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Starting HIV Care

CE / CME

Starting in Care: Ensuring HIV Services Are Inclusive and Equitable

Nurses: 0.75 Nursing contact hour

Pharmacists: 0.75 contact hour (0.075 CEUs)

Physicians: maximum of 0.75 AMA PRA Category 1 Credit™

Released: August 05, 2024

Expiration: August 04, 2025

Ofole Mgbako
Ofole Mgbako, MD
CME/CE Information

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Welcoming Care Starts When They Walk Into The Building

Welcoming a person with HIV into care begins the moment they step into the building. This includes everything from how they are greeted at the security desk to the reception they receive from front desk and clerical staff, who should know their names and express enthusiasm for their visit. This welcoming atmosphere extends to those handling their bloodwork and blood pressure, the nurses checking for acute issues, and finally, the doctor.

Click here to hear from Angelina Namiba, founder member of 4M Network, a peer mentoring project working with Mentor Mothers living with HIV, as she describes how a simple smile can go a long way.

It is vital to have an integrated team approach where everyone respects the identities of the person seeking care. Small gestures, such as displaying pride or trans flags, can show support to people who often face societal challenges. Emphasizing confidentiality and repeating that the visit is both an open and private space allows patients to share their needs freely.

Click here to hear from Dr Terri D. Wright, Adjunct Professor at Emory University’s Rollins School of Public Health, as she describes the importance of confidentiality, dignity, and respect.

Some patients, such as those with disabilities, require extra support. Ensuring resources are in place to accommodate their needs is essential for building trust and connection. For instance, failing to provide access for people who use wheelchairs can quickly erode trust.

Seeing the doctor is a critical part of the visit but not the only part. Patients often focus on this and may feel nervous. Staff members like phlebotomists or medical assistants should check in with patients and ask if there’s anything they want the doctor to know beforehand. This approach helps break the ice and provides the physician with insights into the patient's concerns, making the encounter more productive and reassuring for the patient.

Trauma-Informed Approaches to HIV Services

The adoption of trauma-informed approaches is rapidly expanding in healthcare and the social service settings. In this context, trauma is broadly defined as experiences that cause intense emotional pain, fear, or distress, often leading to long-term physiologic and psychological effects. Traumatic experiences, particularly in childhood, can alter brain structure and contribute to persistent physical and behavioral health challenges.

Applying a trauma-informed perspective is essential for addressing the HIV epidemic in the United States. Research indicates that individuals living with HIV often have significant histories of trauma compared to the general population. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 70% of individuals living with HIV have experienced trauma, making them 20 times more likely to have experienced trauma than the general population.

Trauma-informed care is a critical concept in health and medicine. This approach assumes that patients may have experienced trauma. For those who have experienced trauma, it is crucial to provide the necessary psychological support and care tailored to their needs.

A trauma-informed approach offers a structured way to ensure that healthcare settings are prepared to support those with a history of trauma. It guides us in gathering sensitive information and recognizing opportunities to address trauma.

Building and maintaining these relationships is essential, as trauma is not something resolved in a single visit. It requires a process that is shared between provider and patient, with ongoing care and understanding.4

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When considering a trauma-informed approach to care, you should:

Inquire about HIV Diagnosis

After establishing rapport with the patient and once they’ve navigated through various parts of the clinic and interacted with different staff members, it is crucial to approach their HIV diagnosis with sensitivity.

Many people with HIV may have had traumatic experiences related to their diagnosis, whether it was disclosed insensitively by a provider or shared with others before they were ready. Understanding the circumstances of their diagnosis, how they coped, and who supported them is essential.

People with HIV often face higher rates of social isolation and loneliness due to stigma. For younger people with HIV, identifying supportive individuals in their lives, if not their parents, is vital. For older people with HIV, screening for social isolation is important, as many may have lost friends to HIV/AIDS, which can be a predictor of morbidity and mortality.5,6

In addition, it is important to ask if they have experienced discrimination related to their HIV status, as some may have lost jobs, relationships, or been disowned by loved ones. Understanding their major risk factor for transmission, whether related to sexual practices or drug use, helps in counseling and creating a safe space

Screening for difficult relationships that might hinder their care or medication adherence is also crucial. People in discordant relationships who haven’t disclosed their status, or those experiencing intimate partner violence, may face significant barriers to consistent care. Identifying these issues allows for appropriate interventions to support the person’s overall well-being.6,7

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6 Ps for Sexual Behavior History Taking: Important for All People, No Matter How Old

HIV is predominantly a sexually transmitted infection, making an effective sexual history vital for establishing a good relationship with the patient and providing the best care. Many providers lack training in taking sexual health histories. There are multiple screening tools/rubrics available. One useful approach is the 6 Ps8:

  • Partners: Understand the nature of the person’s relationships—whether exclusive, nonexclusive, monogamous, or nonmonogamous.
  • Past history of sexually transmitted infections (STIs): Inquire about previous STIs, testing, treatment, and frequency of diagnoses.
  • Protection from STIs: Ask how they protect themselves from STIs, their vaccine history, and if they've used preventive measures like doxycycline postexposure prophylaxis (doxy-PEP).
  • Practices: Discuss their sexual practices (anal, oral, vaginal) to address specific health needs, like anal cancer screening, etc.
  • Pregnancy and contraception: Address concerns about having children and provide information on safe pregnancy planning.
  • Plus: For people engaged in sex work, ensure they feel safe and supported.8

STI rates increased significantly over the past 5 years (80% increase in syphilis).9 This rise isn't limited to young people; rates are also increasing among those over 50. It is essential to screen all patients for STIs, regardless of age.10

During conversations, it is critical to find opportunities for patient education about how HIV affects the body and the advancements in treatment. I often ask patients what they know about HIV and their experiences with it, ensuring they understand that people living with HIV can have the same life expectancy as those without it, thanks to effective treatments.8

The concept of U = U (Undetectable = Untransmittable) is particularly important. Many people with HIV are surprised to learn that if they remain undetectable for more than 3 months, they cannot transmit the virus to their partner through sexual intercourse. This knowledge can be liberating and significantly reduce internalized stigma.11

Teaching people about U = U can decrease stigma by alleviating the fear of transmitting HIV to others. This not only provides peace of mind but also allows people with HIV to share this truth with their community, offering a public health benefit.8

Click here to listen to audio from Hanna Tessema, DrPH, MPH, MSW, Co-founder of the Black Women's Learning Institute, as she describes the importance of U = U.

Explaining the reasons for starting medications immediately after diagnosis is also crucial. This approach leads to faster immune recovery and shorter time to viral suppression. In addition, discussing potential side effects, such as weight gain with newer antiretrovirals, prepares people for what to expect.

For people with other infectious diseases like hepatitis B or C, a syndemic approach is necessary, understanding how each infection impacts the management of the other and explaining this clearly to persons with HIV.

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