Human Immunodeficiency Virus

You are working at a physician’s office, and you have just taken C.Q., 38-year-old women into the consultation room. C.Q. has been divorced for 5 years, has two daughters (ages 14 and 16), and works full time as a legal secretary. She is here for a routine physical examination and requested that a human immunodeficiency virus (HIV) test performed. C.Q. stated that she is in a serious relationship, is contemplating marriage, and just wants to make certain she is “okay”. No abnormalities were noted on chemistries and hematology studies. The physician requests you perform a rapid HIV test, which is an antibody test. Within 20 minutes, the results are available and are positive.

Does a positive rapid HIV test mean that C.Q. definitely has HIV? If it is negative, does it mean she definitely doesn’t have HIV?
There are three types of results a person could possibly receive from a Rapid HIV test. A Non-reactive or Negative Result means that the test did not detect any HIV antibodies. However, this does not mean that a person is immune to HIV. It can take up to three months from the time of possible exposure for the body to develop the antibodies to HIV. An Invalid Result: does not apply to this case study, but it means this that the HIV test cannot be interpreted. An invalid test result means there was a problem running the test, either related to the test device or the specimen. In this case, another test would be given.

People are no more likely to receive a reactive or non-reactive result from an invalid one. A Reactive or Preliminary Positive Result means HIV antibodies were detected in her body. Therefore a confirmatory test such as the Western blot will be given to eliminate the chance of a false positive result. The Western blot is the most common test used to confirm positive results from an ELISA or rapid HIV test. Its advantage is that it is less likely to give a false-positive result because it can more effectively distinguish HIV antibodies from other antibodies.

What counseling do you need to provide to C.Q.?

C.Q needs a great deal of teaching and counseling before going home. She should be taught about antiretroviral therapy. This includes the dangers of not adhering to therapeutic regimens, how and when to take each medication, drug interactions to avoid, and side effects that need to be reported to the primary care provider immediately. She will need instruction about maintaining a healthy immune system and preventing transmission of the disease to her family, and sexual partners. She should be taught to recognize clinical manifestations that should be reported to her clinician, including symptoms of advancing disease, drug reactions, and life-threatening opportunistic diseases. C.Q should be encouraged to promote self-care, providing physical care as necessary, making additional referrals for community resources as needed, addressing spirituality issues, and assisting family members and friends cope with her illness. Case Study Progress

The physician informs you that C.Q.’s western blot test results confirm that she is HIV positive; he requests that you be present when he talks to her. Before leaving C.Q.’s room the physician request that you give C.Q verbal and written information about local HIV support groups and help C.Q. call a friend to accompany her home this evening. She looks at you through her tears and states, “I can’t believe it. J. is the only man I’ve had sex with since my divorce. He told me I had nothing to worry about. I can’t believe he would do this to me”.

C.Q.’s statement is based on three assumptions (1) J. is HIV positive; (2) he intentionally withheld he information from her; and (3) he intentionally transmitted the HIV to her through unprotected sex. Based on your knowledge of HIV infection, how would you counsel C.Q.? In this scenario it is possible that C.Q.’s partner may have been infected and not knows about it. There is also a possibility that he did not want to disclose it due to her legal secretary job. Routine testing is key in the prevention of spread. As C.Q’s nurse I would encourage her two daughters (ages 14 and 16) to be tested. If they are infected, they can be started on ART to treat the infection, and delay progression of the disease. Unprotected sexual contact (semen, vaginal secretions, or blood) with a partner infected with human immunodeficiency virus (HIV) is the most common mode of HIV transmission in this case. It is important that C.Q rules out any sexually transmitted diseases before having sexual intercourse with a new partner. Laboratory testing it is recommended as it allows people to first find out they do not have the virus, or other SDTs, and make informed decisions about their sexual partners and activities.

In addition to offering alternative explanations and exploring options, what is your most important role at this time? The most important thing to do at this time is to stablish trust and provide nursing care in a nonjudgmental way. It is also important to provide C.Q. with multiple opportunities to raise questions and concerns. Assess how patient is coping with new diagnosis. Offer support group & encourage discussing feelings towards situation. Immediate interventions include teaching C.Q. about drug therapy, which clinical manifestations to report, supporting her in her (trusting) relationship, and evaluating her ability to manage her disease at home. Discrimination related to HIV infection can lead to social isolation, dependence, frustration, low self-image, loss of control, and economic pressures. It is important for C.Q. to feel that she has a support system that she can go to prevent any negative behaviors that will affect self-management.

C.Q. asks you whether she has AIDS. What do you tell her?

AIDS is diagnosed when an individual with HIV infection develops at least one of the following conditions: a CD4+ T cell count below 200 cells/L. An opportunistic infection; fungal, viral, protozoal, bacterial, cancers, wasting syndrome, and/ or Aids Dementia (ADC). 6.

Why is it a good idea for C.Q. to have someone she trusts transport her home this evening?

It is important to recruit family and friends to support and reinforce the plan to follow. Newly diagnosed patients may not be able to retain or understand information. Having someone C.Q. trust transport home can be extremely helpful for times of support. With these types of diagnosis patients may not be able to cope and develop severe anxiety, panic attacks, and depression. One of the goals of care is patient safety, and ongoing assessment and support based on patient’s input is a must.

C.Q. gives you of the name and phone number of a relative she wants you to call. You remain with her until she leaves with her relative. Has C.Q’s right to privacy been violated? Explain why or why not.

Her privacy has not been violated because she was given the option of calling a relative. She also gave the number and by that action she is consenting her right to inform the relative and obtain the necessary support. Case Study Progress

C.Q. returns to the office 4 days later to discuss her diagnosis.

What are the goals for C.Q at this time?

Immediate interventions include teaching and monitoring C.Q. about drug therapy and which clinical manifestations to report, supporting her in a trusting relationship, evaluating her ability to manage at home, laboratory tests, and compliance with medication regimen.

What additional laboratory test would you anticipate for C.Q?

The progression of HIV infection is monitored by two important laboratory assessments: CD4+ T-cell counts and HIV viral load. 10.

C.Q asks whether there is any treatment available. How would you respond?
Absolutely, with advances in treatment, HIV is managed as a chronic disease, since people are leaving longer. The major drug classifications for HIV include entry/fusion inhibitors, non-nucleoside reverse transcriptase inhibitors (NNRTIs), nucleoside reverse transcriptase inhibitors (NRTIs), nucleotide reverse transcriptase inhibitors (NtRTIs), integrase inhibitors, and protease inhibitors (PIs). Treatment regimens can be complex. The drugs have side effects and frequently interact with other medications. Current guidelines for starting ART are based on the degree of immunosuppression as measured by the CD4+ T-cell count

C.Q. asks why she has to take so many drugs instead of a “big dose” of one drug. What would

you tell her?

The goal of drug therapy in HIV infection is to decrease viral load, maintain an increased CD4+ T cell counts. Prevent HIV-related symptoms opportunistic diseases, delay disease regression, and prevent transmission. HIV cannot be cured, but antiviral therapy (ART) can delay disease progression by decreasing viral replication. Drugs used to treat HIV work at various points in the HIV replication cycle. The major advantage from using drugs from different classes is that combination therapy can inhibit viral replication in several ways, making it more difficult for the virus to recover and decreasing the likelihood of drug resistance. A major problem with most drugs used alone (monotherapy) or taken in inadequate doses. For that reason combinations of three or more drugs should be used. After reviewing the type of drugs and how to take them, I would encourage adherence to antiviral treatment.

The physician starts C.Q. on a regimen of Truvada tenofir and emtricitabine), Reyataz (atazanavir), and Norvir (ritonavir). What general information will you give C.Q. bout ART therapy? Truvada is the first drug approved to reduce the risk of HIV infection in unaffected individuals who are at high risk of HIV infection and who engage in sexual activity with HIV infected-partners. Many antiviral drugs have dangerous and potentially lethal interactions with other commonly used over-the-counter and herbal therapies. As C.Q.’s nurse I would also discuss the dangers of not adhering to therapeutic regimens, how and when to take each medication, drug interactions to avoid, and side effects that need to be reported to the primary care provider.

What other issues will you discuss with C.Q at this visit?

I would discuss the importance of discussing the issue with her daughters, partner so they can also get tested and treated. Another issue I would discuss is prevention strategies. Safe sex practices, including risk reduction and counseling, as well as the importance of regular HIV testing.

Does C.Q. have legal responsibility to inform J. of her HIV state?

As an HIV-positive person, C.Q. has the responsibility to disclose her HIV status with J. She also has the right to question J. regarding his hidden HIV infection as he can be penalized. It is important for C.Q. to also understand about HIV laws in her state. According to “Why California HIV Disclosure Laws Are A Threat To Public Safety (California Health And Safety Code Section 120291) “ “any person who exposes another to HIV by engaging in unprotected sexual activity (anal or vaginal intercourse without a condom), when the infected person knows at the time of the unprotected sex that he or she is infected with HIV, has not disclosed his or her HIV-positive status, and acts with the specific intent to infect the other person with HIV, is guilty of a felony.” The law clarifies that “a person’s knowledge of his or her HIV-positive status, without additional evidence, is not sufficient to prove specific intent.”

C.Q. needs to understand that knowing she is HIV-positive and does not tell her partner she can be charged with a crime. C.Q. also needs to be informed that if a HIV test is positive, the clinic will report the results to the state health department. This is done so that public health officials can monitor what’s happening with the HIV epidemic in the city and state. It’s important for C.Q. to know that because of Federal and state funding for HIV/AIDS services is often targeted to areas where the epidemic is strongest. C.Q also needs to know that there are “third party” laws. Basically, if they know that person has a significant risk for exposure to HIV from a patient the staff member knows is infected with HIV. This is called “duty to warn.”

Case Study Progress

Two weeks later, C.Q. visits the office and asks to speak to you in private. She thanks you for talking to her the day she received the news of her diagnosis. As a nurse, it is always important to have a positive outcome especially on difficult cases such as this one. Collaborating effectively among hospital staff to provide the upmost care is crucial in patient’s chronic disease management. The mail goal is to decrease viral load, maintain an increased CD4+ T cell counts, prevent HIV-related symptoms opportunistic diseases, delay disease regression, and prevent transmission