Form Id: FRM-ENH-ADH
ENGLISH FRANÇAIS PORTUGUÊS ITALIANO| Session number of EAC: | |
| Pill count adherence %: | |
Medication Adherence Scale | |
| 1. Do you ever forget to take your medicine?: | |
| 2. Are you careless at times about taking your medicine?: | |
| 3. Sometimes if you feel worse when you take the medicine, do you stop taking it?: | |
| 4. When you feel better do you sometimes stop taking your medicine?: | |
| 5. Did you take the medicine yesterday?: | |
| 6. When you feel like your symptoms are under control, do you sometimes stop taking your medicine?: | |
| 7. Do you ever feel under pressure about sticking to your treatment plan?: | |
| 8. How often do you have difficulty remembering to take all your medications?: | |
| Medication Adherence Score: | RESULT: SCORE |
| Adherence rating: (automatic evaluation not working in preview) | |
Understanding Viral Load (High/Suppressed): | |
| Has patient received viral load result?: | |
| Was the Viral load result suppressed (less than 1000) or unsuppressed (greater than 1000) ?: | |
| How does the patient feel concerning the result?: | |
| What does the patient think caused the high viral load?: | |
| Way forward:: | |
Barriers to adherence - Assess for possible barriers to adherence | |
Cognitive Barriers | |
| (HIV and ART Knowledge) Assess patient's knowledge about HIV and ART; correct any misconceptions: | |
Behavioural barriers | |
| 1. Let the patient explain how they take their drugs, and at what time and how they store them.: | |
| 2. How does treatment fit the patient daily routines? What reminder tools are used?: | |
| 3. What does the patient do in case of visits and travels?: | |
| 4. What does the patient do in case of Side Effects?: | |
| 5. What are the most difficult situations for the patient to take drugs?: | |
Emotional Barriers | |
| 1. How does the patient feel about taking drugs everyday?: | |
| 2. Motivation. What are the patient ambitions in life? What are the 3 most important things they still want to achieve?: | |
Socio-Economic Barriers | |
| 1. Does the patient have any people in their life who they can talk to about HIV status and ART?: | |
| 2. Discuss how the patient can enlist the support of their family, friends and/or co-workers, a treatment buddy, community or support group?: | |
| 3. Review the patient's and family's sources of income and how well they cover their needs.: | |
| 4. Does the patient have any challenges getting the clinic on regular basis?: | |
| 5. Is the patient worried about people finding out about their HIV status accidentally?: | |
| 6. Does the patient feel like people treat them differently when they know their HIV status?: | |
| 7. Is stigma making it difficult for them to take their medications on time, or for them to attend clinical appointments?: | |
| 8. Find out if the patient has tried faith healing, or if they have ever stopped taking their medicine because of religious belief: | |
Review Adherence Plan from previous session | |
| 1. Does patient think adherence has improved since last session?: | |
| 2. Have any dosses been missed?: | |
| 3. Review barriers to adherence from previous session and if strategies identified have been taken up, identify other gaps and issue emerging: | |
Referrals and Networks | |
| 1. Has the patient been referred to other services? (Nutrition, psychosocial support services, substance use treatment, etc): | |
| 2. Did he/she attend the appointments?: | |
| 3. What was the experience? Do the referrals need to be re-organized?: | |
| 4. Will the patient benefit from a home visit?: | |
| 5. Adherence plan: | |
| Follow up Appointment Date: | |
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