Enhanced Counselling Improves ART Uptake In Rural Chivi

WITH only a staff establishment of four primary care nurses, a nutritionist, a data entry clerk, an environmental health technician alongside the general hand, Madzivadondo Clinic serves 5 376 people.

The clinic offers HIV services which include counselling and ART initiation with the aid of Direct Service Delivery models. The clinic’s Sister in Charge Assyria Zizhou says they employ various strategies to encourage ART uptake.

“On the HIV services offered here at this clinic, we first offer pre and post-test counselling. If one opts in, we test him or her. If the client tests positive, another nurse retests the client to make sure he or she is initiated on ART if the second test indicates Positive.

“If it is a general patient not a pregnant woman, after six months of taking art, the client is going to have blood samples taken for viral load assessment. If it is a pregnant woman, the viral load is taken after three months, of ART initiation.

“If the viral load results come, we offer them to the client. If it is high, we utilise our outreach workers or Partners like Kapnek, CATS, and village WC to call the client to come to the clinic for enhanced adherence counselling sessions,” she said.

Sister Zizhou explains they have three enhance adherence counselling sessions they do with clients.

“If the viral load is high, the enhanced adherence counselling sessions is to be done three sessions per month. In the first session, the client is asked the problem making the viral load high. If we find the problem we counsel according to the problem.

“Then the client will be called for the second enhanced adherence counselling session. In the second session, we first do a recap exercise before starting it. During that session, we discuss the problems the client faces while reiterating the importance of adherence. The importance of taking medicine on time and not omitting medicines as told before while being initiated on ART.

“On the third session, recapping is the first step, asking what was done in the second session. After the recap, we continue counselling the client. On this third adherence session, we repeat the viral load, and if it is high, we send the patient to the next level. When I am saying the viral load will be high, it will be above 1 000 copies. If the viral load is stable, it will be target not detected,” she says.

According to the second nurse in charge Gladys Utete, out of the 5 376 people in their area, 429 are on ART.

“For first line we have 414 and second line we have 15. We managed to collect 386 viral load samples. We have 343 with viral load suppressed. The suppression rate is 89, 9 percent and we have got 44 with unsuppressed viral loads.

“The suppression rate is 11, 3percent for those with high viral loads. The advantage of viral load is it helps us monitor our patients and assess adherence of our patients,” she says.

She added that a high viral loads in women can be attributed to lack of disclosing the status to spouses fearing gender based violence.

Diet plays a vital and crucial role in the management of HIV.  According to Zvifadzo Marare, the nutrition coordinator for Chivi Ward 5 at Madzivadondo Clinic, maintaining a four star diet was critical for people living with HIV.

“We promote a diet consisting of at least four food groups a day. It’s called a four star diet. The first star is for carbohydrates. The second star is for proteins. The protein group is further split into two groups. That is proteins from plant sources and proteins from animal sources. So we now have three stars.

“The last star is Vitamin A rich fruits and vegetables and other fruits and vegetables. So you find that the foods in these groups constitute a balanced diet,” she says.

She urges ART clients to consume locally available foods.

“For example in the carbohydrates group, there are small grain crops like mhunga, rukweza, mapfunde that are locally available. Maize is also included, mbambaira, rice as well. Its not always the case that they have to but those food products, which is why we promote locally available foods encouraging them to eat nutritious foods at little to no monetary costs,”

She adds that proteins from plant sources are mostly legumes. These are ground nuts, roundnuts, peas, beans.

“The protein foods from animal sources include eggs, milk, matemba, ishwa, mbeva, majuru, they can get those again at little to no monetary costs. On vegetables, we promote those rich in Vitamin A. Those are the vegetables mostly yellow or orange in colour like mangoes.”

Prince Chivasa the clinic’s data entry clerk doing quantitative and qualitative data gathering for Madzivadondo says Community ART Refill Groups have been useful in many ways. At Madzivadondo Clinic, 15 CARGS having 94 patients with eight members in each group, the staff reminds them not to miss collection dates to avoid default.

“CARGs save members on transport fares  and also they have nutrition gardens where they interact. The CARGs reduce workload burden, improve quality of services,” he said.

Clients with unsuppressed viral load get a month’s supply while those having their viral load supressed are given drugs for three months.

“Those with unsupressed viral loads come for enhanced adherence counselling sessions,” Chivasa says.

The clinic targets the sexually active age groups of 14 to 49 with HIV testing services. If found positive, they are counselled on pre-initiation and then if defaulting they undergo enhanced adherence counselling.

The clinic in January surpassed a target of testing 89 clients having 156. Translating to about 150 percent, the trend goes on in the following months where they exceed targets set.

The environmental health technician Vimbai Shumba says they encourage screening of TB among HIV clients. She says they promote good hygienic practices such as having Blair Latrine Toilets, pot track, garbage pits at households to maintain household  and environmental hygiene.

The clinic’s pharmacist Jane Kwanayi ensures ART medication is available to prevent defaulting.

“Our aim is we want these patients to have a supressed viral load and this is achieved by enough drugs. If the viral load is high so are the chances of reinfections. CARGs help reduce workload while improving service delivery since we are four Primary Care Nurses here,” Kwanayi says.

The clinic started initiating clients on DTG in August starting with the ART naïve clients meaning new patients. So far, a total of 35 are on Dolutegravir.

Following the clarification by the World health Organisation of  DTG being safe for women of child bearing age, the rural clinic gives them the drug.

Linia Mutsindikwa who collects her ART medication at Madzivadondo clinic had her viral load found above 1 000 copies which was high. Finding her viral load unsuppressed, nurses did three enhanced adherence counselling sessions with her.

“The nurses would counsel me on the importance of adhering to the medication and taking the treatment at stipulated times consistently,” she said.

They enquired why her viral load was high.  Linia explained that she had stress as she was in denial.

After the enhanced adherence counselling sessions, Linia’s viral load was suppressed as she started taking her medication on time.

“I am now healthy as I do many chores. I no longer get sick all the time,” she says.

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