Set and Document Self-Management Goals Collaboratively with HIV/AIDS Patients

  1. Address medication adherence with standardized training and goal-setting:
    • Before beginning HAART, assess patient's readiness for treatment, understanding of the disease, attitudes towards HAART, and understanding of the importance of adherence.
    • Review treatment options, patient's lifestyle and dosing schedules, and number of pills to be taken.
    • Educate patients about side effects and their management.
    • Set realistic therapeutic goals together.
    • Avoid unnecessary medications.
  2. Address other self-management issues that need collaborative goal-setting, such as nutrition and harm reduction. Specific self-management goals may include:
    • Disclosure of HIV status
    • Safer sex practices
    • Entering drug or alcohol treatment programs
    • Attending support groups
    • Seeking help for abusive situations
    • Re-establishing or maintaining a support system
    • Returning to work
    • Maintaining a stable living situation
    • Maintaining body weight
    • Preventing or controlling medication side effects
  3. Assess patients' skill, understanding, and confidence in managing their disease.
  4. Give patients a copy of their goals, and place a copy in the patient record.
  5. Review the patient's personal barriers and enablers in order to link daily tasks to positive self-management behaviors. For example, link taking medication with brushing teeth.
  6. Identify tools that support the following aspects of self-management:
    • An HIV goal contract or promise that includes self-monitoring, guidelines for treatment, and an assessment of the patient's confidence level to help with problem solving about barriers
    • Steps to overcome barriers
    • The patient's confidence level (e.g., on a scale of 1 to 10, how confident are you that you can meet your goals?)
    • A follow-up plan
  7. Review the tool with the multidisciplinary team, including all those who will be involved in its use — physicians, nurses, pharmacists, volunteers, lay health workers, etc.
  8. Test the tool with a few patients and revise as needed. Retest with additional patients and different populations.
  9. Identify high-quality patient education materials.
  10. Review materials for age and cultural appropriateness. Determine if different versions — grade levels, languages, and literacy levels — are necessary to serve patients. Review materials with the care team.
  11. Test materials with a few patients and revise as necessary.



  • Consider electronic pillboxes and reminders.
  • Aim for simplified dosing strategies.
  • Recognize that flexible clinic hours, accessible clinical staff, and availability of bilingual staff help support adherence in special populations.
  • Have medical assistants ask patients about goals when taking vital signs.
  • Be sure that providers briefly review self-management goals with patients.
  • Assign staff to arrange follow-up with patients.
  • Document goal setting in the registry. Include some specifics about the goals and the date(s).
  • Ensure that staff are comfortable with the self-management philosophy and trained in behavioral techniques to support patients.
  • Train culturally informed lay health workers to set goals with patients.
  • Be sure that the planning tool selected is sensitive to issues of culture and language.
  • Be aware that you may need to adapt titles or contents of tools for cultural sensitivity (e.g., use term "Promise" rather than "Contract" for goal-setting tool).
  • Provide patients with calenders if necessary.
  • Think incrementally about behavior change. Encourage patients to take small steps and build confidence through success.
  • Work with patients to define goals. Don't prescribe goals or use checklists.
  • Include family and caregivers in setting goals.
  • Use groups for patient goal-setting.
  • Encourage up-front team input on materials.
  • Coordinate patient education with the center's care guidelines.
  • Clarify team roles for self-management early on.
  • Ask patients to bring materials with them to every visit for review of use.
  • Remove outdated educational materials from the clinic.
  • Make materials available to patients, families, and providers by placing them in examining rooms and waiting rooms.
  • Share materials with pharmacies, faith-based organizations, and community groups.
  • Consider establishing a toll-free number for patient education and information.
  • Develop culturally-specific packets of information to be used when HIV is first diagnosed or for patients new to the clinic.
  • Be selective and keep materials brief. Include materials with larger print. Think about how to meet the needs of clients who cannot read (for example, pictures or support persons). Use literacy assessment tools to ensure appropriate literacy level of materials.
  • Select translators with care.
  • Work with lay health workers and other health workers in the community to select and review materials. Also ask the consumer advisory board to review materials.