HIGH VIRAL LOAD FORM (For enhanced adherence counseling [EAC] and second-line ART consideration) Patient Information Name Facility DOB Age Sex ART Number ARV Information Viral Load Results ARV Regimen Date of Initiation Previous VL (if any) (c/ml) Date Recent VL Current WHO T-staging I II III IV Present Illness (if any) Is this patient currently a presumptive TB? Y N ☐ ☐ History of chronic diarrhea or vomiting? Y N ☐ ☐ Any other OI or signs of immunosuppression? Y N ☐ ☐ History of side-effects with ARV? Y N ☐ ☐ adherence history before EAC Good Fair Poor Patient’s ☐ ☐ ☐ C. EAC Sessions (to be filled by the nurse) For each session, assess major barriers for possible poor adherence (cognitive, behavioral, emotional, socio-economic, as shown above). Treatment supporter present: Y N ☐ ☐ Enhanced adherence counseling (EAC) (To be filled by the Adherence Counselor), Session 1 For each session, assess major barriers for possible poor adherence (cognitive, behavioral, emotional, as shown below). Date: Barriers: Interventions: __/__/____ Knowledge Services Forgot Clinical Adherence: Feeling better Education Good Concurrent illness Counseling (ind) Fair Alcohol/drugs Counseling (grp) Poor Health beliefs/alternative remedies Peer support Depression Treatment buddy Fear disclosure Drug pick-up Lack of family/partner support DOT Pill burden Case mgmt. Side-effects Tools Ran out of medication Pill box Lost/damaged Calendar Sharing medications Journal/log Transport Written instructions Scheduling Phone calls Failure to adjust SMS Food insecurity Alarms Drug stock-out Other: ____________ Long wait Stigma Political crisis
HIGH VIRAL LOAD FORM (For enhanced adherence counseling [EAC] and second-line ART consideration) Patient Information Name Facility DOB Age Sex ART Number ARV Information Viral Load Results ARV Regimen Date of Initiation Previous VL (if any) (c/ml) Date Recent VL Current WHO T-staging I II III IV Present Illness (if any) Is this patient currently a presumptive TB? ☐ Y ☐ N History of chronic diarrhea or vomiting? ☐ Y ☐ N Any other OI or signs of immunosuppression? ☐ Y ☐ N History of side-effects with ARV? ☐ Y ☐ N Patient’s adherence history before EAC ☐ Good ☐ Fair ☐ Poor C. EAC Sessions (to be filled by the nurse) For each session, assess major barriers for possible poor adherence (cognitive, behavioral, emotional, socio-economic, as shown above). Treatment supporter present: ☐ Y ☐ N Enhanced adherence counseling (EAC) (To be filled by the Adherence Counselor), Session 1 For each session, assess major barriers for possible poor adherence (cognitive, behavioral, emotional, as shown below). Date: __/__/____ Adherence: Good Fair Poor Barriers: Knowledge Forgot Feeling better Concurrent illness Alcohol/drugs Health beliefs/alternative remedies Depression Fear disclosure Lack of family/partner support Pill burden Side-effects Ran out of medication Lost/damaged Sharing medications Transport Scheduling Failure to adjust Food insecurity Drug stock-out Long wait Stigma Political crisis Interventions: Services Clinical Education Counseling (ind) Counseling (grp) Peer support Treatment buddy Drug pick-up DOT Case mgmt. Tools Pill box Calendar Journal/log Written instructions Phone calls SMS Alarms Other: ____________