MODULE 5

ADHERENCE COUNSELING

GOAL
The goal of this module is to equip health
care providers with Adherence counseling
skills in HIV care and treatment

OBJECTIVES
At the end of this module, the participants will be able to:
1.
2.
3.
4.
5.
6.
7.
8.

Outline the Psychological issues experienced by

people infected and affected by HIV
Explain the initial assessment of the patient
Perform step by step preparation for starting ARVs
Describe Ongoing Counseling
Describe key concepts in Adherence and Medication
Use Counseling for ART
Describe the importance of disclosure
HIV Prevention (Prevention With Positives)
Explain Adherence counseling in special groups e.g.
Prisoners, IDPs/Refugees.

UNIT 1
PSYCHO-SOCIAL ISSUES
EXPERIENCED BY PEOPLE
INFECTED AND AFFECTED BY
HIV

Psycho-social Issues
Loss and grief reactions
Stigma and discrimination
Psychiatric manifestations
Social issues (poverty)

Loss
Loss : can be due to death of a loved one,
separation, divorce, natural disaster,
miscarriage, loss of a job, deprivation.
HIV brings grief around a variety of losses
like Health, relationships, Sex, Future,
Certainty, Life, Jobs, Family, Self image
Independence, etc

GRIEF
Grief is the deepest human emotion
which is manifested in intense sorrow due
to loss causing suffering.
Types of grief: anticipatory, reactionary,
delayed, aborted and morbid grief
Grief-internal questioning. Making sense
of what has happened. It is a normal
human response to loss. It is not a form
of weakness, or lack of faith.

Stigma and Discrimination

Stigma is a spoilt identity
It is a label that separate other from me or
us
Sees others as inferior because of an attribute
they possess
Stigma is an unfavorable belief or attitude
towards someone or something
Discrimination is treating someone differently
and may involve denial of right and
opportunities

Psychiatric manifestations

Anxiety
Hopelessness
Depression
Denial/guilt
Suicidal ideations
Stress
Self hate
Fear of the future

Social issues

Poverty
Lack of social support
Loss of employment
Isolation
Breakdown of the family system
Disclosure
School dropouts
Increase of street families

UNIT 2
INITIAL ASSESSMENT

Why assess the patient?

HAART is a complex treatment to be taken
life-long
We need to know: Does the patient understand his/her disease?
Is the patient ready to make a commitment to
a life-long treatment?
What are some of the problems the patient
may have that will prevent him/her taking
medications regularly?

Initial assessment of a patient (1)

1. Learning about the patients health
status
Detailed medical history includes:
Past illnesses OIs, hospitalizations
Mental health depression, dementia
Substance abuse alcohol , drugs
Other medications prior use of ART,
experience with adherence

Initial assessment of a patient (2)

2. Learning about the patients
beliefs and attitudes about HIV
infection and treatment.
What does the patient think about:
Effectiveness of HAART
Commitment to treatment
Perceptions about seriousness of
his/her illness
Continuing preventive and protective
behavior

Initial assessment of a patient (3)

3. Learning about the sources of social
support
Lives with family / lives alone
Support from family and friends
Support from outside the family NGOs,
church, workplace etc.
Disclosure of his/her HIV status

Initial assessment of a patient(4)

4. Learning about socio-economic status

Employment and income

Dependants
Migrant status and home district

UNIT 3
STEP BY STEP PREPARATION
FOR ARVs

Patient preparation (1)

Requires at least 2 sessions with
the patient prior to starting HAART

Sets the ground for better

adherence long-term
Ongoing process with a two-way
exchange between patient and
provider

Patient preparation (2)

Components
Establishing trust between patient and
provider
Introduction to the treatment and adherence
program

Patient preparation (3)

Discussion about:
Patients present health status
Past experience with ART and adherence
Expected changes in physical well being
and biological markers with ART
Importance of adherence

Patient preparation (4)

Discussion about:
Patients living conditions
Patients daily routine

Understanding of patients beliefs and

attitudes HIV disease, ART, preventive behaviour
Identification of potential barriers & ways to
address them

Patient preparation (5)

Making a treatment plan
Treatment regimen
Follow-up plan
Integrating treatment into patients daily
routine
Discussion on adherence strategy
E.g. Directly Administered ART (DAART)

Assessment of patient readiness

Before starting ART
Patient should demonstrate an understanding of
his/her disease and health status
Patient should demonstrate an understanding of
his/her treatment regimen and follow-up plan
Patient should show readiness to start
Potential barriers should have been identified and
addressed to the best possible extent
Patient should appear to be ready to start HAART
For children the caregivers should show commitment
to administer drugs to the children and involve the
children in preparation and disclosure to older
children

Adherence
is a dynamic process
Levels change over time
Influenced by multiple factors, no factor
stands alone
Requires a combination of promotion
strategies
Requires an integrated multidisciplinary
team effort

Setting the ground for adherence

First Counseling Session

Step 1: Introduction to the treatment and

adherence program
Explain layout of clinic, laboratory, pharmacy
Introduce HWs involved in care
Explain overall treatment and follow-up plan:
3 counseling sessions prior to starting ART
Monthly follow-up with physician
Monthly pharmacy refill & laboratory investigations as
required
Make the patient feel comfortable!

Step 2: Discuss patients health status

Overall health and physical condition
Disease stage and past OIs
CD4 counts and viral load
Expected changes in health and CD4 counts
with regular ART
Importance of > 95% adherence
Consequences of non-adherence

Patients health status (contd.)

Past use of ARVs / Other medications
Alcohol / drug use
Pregnancy and family planning
Protective and preventive behaviour
During the session assess:
Patients beliefs and attitudes about HIV
infection and treatment
Patients mental health

Step 3: Discuss Patients Living

Conditions and Social Support
Employment and income
Living condition housing,
Disclosure of HIV status
Social support
Dependants other HIV infected persons
Migrant status and travel
Daily routine
Household members
significant others

Step 4: Discuss treatment plan

Treatment regimen
Names and doses
Instructions on food and fluid intake / restrictions
Storage of medications
Take all doses of all medications and do not share!

Side effects discuss briefly, do not overwhelm the patient

Follow-up plan
Next two counseling sessions
Physician check up and investigations
Contact information HW and patient

Step 5: Adherence Strategy

DAART (Direct Administered ART)

Treatment Buddies
Support Group
Community Health workers

Family involvement and Pill diary for all patients

Step 6: Identify barriers to adherence

Identify potential barriers from earlier
discussion
Discuss ways to address barriers
Fix a date for the next appointment

Continued Adherence Counseling:

Second Counseling Session

Counseling Session 2
Use an approach of continuing
discussion and not an evaluation
Repeat information where necessary
Re-emphasize important issues
Use dummy pills to repeat instructions

Counseling Session 2 (contd.)

Step 1:
Review and assess patients understanding
of his/her HIV disease and health status

Step 2:
Review and assess patients understanding
and recall of treatment and follow-up plan

Counseling Session 2 (contd.)

Step 3:
Provide information on side effects
Expected side effects
How to manage them
When to seek care
How to contact health worker

Counseling Session 2 (contd.)

Step 4:
Review proposed adherence strategy

Step 5:
Review Barriers and how to address them

Step 6:
Fix a date for the next appointment

Assessment of patient readiness :

Third Counseling Session

Counseling Session 3
Step 1:

Review treatment regimen and follow plan in

detail:
Treatment regimen
Side effects and how to manage them
Follow-up plan
Adherence strategy
Contact system
Patient goals for adherence

Counseling Session 3 (contd.)

Step 2: Assess patient treatment readiness
Does the patient demonstrate an understanding
of his HIV disease and health status?
Does the patient demonstrate an understanding
of his treatment regimen and follow-up?
Does the patient appear to make a commitment
to take treatment long term?
Does the patient have a major barrier to
adherence? Has that been addressed?
Is he ready to start HAART?

Counseling Session 3 (contd.)

Step 3:
Adherence notes should guide the clinician on
patient readiness
Refer patient to the pharmacy to receive ARVs

Set appointment for next visit

UNIT 4
ONGOING ADHERENCE
COUNSELLING

Step 1: Review and assess adherence

over last month
Medications
Change in meds or doses
Dietary instructions
Storage

Adherence

Taken all doses

Taken on time
Reasons for missing dose
Complete pill count and self report

Difficulties or side effects experienced

Assess Adherence
Adherence from pill counts:
# pills taken

X 100 = % Adherence

# pills should have taken

Adherence from self report:

% Adherence over last 4 days =
# doses should have taken # missed doses X 100
# doses should have taken

 Challenges:

Barriers change over time

Multiple factors influence adherence at any
time
Adherence changes over time

Although counseling needs change over

time, the approach remains the same !

Away from home

Forgot/ Busy

Felt ill

Ran out of pills

Felt better

Reasons for
missing doses
Fear of side effects

Did not want

others to see

Family said no to
medications

Slept in

Side effects

Pills do not
help

Instructions not
understood

Challenges with children

Children depends on adults for their medications
Previous mediation history
Ability to swallow pills
Taste/texture
Volume of liquid
With or without foods
Refusal, fight
Intercurrent illnesses

Reasons
for
missing
doses

Barriers

Problem solving

Forgot to
take
pills

BARRIERS

WHAT WE CAN DO

Traveling
Busy

Collect meds in
advance
Carry meds with
them
Use reminder cues

Alcohol / drugs
Depression/
psychiatric illness
Living alone

Enlist family support

Address addiction

Treat depression
Enlist family
support
Use PLHA support
groups COPE

Problem solving

Pills do not
help

Felt better so
did not
continue
__________
Did not want
others to see

(contd.)

BARRIERS

WHAT WE CAN DO?

Inadequate
knowledge

Enhance counseling

Patient attitudes
_________________
Stigma
Difficulty with
disclosure

Use literacy
materials

Involve family
members
_________________
Counseling
Support disclosure
Keep medications
with friend

Problem solving (contd.)

BARRIERS
Unable to
care for self

No employment

Living alone
AIDS dementia

WHAT WE CAN DO?

Use PLHA support groups
COPE
Income generation
activities

Food donation programs

Send CHW home
Family support

Literacy levels

Use literacy materials

Use dummy pills
Repeat instructions

Depression/
psychiatric
illness
Alcohol / drugs

Enlist family support

Treat depression and
addiction

Instructions
not
understood

Ongoing Support (contd.)

Missed appointments (sick , distance)
Send tracer CHW
Reminders, Phone call
Change to nearest treatment site

Missed Doses
Do not take a double dose
Within 3 hours of scheduled dose take the
missed dose
If > 3 hours of scheduled dose, miss dose
and go on to the next dose, carry on the
treatment schedule

Ongoing Support (contd.)

Pill Fatigue/Drug Holidays
Counsel, support the patient
Manage side effects
Enlist family support
Side effects
Discuss how to address them at start of
ART as
well as during treatment
Inform patients when to seek medical
care
Use patient literacy materials

Side effects: Nausea and vomiting

Commonly seen with AZT, DDI and Kaletra
Usually transient and resolves in 24 weeks
Refer to the physician:
If severe abdominal pain, respiratory
difficulty and
disorientation - may be a
sign of lactic acidosis
Severe abdominal pain may also be a
symptom of
pancreatitis
If patient is dehydrated
If fever, headache, disorientation, altered

Advice to patients
Take with food if permitted
Eat more frequent small meals
Avoid greasy, spicy and fatty foods. Take bland
lightly
cooked food rice, soups, bananas,
biscuits
Drink sips of clean boiled water, weak tea, and
lemon water. Maintain hydration
Contact nurse or doctor in case of fever, vomiting
more than three times / day, thirsty but unable to
drink, pain in abdomen, breathlessness, confusion

Side effect: Headache

Usually transient and passes over 24 weeks

If accompanied by fever, disorientation,
altered consciousness or convulsions may
indicate meningitis, encephalitis or space
occupying lesion refer patient to physician

Advice to patients
Rest in a quiet, dark room
Place cold cloth over eyes and forehead
Avoid strong tea or coffee
If not relieved with 45 doses of Paracetamol, consult
health worker
If frequent and severe headaches or fever, vomiting,
altered consciousness, blurred vision or convulsions
contact a nurse or doctor immediately

Side effects: Diarrhea

Usually transient and passes over 24 weeks

Refer to the physician

If blood or mucus or fever refer to physician to treat
infection
If

severe diarrhea
More than 5 times per day
5 or more consecutive days
Weight loss of more than 2 kg

Advice to patients
Eat small meals more times a day
Eat soft, easy-to-digest food rice,
bananas, biscuits. Avoid greasy, spicy
and fatty foods.
Drink sips of clean boiled water, weak
tea, ORS, lemon water. Avoid orange juice
or very salty soups as they can increase
diarrhea. Maintain hydration.
If fever, mucus or blood in stools,
diarrhea more than 45 times a day for 5

Side effects: Rash

Rashes mostly seen with NVP, EFV, Abacavir
*Any new medication may cause allergic rash
Mild rash and itching
Severe rash (peeling of skin, watery
discharge, blistering, and ulceration) requires
immediate physician referral and removal of
medication

Advice to patients
Keep skin clean and dry
Use mild soaps( soaps that do not have strong
fragrance and non medicated)
Drink plenty of water to keep skin hydrated
Antihistamines to relieve itching and rash
Use Calamine lotion
If peeling of skin, blistering, or ulceration contact
nurse or doctor immediately

Side effects: CNS Symptoms

(Nightmares, sleeplessness, sadness or
worry)

Mostly seen with EFV

Usually transient and disappear in 24 weeks
If severe depression, loss of interest or
suicidal ideas, refer to the physician and
counselor

Advice to patients
Usually temporary and will resolve in few weeks
Take EFV at bedtime
Avoid heavy meals before sleeping
Avoid alcohol, drugs
Talk about your feelings with your friends or
family
If feeling very sad, have thoughts of killing
yourself, contact a nurse or doctor immediately

Side effects: Fatigue

Fairly common
Multiple causes HIV infection, medications,
depression, anemia
Alcohol and use of recreational drugs worsen
fatigue

Advice to patients
Avoid alcohol, tobacco, Miraa and other
recreational drugs
Light physical exercise may help
Balanced diet with fruits and vegetables
Consult relevant Health care Provider if you
feel depressed
Regular and restful routine helps to reduce
fatigue

Side effects: Numbness, tingling or

burning
Mostly seen with D4T, DDI
Other ARV medications and INH, Rifampicin can
also cause neuropathy
If severe and associated with weakness and
inability to walk refer to the physician.
Medications may need to be changed
Usually non-reversible

Advice to patients
Protect your feet
Wear loose fitting shoes and socks
Keep feet uncovered in bed
Soak feet in warm water, massage feet
Dont walk too much at a time
Inform health worker
Vitamin supplements and antidepressants may relieve
symptoms

Side effects: Change in

appearance
Lipoatrophy / Lipodystrophy fat redistribution
Usually seen after several months treatment mostly with
D4T and PIs
Usually not reversible
Limited treatment available
When associated with metabolic disturbances like e.g.
hyperlipidemia or hyperglycemia, regimen may be changed
Management of diabetes and hyperlipidemia required

Advice to patient

Aerobics
Exercises
Substitute the offensive drug
Client to check regularly on themselves
Supplement therapy

Adverse Drug Reaction

(Other side effects)
Hepatitis, pancreatitis, renal dysfunction,
anemia, metabolic disturbances like
hyperglycemia or hyperlipidemia are
diagnosed through laboratory tests
Refer to the clinician for management when
any of the above seen

Ongoing counseling
Step 2:
Discuss the follow up plan
Review upcoming travel plans, contact
information
Review patients goals. Set new goals
Step 3:
Set up appointment for next visit

UNIT 5
ADHERENCE AND MEDICATION
USE COUNSELLING (MUC)

What is Medication Use Counseling?

the exchange of information between a
suitably trained health care provider and a
patient regarding the use of medicinal
products that is aimed at ensuring the product
achieves its intended treatment goal

74

MEDICATION USE COUNSELING

Requires:
Up to date knowledge by the pharmacist
(continuous education)
An open, trusting and non judgmental relationship
between the pharmacist and patient
Adequate time
Use of updated Patient education aids
Medication use counseling is therefore a mechanism
of enhancing adherence to medicines

Why is MUC important?

To promote adherence
To educate the client / patient
To improve clients / patients confidence in the
healthcare system
To assess clients / patients understanding of their
therapy
To establish communication with the client / patient
and get feedback from them
76

Steps in Medication Use Counseling

1. Introduce yourself
2. Identify who is being counseled
3. Check what the patient or his/her
representative already knows about the
medicines

Checking what the patient was told by the healthcare

provider about the medication
What the medication is for
How the healthcare provider told the patient to take the
medication
Other information the healthcare provider told the patient
about the medication

Steps In Medication Use Counseling

contd
4. Making sure patient and/ or representative
understands how these medications work;
-Not a cure, only suppresses the virus
-May still infect others
-Can still get sick from other illnesses

5. Ask for the patients questions and

concerns.

Patient may have some concerns that were not

addressed by the healthcare provider.

Steps In MUC contd

6. Give name of medicine and describe
appearance:
Show label and identifier code
Open package if possible to show tablets

7. Name the route of administration

Steps In MUC contd

8. Give Directions/ instructions/
adherence
Number of pills, amount of fluid
When to take, missed doses
Completion of dosing period
Not stopping to take drugs without
doctors knowledge

Steps In MUC contd

9. Give information on the possible drug

interactions
10. Give information on the side effects of
the medicines:
Informed on common side effects
That if side effects cant be tolerated,
he/she should come back to clinic

Steps in MUC contd

11. Give information on the storage

requirement of the medicines.

12. Check the understanding of the patient
or his/her representative
Ask them to repeat back to you key
information
Remind them of the information left out
13. Final check for questions and concerns .

Special Considerations for Children

A third party is usually involved, e.g. a

guardian or caregiver
Demonstration on proper use of the
medication should be done
For school-going children, it is important to
discuss

Timing of dosing
Aid from the domestic help
Stigma

Disclosure to the child -improves adherence

83

MUC ROLE PLAY

(Allow 15 Minutes)

Mr. M is a 24 year old factory worker to be

started on ART. He sometimes works at on
night shift at the factory and enjoys the
occasional social drink with his friends
until late at night.
Devise a role play to cover medication use
counseling for this patient

UNIT 6
DISCLOSURE

Definition of disclosure
It is the process of revealing HIV status to
another
The process in pediatrics is different from
that in adults
Disclosure in children involves informing
the child about their status
Disclosure in adults involves revealing
own status to significant others
In either of them there are challenges

Disclosure in children
It is making known to the child their
status and may also involve sharing
the status of the caregiver/other
family member
An optimal process involves a
supportive role by the HCW to enable
the caregiver/parent
Initiate disclosure to the child
75% parents are more likely to
disclose to children, (40%) and to
daughters more than sons.

Disclosure in children
Ownership: caregivers/parent are the ideal
individual to inform the child about HIV status and
enables one to take charge over their health care
Time: appropriateness is to the discretion of the
informer and it may take some time following
several sessions
Support: continuous from HCW using a family
centered approach to form a strong treatment
alliance
Support groups: to reduce stigma, discrimination
and improve psychological well being

Disclosure Triangle
PARENT/GUARDIAN
(CARE GIVER)

89

Paediatric Health
Care
Worker

CHILD

Disclosure in children and

adolescents
The child and caregiver/parent may
have some information on the childs
health and on HIV
This is explored so as to begin from the
known into the unknown
The caregiver/parent is then supported
to initiate disclosure
Resultant emotions are dealt with
addressing pain and distress that may
arise following the knowledge

The role of the Health Care

Worker
Establishes a therapeutic relationship to
ensure continuum of care
Uses age-appropriate mediums to begin
a social relationship and create a sense
of security for the child
Involves the caregivers/parents at all
stages of medical care
Addresses emotional expressions e.g.
fear, secrecy, anger

The role of the Health Care Worker

Identifies barriers to disclosure and
support to overcome them
Assesses social/family support
Assesses knowledge of HIV necessary in
childs care
Prepares caregiver/parent for the
disclosure process through coaching and
role play

Counseling the child

Involves:
continued assessment of psychological
symptoms
Continued support and counseling
Addressing childs outlook on life, self
esteem, exploring talents, interests to
enhance psychological well being
Assisting to identify inner strengths and
available social support

Counseling the child

Enroll the child into a post-disclosure
group
Enables the child to relate with peers
Psychological changes are notable
Deals with emotional process

Counseling the child

Educating the child on age-appropriate
positive living
Personal hygiene, stress management,
sexuality, infection prevention

Allow for questions and address anxieties

Encourage plans, ambitions etc and
enable build realistic approaches to life

Dealing with barriers

Brainstorm on Barriers to Disclosure
(Allow participants 10 minutes)

Barriers to disclosure
Child:
Too ill, self blame, developmental stage

Caregiver/parent:
Fear, too ill

Health Care Worker:

Lack of skill, challenges of process

Social-cultural issues:
Taboos, traditions, religion, stigma

Advantages of disclosure to children

Develops better coping skills

Enables parents make custody plans
Reduces problem behaviors
Improving parent-child relationships
Reduce emotional distress
It enhances adherence
It enhances self esteem

Disclosure in adults
Who and how to tell about HIV status can
be very complex
It is a personal decision yet considered
paramount in enhancing adherence

who to disclose to
Not every one needs to be informed
Contact persons need to know in
order to be tested and receive care
Employer???
When to disclose to prospective
relationship partnersconsidering
the legal requirements that one must
disclose status to sex partners

Importance of Disclosure
Effective disclosure should result in
emotional and practical support e.g.
post test clubs
Many who disclose to the public in
order to help others e.g. in education,
encourage, etc
Support groups for both the infected
and affected will be useful in dealing
with resultant psychological reactions

Importance of Disclosure
Educate child on: positive living e.g. personal
hygiene, sexuality, self awareness and stress
management to help child lead a healthy lifestyle
Encourage child to always ask questions and
discuss his/her concerns/fears
Explore the childs hopes, ambitions and plans
for the future using questions addressing wishes

108

Effects of disclosure
Disclosure can be very stressful
Some may accept the individual while others
will discriminate, stigmatize, segregate etc
Misconceptions and preconceived notions
about HIV will greatly affect the receivers
response
Failure to disclose has been associated with
anxieties, fears etc that compound the
emotional state of dealing with the HIV test
results

Coping with Disclosure

Assure the caregiver of shared confidentiality
Assure caregivers that disclosure process has multiple
benefits & that the child should understand his/her
current status
Allow children & caregivers to share feelings openly;
provide them with a safe place to cry & express bottled
up emotions
Encourage the expression of difficult feelings (bitterness,
grief & pain) using the available tools so healing can start
Assure child & caregivers that you will be available, to
work with them as a team, for ongoing support
110

The role of the Health care

worker
Support is very crucial during the period of
disclosure
When response is uncertain, presence of
someone else is recommended e.g.
counselor

Note:
REMOVING THE SILENCE AND STIGMA
AROUND HIV STATUS MAKES US ALL
HEALTHIER
HIV testing and pre-and post-counseling is
an important element can be helpful in
the decision to disclose sero-status.

Exercises
(Allow participants 15 minutes)

Wives are less likely to disclose than

husbands:
Discuss.
Physical abuse and marriage break ups
are noted to be higher when females
disclose than in their male counterparts:
Discuss.

Food for thought

How often would one ask the HIV status of
opposite sex?
How often is an assumption made on the HIV
status of another?
Should health care workers disclose HIV
status to their patients?
Would YOU rather know the HIV status of your
sexual partner before contact?
How Easy would it be to disclose own HIV
Positive status?

UNIT 7
PREVENTIONS WITH POSITIVES
(PWP)

Background
Most prevention efforts focus on helping people avoid
acquisition of HIV
Traditionally target HIV negative persons or ignore
HIV status
Basic infectious disease epidemiology suggests we limit
spread of HIV from its source
To significantly slow the spread of the epidemic,
prevention efforts must also be directed toward HIV
infected persons who can transmit the virus.

What is Prevention with

Positive?
Positive Prevention refers to prevention
efforts that support HIV-infected persons to
reduce their risk of HIV transmission
Interventions can be clinic- and communitybased
Prevention interventions should be both
behavioral and biomedical

Positive Prevention Strategies

Help HIV infected persons learn status
Test sex partners and identify discordant
couples
Encourage disclosure of HIV status to sex
partners
Encourage Contraceptive use to prevent
unintended pregnancies and counseling
on safe pregnancy approaches/PMTCT

Positive Prevention Strategies

STI screening and treatment
Provision of /and adherence to ART
Behavioral interventions for HIV positive
persons
Address impact of alcohol abuse on
sexual risk behaviors and medication
adherence

UNIT 8
ADHERENCE COUNSELLING IN
SPECIAL GROUPS

Special groups
This group includes

Internally Displaced Persons (IDPS) and refugees

Prisoners
Long distance drivers
Orphaned and Vulnerable Children (OVCs)
Mentally ill
Commercial Sex Workers
Street families
Bedridden patients

Adherence in special groups

The adherence process is the same like
for all other groups only that the counsellor
needs to pay particular attention to the
challenges that these individuals are
experiencing or have gone through
These challenges could act as barriers to
adherence

THANK YOU