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The Role of the Nurse in HIV Care. Eileen Nixon HIV Nurse Consultant Brighton and Sussex University Hospitals. Aim of Presentation. Overview of key issues that affect people with HIV Identify the role of the nurse in caring for people with HIV Highlight nursing competencies required

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the role of the nurse in hiv care

The Role of the Nurse in HIV Care

Eileen Nixon

HIV Nurse Consultant

Brighton and Sussex University Hospitals

aim of presentation
Aim of Presentation
  • Overview of key issues that affect people with HIV
  • Identify the role of the nurse in caring for people with HIV
  • Highlight nursing competencies required
  • Benchmark current competency level
  • Relate nursing role to course content
slide4

Adults and children estimated to be living with HIV, 2006

Eastern Europe & Central Asia

1.6 million

[1.2 – 2.1 million]

Western &

Central Europe

North America

2.1 million

[1.1 – 3.0 million]

North Africa & Middle East

380 000

[270 000 – 500 000]

Asia

4.9 million

[3.7 – 6.7 million]

Caribbean

230 000

[210 000 – 270 000]

Latin America

1.6 million

[1.4 –1.9 million]

Sub-Saharan Africa

22.5 million

[20.9 – 24.3 million]

Oceania

75 000

[53 000 – 120 000]

Total: 33.2 (30.6 – 36.1) million

global epidemic of hiv
Global Epidemic of HIV
  • Multiple cultures of people affected
  • Media coverage
  • Immigration and asylum issues
  • Political and ethical issues
  • Discrimination
  • Travel
  • Returning to home countries
  • Treatment eligibility
treatment eligibility

Can we see your passport, please?

Treatment Eligibility
  • Emergency and lifesaving care is free
  • TB treatment is free
  • Separating “tourists” from other health seeking actions
  • Balancing conversations about eligibility
  • Prioritising health
  • Discharge plans
  • NMC Guidelines
nursing role in stigma
Nursing Role in Stigma
  • Appropriate universal precautions
  • Non-judgemental approach to care
  • Encouraging patients to become involved in service planning
  • Supporting patients with disclosure of HIV diagnosis
  • Supporting ongoing sexual relationships
  • Referral for counselling services
  • Peer Support
  • Addressing misconceptions
nursing competencies stigma
Nursing Competencies - Stigma
  • Level 2: Recognises the impact of HIV/AIDS stigma on the patient experience of living with HIV
  • Level 2: Recognises difficulty in disclosing HIV diagnosis after death and acts as a patient advocate when this arises
  • Level 3: Proactively supports patients where stigma impacts on their health and well-being

National HIV Nursing Competencies, 2007

competency levels
Competency Levels

Level 2 Registered Practitioner: Entry point for RN to HIV specialty or working with HIV in a non-specialist setting

Level 3 Senior Registered Practitioner: HIV specialist area at Team Leader, Charge Nurse or CNS level

Level 4 Consultant Practitioner: Consultant or Senior Nurse Manager in HIV

defining late presentation
Defining Late Presentation ?
  • AIDS at diagnosis
  • AIDS within 3-12 months
  • CD4 < 200
  • CD4 < 50
bhiva audit 2006 scenario leading to death
BHIVA Audit 2006: Scenario leading to death

Top bars: reclassified during audit

Bottom bars: as initially reported

Mortality audit BHIVA audit and Standards Sub-Committee 2006; accessible at www.bhiva.org

slide15

Evidence for late diagnosis in heterosexual men & women, and MSM – AIDS casesLate diagnosis is defined here as an interval of less than 3 months between HIV diagnosis and AIDS

1200

1400

Diagnosed for 3

months or longer

1200

1000

Late diagnosis

1000

800

800

Number of AIDS cases diagnosed

600

600

400

400

200

200

0

0

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

Year of AIDS diagnosis

Year of AIDS diagnosis

Men who have sex with men

Sex between men and women

Data source: HIV/AIDS reports. Reports received by the end of September 2005.

late presenters in brighton last 100 admissions
Late Presenters in Brightonlast 100 admissions

37%

23%

Bed days on Inpatient Unit

Number of admissions

haart in late presenters
Wait , but not too long …

2 weeks to 2 months

Avoid significant interactions

Rifampicin and PIs

Some chemotherapy and PIs

Avoid overlapping toxicities

AZT - high-dose septrin

“D” drugs - isoniazid

Avoid unnecessary diagnostic difficulties

Allow for other co-morbidities

Renal dysfunction

NG administration if on ITU

Chose likely effective regimen

Avoid NNRTIs until genotype available

HAART in late presenters
nursing care of late presenters
New HIV diagnosis

Coping with HIV and often AIDS diagnosis

Disclosure of diagnosis and contact tracing

Acute hospital care – usually prolonged

Ongoing risk assessment

Care of opportunistic infections

Support in starting ARV’s

Establishing support structures

Effective discharge planning and f/u

Employment and finance advice

Family planning and sexual health

Nursing care of late presenters
nursing care of opportunistic infections
Nursing Care of Opportunistic Infections
  • Monitoring presenting condition – vital signs and observation
  • Monitoring for other opportunistic infections
  • Administering IV Treatments
  • Nutrition
  • Care of activities of daily living
  • Discharge Planning
nursing competencies of lp
Nursing Competencies of LP
  • Level 2: demonstrates a knowledge and understanding of, and can identify the major signs and symptoms of acute and chronic HIV related conditions and risks of illness associated with relevant CD4 counts
  • Level 3: Recognises signs and symptoms of complex and unstable health problems requiring review by senior colleagues

National HIV Nursing Competencies, 2007

palliative and terminal care
Palliative and Terminal Care
  • Level 2: Is aware of the assessment needs of a patient who requires terminal care and the evidence based tools available e.g. Liverpool care pathway
  • Level 3: Makes a comprehensive assessment of a patients palliative care needs and fully assess the physical needs of a patient who requires terminal care

National HIV Nursing Competencies, 2007

hiv diagnoses aids case reports and deaths in hiv infected individuals uk
HIV diagnoses, AIDS case reports and deaths in HIV-infected individuals, UK

1

1 Numbers will rise, for recent years, as further reports are received.

Data Source: HIV/AIDS reports. Reports received by the end of September 2005.

increasing numbers of people with hiv
Increasing Numbers of people with HIV
  • More patients
  • Living with chronic HIV disease
  • Co-morbidities
  • Co-infections
  • Treatment experienced
  • Review of benefits
  • Returning to work
modernisation of hiv services
Changing focus of service delivery:

Clinic visits

Chronic manageable illness

ARV’s

Telephone/Email clinics

MDT

Patient continuity

Multicultural aspects

MOT

Nurses role development:

Triage

Nurse Led Clinics

NHIVNA Competencies

Activity v Resources:

GUM Targets

Primary Care

Sexual health screening

Modernisation of HIV services
nursing competencies in developing roles for nurses
Nursing Competencies in developing roles for nurses
  • Level 2: Describes the local policy relating to the inclusion/exclusion criteria for stable patients whether on or off therapy
  • Level 3: Identifies and implements essential aspects of managing stable patients, such as adherence, toxicity management and psychological and sexual health

National HIV Nursing Competencies, 2007

managing patient expectations
Managing Patient Expectations
  • Keep patients informed
  • Give explanations
  • Address concerns
  • Act on patient feedback
  • Expert Patient Programme
  • User representation
    • Eliciting user views
    • Involving users in service provision
co morbidities and co infections
Diabetes and insulin intolerance

CVD

Lipodystrophy

Liver disease

Hypogonadism

Osteoporosis

Hepatitis B

Hepatitis C

Tuberculosis

Leishmoniasis

Infectious diseases

Haemophilia

Co-Morbidities and Co-Infections
nursing people with chronic hiv disease
Nursing people with chronic HIV disease
  • Chronic Disease NSF
  • Identifying what is and what is not related to HIV disease
  • Adjusting to multiple pathology
  • Long term therapeutic relationships
  • Empowering people to live with HIV
  • Coordinating appointments
  • Engaging with GP’s
  • Recognising when people are struggling
nursing competencies in co morbidities and co infections
Nursing Competencies in Co-morbidities and co-infections
  • Level 2: Demonstrates an understanding of treatment choices open to people with HIV co-infections and co-morbidities
  • Level 3: Demonstrates an understanding of the administration, side effects and risks associated with treatment of different HIV co-infections and co-morbidities

National HIV Nursing Competencies, 2007

patient age in brighton cohort 1996 2006
Patient age in Brighton Cohort: 1996–2006

300

>50 years old

250

>60 years old

200

>70 years old

Number of patients

150

100

50

0

1996

1998

2000

2002

2004

2006

Personal communication, M. Fisher, August 2007

nursing role in psychological care
Coping with diagnosis

Establishing support structures

Appropriately involving patients in care

Mental Health

Adjustment disorders

Health beliefs and behaviours

Chronic Disease Management

Empowering people to live with HIV

Expert patient Programmes

Social care, finances, employment

Nursing Role in Psychological Care
nursing competencies in psychological care
Nursing Competencies in Psychological Care
  • L2: Demonstrates an awareness and understanding of the psychological and emotional impact of an HIV diagnosis on a newly diagnosed HIV patient, patients starting or switching therapy or a patient with acute, chronic, terminal condition or palliative needs
  • L3: Works autonomously to comprehensively assess complex psychological and emotional needs of the above groups of patients

National HIV Nursing Competencies, 2007

nursing role in antiretroviral therapy
Nursing Role in Antiretroviral Therapy
  • Discuss common treatment options
  • Recognise common side effects (s/t and l/t)
  • Discuss treatment outcomes
  • Administer ARV’s correctly
  • Assess patients beliefs about ARV therapy
  • Assess adherence to ARV’s
  • Explain implications of poor adherence
nursing competencies and art
Nursing Competencies and ART
  • Level 2: Demonstrates an understanding of how ART works, drug classes, administration, times, dietary restrictions and key side effects
  • Level 3: Assess and triages problems associated with medications and side effects including short and long term side effects

National HIV Nursing Competencies, 2007

nursing care and adherence
Nursing Care and Adherence
  • Level 2: Recognises when situations are detrimental to the correct administration of ART, such as nausea and vomiting and hospitalisation
  • Level 3: Anticipates any threats to ART administration and intervenes to facilitate optimal adherence (i/p and o/p)

National HIV Nursing Competencies, 2007

role of the nurse in sexual health of people with hiv
Role of the Nurse in Sexual Health of people with HIV
  • Promote prompt access to routine STI screening
  • Promote safer sex practices
  • Advise on disclosure / partner notification
  • Understand criminalisation
  • Family Planning possibilities
  • PEPSE
sexual health competencies
Sexual Health Competencies
  • Level 2: Assists in the assessment and treatment of the sexual health needs of patients living with HIV
  • Level 3: Undertakes sexual health risk assessment as part of routine assessment of patients with HIV and describes treatment options for STIs

National HIV Nursing Competencies, 2007

health promotion in hiv
Health Promotion in HIV
  • CVD risks and smoking cessation
  • Nutrition
  • Exercise
  • Stress management
  • Mental health
  • Alcohol and drug use
  • Screening for hepatitis, cervical smears, lipids, BP, BMI
nursing competencies in health promotion
Nursing Competencies in Health Promotion
  • Level 2: Demonstrates an understanding of maintaining a health lifestyle and how this relates to HIV
  • Level 3: Undertakes detailed risk assessment in relation to smoking, cardiovascular risk, sexual health etc. Develops action plan and makes onward referrals based on the assessment

National HIV Nursing Competencies, 2007

core principles of hiv nursing
Core Principles of HIV Nursing
  • Ability to identify stage of illness and disease manifestations including surrogate markers
  • Understanding ART and adherence
  • Holistic and patient centered approach to care
  • Incorporating the sociology of HIV into care
  • Managing the changing skills profile
slide52

Adults and children estimated to be living with HIV, 2007

Eastern Europe & Central Asia

1.5 million

[1.1 – 1.9 million]

Western &

Central Europe

730 000

[580 000 – 1.0 million]

North America

1.2 million

[760 000 – 2.0 million]

East Asia

740 000

[480 000 – 1.1 million]

Middle East&North Africa

380 000

[280 000 – 510 000]

Caribbean

230 000

[210 000 – 270 000]

South & South-East Asia

4.2 million

[3.5 – 5.3 million]

Sub-Saharan Africa

22.0 million

[20.5 – 23.6 million]

Latin America

1.7 million

[1.5 – 2.1 million]

Oceania

74 000

[66 000 – 93 000]

Total: 33 million (30 – 36 million)