess the
social support. The patient was psychologically ready to start ART and
the husband was mason. The health worker discussed on th need for
complete adherence to medication for maximal viral suppression and
also the need for more disclosure to a person who will be within during
the day when the husband work.
The husband said there was no need as he is constructing in the
neighborhood. He promised to be supportive in ensuring the patient
has taken drugs.
Adherence plan was discussed where the patient suggested that she
will be keeping drugs near the matchbox so that when she wakes up
she will remember to take drugs. The husband said he will be
reminding her to take drugs.
Refusal of the couple to disclose her status to other family members
was a barrier to adherence as the husband may not be around due to
work.
The laboratory investigation were done in October 2010 where by the
CD4 count was132 cells/ul; it assesses the body’s immune functions.
Creatinine levels were 95.7uoml/l which checks the kidney function. It
was within the normal limit (40.0-97 umol/l). the ALAT GPTF.S was 17.7
u/l which test the liver function and was within the normal limit (0.0-
34.0 ul). The total blood count was not done which was a challenge.
The CD4 count of 132 cells/ul makes the patient eligible for ART
according to national guideline on ART 2010 which says all patients
with a CD4 count less than 350 cells/ul are eligible for ARV.
The patient was diagnosed HIV positive on 24.4.2010 while in the
ward with tuberclosis. She was treated and discharged through the ccc
where she was enrolled forcare on 5/5/2010 patient was started on
adherence counseling and cotrimaxole prophylaxis. The patient has
been having an unstable relationship with her husband who tested HIV
negative on 5/5/2010. she has separated twice with the husband but
before ART initiation she was at her husbands home. The CD4 count
was not done until October and the patient was not initiated on
ART.the patient says she was told to wait until she finishes the anti-tb
drugs contraly to the WHO staging eligibility criteria which put all the
T.B patients in stage 3 and eligible for ART.
Initiation of ART
The patient was initiated on ART on 17/11/2010 after 6 sessions of
adherence counseling. She was put of INNRTI and 2NRTI’s. that is tabs
zidovudine 300mgs and tabs lamivudine 150mgs (fixeddose
combination) twice daily for two weeks and tabs nevirapine 200mgs
once daily for two weeks.
The patient was started on ART according to the national guidelines on
ART whereby the CD4 count is supposed to be < 350 cells/ul and was
132 cells/ul. The WHO staging eligibility is supposed to be stage 3 and
4 and the patient was is stage 3.
The patients general condition was deteriorating with the development
of boils despite taking cotrimaxole prophylaxis . the haemoglobin level
was not done. The patient was assessed clinically and noted was not
pale and ART was initiated. the clinical assessment is not accurate
hence the problem with monitoring the development of haematological
deficits after using zidovudine. The health worker had to weigh the
benefits of ART initiation versus delayment awaiting haemoglobin
results. The patient was referred to district hospital for HB check.

Adherence counseling was done prior to initiation of ART during clinic

days and also during home visits where assessments of patient
readiness, knowledge of HIV/AIDS and ARV, family support, and
preparing treatment buddy in his roles as done.
During initiation adherence counseling was revised where by the
patient was reminded of the benefits of adherence, dangers of non
adherence, drugs and dosages and time to take. Adherence plan was
revised whereby the patient planned to take drugs at 7am and 7 pm
and will keep the drugs near the matchbox for easy remembrance.
The drugs side effects were revised where by the patient was advised
to report the health facility in case of any side effect or reaction and
never to stop the drugs. The patient was also informed that she should
not take any herbal medicine together with the ARV drugs before
consulting the health worker .
After initiation adherence was assessed in the consecutive home visits
where by the health worker reminded the treatment buddy of her roles
and also helped in counting the remaining tablets. The health worker
guided the family towards care and support, physically, socially,
psychologically, and spiritually. This support enabled the patient to
cope with the stress about the illness and also adhere to the drugs.

Follow up visits.
The health observed that there was poor family support secondary to
none disclosure on the patients HIV status to the other family
members apart from the husband. This was handled through health
education on the importance of family support in HIV care and
management.
The patient was separated from the husband and went to her parents.
In this new family the patient had disclosed her status to the father
and sister in law. There was good family support nevertheless
disclosure was not done to the brothers because the patient feared to
be neglected.
The health worker visited the husband to the patient and discussed the
need for a repeat HIV test. The patient said he feared to be tested as
sometimes he forgot to use condoms. The health worker discussed on
discondancy, benefits of HIV test, disadvantages of not being tested in
relation to destruction of the immune system by the virus and later
developing AIDS. The patient understood the need but said he needed
the time to think about it.
The patient developed a mild rash due to nevirapine and the health
worker encouraged the patient to wait them out. The rash cleared after
3 weeks. The patient was initially disturbed by the rash over the face
but after reassurance she relaxed.
The patient was unable to perform household chores with the spouse
not understanding the reason. It is paramount to share knowledge on
HIV/AIDS especially on the effects and demands for better family
support, nevertheless issues of discondancy is not clear to the victims
despite trying to explain.
In the patient’s current home there was no issue with the inability to
performs household chores as the father and sister in law knew the
status and received education on HIV, prevention and management,
the effects of ARV and improvement of patient’s immune system with
good adherence.
The patients needs were listened to and handled well by the family
health team i.e. providing funds for transport to the health facility, to
the church of choice and also to open an IGA.
The patient had issues with adherence whereby she delayed taking the
ARV tablets by 2 hours. The health worker repeatedly reminded the
treatment of her roles and shared with the family on the dangers of
non adherence in relation to poor improvement of the patient health
status leading to the unproductively, suffering and dependency.

Documentation:
Confidentiality is maintained by storing the patients records in the
cabinet. Counseling notes