1. HIV Treatment and the nurses role
Patrick Byrne
Anele Waters

2. What should you know? Generic HIV nursing competencies
For all nurses looking after HIV patients irrespective of where they are clinically based
Specialist HIV nursing competencies 
Experience HIV nurses working in a specialist HIV role such as a team leader or specialist nurse.
Reference National HIV Nurses’ Association (NHIVNA), HIV nurse competencies

3. What should you know? Generic HIV nursing competencies
HIV transmission
identify the major presenting signs and symptoms
risks of illness associated with relevant CD4 counts
awareness of the impact of stigma
the impact of health beliefs, including adherence to medication
NHIVNA competencies

4. What should you know? Generic HIV nursing competencies
ART (how it works, drug classes, administration, times, dietary restrictions and key side-effects both short and long term)
Routine bloods and investigations for stable patients
Common co-morbidities
NHIVNA competencies

5. What should you know? Generic HIV nursing competencies
Confidentiality issues
Disclosure of HIV status and issues (emotional difficulties, sexual partners, post-exposure prophylaxis and the potential criminalisation of HIV transmission)
Recognises own limitations and seeks advice
NHIVNA competencies

6. What should you know? Specialist HIV nursing competencies
All of previous but in more depth
Aetiology, manifestation, management and treatment of main symptoms of HIV
Co-morbidities interpretation of investigations
Advises patients on ART, side effect, symptom control, adherence support and treatments
NHIVNA competencies

7. What should you know? Specialist HIV nursing competencies
Support patients in HIV education and impact on the patient
Supports patients with a new diagnosis in treatment, psychological and social support
End of life issues with patient and loved ones
NHIVNA competencies

8. Antiretroviral treatment

9. HIV therapy Highly Active AntiRetroviral Therapy (HAART)
Antiretrovirals (ARV’s)
Antiretroviral Therapy (ART)
Combination AntiRetorviral Therapy (cART)
Anti HIV drugs

10. What is HIV therapy?
Antiretroviral medication usually with at least 3 drugs
May be combination tablets
Many classes of drugs

11. Goals of HIV therapy
The primary goal is to prevent HIV-related morbidity and mortality.
Suppress HIV viral load to undetectable
Restore and/or preserve immunologic function
Prevent HIV transmission
Tx is lifelong
Stops the Viral load from replicating therefore allowing restoration of CD4
Undetectable doesn’t mean its not there, but at lowest level we can measure ie <20 copies per ml blood
Allowing immune system to replenesh allowing increased lifespan
Prevents HIV transmission ie greatly reduces the risk of HIV transmission with an undetectable viral load

12. Combination antriretroviral therapy started in 1996 greatly reducing deaths and AIDS diagnosis

13. Time line of ARV’s

14. When to start ART Chronic infection
Start ART if the CD4 cell count is <350 cells/mL
AIDs diagnosis
HIV related co-morbidity
Non-AIDS-defining malignancies requiring immunosuppressive radiotherapy or chemotherapy
BHIVA guidelines
it is important not to delay treatment initiation if the CD4 cell count is close to this threshold.
• AIDS diagnosis [e.g. Kaposi sarcoma (KS)] irrespective of CD4 cell count.
• HIV-related co-morbidity, including HIV-associated nephropathy (HIVAN), idiopathic thrombocytopenic
purpura, symptomatic HIV-associated neurocognitive (NC) disorders irrespective of CD4 cell count.

15. When to start ART Co-infection
HBV if the CD4 cell count is <500 cells/mL
HCV if the CD4 cell count is <500 cells/mL
HBV if the CD4 cell count is >500 cells/mL and treatment of hepatitis B is indicated
BHIVA guidelines
• Coinfection with HBV if the CD4 cell count is >500 cells/mL and treatment of hepatitis B is indicated
This is because some of the drugs used to treat Hep B are antivirals and also used for HIV such as tenofovir so in order to prevent resistance tx for hiv is also initiated

16. When to start ART Patients presenting with AIDS or a major infection
Treatment of primary HIV infection
Treatment to reduce transmission
BHIVA guidelines
Patients presenting with AIDS or a major infection
patients presenting with an AIDS-defining infection, or with a serious bacterial infection and a
CD4 cell count <200 cells/mL, start ART within 2 weeks of initiation of specific antimicrobial chemotherapy.
Treatment of primary HIV infection
patients presenting with primary HIV infection (PHI) and meeting any one of the following criteria start ART:
• Neurological involvement.
• Any AIDS-defining illness.
• Confirmed CD4 cell count <350 cells/mL.
Treatment to reduce transmission
treatment with ART lowers the risk of transmission is discussed with all patients, and an assessment of the current risk of transmission to others is made at the time of this discussion.
if a patient with a CD4 cell count >350 cells/mL wishes to start
ART to reduce the risk of transmission to partners, this decision is respected and ART is started.

17. Blood tests before starting
CD4
Viral load
Tropism test
Resistance assay
HLA B*5701
Liver function tests
FBC

18. ARV Classes Reverse Transcriptase (RT) Inhibitors
NRTI, NNRTI
Protease Inhibitors (PIs)
Fusion/Entry Inhibitors
Integrase Inhibitors

19. HIV penetrates its target
HIV releases RNA into the cell. RNA must be converted to DNA by an enzyme called reverse transcriptase.
The viral DNA enters the cell's nucleus. Viral DNA becomes integrated with the cell's DNA by integrase enzyme
The DNA of the infected cell now produces RNA.
A new virus is assembled from RNA.
The virus pushes (buds) through the membrane of the cell, pinching off from the infected cell.
To be able to infect other cells, the budded virus must mature. It becomes mature when another HIV enzyme (HIV protease).

20. Problems with ART We cannot eradicate the virus
There are reservoir sites for HIV
ART cannot penetrate into come areas
The body contains reservoir sites for HIV-1 even during during virally suppressive (HAART).
RNA hides within other cells without replicating in this form for significant periods of time. It can then start to replicate at any time.
Also there are places in the body that antiretroviral therapy may not be able to penetrate such as in the brain, testes, kidney or heart.

21. What ART to start PREFERRED ALTERNATIVE NRTI backbone Tenofovir and
PREFERRED
ALTERNATIVE
NRTI backbone
Tenofovir and
Emtricitabine (Truvada)
Abacavir and lamivudine (Kivexa)
Third Agent
Atazanavir/ritonavir
Darunavir/ritonavir
Efavirenz
Raltegravir
Elvitegravir/cobicistat
Rilpivirine
Lopinavir/ritonavir
Fosamprenavir/ritonavir
Nevirapine
What to start
We recommend therapy-naïve patients start ART containing two nucleos(t)ide reverse transcriptase inhibitor (NRTIs) plus one of the following: a ritonavir-boosted protease inhibitor (PI/r), an NNRTI or an integrase inhibitor (INI).
Abacavir is contraindicated if HLA B*5701 positive
Nevirapine is contra-indicated CD4 >250/400 cells/μL in women/men
Abacavir or Rilpivirine use only for viral load <100,000 copies/ml

23. Adherence Must take 95% of the doses
Adherence is the second strongest predictor of progression to AIDS/death, after CD4
Reduces HIV transmission
Prevents transmission of drug resistant strains of HIV
95% adherence means missing no more than three doses of HIV treatment a month.
HIV transmission much reduced with an undetectable viral load.
From CROI 2014 PARTNER study showed no linked transmissions in those with VL <200 best guess is that rate is 0 but not enough certainty
There is uncertainty regarding risk for receptive anal sex with ejaculation so more research is needed
Drug-resistant strains of HIV selected through ongoing replication in the presence of ART also can be transmitted to uninfected or drug-naive patients, leaving them with fewer treatment options.

24. Adherence vs Compliance
Adherence: the act or quality of sticking to something, steady devotion; act of adhering
Acceptance of an active role in one’s own health care
Compliance: The act of conforming, or yielding
Lack of sharing in the decision made between provider and client

25. Consequences of poor adherence
Incomplete viral suppression
Continued destruction of immune system
Disease progression
Emergence of resistant strains
Limited future options

26. Adherence associated Factors
Lack of understanding
Younger age
Psychosocial issues
Nondisclosure of HIV serostatus
Substance abuse
Stigma
Lack of understanding- Not enough knowledge about how HIV works and how it affects the virus, Not taking the drugs will advance the HIV, just taking it sometimes will develop resistance
Younger age- youths and young adults and active life all kinds of things going on to but up barriers to adherence, late nights, partying, university, disclosure
Psychosocial issues housing, friends family issues
Nondisclosure of HIV serostatus taking drugs may somehow disclose their status
Substance abuse alcohol or drug use can make adherence difficult
Stigma

27. Adherence associated Factors
Personal commitment
Lifestyle and work
Difficulty with taking medication
Complex regimens and adverse drug effects
Cost issues
Support from partner, family, friends
Personal commitment
Lifestyle and work- working nights, busy life, children
Difficulty with taking medication – physical problems with swallowing, psychological problems making it difficult,
Complex regimens and adverse drug effects; co morbidities making the number of tablets taken difficult, or interactions or different food restrictions
Cost issues- do they have to pay, can they pay?
Support from partner, family, friends lack of support has been shown to be a barrier, with support, people can remind them and emotionally support them through it

28. Nursing Role in ongoing adherence
Acknowledge you understand it’s difficult
Confirm understanding of their regimen
Assess adherence
Find out reasons for missed doses
Ask about side effects
Offer suggestions to overcome obstacles
acknowlede that difficulties taking antiretrovirals are common and inevitable at some point in treatment.
Your role is to help identify these difficulties and try to make it easier for the patient to take the medication.
Example:
Taking pills every day is really hard. Most people have problems taking their pills at some point during treatment. I am going to ask you about problems that you have had taking your pills. Please feel comfortable telling me about pills you may have missed or taken late; I am asking because I want to make it easier for you to take them.
Confirm Understanding of Regimen
Using a visual aid, such as a chart that shows color images of the available antiretroviral pills, ask the patients which medications they are taking.
For each of the indicated pills, ask how many and exactly how often they are taking them.
Ask if they have special instructions for any of the pills, such as dietary restrictions or extra fluid requirements.
If any answers are incorrect, it is important at this time to focus on clarifying the regimen prior to completing the adherence assessment.
Assess Adherence
Ask the patients about their adherence over the past 3 days, 1 day at a time.
Start with the day prior to the interview (ie, yesterday) and ask them how many of their pills they had missed or taken late that day.
Then ask about the 2 days prior to that, addressing each day separately. Next, ask about how many doses they had missed or taken late over the past 7 days and 30 days.
If they report no missing doses, ask them how long it has been since a dose was missed.
Alternatively, a visual analogue scale can be used to assess recent adherence using a more simple visual scale.
Ask About Reasons for Missing Doses
For patients that report missing any dose, ask them if they know the reasons why.
Prompt them if they cannot offer an explanation. Common reasons why people miss medications include simply forgetting, being away from home, being too busy with other things, a schedule change, too many side effects, feeling sick or depressed, and running out of pills.
Ask about Patient attitudes (beliefs and perceptions)
Discuss disclosure, family or friend support
Identify barriers (Housing, shared)
Integrate tx into patient daily routine
Ask About Medication Side Effects or Other Problems
Ask the patients about medication side effects or other problems that they may be experiencing.
Prompts can be offered, such as asking about nausea, diarrhea, difficulty swallowing the pills, headaches, fatigue, depression, or any other physical or emotional complaints.
Collaborate with the Patient to Facilitate Adherence
Reassure the patients again that problems with adherence are common.
Explain that your concern is based on the fact that missing more than 5-10% of the doses in a month (eg, more than 3-6 doses a month in a twice-daily regimen) can lead to the medications not working well anymore, and that missing less than this would be a good goal.
Take seriously all complaints about side effects or other physical or emotional problems and address them concretely. Offer suggestions to overcome specific obstacles the patients may have mentioned, such as the use of a watch alarm, medication organizer, extra packages of pills at work or in the car, or an unmarked bottle for enhanced privacy.
Ask the patients if they have any ideas of their own to make it easier to take the medications.
Finally, do not worry if the problem cannot be solved immediately; uncovering a problem with adherence is an important accomplishment and solutions to it can evolve in subsequent visits.

29. Multidisciplinary approach
Same message from all
Doctors
Nurses
Adherence message for the patient
Pharmacist
Counsellor

30. ART resistance Resistance occurs with poor adherence
Mutations cause virus to multiply while on ART
Resistant drugs lead to viral load failure
Resistance testing
No antiretroviral drug is resistance-proof HIV drug resistance may evolve naturally.
When HIV replication is not fully suppressed, drug resistance results.
This situation is frequently linked to non-adherence of ARV therapy.
Resistant viruses can spread and affect ARV therapy.
Transmission of HIV resistance strains is of increasing concern.
Early prevention of viral load failure (where the viral load becomes detectable) is important to reduce the incidence of resistance.
An elevated viral load may be a sign of poor adherence and with adherence counselling this may be brought under control if it is not too advanced.
HIV is “resistant” to a drug occurs if it keeps multiplying rapidly while taking ART.
Changes (mutations) in the virus cause resistance. HIV mutates almost every time a new copy is made. Not every mutation causes resistance.

31. ART resistance
When the patient starts to take the medication the viral load goes down and the drug sensitive virus decreases.
Once that is gone then the drug sensitive virus is then able to replicate with no pressure

32. Side effects Common short acting
GI gastrointestinal : nausea, vomiting, diarrhoea, abd pain
CNS Central nervous system: headache, dizziness, fatigue, insomnia, vivid dreams, depression, anxiety
Skin: Jaundice, rash

33. Side effects Efavirenz: CNS effects,
sleep disturbance, abnormal dreams, rash
Atazanavir: Jaundice, increased bilirubin
Abacavir: Hypersensitivity reaction
Nevirapine: Stevens Johnson syndrome, liver toxicity
Kaletra: Diarrhoea
Truvada (FTC and tenofovir)
GI: diarrhoea, nausea and vomiting, flatulence, stomach pain, bloating,
CNS: headache, dizziness, feeling of weakness, tiredness, insomnia and abnormal dreams
Skin: rash,
Atazanavir
GI: Nausea, vomiting, diarrhoea, rash, stomach ache, heartburn,
CNS: headache, insomnia, , tiredness,
Skin: jaundice
Efavirenz
Skin: Rash
CNS: headache, dizziness, tiredness, confusion, impaired concentration, sleep disturbance, abnormal dreams. Mental health problems including depression, anxiety and low mood have also been reported
GI: diarrhoea, nausea, vomiting, stomach ache
Kivexa (3TC and abacavir)
CNS: tiredness, headache,
GI: loss of appetite. nausea, vomiting and diarrhoea, stomach ache
General: hypersensitivity reaction, rash, fever, cough, nasal symptoms,
Possible increased risk of heart attack
Skin: rash, fever
CNS: headache, tiredness
GI: nausea, vomiting, stomach ache, diarrhoea,
Rare: Stevens Johnson syndrome, liver toxicity

34. Managing side effects Diarrhoea
Anti-diarrhoea medications (loperamide)
Avoid spicy foods
White rice, white pasta, pulses, bananas
Continue to eat and drink
If severe contact Dr; >5xday, >5days, weight loss, blood/fever/mucous

35. Managing side effects Nausea/Vomiting Anti nausea drugs
Small frequent meals, bland foods
Dry or salty foods, crackers, dry toast
Herbal tea or root ginger
Sips fluids
Refer to Dr: dehydrated/unable to drink, fever, abd pain

36. Managing side effects Headache Paracetomal Avoid caffeine
Rest, quiet, dark
Refer to Dr: frequent and severe, blurred vision, altered consciousness

37. Managing side effects CNS effects
Inform Dr especially if depression etc
Take medication at night
Avoid alcohol or drugs
Seek counselling
If does not lessen or not tolerated may switch
Efavirenz can cause a number of mood and sleep problems, including anxiety and depression, feeling spaced out during the day or having vivid dreams at night.
they are normally mild and lessen or go away after a few weeks of treatment.
But for some people they are not tolerable and they need to change treatment because of them.
Some people find that taking efavirenz just before going to bed helps them to feel better during the day.

38. Managing side effects Rash Use mild soaps, Tepid baths Keep hydrated
Inform Dr
Check for additional effects
Are they on ABC EFV or NVP
May treat through with antihistamines
Rash can be a side-effect of a number of anti-HIV drugs.
Such rashes often lessen or go away after a few weeks of treatment.
A rash can also be a sign of an infection.
Some rashes can indicate the presence of serious side-effects.
This is particularly important with abacavir, etravirine, maraviroc, nevirapine or raltegravir, where there is a possibility of a serious hypersensitivity (allergic) reaction.

39. Managing side effects Fatigue Get enough sleep Good balanced diet
Avoid alcohol tobacco or drugs
Regular exercise
Inform Dr
As with most other side-effects, the risk of fatigue is greatest in the first few weeks

40. Long term side effects Kidney problems Metabolic changes Heart disease
Liver problems
Lipodystrophy
Peripheral neuropathy
Bone
Kidney problems .
Tenofovir is processed by the body through the kidneys, and there is evidence that it can cause damage to the kidneys over time.
UK treatment guidelines recommend that people with moderate or severe existing kidney disease should not take tenofovir if there is a suitable alternative.
People with other risk factors for kidney disease (for example high blood pressure or diabetes) might have an increased risk of developing kidney problems when taking this drug.
Metabolic changes
anti-HIV drugs can cause abnormal levels of lipids – blood fats, or cholesterol and triglycerides – and also blood sugar.
With high LDL cholesterol, the following factors increase risk of heart disease even further:
Smoking.
High blood pressure.
A family history of heart disease.
Being physically unfit.
Being aged over 45 for men and over 55 for women.
Diabetes or insulin resistance.
High blood sugars.
Being very overweight, particularly with a lot of fat around the waist.
Use of stimulant recreational drugs such as cocaine or amphetamines.
It is particularly important to monitor LDL cholesterol levels with protease inhibitor.
Glucose
May get increased glucose and insulin resistance.
Heart disease and anti-HIV drugs
Large studies of people taking protease inhibitors have shown that they have a slight, but nevertheless significant, increase in their risk of heart disease.
Some (but not all) studies have also suggested that abacavir might increase the risk of heart disease, particularly for people who already have risk factors for heart problems.
Eating a healthy diet, with lots of fresh fruit and vegetables and without too much fat, taking regular exercise, and not smoking to reduce risks.
Liver problems
In many cases, they had other risk factors, such as also having hepatitis B or C, having an opportunistic infection or being treated with other medicines that can harm the liver.
Having a low CD4 cell count when starting HIV treatment, especially withan opportunistic infection, and the treatment for some of those infections, can cause liver problems.
Lifestyle choices can affect the liver, such as drinking heavily or using recreational drugs.
Lipodystrophy
Lipodystrophy is a syndrome which causes changes in body shape.
Rarely seen now in the UK. It was originally thought that the cause was protease inhibitors, but it now seems that some drugs in the NRTI class may be the main cause.
The long-term use of the drugs most associated with lipodystrophy – AZT and d4T – is now avoided as much as possible.
Peripheral neuropathy
Rarely seen now
The drugs most closely linked to peripheral neuropathy are d4T and ddI, no longer routinely used in the UK, and ddC, which is no longer available.
Bone problems
Loss of bone density is more common in people with HIV than in the general population.
There is a link between HIV itself and bone loss, possibly caused by HIV-related inflammation.
There is also a link between the anti-HIV drug tenofovir and bone problems.
Some research has suggested there is also a possible link between bone loss and protease inhibitors.
Overall, the benefits of being on HIV treatment outweighs an increased risk of bone loss. In many cases, people had other risk factors for bone problems.
These include being older (and for women, having gone through the menopause), smoking, heavy drinking, being underweight, lack of exercise, a family history of bone loss, and low testosterone levels.
Reduce the risk of bone loss, include eating a healthy diet, with enough calcium and vitamin D, getting some sunlight on the skin and doing weight-bearing exercise.

41. Summary ART prolongs life Adherence is important
Side effects can be managed
Nurses can be an important support for those taking ART

43. Case Studies

44. Lydia 30 year old, sex worker
Recent partner died of AIDs related illness
Has 5 year old child
They live with Lydia’s mother
Lydia provides only source of income
Case Study: Sex Worker
Lydia is a 30 year old sex worker who recently found out her former partner died of an AIDS related illness.   He was a former IVDU and he is the father of her 5 year old child.  Lydia and her child live with her mother who provides care for the child when she is out working.  Lydia’s sex work is the only income for this household. 
Lydia usually uses condoms with her clients but on occasion she is paid more for not using them. She has been a sex worker for the past two years and has not had a sexual health check-up since then. She has had no health related issues.
Lydia attends the clinic and has an HIV test which is found to be positive.  She is devastated over the news.  She is concerned about whether she will be alive to see her daughter grow up.  The healthcare worker discusses several important issues with Lydia.  As Lydia is a sex worker the issue of safer sex is very important.   She is advised to use condoms with every client.  This is difficult for her as there is more money from clients where condoms are not used.  Next it important to find out what stage of disease Lydia is at so she has lab tests done and an appointment with an HIV consultant is made.
At the appointment with her consultant it is found that Lydia has a CD4 count of 370 cells and a viral load of 120,000 copies.   

45. Lydia Usually uses condoms with clients 2 years as sex worker
No sexual health checks in last 5 years
Tests positive for HIV
Feels devastated

46. Lydia
Has several concerns
Sex work?
Daughter?
Mother?
Will she live?

47. Lydia Has blood tests and sees consultant CD4 370 Viral load 120,000
What next?

48. Lydia What reasons should she start ART?
What combination should she start and why?
What should be considered when starting ART?

49. Lydia She starts ART because
She is very close to the recommended starting CD4
She has a high viral load so taking ART will reduce her risk of transmitting HIV
Starts Truvada and Efavirenz (cannot take Kivexa due to VL >100,000)

50. Maria 45 years old with 4 children
Works as a ward nurse in local hospital
Husband is international truck driver
Not been feeling well for the last year, always tired
Has had some minor skin and mouth infections
Recent antibiotics for chest infection
Case Study: Late presentation
Maria is a 45 year old woman with 4 children (20, 18, 12 and 5). She works as a ward nurse in the local hospital and her husband is an international lorry driver.
She has not been feeling well for the last year, always tired which she put down to shift work and caring for her family. She has been to her doctor a few times with minor skin and mouth infections and has had antibiotics for a chest infection.
Over the last 6 weeks she has noticed that she gets short of breath going upstairs, she is exhausted and has a cough. It was dry at first but now is productive. She has also had night sweats, which the doctor thought were due to an early menopause.
She collapsed at work and was admitted as an emergency. After investigations for her respiratory symptoms she was tested for HIV and told she was HIV and presumptive PCP. She was started on antiretroviral therapy. She is terrified that the medical team will tell her husband or he will find out especially if she is on pills. Her husband is away and her eldest daughter is looking after the family whilst Maria is in hospital. Her daughter knows Maria has a pneumonia.

51. Maria Last 6 weeks short of breath going upstairs Exhausted
Cough was dry at first now productive
Night sweats that doctor thought were early menopause
Collapsed at work admitted as an emergency
Case Study: Late presentation
Maria is a 45 year old woman with 4 children (20, 18, 12 and 5). She works as a ward nurse in the local hospital and her husband is an international lorry driver.
She has not been feeling well for the last year, always tired which she put down to shift work and caring for her family. She has been to her doctor a few times with minor skin and mouth infections and has had antibiotics for a chest infection.
Over the last 6 weeks she has noticed that she gets short of breath going upstairs, she is exhausted and has a cough. It was dry at first but now is productive. She has also had night sweats, which the doctor thought were due to an early menopause.
She collapsed at work and was admitted as an emergency. After investigations for her respiratory symptoms she was tested for HIV and told she was HIV and presumptive PCP. She was started on antiretroviral therapy. She is terrified that the medical team will tell her husband or he will find out especially if she is on pills. Her husband is away and her eldest daughter is looking after the family whilst Maria is in hospital. Her daughter knows Maria has a pneumonia.

52. Maria Investigated for respiratory symptoms
HIV test done was done and positive
Presumptive PCP (pneumocystis pneumonia)
Started on Antiretroviral therapy
Case Study: Late presentation
Maria is a 45 year old woman with 4 children (20, 18, 12 and 5). She works as a ward nurse in the local hospital and her husband is an international lorry driver.
She has not been feeling well for the last year, always tired which she put down to shift work and caring for her family. She has been to her doctor a few times with minor skin and mouth infections and has had antibiotics for a chest infection.
Over the last 6 weeks she has noticed that she gets short of breath going upstairs, she is exhausted and has a cough. It was dry at first but now is productive. She has also had night sweats, which the doctor thought were due to an early menopause.
She collapsed at work and was admitted as an emergency. After investigations for her respiratory symptoms she was tested for HIV and told she was HIV and presumptive PCP. She was started on antiretroviral therapy. She is terrified that the medical team will tell her husband or he will find out especially if she is on pills. Her husband is away and her eldest daughter is looking after the family whilst Maria is in hospital. Her daughter knows Maria has a pneumonia.

53. Maria Terrified the medical team will tell husband
Afraid husband will see the pills and know
Eldest daughter looking after family as husband is away
Daughter only knows Maria has pneumonia
Case Study: Late presentation
Maria is a 45 year old woman with 4 children (20, 18, 12 and 5). She works as a ward nurse in the local hospital and her husband is an international lorry driver.
She has not been feeling well for the last year, always tired which she put down to shift work and caring for her family. She has been to her doctor a few times with minor skin and mouth infections and has had antibiotics for a chest infection.
Over the last 6 weeks she has noticed that she gets short of breath going upstairs, she is exhausted and has a cough. It was dry at first but now is productive. She has also had night sweats, which the doctor thought were due to an early menopause.
She collapsed at work and was admitted as an emergency. After investigations for her respiratory symptoms she was tested for HIV and told she was HIV and presumptive PCP. She was started on antiretroviral therapy. She is terrified that the medical team will tell her husband or he will find out especially if she is on pills. Her husband is away and her eldest daughter is looking after the family whilst Maria is in hospital. Her daughter knows Maria has a pneumonia.

54. Maria What issues are there in her starting ART?
What issues are there for her regarding her husband and daughter?
Case Study: Late presentation
Maria is a 45 year old woman with 4 children (20, 18, 12 and 5). She works as a ward nurse in the local hospital and her husband is an international lorry driver.
She has not been feeling well for the last year, always tired which she put down to shift work and caring for her family. She has been to her doctor a few times with minor skin and mouth infections and has had antibiotics for a chest infection.
Over the last 6 weeks she has noticed that she gets short of breath going upstairs, she is exhausted and has a cough. It was dry at first but now is productive. She has also had night sweats, which the doctor thought were due to an early menopause.
She collapsed at work and was admitted as an emergency. After investigations for her respiratory symptoms she was tested for HIV and told she was HIV and presumptive PCP. She was started on antiretroviral therapy. She is terrified that the medical team will tell her husband or he will find out especially if she is on pills. Her husband is away and her eldest daughter is looking after the family whilst Maria is in hospital. Her daughter knows Maria has a pneumonia.