HIV / AIDS Course > Chapter 4 - Treatment Issues

Chapter 4: Treatment Issues

IV. Treatment Issues

A. Physical Treatment

1. Treatment Adherence Issues

As a result of their difficult emotional response to the infection, HIV treatment adherence is an issue to be addressed. Different character disorders, mood disorders or pre-morbid thoughts can deter treatment adherence. Medical treatment adherence in particular becomes one of the most crucial issues in treating HIV positive patients as it so directly affects quality and length of life. Stress can also be debilitating to the infected individual as it both has shown to contribute to the greater breakdown of the immune system, and may€ exacerbate already present mood issues.

Although this section discusses physical treatment of HIV/AIDS, there is a strong psychological component to the treatment. Physical treatment focuses on containing the spread of HIV in the body and prevention of opportunistic infections which result in AIDS. Early and consistent adherence to the physical treatment regimen is crucial to maintain the health of the infected individual. As "with many diseases, whether chronic or acute, psychological issues can have a great impact on the patient's willingness to adhere to treatment."(Miramontes and Frank, 2005)

Psychiatric illness impairs the client's ability to adhere to treatment. Health care providers need to be cognizant of the importance of appropriate psychiatric evaluation and treatment to enhance the client's treatment adherence. Depression, anxiety, psychosis, dementia, and personality disorders interfere with the client's ability to adhere. Psychiatric illness requires psychiatric treatment. Many providers of HIV care are inexperienced and lack expertise in treating psychiatric disorders. These providers need to seek consultation and/or refer clients to appropriate providers.

2. Viral Load, CD4 Cell Count and When to Begin Medical Therapy

In the previous section of assessment the topic of viral load and t-cell count were addressed in helping to determine the progress and potential of the disease. In this section we take the information of the assessment to determine when medical personnel might implement physical/medical interventions based on those assessments.

(From Project Inform)

In late 2000, a panel of researchers revised suggestions for how to use anti-HIV therapy based on CD4 cell count and viral load information.

In people with viral load levels more than 30,000-50,000, regardless of CD4 cell count, treatment may or may not be started. A conservative approach recommends more frequent monitoring of CD4 cell counts without anti-HIV therapy, a more aggressive approach recommends offering therapy. Therapy, regardless of the absolute CD4 cell count, may be justified if trend in CD4 cell count decline is dramatic.

Research strongly confirms that anti-HIV therapy benefits people with CD4 cell counts below 200, optimally started when counts fall to 200, regardless of viral load levels. Other research suggests that therapy may be beneficial if started when CD4 cell counts are between 200 and 350. With CD4 cell counts between 200 and 350, considering other factors like viral load, trend in CD4 cell count decline and overall general health, may influence an individual to start anti-HIV therapy when CD4 cell count is above 200. It is unknown if starting anti-HIV therapy when CD4 cell counts are above 350 will provide an individual long-lasting benefits that outweigh concerns about potential short- and long-term side effects of current anti-HIV therapy options.

There have been some cases of people with low CD4 cell counts, and low to undetectable HIV RNA levels, not on anti-HIV therapy. There are no clear guidelines on what to do in this setting. Doctors report that when they start three-drug therapy in these individuals, they see rises in CD4 cell counts. It may be that the anti-HIV combinations are affecting virus in harder to access regions, like lymph nodes. (Project Inform, 2005)

3. Treatment And Prevention Of Specific Opportunistic Infections

As previously mentioned, when a person is infected with HIV they become susceptible to many opportunistic infections. Many of these diseases can either be prevented, or the likelihood of infection greatly decreased with the right care.

Medical Intervention

For medical intervention to prevent or reduce specific opportunistic infections the Center for Disease Control suggests as examples the following as found at the San Francisco AIDS Foundation (SFAF) Website (2005)

"Pneumocystis carinii pneumonia (PCP) used to be the leading cause of death for people with AIDS in the United States. With the advent of new medications, it is now nearly 100% preventable:

The CDC recommends PCP prophylaxis for anyone whose T-cell count falls below 200 or has an unexplained fever for more than two weeks, or has thrush. Until recently, aerosol pentamidine (pentamidine breathed directly into the lungs via a mask) was the prophylaxis of choice. Current guidelines suggest Septra (also called Bactrim or trimethoprim), a systemic prophylaxis which is taken orally, as the primary choice, with dapsone or pentamidine as an alternate.

Other infections where prophylaxis is recommended as a preventative measure includes:

Mycobacterium tuberculosis (TB): Tuberculosis is also a life-threatening lung infection. Prophylaxis is recommended if someone has a positive PPD ("skin test") which is greater than 5 mm in size, or if they have been exposed to someone with active TB, or if they have had prior positive PPD without treatment.

Toxoplasmosis or "Toxo": People who have been exposed to Toxoplasma gondii develop antibodies to it, just as they do with HIV. Anyone with a CD4 (T-cell) count below 100 who also has antibodies to Toxoplasma should be taking Septra. Conveniently, this medication is also used to prevent PCP."

Recommendations are made on a case by case basis, dependent on the t-cell counts and the likelihood that a person has been exposed to a possible infection.

Diet and Nutrition

Another important part of treatment is diet. With the immune system already under great stress, it is important that the diet help to strengthen the immune system as much as possible.

The following guidelines and suggestions come from SFAF (2005):

Nutrition

"With HIV disease, the immune system is under great stress. Eating a balanced diet based on a variety of foods will help strengthen the immune system and maintain body weight at an optimum level. A balanced diet is based on selecting foods from the four basic food groups: proteins, fruits and vegetables, breads and grains, and dairy products. Because some AIDS-related conditions affect the ability to eat and some treatments have dietary restrictions, it is important to consult a physician and an HIV-knowledgeable dietitian to ensure adequate nutrition, which is individualized and appropriate.

People with HIV disease are encouraged to eat a balanced diet high in protein and calories, which the immune system requires to fight illness. Most people with symptoms of HIV disease need up to 3,500 calories per day. They also need one and a half to two times the normal protein requirement of other people (as much as 130 grams per day).

Protein foods

The immune system requires complete proteins in order to form antibodies and repair tissue damaged by illness. Complete protein foods include meat, fish, fowl, eggs and meat substitutes. These foods are also good sources of B vitamins and iron.

Legumes, when combined with grains also provide complete protein. Examples of legumes include soybeans, lentils, peanuts, peas, and beans. Legumes should be eaten with rice, wheat and other grains to get the same quality protein provided by meat.

Fruits and vegetables

Fruits and vegetables provide a wide variety of vitamins and minerals, but generally are not rich in calories. Some exceptions include bananas, yams, sweet potatoes and avocados. Adding sauces and dairy products to fruit and vegetable dishes also increases calories.

Breads and grains

Breads and grains are good sources of carbohydrates, fiber, B vitamins and some minerals. They also complement beans and other legumes to make a complete protein meal. Many people eat unprocessed whole grains to get the full nutritional value. Whole wheat products and brown rice are examples of high fiber unprocessed foods.

Dairy foods

Dairy foods provide calcium, protein, vitamins and fat. Adding dairy products to other foods can substantially increase protein and calorie intake. People who have trouble digesting dairy products can use low-lactose dairy or soy products.

Fats and sugars

Fats and sugars add calories, which can be important for people with HIV, especially if they are experiencing weight loss (wasting). High fat and sugary foods can aggravate symptoms of some opportunistic infections, so people should test their tolerance for fats and sugars before consuming a lot of them.

Junk food

Many dietary guidelines for the "average person" do not hold true for people with advanced HIV disease. Some types of "junk food" can actually be good sources of protein and calories. Pizza, hamburgers, tacos and ice cream are made from bread, meat, dairy and vegetable sources. On the other hand, foods like candy, cookies, soft drinks, and cakes provide calories but are not very nutritious. They can be added to a high calorie diet to counteract weight loss, but it is best to eat them after eating foods that are more nutritious.

Vegetarian diet

Many different types of vegetarian diets have been put forward as healthful, or even therapeutic for people with various illnesses. Dietary improvements and modifications are often necessary when someone is ill. Some published books have claimed a dietary "cure" for AIDS. Vegetarian diets have certain benefits, but also present several potential problems to people with HIV disease.

Maintaining weight is so important for most people with HIV disease that a low calorie diet can actually threaten their ability to survive. Some vegetarian diets are too low in calories and protein to sustain someone with HIV disease for an extended period of time. The macrobiotic diet is one example, although some people report they have received great benefit from this diet.

A high calorie, high protein vegetarian diet can be designed using soy protein products, such as soy milk, tofu and tempeh, which substitute for meat, fish and fowl. These items are available in many large supermarkets and health food stores. Legumes and grains can also be combined to get the same quality proteins provided by meat. Beans or lentils combined with rice, hummus and pita bread, bean burritos, and peanut butter on whole wheat bread all provide protein, fat, and B vitamins.

Vitamin and mineral supplements

The vitamins that are most vital to the immune system include A, B, C and E. Iron, zinc, magnesium, copper and selenium are important minerals. There are recommended doses for each of these vitamins and minerals, and many experts caution against exceeding them. Some vitamins and minerals can even cause health problems if taken in large doses. For example, high doses of vitamin A can cause liver damage. Some nutritionists suggest carefully monitored vitamin and mineral doses which exceed normal limits, explaining that a body fighting HIV disease has additional needs. It is wise to discuss options with a qualified nutritionist and to read up-to-date literature on nutritional supplements and HIV. Never rely on nutritional supplements to take the place of a well-balanced diet."

4. Antiretroviral Therapy (ARV)

ARV is the pharmacological response to HIV/AIDS. It is a subject that involves many studies and medications, regimens and treatments. The purpose of this section is to provide the healthcare professional with a basic understanding of what ARV is, when it might be administered and what its purpose is. The HIV-positive individual, if they have not already done so, should be referred to a knowledgeable doctor who can counsel with them and prescribe for them the appropriate ARV regimen. The healthcare professional needs to encourage that patient to get the medical attention necessary and to adhere to the treatment prescribed. Adherence to this therapy is one of the key objectives in counseling anyone with HIV/AIDS.

What is Antiretroviral Therapy?

Antiretroviral therapy (ARV) is the pharmacological treatment that is used to combat HIV/AIDS. An antiretroviral medication is"substance that stops or suppresses the activity of a retrovirus such as HIV. AZT, ddC, ddI and d4T are examples of antiretroviral drugs." (Dark, 2005) These medications are often used in combination. New trials are constantly being run to find more effective medications. For a list of medications and the explanation of how they work go to the United States Department of Health and Human Services (DHHS) Website here: http://aidsinfo.nih.gov/drugs/alldrugs.asp?#a

When should ARV be started?

Therapy should begin before the CD4 (T-cell) count goes below 200 cells and not until after it is below 350 cells. (DHHS, 2005)

What is the goal of ARV Therapy?

The goal of the therapy is to prevent further deterioration of the immune system and prevent death. (DHHS, 2005)

[QN.No.#18. What is the purpose of Antiretroviral therapy (ARV)?]

ARV as a Prevention Tool

Currently there are no vaccines for HIV, however, current studies are focusing on the possible role certain ARV medications can play in reducing the likelihood of prevention. The CDC is currently encouraging clinical trials of the ARV medication tenofovir disoproxil fumarate (tenofovir, brand name Viread). This medication is taken daily as an oral preventative and may serve to reduce the likelihood of transmission of HIV. (CDC, April 2005)

What is TMP-SMX?

As mentioned above, it is advised that ARV therapy begin before the CD4 cell count falls below 200 cells. If the HIV infection gets worse and the CD4 count fall below 200, then the patient is at further risk of getting more infection. A "doctor will prescribe TMP-SMX (trimethoprim-sulfamethoxazole [try-METH-o-prim - sul-fa-meth-OX-uh-zole]) - also known as Bactrim, Septra, or Cotrim - or other drugs, to prevent PCP [Pneumocystis Carinii Pneumonia]."(CDC, May 2005).


B. Treatment of Social Issues

As mentioned in the assessment of sociological issues related to HIV, those so diagnosed often suffer a range of social challenges including rejection, loss of intimacy and other relationships, loneliness and ridicule. These issues are often contributing causes to emotional and psychological issues, and also serve to impede the desire of the client to adhere to treatment. The objective for the healthcare professional in treating these issues is to first have a clear assessment of what the individual is going through. Having done that, the healthcare professional can set up a plan with the individual in managing and resolving these issues.

1. Empowerment

One of the first and most important steps to social intervention is empowerment. Work with the client to find out what their goals are as far as social interventions. The client may be feeling helpless and seeking their input can go a long way in resolving that feeling. When they are able to see a path and set goals, it gets them forward thinking to a positive outlook for the future, supplying them with a great resource that is often in short supply for people with serious diseases such as HIV: Optimism.

2. Intervention versus management

We discussed the possible positive and negative effects that come from disclosure. Unfortunately, the reactions of loved ones can be difficult to predict, but the patient and practitioner can work together to determine who to disclose to and prepare for the possible effects of doing so. Some of the reactions to disclosure can be improved through interventions, while others, where the reaction is poor, the situation can only be managed. This is illustrated in the following case:

John grew up in a very conservative and religious family where strict moral values had been passed down through multiple generations. John's family life was close andhappy. John played sports in high school and was very popular. He went through the motions of his religious upbringing, was very active in church activities, went to many of the school dances with girls, and by everybody's account had no struggles regarding sexual preferences. As he grew into adulthood, and went to college away from home, John began having intimate relationships with other young men, and also began to experiment with drugs, including intravenously. When John was diagnosed as HIV positive, he was very hesitant to tell his parents. Telling them would open up a lot of questions, questions that he knew he wanted to answer honestly, but he was hesitant because of what their reaction might be. As a result of his diagnosis, many of John's associates at college began to distance themselves in subtle ways. He was invited to fewer parties and those he spent time with before were suddenly busier in their studies. John's social support was rapidly deteriorating at a time when he needed the support more than ever before. At this point, he went to see a licensed therapist as he was having difficulty coping and did not know what to do.

Although it was explained to John that the fact he had HIV was and could be kept confidential from his family, he wanted to tell them. He wanted their support and was willing to risk the rejection. Initially the therapist prepared John with the different scenarios of possible reactions his family might have, their probable questions, and role played with him giving answers and responding to their reactions. This helped prepare him for the obvious shock and the possible anger and rejection that his family might have about the news.

On the night John told his parents, they were shocked, they were saddened, they were upset, but they did not reject him. It was a lot for them to take in; however, they loved their son, and their greatest concern was for his well-being. John invited them to go with him to see a therapist together, which they agreed to do.

In the sessions with the family the therapist was able to educate the family to a greater extent about the disease, how it progresses and how it could, and could not, be transmitted. Other objectives and interventions included helping John and his family work through their feelings about John's new lifestyle, providing them resources, and empowering them as a family to help John as he deals with the different stages of the disease.


Case notes:

As the case begins it would be easy to jump to the conclusion that John would never be welcomed around his home again. He had gone against the norms and values of his family to the extreme. Families are greatly defined by their values and norms, and John no longer fit within those norms. Not only was his behavior unacceptable, but now he was also carrying a deadly, contagious disease.

These circumstances illustrate the importance of taking clients as individuals and respecting their decisions. The therapist could have used all elements of power and persuasion to convince John not to tell his family, and to avoid the seemingly imminent rejection that would be coming his way. Truthfully, that very well could have happened, but John, having grown up in his family, knew and understood his parents and family better than the therapist. John knew of the possibility that his family would be there for him, and the therapist was wise in allowing and helping John prepare for telling his family. Such scenarios serve as a reminder that therapists should not make decisions for clients, but to help the client see alternatives, consider the consequences of such, allow them to make a decision, and then to help them follow through with that decision (with the presumption of course that the decision falls within ethical guidelines).

This case called for interventions with the family and John because the family made themselves available to such. In the same scenario, if they had rejected John outright, then it would be a matter of managing John's feelings in regards to his family, as interventions with the family would not be available. Further interventions would include finding sources of social support.

In treating social issues with HIV there are times when interventions in current relationships are not possible as a result of the unwillingness of one of the individuals to participate, or because particular resources are not available. At that point, management of the circumstances becomes an objective as well as the intervention of broadening support services available to the client.

3. Resources for Individuals, Friends and Families

The following is a list of a few online resources available for individuals, friends and family members who have been affected by HIV/AIDS. Many websites also provide links to other sites. It should be noted that throughout the United States there are local hotlines, clinics and organizations. Professional healthcare providers should be aware of these local resources in order to link the clients to them.

List of some online resources:

AIDS Project LA: www.apla.org

AIDS Education Global Information System (Aegis): http://www.aegis.com/topics/oi/

The Center for Disease Control: www.thebody.com

New Mexico AIDS InfoNet : http://www.thebody.com/nmai

Project Inform: www.projectinform.org/fs/HIVDiagTest.html, (May 9, 2005)

San Francisco AIDS Foundation: www.sfaf.org

UNAIDS Organization: www.unaids.org

United States Food and Drug Administration (FDA): http://www.fda.gov/oashi/aids

United States Department of Health and Human Services (DHHS): http://www.aidsinfo.nih.gov/


C. Treatment of Psychological and Emotional Issues

Miramontes and Frank (2005) provide the following list of support interventions as it relates to the psychological response to HIV:
  • Educate about the disease and treatments
  • Educate about the importance of adherence
  • Explore impact of symptoms & how treatments impact activities of daily living
  • Explore impact of symptoms and treatment on self-image and psychological state
  • Tailor treatment to lifestyle
  • Assist in developing coping skills
  • Anticipatory planning and problem solving
  • Educate about community resources

1. Education and Coping Skills

a. Educate about the disease and treatments

The information in this course along with the links to other websites provide the information necessary for the healthcare practitioner to educate individuals, families and friend about HIV/AIDS. It is important to help the individual, along with assistance of medical personal, to understand what the disease is, how it can be transmitted, how it progresses and to dispel any misinformation and myths that exist.

b. Educate about the importance of adherence

The issue of adherence has also been covered in this course. With the progress of medications in treating the disease, life expectancy has greatly increased. The quality of life and life expectancy are very dependent on the client adhering to treatment therapies, including nutrition and ARV regimens.

It is also important that if the person is suffering from psychiatric illness that they get the necessary treatment to continue adherence:

"Psychiatric illness impairs the client's ability to adhere to treatment. Health care providers need to be cognizant of the importance of appropriate psychiatric evaluation and treatment to enhance the client's treatment adherence. Depression, anxiety, psychosis, dementia, and personality disorders interfere with the client's ability to adhere. Psychiatric illness requires psychiatric treatment."(Miramontes and Frank, 2005)

c. Explore impact of symptoms & how treatments impact activities of daily living

Along with the progress of HIV comes the physical symptoms attached to it. These symptoms will impact everyday life functioning, besides the discomfort of feeling and being sick and in pain. Symptoms of HIV include:
  • breathing problems
  • mouth problems, such as thrush (white spots), sores, change in taste,dryness, trouble swallowing, or loose teeth
  • fever for more than two days
  • weight loss
  • poor vision or "floaters"(moving lines or spots in your vision)
  • diarrhea
  • skin rashes or itching

In addition to these symptoms that impact lifestyle are the myriad of treatment and invasive lifestyle changes necessary for the HIV positive individual to be healthy. This includes concerns regarding eating, sleeping, working, cleanliness, medication schedules, doctor appointments, blood tests, all in addition to the impact of the physical symptoms that occur from the disease. It involves a pretty drastic change in many facets of a person's life.

On the other hand, it should be pointed out that some of these changes can be seen as positive: eating healthier, better sleep habits, cleanliness and exercise are prescribed habits for all people wishing to have a healthy lifestyle.

d. Explore impact of symptoms and treatment on self-image and psychological state

As we discussed earlier, anxiety and depression are common emotional symptoms for HIV positive clients. As the physical symptoms of the disease become more severe, issues of self-image and psychological state may have a greater negative impact. Rashes, embarrassing accidents from diarrhea, severe weight loss and visible skin rashes can all impact self-image. It will also create concern for how others see them. These, the constant management of such symptoms, and having to abide by treatment day in and day out, can wear on the coping skills.

The therapist should be empathetic towards the clients concerns about their changing body and the difficulty dealing with the constant barrage of issues they must handle. But, understanding, although necessary and important, is not all that is needed. To help the client create a more problem-solving type of coping there also needs to be some empowerment. Client should be helped to see how they have control over their lifestyle and still a lot of control over their health. Efforts of compliance to treatment should be recognized and praised. Small victories should be celebrated.

Generally, helping the client reframe the symptoms and developing a plan of motivation and empowerment will help with the client's self-image and confidence. If it is assessed that the client is becoming increasingly self absorbed by focusing on the negative things happening, it may be useful to provide the client with opportunities to help others in some way. Taking the focus off of one's problems and taking on a helping role can boost confidence, self-image, and mood.

The emotions and psychology of the person, which can include anxiety, depression, and others, can also be helped with journal writing. Used to help clients with anxiety and mood disorders, it can be both a great way to reinforce progress, express feelings, organize thoughts and set goals. It helps to clear the mind and make things become more manageable.

d. Tailor treatment to lifestyle

As much as possible, the treatment of individuals should be tailored to that persons current, or desired lifestyle. This may include a doctor to consider times of medical doses, doctor's appointments, testing, etc. The fewer things that have to be changed in the daily routine and typical activities of a person with HIV, the less stress for that person, and the greater likelihood for treatment adherence.

e. Assist in developing coping skills

Coping skills have been mentioned in regards to managing the many stressors and changes in the daily routine for the person with HIV. Coping skills can be enhanced through education of the disease and treatment, empowerment strategies, strength-base interventions, cognitive reframing, broadening resources and referrals to support mechanisms and groups. The enhancement of coping skills will help keep stress, a contributor in lowering immune strength, at a more manageable level, reducing anxiety and increasing mood and optimism.

f. Anticipatory planning and problem solving

Anticipating what will occur with time in HIV will allow the client to prepare themselves physically, emotionally and mentally for their occurrence. As iterated, clients need to be educated regarding accompanying symptoms of the disease, what tests will be taken, what different test results will signify, AVR therapy, and general impact on lifestyle. Being able to anticipate and put a plan in place beforehand will help the client manage the impact of the disease. This is part of the empowerment strategy in helping the client cope with the disease.

There may also come a time when preparations must be made for greater debilitating symptoms that require greater medical care and even the possibility of death. Having these issues planned ahead of time will make them much more manageable when they occur. It will also allow greater thoughtfulness in making those plans rather than when they are done in the heat or emotions of the moment. Because some clients will experience a severe decline in neurological functioning, it is important for them to be clear about their desires for treatment and care issues prior to when their ability to make clear decisions is past.

This may include the help of an attorney to consider living wills, do not resuscitate orders, and other end of life decisions.

g. Educate about community resources

As mentioned, the healthcare professional needs to be aware of community resources so that they can link their clients to them. There is great support in the communities for people with HIV. This support will go along way in helping the patient's biopsychosocial adjustment to the disease.

2. Cognitive Approach

Cognitive therapy is one of the more common therapies used to help with depression or other pessimistic thinking that can be so harmful to clients with AIDS. If not contraindicated by a client's mental capacity, it can be effective in alleviating or lessening the depressive symptoms. In cognitive restructuring the professional helps the client replace faulty thinking or misconceptions with beliefs and thoughts that are more aligned with reality and lead to enhanced functioning. The therapist helps people improve their self-dialogue and educates them that it is this inner dialogue that is affecting their depressed mood. In cases working with the HIV client, much of the dialogue may be pessimistic and negative about the client's life situation, and feeling of complete hopelessness. It is important to replace these with some optimism about treatment and that how they behave and think can make a difference in their health and their happiness.

[QN.No.#15. Cognitive restructuring in therapy with HIV patients primarily focuses on:]

The following steps are useful in cognitive restructuring:

  • Assist clients to accept that their statements and beliefs affect their emotional reactions to life's events.
  • Assist clients to identify dysfunctional beliefs and patterns of thoughts that underlie their problems.
  • Assist clients to identify situations that engender dysfunctional cognitions.
  • Assist clients to substitute functional self-statements in place of self defeating cognitions.
  • Assist clients to reward themselves for successful coping efforts.
( Cormier and Cormier 1979)

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Question No.15. Cognitive restructuring in therapy with HIV patients primarily focuses on:

a. Behavioral patterns
b. Thought patterns
c. Feelings
d. The patients relationship with their mother

Question No.18. What is the purpose of Antiretroviral therapy (ARV)?

a. To cure HIV
b. To act as a vaccination against HIV
c. To prevent further deterioration of the immune system and prevent death
d. Specialized aromatherapy

 
HIV / AIDS Course > Chapter 4 - Treatment Issues
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