While nurses in developed countries benefit from many additional resources compared to their colleagues working in resource-poor settings, both groups confront challenges in promoting adherence to HIV treatment, particularly among patients with numerous, complex needs. Through this online discussion, nurses working globally will exchange tools and lessons learned. The discussion will start off with two short patient case descriptions followed by several panelists describing various approaches and tools they have used to improve the care quality for patients with such challenges.
My name is Christopher Shaw, I am a nurse working with HIV patients in an outpatient clinic in Boston. From 2001 - 2006 I worked in a number of sub Saharan African countries and was struck by the great work that nurses, health care workers and activists did in teaching and supporting patients. The following two patients represent a number of the patients we see in our clinic.
A 33 year old Zambian HIV-positive mother of four children, ages 10-15, was admitted to the hospital in June 2010 with seizures. She had multiple enhancing CNS lesions, CMV retinitis, CNS toxoplasmosis, and chronic leukopenia. Her CD4 count was 22 and her viral load was more than 1 million copies. During her two-week hospital stay, she stabilized. After discharge, returned home but had difficulty adhering to the multiple drug regimens. When a nurse visited her at home, the woman said she throws her pills in the trash, believing they caused her exhaustion and nausea. Estranged from her husband, she receives little financial or personal support except from an older sister, who lives nearby but is unaware of her diagnosis. The woman now has missed several follow-up appointments.
2. A 72-year-old Haitian man was admitted to the hospital 6 months ago with Pneumocystis pneumonia and then diagnosed with HIV (CD4 30, VL 444K). Upon discharge, he was given Pneumocystis prophylaxis and instructions to come to the outpatient clinic one week later to start antiretroviral therapy. For the next few months, he missed several appointments and then returned to the hospital emergency department with declining health. Following that visit, he started HAART and two months later had an undetectable viral load and CD4 count of 96. However after feeling better his adherence declined, resulting in his CD4 icount is dropping (now 55 and his viral load now 8,000 copies). The patient emigrated from Haiti 40 years ago and returns there each year for one month. He and his wife live 10 miles outside Boston and have primary custody of their 5-year-old grandson. He speaks little English, struggles financially, and is reluctant to have visitors, including nurses and community health workers, visit his home.
What particular cultural considerations should nurses be thinking of when providing teaching to these patients?
What system-level modifications might be necessary to better care for these patients?
What tools or trainings have worked well elsewhere?
Do you think getting family or close friends involved would be beneficial but privacy laws prevent it. Have others found ways around this?
What lessons do we need to learn and incorporate into practice before initiating treatment with such challenging patients?