Where people have been diagnosed late with HIV infection, skilled nursing is essential to their ability to follow through with treatments and remain engaged with the health system. The OIs (also referred to as AIDS-defining illnesses or AIDS-indicator diseases) with which those diagnosed late and with advanced disease may present are now relatively rare, due to effective treatments. Nurses in low HIV prevalence settings such as Australia and New Zealand may not have first-hand experience and knowledge of such illnesses. Thus, it remains important for nurses to understand the natural history and management of HIV and opportunistic illnesses.
Psychological and emotional reactions to a new HIV diagnosis can vary and can be serious (see Section 1 New diagnosis of HIV). The person may display signs of depression, appear withdrawn or become completely overwhelmed. Nurses can identify signs of difficulty with adjusting to and managing illness and can intervene and make appropriate referrals for counselling. They can support the person by listening, giving clients time to talk through their problems, providing empathy and care, and emphasising to the client that he or she is not alone. Utilising resources such as written information in the person’s chosen language, audio-visual aids, and peer support (through meeting other PLHIV) can help ease the adjustment process. These interventions are all useful to promote engagement and retention in care (17, 18).
Nurses can educate clients, family members, and professional colleagues about specific issues to be aware of during this period; for example, signs of anxiety and depression; barriers to care, signs of disengagement; indications of opportunistic illnesses; difficulty with adherence to medication and treatment toxicities or adverse reactions (see also Therapeutics and monitoring).
Clinical, primary health and community nursing services that are well integrated with peer support agencies (19, 20) and volunteer-based services can be fundamental to supporting the emotional and social adjustment of those diagnosed late and those with advanced disease (21).
Medication Support
People hospitalised following late HIV diagnosis and illness are often discharged with multiple medicines. In addition to antiretroviral therapy (ART) to reduce HIV viral load and improve immune function, they may require medicines to treat OIs and others to reduce the risk of other opportunistic infections developing while their CD4 count is low (below 200 cells/μL). This entails a significant pill burden, recognised as a barrier to adherence (22).
Managing multiple medicines can be difficult, especially for clients who have never taken tablets before. Nurses may assess, assist, administer and supervise medication management. High, sustained levels of adherence to ART (over 95% of all prescribed doses taken) maximise its effectiveness, reduce the chance of new or recurrent illness, reduce short- and long-term mortality and prevent the onward transmission of HIV (23). Of equal importance is adherence (doses taken and completion of the prescribed course) to medicines prescribed to treat OIs and those used to prevent new OIs (See Clinical manifestations of HIV disease).
Nurses can educate clients about their medicines and monitor for side-effects. (See Adherence support for more details). Nurses can also foster hope and optimism through educating people about U=U (Undetectable=Untransmissible)– that is, if people living with HIV achieve an undetectable viral load by adhering to their antiretroviral therapy, they cannot transmit the virus sexually.
Formulations of ART in single-tablet regimens can improve adherence (23).
Stigma
HIV-related stigma remains very real for many people, and disclosure of a person’s HIV status can have serious consequences for the person with HIV. Respect for people’s privacy and confidentiality is essential and should be actively communicated. Strategies such as providing a locked box to store medicines and medical documentation in the home can help maintain privacy and confidence in services.
Access to and retention in HIV specialist clinical care, and safe medicine administration delivered by qualified and competent professionals underpin increased survival for people with HIV (5). People diagnosed late should have access to the assistance of community nurses upon discharge from acute services and referrals should be made early, even where an obvious nursing clinical procedure is not needed. Close collaboration and liaison between hospital- or clinic-based nurses, nurses in primary care and community nursing services are essential and are a robust feature of the HIV sector in Australia and New Zealand (see also Evolving roles of nurses in HIV care).