First Clinic Visit for Patients with HIV Infection

1. First Clinic Visit for Patients with HIV Infection HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 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

3. 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

4. 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

5. 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

6. 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

7. Question: What are some principles of good chronic care?

8. 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

9. 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)

10. The Multidisciplinary Team Treatment of HIV is best accomplished by a team, which may include: • Doctor • Nurse • Counselor • Pharmacist • Treatment supporter • Family members • Case manager • Social worker • Peer educators/PLHIV • Others (?) Each team member has specific roles in the long-term care and treatment process

11. Brainstorm: What are the Elements of the First Clinic Visit?

12. 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

13. 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

14. 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

15. 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)

16. 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

17. 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

18. 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

19. Physical Examination • A comprehensive physical examination, including weight and height, should be performed as part of the initial evaluation

20. 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

21. Assessment and Diagnoses • Determine clinical stage • Diagnose Opportunistic Infections • Assess need for OI prophylaxis • Determine need for ART

22. Treatment Plan • Create a management plan based on the assessment • Provide counseling and support • Provide appropriate referrals where indicated • Create plan for follow-up

23. Role Play Activity:Putting These Steps into Practice

24. 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

25. Thank you! Questions?