Many patients with HIV/AIDS experience numerous challenges beyond those posed by the physical effects of their disease—including poverty, mental illness, drug addiction, social alienation, racism, and homophobia. Counseling patients who face these issues can be difficult, but a careful risk assessment along with patient education can improve a patient’s ability to cope and lead to better outcomes, said Marshall Forstein, MD, associate professor of psychiatry, Harvard Medical School, Cambridge, Mass, in a presentation at the US Psychiatric Congress in Las Vegas. On the basis of his extensive experience in treating patients with HIV/AIDS, he said it is also important to provide hope and to encourage treatment adherence.1
When conducting a thorough risk assessment, Forstein emphasized the importance of asking all patients about their specific sexual behaviors. This opens the door for candid discussions about HIV prevention and nonoccupational exposure prophylaxis. “It is important to know what these behaviors are so we can try to help patients keep themselves out of harm’s way,” he said. It is critical to discuss the behavior through which the patient contracted HIV. This not only helps the patient come to terms with his or her disease, but it also forces him to consider the manner and risk of secondary transmission. “The issue is how to discuss sexual or drug use behavior with patients without seeming condescending or judgmental,” Forstein said.
Patients should not only be educated about disease prevention and transmission, but also about the course of the illness. In addition, health care providers must be careful to make sure that patients understand the meaning of the medical terms. For example, some patients who have been treated with ART and have HIV that is clinically considered to be “undetectable” (meaning that the viral load is below the ability of the current available tests to detect the level of virus) does not mean that there is no HIV, and thus the risk of viral transmission, though lower, is still possible. Patients may misinterpret the term “undetectable” and fail to understand that they still have HIV, said Forstein. Others may see HIV now as a chronic disease, so they may think becoming HIV infected is no longer a significant medical illness.
A number of factors also contribute to treatment fatigue and noncompliance with the therapeutic regimen. Adverse drug effects and complicated regimens are chief among these. Constant reinforcement on the need for lifetime adherence may be necessary. Advise patients that 95% adherence is required to suppress viral replication. Forstein also said simplifying dosing schedules can increase adherence.
Age can also contribute to treatment fatigue. Forstein has treated a number of patients who have had HIV infection since the 1990s but who have no detectable viral loads after years of ART. Some of his older patients (ie, those who are approaching their 60s) want to experience their remaining years free of the effects of medication and opt to discontinue therapy. “It is important for providers to explore that type of thinking,” he said.
All patients with HIV infection will find it difficult to adjust to changes in their medical status, regardless of whether their symptoms are getting better or worse, said Forstein. For example, some patients have had trouble accepting the fact that they might do well, including the possibility of returning to work or thinking about re-engaging in relationships. Some have felt that HIV has given their life a purpose, such as participating in community activism. “Getting well and staying well requires a renegotiation of those factors that inform their lives,” he said.