Topic Name: HIV/AIDS: Issues and Attitudes In this essay I will explain why the following issues are most important to consider and keep in mind when caring for a person identified as being HIV positive or having AIDS. The issues that I consider most important are how this illness impacts on the patient psychologically; how to prevent HIV transmission and the interventions that are effective; what treatment is available; and the issues surrounding medication adherence and its importance.
How this issue impacts on the patient psychologically Depression and depressive disorders are a common issue for people who are HIV positive, 40% to 48% of people who are HIV positive suffer from depression (Buchanan 2002; Lichtenstein 2002). This issue is important to consider when caring for a patient who is HIV positive because they are twice as likely, compared to other people without HIV to have a major depressive disorder (Buchanan 2002).
Clinical depression is also more likely to occur the longer the patient has been affected, in the later stages of the HIV disease (Buchanan 2002; Lichtenstein 2002). The possibility of a HIV positive person developing depression significantly increases 18 months prior to the onset of symptoms, and it can increase morbidity and mortality (Lichtenstein 2002). Depression is a significant issue when caring for any patient as it has a considerable negative impact on quality of life, and a severely debilitating effect on functioning than most other medical conditions (Buchanan 2002).
People with HIV who are also diagnosed with a mood disorder have poorer physical health, mental health and wellbeing compared with people with HIV and without mood disorders (Buchanan 2002). The risk factors for people with HIV developing depression include a lack of social support, bereavement and poor relationships with close friends and family (Buchanan 2002). A study was carried out with nursing home residents who were HIV positive, it compared nursing home residents who are HIV positive with depression to nursing home residents who were HIV positive without depression (Buchanan 2002).
Residents with HIV and depression were more likely to be female; experience reduced social interaction or withdrawal from activities of long standing interests; have unsettled relationships; experience conflict with staff, family or friends; have no contact with family or friends; experience delusions or hallucinations; have nutritional problems; experience pain; have unstable health problems or an acute episode of a long term health problem; take more medications; receive a range of treatments and procedures; be evaluated by a mental health specialist; receive group therapy; receive interventions for reorientation; participate in a behaviour symptom evaluation program; and have a range of other diseases and infections (Buchanan 2002). When a person is first diagnosed as being HIV positive they are faced with a range of psychological issues in coming to terms with the illness. Being diagnosed with a stigmatised illness results in HIV positive people believing their identity is insignificant (Lichtenstein 2002). Accepting this change results in a loss of self-esteem and compensatory behaviour, for example passing as normal in an effort to avoid being stigmatised by others (Lichtenstein 2002). There are many gender differences that exist in relation to psychological issues.
HIV positive women are more likely to suffer from depression because they were unaware of being at risk; less likely to be supported by family, partner and friends; more likely to become socially isolated; are caregivers for children or HIV positive partners; and are more stigmatised (Lichtenstein 2002). Women also find it more difficult to come to terms with the illness as they were infection by their male partner who they trusted and feel betrayed and victimised as women assumed their heterosexual status would protect them from risk of infection (Lichtenstein 2002). HIV positive men have more social supports; are less likely to be isolated; are more likely to be supported by family; and men who identify as being gay have supports within the gay community (Lichtenstein 2002). For a person who is HIV positive the diagnosis is not the only cause of psychological distress, the symptoms they experience can also contribute (Siegel 2010).
The acknowledgement of the symptom, the interpretation of the symptom and the limitations the symptoms have on the daily lives can all be sources of psychological distress (Siegel 2010). For example if a symptom is interpreted as a sign of progression of disease in the HIV positive individual, this can lead to negative emotions and psychological distress (Siegel 2010). Uncertainty regarding the cause of symptoms is a distressing issue in middle age and older infected HIV adults (Siegel 2010). The symptoms of an individual with HIV causes psychological distress, depression and affects quality of life (Siegel 2010). How to prevent HIV transmission and the interventions that are effective
There are many intervention strategies that exist in Australia to prevent the transmission of the HIV infection. The first national HIV/AIDS strategy was implemented in Australia in 1989, also Australia’s first national STI strategy was implemented in 2005 (Kang 2010). The purpose of these strategies is reduce and prevent the transmission of infectious diseases and improve the treatment, care and support for those people affected (Kang 2010). These strategies achieved the lowest HIV rates in the world among sex workers, lower rates among injecting drug users and lower rates among homosexual men (Kang 2010). This success was due to harm minimisation approaches, peer education, community participation, and health promotion (Kang 2010).
A study was carried out that reviewed intervention programs that aimed to reduce the transmission of HIV (Kang 2010). Interventions included facilitating direct access to HIV testing in non-health community settings, participation rates ranged from 10% to 90% and there was very high follow up and treatment rates for those who tested positive (Kang 2010). The second intervention facilitated STI testing by encouraging referrals to relevant services (Kang 2010). One intervention signed up young people at a music festival to receive text and email messages about STIs, this resulted in increased STI knowledge among all participants and increased STI testing in females (Kang 2010).
The third intervention observed young people’s knowledge, attitudes and behaviour in response to information, education and training relating to HIV (Kang 2010). One intervention conducted information sessions in schools, this resulted in a significant improvement in attitudes related to HIV (Kang 2010). The forth intervention involved enhanced surveillance to control the transmission of STIs (Kang 2010). In the literature there has been a significant concern in relation to men who have sex with men and women, and the role of these men in the increasing HIV infected women (Kendall 2007). Non-gay identified men feel they lack adequate information about HIV and AIDS.
This is due to HIV and AIDS programs of gay community-based organisations not reaching non-gay identified men who have sex with men (Kendall 2007). The lack of intervention programs for non-gay identified men is a significant issue as they lack the information and knowledge of HIV prevention. The lack of intervention programs are due to the stigma and discrimination that exist in relation to non gay identified men who have sex with men (Kendall 2007). Intervention programs need to be developed that aren’t stigmatising and should consider how men who have sex with men and women perceive sex and the HIV related transmission risk (Kendall 2007). Therefore, developing a program that is non threatening and appropriate.
Another method of preventing HIV transmission is peer interventions; this is beneficial because it is less expensive than individual interventions, information is provided in a culturally appropriate way, peers can communicate with individuals who do not visit health care facilities regularly and peers are familiar with the risks and concerns of the general public (Latkin 2004). Examples of some peer interventions include distributing condoms and safe needles and syringes; and encouraging in depth discussions (Latkin 2004). A study was carried out that assessed peer intervention strategies, the results were that individuals who discussed how HIV affected their lives and also discussed issues with partners, family and acquaintances were more likely to report being HIV positive (Latkin 2004).
Older participants were more active than younger participants in HIV prevention activities; women are more likely to engage in HIV prevention conversations; and drug users were less likely to communicate with others regarding HIV prevention and were less likely to participate in HIV prevention activities (Latkin 2004). Treatment Antiretroviral treatment should be started when the CD4 count drops below 350; if there is a history of an AIDS defining illness; if HIV symptoms are severe; and women who are pregnant to reduce the risk of transmission to the foetus (AFAO 2008; Phillips 2007). There are many reasons why antiretroviral treatment is delayed this is due to adverse effects, such as headaches, nausea, diarrhoea, toxicity, pancreatitis, hypersensitivity reactions, acute hepatitis, lactic acidosis and myocardial infarction (Murri 2005; Phillips 2007).
Other reasons why treatment is delayed is due to the minimal risk of an AIDS illness developing if CD4 counts are above 250; the fear that staring antiretroviral treatment too early could lead to exhaustion of all treatment options due to resistance; difficulties in adherence; and immune function can be restored even if CD4 count is low (Murri 2005; Phillips 2007). The benefits of immediate therapy are it prevents the destruction of the HIV specific CD4 host response, lowers the viral load, reduces the severity and duration of symptoms associated with HIV, reduces the likelihood of viral evolution, reduces the distribution of HIV to sanctuary sites and reduces HIV transmission to others (Smith 2004).
The disadvantages of immediate treatment include extended exposure to toxicity and development of viral resistance due to poor adherence as patients are confronted with psychological issues in relation to a positive diagnosis (Smith 2004). Studies have confirmed that treating primary HIV infection improves disease progression rates when compared to no treatment (Smith 2004). However, a huge disadvantage of starting treatment early is the risk of exhausting treatment options, as mutations result in resistance to antiretrovirals (Murri 2005). Non-adherence to the strict medication regime leads to failure of an antiretroviral regime and resistance develops (Murri 2005).
There are six classes of antiretrovirals, their purpose is to stop the virus from replicating, therefore protecting the immune system from damage (AFAO 2008). The classes of drugs include nucleoside reverse transcriptase inhibitors, non-nucleoside reverse transcriptase inhibitors, protease inhibitors, fusion inhibitors, integrase inhibitors and CCR5 entry inhibitors (AFAO 2008). Highly active antiretroviral treatment (HAART) is a combination of at least three of these drugs; studies have shown significant reduction in disease progression in HIV positive people treated with HAART compared with HIV positive people treated with two medications (Sterne 2005). A study showed that HAART reduces the rate of progression to AIDS or death by 86% (Sterne 2005).
HARRT has increased the life expectancy for HIV positive people, reduced the amount of deaths related to opportunistic infections and also improved quality of life (Sighem 2003). Reaching undetectable levels of viral load and a high CD4 count during treatment with HAART are associated with a better prognosis (Sighem 2003). Also young patients starting continuous HAART at a primary HIV stage have a 90% chance of surviving 5 years (Sighem 2003). One of the main issues of antiretroviral medications that have the most impact on the HIV positive person is the side effects that come with treatment. This may affect adherence but it’s important to inform patients the risks of non-adherence and resistance.
Some of the adverse side effects include nausea, diarrhoea, nerve damage, rashes, vomiting, jaundice, disturbed thinking, nervousness, anaemia, changes is body fat distribution (lipodystrophy), nightmares, peripheral neuropathy, fatigue, muscle pains, changes in menstrual patterns, and changes in blood sugar and cholesterol levels (AFAO 2007). Medication adherence The most important predictor of success in treating HIV is the adherence to antiretroviral treatment (Wilson 2004). Non adherence results in treatment failure due to the development of resistant mutations (Godin 2005; Wilson 2004). For a good outcome to be achieved adherence rates need to be at least 95%.
Failure to meet the strict medication regime results in breakthrough of the virus, increased viral replication, increased viral load and the forming of drug resistant HIV strains (Godin 2005; Hinkin 2004; Johnson 2009; Lopez 2010). High adherence rates result in decrease in viral loads, and improved functioning of the immune system (Johnson 2009; Lopez 2010). Treatment adherence begins to decline when the number of medications increase; when the dosing frequency reaches 4 times a day; and when the duration of treatment is prolonged (Godin 2005). Therefore to improve adherence rates health professionals should attempt to design medication regimes with the least amount of medications, a dosing frequency of once or twice a day and defer the commencement of treatment for as long as possible.
Barriers to medication adherence can include illicit drug use, poorly organised lifestyle, low self-efficacy, negative attitude, living alone, low perception of social support, poor relationship with doctor, side effects, erratic routines, loss of income, fear in disclosing HIV status to others, partner violence and depression (Godin 2005; Lopez 2010; Wilson 2004). HIV positive people are more likely to be adherent if they have a high perception of self efficacy, a positive attitude about their medication, a high perception of social support and were satisfied with the relationship with their doctor (Godin 2005). Medication adherence is dependant on the HIV positive person opinion on the benefits of taking the medication and desired effects (Godin 2005).
For improving medications adherence interventions should involve reinforcing self-efficacy, forming a positive attitude about the medications, build positive trusting relationships between patients and health professionals and promoting social support by developing group interventions (Godin 2005). HIV positive older adults are more likely to be successful in improving adherence if adaptive coping strategies, social support and effect are enhanced (Johnson 2009). Health professionals can improve the lives of HIV positive older adults by encouraging them to seek social support, including online or telephone based support groups which can reach out to patients who feel isolated by their diagnosis (Johnson 2009).
In HIV positive older adults neurocognitive deficits have been associated with decreased adherence, including deficits in function, memory and attention (Hinkin 2004). Older adults with cognitive impairment also have increased difficulty in adhering to complex medications regimes (Hinkin 2004). A model has been formed which describes the changes in cognitive thinking which needs to take place in order for a change in behaviour and therefore medication adherence to occur. This model suggests that when someone is engaged in changing controlled actions and behaviour they also need to engage in ‘process-regulating cognition’ (Godin 2005). According to this model the individuals needs to go through a series of cognitive processes to engage in self-control behaviour (Godin 2005).
This involves firstly noticing a disruption in their way of thinking (acknowledging they are HIV positive), evaluating the change in behaviour important for wellbeing and quality of life, believing that the action or behaviour will result in a desired outcome and a positive attitude that they will be able to make the change (Godin 2005). Conclusion In conclusion HIV/AIDS is a life changing illness that has severely debilitating consequences on the individual psychologically, physically and emotionally. A HIV positive diagnosis can affect all aspects of a person’s life and psychological issues can arise such as depression due to stigma and fear of death. The HIV positive person feels isolated, lacks social support, feels guilty, fears their partner and family will reject them and faces challenges in disclosing their HIV status. Having a committed long term relationship and also starting new relationships also becomes an issue due to risk of transmission of HIV.
The HIV positive person is then confronted with the issue of disclosing their HIV status and fear of how their partner will react. As there is no cure for HIV there should be more emphasis on prevention and intervention programs. This should involve educating HIV positive people and the general population and should not stigmatise or isolate groups. Education and intervention programs should reach heterosexual people; homosexual people; men who have sex with men and women; non gay identified men who have sex with men; and sex workers. This would involve education and interventions not only implemented in the gay community but also in hospitals, clinics, and non health community settings.
The treatment for HIV/ADIS is still not well understood, there are conflicting ideas in relation to when treatment should be started and the strategies to prevent treatment exhaustion. However, there is evidence regarding the importance of adherence to the strict treatment regimes in order to prevent treatment failure due to the development of resistant mutations. Adherence to the medication regime is influenced by a variety of factors including side effects; the belief that the treatment will result in a desired outcome; the number of medications and dosage frequency; attitude; living arrangements; social support; income; disclosing of HIV status; partner violence; depression; lifestyle; self-efficacy; relationship with doctor; daily routines; partner violence; and neurocognitive deficits.
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