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First Clinic Visit for Patients with HIV Infection

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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Learning Objectives

By the end of this session, participants should be able to:

Explain principles of good chronic care

Describe how to conduct a first clinic meeting with an HIV positive patient

Explain how to follow up with a patient after the first clinic visit

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Difficulties Treating Patients with HIV

HIV is a chronic disease that requires a lifetime of regular clinical monitoring

Successful treatment outcomes require excellent treatment adherence

HIV treatment is made more difficult by many social and cultural factors

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Effective Communication Skills

Effective communication involves:• Actively listening• Attending to a patient• Demonstrating a caring, respectful attitude • Praising, encouraging patient• Speaking clearly and simply at a level the

client can understand• Encouraging patient to ask questions• Building rapport

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What is Rapport?

Rapport is… • Building a comfortable connection so

that people can share information• Creating a relationship based on trust

and respect • Created through both verbal and non-

verbal actions

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How to Build Rapport

Shake hands Introduce yourself Use same language as client Show patience Do not interrupt Make eye contact Do not attend to other clients while

busy with another

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Question: What are some

principles of good chronic care?

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Principles of Good Chronic Care (1)

Develop good treatment partnership with patients

Listen to patient’s concerns in a non-judgmental way

Promote patient education and active participation in care

Encourage involvement of treatment supporters: family, friends and peer educators

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Principles of Good Chronic Care (2)

Link patients to community and home-based supports

Provide counseling and supports for better treatment adherence

Work as a clinical team with nurses, counselors and other health workers (multidisciplinary team approach)

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The Multidisciplinary Team

Doctor Nurse Counselor Pharmacist Treatment

supporter

Family members Case manager Social worker Peer

educators/PLHIV Others (?)

Treatment of HIV is best accomplished by a team, which may include:

Each team member has specific roles in the long-term care and treatment process

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Brainstorm: What are the Elements

of the First Clinic Visit?

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Elements of the First Clinic Visit (1)

History of Present Illness Past Medical History Medication History Drug Allergies Social History History of tobacco, alcohol and drug

use

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Elements of the First Clinic Visit (2)

Complete Physical Exam Assessment of Diagnoses, Current

Problems Laboratory evaluation Treatment of OIs, prophylaxis Counseling Plan for follow-up

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History of the Present Illness

Chief complaint• “Why is the patient in clinic today?” • Does the patient have any symptoms?

Ask specifically about symptoms of tuberculosis

Perform a review of systems

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Past Medical History

HIV History • Risk factors for acquisition of HIV• Date of diagnosis• Approximate date of acquisition of HIV• CD4 cell counts (first, lowest, and most recent)• Viral loads (if available)• Opportunistic infections• AIDS-related malignancies• AIDS-related symptoms (e.g. wasting)

Other medical history• TB • Hepatitis (HBV, HCV)

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Medications and Drug Allergies:

Current Medications• Doctor prescribed• Self prescribed• Herbal or traditional medications

Antiretroviral therapy history Hepatitis treatment history Drug addiction treatment (e.g.

methadone) Drug allergies and adverse reactions

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Social History

Marital status and children Family planning Housing or living situation Social and financial support from

family, friends, or others Employment status and occupational

history Sexual History

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Substance Use

Current or prior use of:• Intravenous drugs• Tobacco• Alcohol: beer, wine, liquor• Prescription drug abuse• Opium, heroin• Amphetamine-like substances (e.g.

ecstasy, crystal meth)• Cannabis

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Physical Examination

A comprehensive physical examination, including weight and height, should be performed as part of the initial evaluation

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Laboratory Evaluation

HIV antibody for confirmation Complete blood count (CBC) CD4 count ALT Creatinine HBsAg Anti-HCV Additional testing based on patient’s

symptoms and/or physical examination

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Assessment and Diagnoses

Determine clinical stage Diagnose Opportunistic Infections Assess need for OI prophylaxis Determine need for ART

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Treatment Plan

Create a management plan based on the assessment

Provide counseling and support Provide appropriate referrals where

indicated Create plan for follow-up

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Role Play Activity:Putting These Steps

into Practice

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Key Points

HIV is a chronic disease that requires lifetime regular follow-up

From the first visit, it is important to build a patient-doctor relationship based on mutual trust and respect

Multidisciplinary team approach is the best way to care for and treat PLHIV

The first visit is important to evaluate the patient’s clinical status and make a treatment plan

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Thank you!

Questions?