A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 2: Approach to the Patient 2 RISK ASSESSMENT AND COUNSELING What risk-taking behaviors should be reviewed with patients? Patients infected with HIV who practice unsafe sex or inject drugs can infect others, be reinfected themselves with new HIV strains, or contract STDs, viral hepatitis, or other infections. Abuse of alcohol or illicit drugs is directly harmful and may affect adherence to a complicated medical regimen. Accordingly, providers need a detailed understanding of their patients’ risk-taking behaviors to guide patient education and counseling efforts and to assess the advisability of initiating antiretroviral treatment. Table 2-2 lists specific risk-taking behaviors to review with patients. See also Chapter 4: Prevention of HIV in the Clinical Care Setting and Chapter 13: Management of Substance Abuse. Table 2-2. Risk-Taking Behaviors to Review with Patients Infected with HIV Sexual Practices Number and gender of partners Specific sexual practices Frequency Condom use HIV status of partners and disclosure of patient’s HIV status Anonymous partners Association with drug use Prior STDs Genital ulcer disease Drugs Substances used Routes of administration Tolerance and history of withdrawal History of drug treatment How should one ask about risk-taking behaviors? Explaining the rationale for reviewing risk-taking behaviors, informing patients that such a review is routine, and asking for a patient’s permission to discuss these topics is a good way to initiate the conversation. Projecting comfort with the subject material and proceeding in a poised, professional, nonjudgmental, and supportive fashion will engender trust and help patients feel safe enough to discuss their behavior. With regard to sexual behavior, asking “Do you have sex with men, women, or both?” indicates the provider’s openness to all sexual orientations. Making a comment that many men who have sex with men, particularly in certain cultures, do not self-identify as gay assures patients that discussing their behavior will not cause the provider to categorize them without their consent. Providers should also explore factors associated with sexual abstinence. At the same time, it is important for providers to be realistic. Wanting a satisfying sex life is a reasonable desire; the goal is to minimize risk associated with sex. Similarly, changing addictive behavior is extremely difficult and often requires several attempts. Discussing realistic goals will enhance a provider’s credibility and minimize a patient’s resistance to discussing these subjects. The goal of this initial survey is to learn what patients are doing, not to draw battle lines. What are effective counseling strategies to help patients decrease their risk taking? When discussing risk-taking behaviors, a key first goal is to assess a patient’s state of preparedness for change. Some patients with newly diagnosed HIV come to care motivated to make healthy lifestyle changes. For these individuals, an enhanced understanding of the risks associated with certain behaviors in conjunction with a provider’s strong recommendation to modify behavior may suffice. Providers should also be prepared to offer appropriate medications (e.g., to assist with smoking cessation) or referrals for drug and alcohol abuse counseling. For patients with complicating factors such as severe mental illness, substance abuse, domestic violence, or sexual abuse, referral and close linkages with specialty care are essential. What if a patient is not prepared to make lifestyle changes? Providers should deliver a clear, unequivocal message regarding the risks to patients and others associated with unsafe sex and ongoing drug use and advise patients of ways, such as safer sexual practices and needle exchange programs, to reduce risk. It should be kept in mind, however, that pushing patients unprepared for behavioral change may lead to animosity and resistance and that direct advice alone is unlikely to result in immediate or sustained behavioral change. For example, advice to stop smoking generally results in 12-month success rates of 5%- 10 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 2: Approach to the Patient 10%. For patients unprepared to alter their risk-taking behavior, a longer-term strategy is required, and a nonconfrontational approach such as motivational interviewing is recommended (see Table 2-3). When working with a patient over time to support behavioral change, it is crucial for the provider to be a consistent source of support, hope, and optimism. By acknowledging positive efforts even when initial attempts to modify behavior fail, by continuing to offer encouragement, and by supporting even small progress, the provider can help bolster a patient’s resolve and sense of control over his or her actions. Table 2-3. Motivational Interviewing Basic Steps: • Seek to understand the patient’s experience through careful and reflective listening. • Help the patient voice his or her own reasons for change. • Recognize and accept resistance to change. • Affirm the patient’s ability to control his or her own actions. In this patient-centered approach, the provider seeks an accurate understanding of the patient’s unique experience with certain behaviors. The interviewer listens carefully to the patient’s thoughts about his or her behavior, monitors readiness for change, clarifies what the patient believes to be obstacles to change, identifies the patient’s own selfmotivational statements, and selectively reinforces these expressions of desire, intent, and ability to change. In this manner, the provider yields the role of “expert” and offers affirmation and support for the patient’s ability to control his or her own behavior. Principles to Remember: • For most people, motivation for change must come from within. Direct persuasion does not often result in sustained behavioral change. • It is the patient’s task to articulate resolve and ambivalence. • When patients voice resistance to change, it is preferable to recognize and accept a lack of readiness than to press for immediate change. Timing is important. • Patients must understand that resolutions to change often slip, and failure should not become a reason to avoid contact with the provider. KEY POINTS Caring for patients with HIV/AIDS requires a strong provider-patient relationship, a multidisciplinary care team, and frequent office visits. Stigma and discrimination must be addressed through strong confidentiality protections, emotional support, and cultural sensitivity. Patient education about the disease process, treatment, and community resources is a vital component of care. The primary care provider plays a key role in risk assessment and counseling for all patients with HIV. SUGGESTED RESOURCES Aranda-Naranjo B, Davis R. Psychosocial and cultural considerations. In: A Guide to the Clinical Care of Women with HIV/ AIDS, 1st ed. Washington: US Department of Health and Human Services, HRSA, HIV/AIDS Bureau; 2001. Available at http://www.hab.hrsa.gov. Centers for Disease Control and Prevention. Incorporating HIV prevention into the medical care of persons living with HIV. MMWR Recommendations and Reports, (July 18, 2003; 52(RR12);1-24. Hecht FM, Wilson IB, Wu AW, Cook RL, Turner BJ. Society of General Internal Medicine AIDS Task Force. Optimizing care for persons with HIV infection. Ann Intern Med. 1999;131:136-143. Positive Living. A practical guide for people with HIV. Seattle: Public Health–Seattle & King County, HIV/AIDS Program; 1999. 2 Rollnick S, Miller WR. What is motivational interviewing? Behavioral and Cognitive Psychotherapy. 1995;23:325-334. U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 11
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