Management of the Newly Diagnosed Patient. Jane Bruton Clinical Research Nurse Imperial College

Patient Medical needs Social Needs Psychological needs Spiritual needs Holistic approach to HIV care

2 case studies Lydia and Maria Asymptomatic presentation Late presenter

25 year old sex worker requesting an HIV Test Recently found out her former partner a former IVDU died of AIDS Has a 5 year old child with this partner They live with Lydia’s mother Sex work is the only income for family Lydia

All with differential diagnosis of HIV All with sexually transmitted infections (STI) All sexual partners of those HIV+ve All MSM (and female partners of) All IVDU (and their partners) All those known to be from a country of high HIV prevalence (and those they have sex with) Who should be tested?

Brief discussion with Lydia Has she had any prior HIV tests Her risk factors Sexual history Who will give the results to her Pre HIV testing

Detects HIV antibodies and or p24 antigen Antigens can be detected Antibodies can be detected Tests for HIV-1 and HIV-2 Different types, venous blood, oral fluid, finger prick, urine The test

Post test: HIV positive Lydia tests HIV positive What might be her initial concerns? 1)About herself 2)About her daughter 3)About her mother 4)About her income

Lydia Feels devastated and alone Will she die? Nurse to deal with the immediate issues – Who will be at home for support? – Give space and time to talk – Disclosure – Baseline bloods – Book follow up appointment – doctor nurse

Disclosure Disclosure is a process Personal decision Difficult due to own feelings about HIV Can be a powerful support or devastating

What’s next for Lydia? Check in with how she is – stigma impact? Support Check understanding of HIV Prevention of Transmission Orientation to the service Appointment with HIV doctor/nurse

Lydia CD4 370 Viral load 120,000 Asymptomatic no medical issues Sexual health screening no check for 5 years Treatment - when to start

Psycho-social Assessment Work: Usually uses condoms with clients Sex work for last 2 years Home: Was able to disclose to her mother and can stay living with her Daughters status to be checked Support needs – referrals needed Spiritual needs

Lydia What reasons should she start ART? What assessment does she need to start ART? What combination should she start and why? What should be considered when starting ART?

Lydia She starts ART because She is very close to the recommended starting CD4 She has a high viral load so taking ART will reduce her risk of transmitting HIV Starts Truvada and Efavirenz (cannot take Kivexa due to VL >100,000) ‘Readiness to start’/adherence assessment

Ongoing care Treatment support - adherence Education about HIV and treatment Support and advice Health promotion – smoking, alcohol, healthy eating Promotion of self management skills – negotiation skills Advocacy within the health care system Accessible service – who to contact?

Maria 45 years old with 4 children Works as a ward nurse in local hospital Husband is international truck driver Not been feeling well for the last year, always tired Has had some minor skin and mouth infections Recent antibiotics for chest infection

Maria Last 6 weeks short of breath going upstairs Exhausted Cough was dry at first now productive Night sweats that doctor thought were early menopause Collapsed at work admitted as an emergency

Maria Investigated for respiratory symptoms HIV test done was done and positive Presumptive PCP (pneumocystis pneumonia) Started on treatment for PCP Started on Antiretroviral therapy

Maria Terrified the medical team will tell husband Afraid husband will see the pills and know Eldest daughter looking after family as husband is away Daughter only knows Maria has pneumonia

Nursing Priorities Nursing care for respiratory infection Observe and respond to deterioration in her condition Support and give her time and space to talk Help her understand HIV and her future. Support her with the fear of disclosure Peer support - meet someone with HIV who is well

Maria Prepare for discharge Information about the clinic and what to expect Link in to support services Disclosure Husbands status Getting back to work

Conclusion HIV is a manageable condition if treated To stay healthy the patient needs:  Nurse/patient partnership working  Treatment support  Psychosocial support  Education  Regular psycho-social assessments  Support to develop self-management skills