Continuing Education At Home
Addiction Professional - NAADAC
HIV / AIDs
Credits
7 CE credit hours training
Cost
$43.75
Target audience and instructional level of this course: foundational
There is no known conflict of interest or commercial support related to this CE program.
Course Description
The improvement of HIV and AIDS education around the world is essential to preventing the spread of HIV. There are millions of people living with HIV or AIDS. Effective HIV and AIDS education can help prevent new infections by providing people with information about HIV and how it is passed on, and in doing so equip individuals with the knowledge to protect themselves from becoming infected with the virus. Few mental health or health care professionals receive specific training in counseling people living with HIV or AIDS. HIV/AIDS counseling assists clients dealing with issues or abandonment, isolation, partner notification, safety, depression, remaining healthy, treatment plans and other life altering issues.
There is no known conflict of interest or commercial support related to this CE program.
Course Description
The improvement of HIV and AIDS education around the world is essential to preventing the spread of HIV. There are millions of people living with HIV or AIDS. Effective HIV and AIDS education can help prevent new infections by providing people with information about HIV and how it is passed on, and in doing so equip individuals with the knowledge to protect themselves from becoming infected with the virus. Few mental health or health care professionals receive specific training in counseling people living with HIV or AIDS. HIV/AIDS counseling assists clients dealing with issues or abandonment, isolation, partner notification, safety, depression, remaining healthy, treatment plans and other life altering issues.
WHAT IS HIV? THE DIFFERENCE BETWEEN HIV AND AIDS.
AIDS is an acronym used for acquired immune deficiency syndrome. AIDS is a disease that slowly destroys the body's immune system and a person with a suppressed immune system can't fight off germs, infections and diseases. AIDS is caused by a virus known as the Human Immunodeficiency Virus (HIV) that is a member of the retrovirus group. The virus responsible for causing AIDS in a person is the lentivirus.
The lentivirus kills an important kind of blood cell -- the CD4 T lymphocyte, or T cell. These T cells are the quarterbacks of the immune system. As the cells die the body becomes weaker and susceptible to other diseases. Microbes and other pathogens take advantage of this situation and infect the body since the body cannot fight off the pathogens. The diseases and infections caused by these pathogens are termed as opportunistic infections. When people infected HIV get these infections; or when their T-cell levels get too low, the people are HIV infected and can get AIDS after a period of time.
Usually it takes many years for HIV to weaken the body's immune system to the point of AIDS. Depending on the spread of the virus it can take up to 10 years or more for the body to be infected with AIDS. It may take that long for damage to the white blood cells to show up. White blood cells are part of the body's immune defense against infection and these cells help fight off any kind of infections.
HIV causes certain white blood cells to become weak or die off hence the body becomes immuno-deficient. This means that the body can no longer fight off infection and the body can be infected by a vast number of pathogens. In this stage the syndrome is called Immuno-deficiency Syndrome and the syndrome is acquired due to the lentivirus because before the attack of the virus the body was healthy. AIDS also known as Auto Immune Deficiency Syndrome gets the name due to this reason. It is important to remember that a person can be infected with HIV and not have AIDS since when a person is HIV infected the white blood cells are not yet completely damaged and the immune system can still fight off infections.
Anti HIV drugs help a person who is suffering from HIV or AIDS live a healthier life and these drugs help the body fight off infections. These drugs help a person stay infection free as long as the person takes the drugs regularly. Although combining HIV drugs can help a person combination of drugs can have side effects such as vomiting, diarrhea and fatigue. These medications are prescribed by a health care professional and these medications need to be taken every day, as long as the person doesn't want to get infected.
Although most AIDS cases are in Africa, but the disease is spreading most rapidly in Eastern Europe and Asia and is becoming a worldwide problem.
HIV is the most feared sexually transmitted disease because there is no cure and it can cause death of the infected person. Currently there is no cure for HIV or AIDS and since the person who is affected by the HIV lentivirus, has a weak immune system without medications the person's immune system cannot fight off pathogens and infections.
The infected person's body starts making anti bodies soon after the person is infected and he can be tested for HIV infection after 3 months of being infected. Although 3 months is the regular time frame for most HIV tests, a person may not test positive for up to 6 months to 1 year, hence repeated testing may be required.
There is no cure for HIV and AIDS but anti-HIV drugs keep infections in check however, 95% of the world's HIV infected people cannot afford this medicine. Certain health care professionals and scientists say that HIV does not cause AIDS but there is no scientific proof to support their claims. Overwhelming medical and scientific evidence shows that HIV is the AIDS virus and every major health organization in the world says that HIV eventually causes AIDS which can cause death in the person who is infected.
HIV AND PREGNANCY
New born babies can get infected with the HIV virus by coming in contact with vaginal fluids or blood that is infected with HIV during or before birth. They can also contract HIV by HIV infected breast milk. If the mother takes medications during her delivery and while breast feeding there are good chances that the child will not get an HIV infection. The children who are born before 1985 have a good chance of being infected if their mothers were carrying the virus due to lack of medications available at that time.
It is crucial to remember that a baby born to an HIV positive woman will test positive for the HIV antibody. The mother passes her antibodies, which includes the antibodies for HIV to her unborn child. Although the baby may not be infected with the HIV virus, the antibodies will induce a positive HIV test and the baby will need to be tested over time until they reach 24 months. Since children lose their mothers' antibodies within 9 to 15 months after birth there is a good chance that some children will not have the infection.
Babies and children with HIV disease can suffer from the following:
HOW DOES A HIV TEST WORK?
Testing for HIV is a simple process and it is possible to get home tests. It is also possible to get tested at professional labs that keep the person's identity discreet or the person can get tested by his doctor and at the public health department.
If the result is positive in a home test or lab test it is important to go to a doctor and confirm the test results and to start medication.
If the person knows that he is at high risk of HIV infection and come down with a bad case of the flu, it is important for him to see a doctor right away as this could be the early signs of HIV infection. It is crucial that he tells his doctor about the test and any symptoms.
Before getting tested it is important to understand why he is taking this test. If he tests negative he may want to understand about how to reduce your future risk since you were concerned about the risk in the first place. There are many private AIDS organizations that can give you this kind of help and usually these organizations have experienced counselors that may or may not have encountered a similar experience.
If he tests positive, he will need help deciding what to do next. HIV infection isn't a death sentence but it does mean that he will need to take special care of his health. It also means that he will have to take special care not to infect anybody else with the AIDS virus.
If he tests positive for HIV, he must have proper medical care and he should get some help from a person you trust or a medical counselor. The person he chooses should accompany him to the doctor to provide support.
If he tests positive, he will have to tell his sex or needle-sharing partners that they too need to be tested. If he has children then it may be important to also get his children tested after his test is confirmed.
HIV TESTING - DECISIONS
Here are some things the person will need to decide before and after he takes the HIV test:
If infected the person is infected he will need to do the following things.
HIV TESTING - REACTIONS
These are the common reactions a person can encounter after being tested positive:
It is important for the care giver to give the test results promptly. The care giver or medical health care professional should not overload the patient with information and give him some time to cope with the new situation. The care giver should mildly encourage the patient to opt for supportive counseling about his feelings and the patient's personal concerns then move on to education and counseling when the time is appropriate. Information can be given in print or at a later appointment when the person has started accepting the new situation and is ready for advice or information.
The health care professional should ask the patient to learn more about HIV and AIDS since knowledge can help the person avoid any further problems. He should also ask the person to visit a care provider who is experienced in the HIV field. The care provider will further on test the infected person for various things such as a T- cell count, Tuberculosis test, virus load test and may prescribe any medications that are needed.
The health care professional should also tell the patient that since the immune system may weaken over time with medications and the virus it is important that the person stops consuming drugs, nicotine, alcohol and other unhealthy substances that can cause complications. Adequate rest, exercise and a healthy diet will help the body fight off secondary infections with the help of the medication.
It is important for the health care professional to remind the infected person that he has to inform the people he is having sexual relations with or sharing infected needles with. It is also important for the person to ask those people to get tested and seek the required medical care.
HIV tests under rare circumstances can be incorrect; the chance is less than 1 in a thousand. However, if the person does want to re test he should be asked to use a different laboratory or testing company.
If the test came back negative it is important for the health care professional to tell the person who was tested that the test was to search for antibodies created by the body to combat the virus and the test was not for the virus itself. It is also important to tell the person that these tests are accurate but if the person has performed any questionable activity within the last 1- 3 months he will need to wait for another 3- 6 months to take another test since these test only counts for any activity that happened 3 - 6 months ago.
If the test came back negative the health care professional will need to inform the person that he may not have been exposed or may have been exposed but not infected. He should also inform the person that he was fortunate at this time but to be cautious in the future as he can be infected later on if he continues indulging in similar activities.
The health care professional should keep in mind that the HIV test does not determine how long the person has been infected or if the person has moved on to the latter stage known as AIDS. The health care professional should also keep in mind that this test does not determine if the person can or cannot get AIDS and the status of the person's current immune system.
AIDS SYMPTOMS
A person who is infected with HIV may not show symptoms of AIDS for many years depending on how long his immune system can manage to fight off secondary infections. HIV and AIDS symptoms include but are not limited to fever, night sweats and swollen lymph glands. These symptoms can show up anywhere from several weeks to several months after being infected with the virus. These symptoms can last for a month or so and then they will go away although these early symptoms are not present in all cases. Since they resemble the flu then many people may experience these symptoms without thinking that it may be anything more than the flu.
Kaposi's Sarcoma - ?The immune system helps protect our bodies from contracting certain types of cancers. When a person has AIDS their body is unable to fight off such cancers and the person becomes susceptible and vulnerable to such cancers. One type of cancer that an AIDS patient can contract is Kaposi's Sarcoma. This type of cancer affects the skin and other body organs. The marking on the skin from this type of cancer looks like a bruise or black and blue mark and these markings are permanent. This type of cancer has been a leading cause of death among AIDS patients.
TREATMENT
In a controlled environment these drugs can help a person who is infected live a longer and healthier life, but in real situations when a person forgets to take his anti retroviral medications, these medicines can be less effective. For the HIV and AID S treatment drugs to have effect it is important for the person to take the prescribed drugs in the right quantity at the right time every day. Although most doctors agree that the treatment and medication should be started at the first stage of being infected, at times people are not diagnosed until their systems have already been badly infected.
Majority of the scientists and health care professionals agree that the drugs should be started when a CD4 test that helps determine the T cell count states that the cell count is below 350 cells /mm. Other considerations such as opportunist infections and viral overload may also be taken into account.
Combination drugs are often prescribed to patients with the most common combinations being two NRTIs (Nucleoside/Nucleotide Reverse Transcriptase Inhibitors) combined with a NNRTI (Non-Nucleoside Reverse Transcriptase Inhibitors) or a boosted protease inhibitor. When the antiretroviral drugs have been combined into one pill or medicine these drugs are known as fixed dose combination drugs. The main benefit of these drugs is that the person infected has to take a lesser amount of drugs every day.
Since HIV has to get into a T cell and latch on to the cell to fuse its outer membrane to the T cells, new and improved drugs known as attachment inhibitors or fusion inhibitors are being tested in humans to help tackle this virus.
Interluekin - 2 or IL- 2 are chemicals that help the body's immune system stronger to fight the virus more effectively. Constant clinical trials are conducted to reach a conclusion however no decision regarding this drug has been finalized yet.
Antisense drugs help for a mirror image of the HIV's genetic code that helps shut down cellular factories that are creating disease causing proteins. Although these drugs are not released to doctors yet due to continuous testing, scientists agree that these drugs will not have side effects.
Anti retroviral drugs can cause side effects until the body gets used to the medications. Possible side effects of anti retroviral drugs are mentioned below.
HIV Dementia/ HIV-Associated Dementia Complex (also known as AIDS Dementia Complex) is a progressive neurological disorder that can affect people who are infected with the Human Immunodeficiency Virus (HIV). HIV-Associated Dementia Complex (HAD) is thought to be a subcortical dementia and is characterized by cognitive, motor and behavioral impairments severe enough to interfere with an individual's ability to function occupationally or socially.
Although the precise incidence and prevalence of HIV-Associated Dementia Complex is uncertain, it has been estimated that as many as two-thirds of the individuals with AIDS will develop dementia or related neurological disorders at some point of time. The leading hypothesis regarding HIV Associated Dementia is that it is caused by direct infection of the brain by the Human Immunodeficiency Virus (HIV) which is the cause of AIDS. In 1987 the Centers for Disease Control included HIV-Associated Dementia Complex as a primary diagnostic condition that warrants a diagnosis of AIDS.
Symptoms of HIV Dementia The early manifestations of HIV-Associated Dementia Complex ) (HAD)may include:
Adolescent and adult clients should be advised about risk factors for STDs and counseled appropriately about effective measures to reduce risk of infection. Counseling should be tailored to the individual risk factors, needs, and abilities of each client. Assessment of risk should be based on a careful sexual and drug use history and consideration of the local epidemiology of STDs. Sexual history should include questions about number and nature of current and past sex partners including same-sex partners or partners who have injected drugs, any history of past STD infections, the use of condoms or other barrier protection and particular high-risk sexual practices such as anal intercourse.
People at risk of STDs should receive information on their risk and be advised about measures to reduce their risk. Effective measures include abstaining from unprotected sex, maintaining a mutually faithful monogamous sexual relationship with a partner known to be uninfected, regular use of latex condoms, and avoiding sexual contact with casual partners and high-risk individuals like intervenes Drug Users, commercial sex workers, and persons with numerous sex partners. People who have sex with multiple partners, casual partners, or other persons who may be infected should be advised to use a latex condom at each encounter and to avoid anal intercourse.
Condoms need not be recommended to prevent infection in long-standing, mutually monogamous relationships in which neither partner is an injection drug user or is infected with HIV. People using condoms should be informed about the importance of using them in accordance with recommended guidelines.
It is beneficial to involve the client in his own education as much as you can. He can repeat instructions in his own words and simulate anticipated conversations with his partner or parent. The average person can absorb about three take-home messages in one educational session. Give your messages careful priority ranking, and don't overload people with data. Pay attention to the person's agenda and allow time for the client to discuss his questions and concerns.
There will almost certainly be questions you haven't thought of and the most important way to show respect for a patient is to give time to his issues. Evaluate your client's learning since you don't know what the client has already learned until you hear what he says. Ask a few keys questions and see how he responds. Education must be ongoing since almost no client can learn all he needs to know in one visit.
Invite calls to the clinic or office or hot-line later as people learn best in an environment that feels safe and calm. A person on the way to a medical exam rarely feels safe and calm hence you should allow time after the exam for more education and discussion and invite clients to call back later with questions. Teens and adults may need a different style of education and understanding intellectual and emotional developmental stages can help you pitch educational messages appropriately.
Information reassures some people and overwhelms others. Not all clients need or want to know every single fact you know. You can do no harm if you do not make decisions for the client. You will almost certainly do harm, sooner or later, if you are extremely authoritative. The best response to "What do you think I should do?" is "What do you think? is that I'll help you sort out all your options, and then we'll look at your ideas about the pros and cons for each option."
Listening is very helpful and listening to concerns and the responding is the best way to answer questions. Often clients need to be understood more than they need anything else. Avoid thinking in me or them terms since the successful counselor recognizes the common human ground he has with each client. Not all people are able to be "compliant" and when you and your clients are face to face, support them and hold them accountable for their actions. Once they leave your office, let it go.
Denial and anger are common, normal responses to trouble. You will need to be skilled at reflecting and discussing these feelings. Anger is usually a sane, healthy response to feelings of vulnerability and loss of control and denial can be given up by the denier, but never forcibly taken away be the counselor. Help preserve hope, even in the face of fatal illness and you can actively help clients have as many good days as possible. That is a worthwhile, valuable goal. Avoid asking "why" questions as reasons for feelings or actions can be murky and complex, and "why" questions are usually difficult or impossible to answer. Clients are likely to feel attacked or embarrassed so offer the option of including others in counseling. Partners, parents, and best friends may be helpful in reducing anxiety for some clients and for others privacy in counseling is absolutely essential. The ultimate choice belongs to the client and your opinion should not be forced.
Assure the client you only want to know what he wants to tell you. This powerful phrase returns control of the encounter to the client, and often results in a remarkably candid discussion. Be open to the broad variety of healthy, effective human coping styles. Your way will almost never be the only way. People solve their own problems! Assume nothing and discipline yourself to forestall labeling, categorizing, and stereotyping. Just listen. Accept your client where he is right now and the client knows what he wants from you. Just ask!
Here are some practical tips the health care professional can ask their clients to use if they feel that their families are having a hard time coping with the situation.
Listed below are some social and emotional stressors that people who are infected with HIV or AIDS can feel and go through.
Sexually Transmitted Diseases (STD's) can cause serious illness, sterility and even death. Safe Sex means ways of having sex that reduce or eliminate a person's risk from STD infection. Body fluids such as blood, semen and vaginal fluid can carry many STD's including the HIV virus, which can lead to AIDS. Never letting body fluids transfer from one partner to another during sex will greatly reduce the risk of catching STD's. So, if engaging in intercourse whether it is vaginal or anal, always use a condom. A condom properly used is an effective barrier against most STD's including HIV, but not against herpes or genital warts if the infected area is not covered by the condom. Only lubricate a condom with water based lube and not Vaseline which will cause the condom to tear.
Other forms of Safe Sex include any non penetrative activity such as mutual masturbation, kissing, massage or using dildos or vibrators but never share them without cleaning them first. These can be great fun too - talk to your sexual partner about protecting yourselves and only having safe sex.
Oral Sex (mouth to genitals) is thought to be only a very low risk from HIV, but higher risk from other STD's such as Herpes, Genital Warts or Gonorrhea. To reduce the risk further, avoid semen in the mouth and consider using a condom for oral sex on a man and a dental dam on a woman. Don't have oral sex if either partner has cuts or sores on the mouth, lips or genitals.
While injection-drug use once accounted for most new cases of AIDS in women, the latest data show that the majority of females are now infected through heterosexual sex with an HIV-positive partner. While injection-drug use once accounted for most new cases of AIDS in women, the latest data show that the majority of females are now infected through heterosexual sex with an HIV-positive partner.
The best protection is to follow these guidelines:
Do not share needles. If you share needles clean them with bleach and water after every use. Practice only safe or "Possibly" safe sex.
Talk with your sexual partner(s). Take the time to discuss how each of you can reduce the risk of exposure to the HIV virus.
SAFE ACTIVITIES:
COUNSELING
Using alcohol or drugs can lead to high-risk sexual behavior. People who inject drugs should be referred to available drug treatment facilities, warned against sharing drug equipment and where possible referred to sources for uncontaminated injection equipment and condoms. Drug users should be advised of the importance of being tested for HIV, of using condoms regularly with both casual and steady partners, and of following specific steps to reduce the risk of transmitting infection during preparation and injection of drugs.
HIV counseling requires explicit discussion of death and dying. Counselors are likely to encounter clients who hold opinions and values very different from their own, and will be challenged to become aware of their own biases and stereotypes that could interfere with effective counseling. HIV counseling requires that the counselor consider the reactions and needs of partners and other family members as well as those of the client.
COUNSELING COUPLES AND GROUP COUNCELING
In all cases the counselor's role includes assisting each member of the couple to cope with their emotional reactions to their HIV status and to the HIV status of their partner. In the case of concordant seropositive couples or discordant couples, it is not uncommon for one partner to blame the other for behavior that may have resulted in infection.
While the expression of emotional reactions is necessary and often helpful in risk reduction, counselors must set limits to prevent partners from verbally or physically abusing each other and re-focus them away from assigning blame to developing a plan for living positively with their couple serostatus.
Couples being counseled together should be encouraged to discuss their plans regarding pregnancy and family planning. Counselors are reminded that the question of whether discordant or seropositive couples should have more children is a complicated issue that involves considerations of their health status, resources, family circumstances, spiritual beliefs, etc. While it is not the role of the counselor to tell the couple what to do, the counselor raises the discussion for the purpose of providing information and encouraging communication within the couple.
Couples should be referred for family planning services and medical evaluations. It is the responsibility of the counselor to keep referral information current.
In some cases, it may be harmful to discuss antibody status immediately after receiving a test result or when a person is reluctant to do so. Individuals need time to develop an understanding about how they feel and about the health, psychological, financial, and relationship implications of their results. This process may be aided by disclosing to a partner, but clients first need to acknowledge these concerns by themselves. At the same time, counselors should encourage clients who are uncomfortable about disclosing to partners at all. They may need to explore further their concerns, possibly through individual or group therapy, or by first talking to a friend or family member other than their partner.
Partners may accompany patients to test sites and patients may ask that partners join the counseling session. With both partners present, a counselor can help the couple acknowledge HIV as a "third party" in the relationship, an element that will affect their lives and plans together. By acknowledging this, partners may better accept and deal with infection, and diminish the effects of its intrusion in their relationship.
For some couples a shared session may encourage open discussion of certain concerns, such as safe sex, health care, and emotional support. However, counselors should be aware that shared sessions may be unproductive especially if they result from unequal power-sharing in the relationship for instance, if one partner has demanded to be part of the session. A partner's presence may inhibit a client's emotional response, and partners may limit their discussion to protect each other. Counselors should acknowledge these concerns before asking or allowing partners to join in sessions.
To facilitate joint sessions, counselors should make sure that they address their clients' primary concerns before partners attend. When partners are present, counselors should encourage both individuals to freely express their thoughts but counselors should remember that while they are offering support to both partners, their primary counseling responsibility remains with partners to whom they have disclosed test results.
For the client who has recently tested positive and who is experiencing a flurry of disturbing and disorganizing emotions some form of crisis intervention is frequently indicated. This means providing support and validation for feelings, mobilizing resources for coping, providing educational information, and helping the client solve pressing situational demands.
The counselor can begin by normalizing the emotional "roller coaster" that is so commonly experienced. As many of these clients have had little if any opportunity to discuss their situation with anyone in depth, the experience of feeling heard and understood, and accepted by an empathic counselor who actively listens can be a significant starting point. Learning that many others have experienced similarly severe reactions to testing positive can also help reduce their sense of isolation.
The counselor should be sensitive to the possibility of suicidal ideas, though actual hospitalization of suicidal HIV clients has been a rare occurrence in medical experience. A useful initial response to such thinking is to normalize it by pointing out its commonness among HIV individuals. When present, suicidal ideas should be monitored carefully and can be expected to subside as the client begins to adjust to the information and the sense of immediate crisis is alleviated.
Helping the patient find resources for coping can include identifying internal strengths and abilities as well as external supports such as friends, family and social services in the community. Identifying effective coping strategies that the patient may have used in the past during high stress or crisis is also useful. Teaching coping strategies ranging from controlled breathing, visualization, or taking a walk in the park, to problem-solving approaches such as "taking things one step at a time," ensuring frequent rest periods or "mini vacations," and remembering other successes in coping with past adversity have all been used effectively.
Often friends and family as supports are underutilized in the case of HIV infections. This is because of the fear to a negative reaction or fear or overburdening them. The counselor can assist the client in helping the patient decide which friends or family members would be the most likely to respond in an accepting and supportive way. Referral to support services in the community, such as emotional support groups and AIDS informational centers, contributes further to the sense of having a range of resources from which the patient can draw support from.
Finally, reminding clients who have recently tested HIV that the emotional turmoil of the initial adjustment period is hard but once the patient gets used the situation life can become normal again if the patient has strength and determination. It is critical that the counselor provides an opportunity for clients to recognize, express, and eventually accept the full range of feelings that are sparked by facing a life-threatening illness. When negative thinking predominates, however, and clients become trapped in a downward spiral of hopelessness, cognitive techniques can help to replace some of the dysfunctional thought patterns with more constructive ways of thinking. For instance, clients who repeatedly think that they are going to die so there is no sense trying or they are exempted from the joys of life because they are HIV positive can be helped to examine the dysfunctional nature of these thoughts and to recognize the potential for changing them. Through support and therapy the client can realize that life is not yet over and he has to be happy and healthy for himself, his family and his friends.
The negative thoughts should be converted to positive thoughts over a period of time and the patient should not be rushed but should be encouraged to think of all the positive things that life holds for him. Often patients feel that this is the worse situation and they are doomed for life. The patients should be told that there are better off than many people who face a lot of problems and if they take their medications on time they still have a chance of leading a normal life. The words used to convey positive messages should be altered according to the severity of the patient's mindset and the therapist should refrain from using any negative words that may cause the patient to think that he has no chance of living a normal life.
Often the client's difficulty in disclosing antibody status to friends or family reflects problems with self-esteem associated with being HIV positive. In such cases, it may be important to first address negative feelings before encouraging disclosure to others.
It is not uncommon for the counselor to encounter a client who is continuing to engage in potentially self-destructive behaviors such as drug or alcohol abuse, unsafe sexual activity, or poor daily health habits involving diet, sleep patterns, and so on. If these behaviors do not change during the course of counseling, firm but gentle confrontation of the behaviors is recommended. Sometimes providing information about the potential harm of such behaviors to an already vulnerable immune system can help motivate the client who is poorly informed.
For others, being pushed to seriously to examine such behaviors requires confronting the potential seriousness of the situation in a way which may have been avoided out of fear. Such fears need to be examined and explained with careful timing and in an atmosphere of respect. In other cases unhealthy patterns such as those involving diet, sleep, or substance use may reflect an underlying depression or crippling anxiety, which inhibits the client from making important changes. In such instances, a referral to a psychiatrist for evaluation for medication should be made if the person does not respond to regular therapy.
Throughout the sessions it is important that the counselor conveys a sense of hope and encouragement while at the same time allowing space for experiencing emotional pain and loss. The re-examination of basic values and priorities in life that many HIV positive clients undergo can be framed by the counselor as an opportunity to enrich the quality of life. Giving examples of others in similar circumstances who have managed to survive and make progress over time can be inspiring. Supporting the patient's right to engage in "healthy" denial like regularly taking breaks from dealing with emotionally painful realities can also help the patient heal.
The crisis which most clients experience following an antibody-positive test result can be a source not only of emotional turmoil, but also of motivation for making significant positive changes. The confrontation with potential mortality brought on by the test result leads many individuals to a commitment to work through troubling personal issues which they previously lacked ability or motivation to address effectively. For such clients, a decision to enter longer-term psychotherapy may be an important step towards turning the crisis into a profoundly life-enhancing transition.
HIV positive clients must cope with a range of painful emotions which typically accompany an antibody-positive test result which include fear, grief, anger, and sadness. They must also deal with decision-making in a number of important areas of their lives in which there is a great deal of uncertainty. This includes uncertainty about medical prognosis, health care options, how best to spend one's time and plan for the future, and how to share the news of being HIV positive with others. Furthermore, social restrictions and the strain often imposed by the antibody-positive test result on important interpersonal relationships may contribute to a plummeting self-esteem.
Counselors who choose to work with this client population face a demanding set of challenges. They must struggle with a high degree of ambiguity and with the difficulty of identifying clear guidelines for how to address the client's needs and how to measure progress. The counselor's own attitudes and anxieties about AIDS and HIV must also be channeled in a healthy direction. Ultimately the counselor, along with the patient, has an opportunity to develop an enhanced sense of purpose and meaning within a situation of crisis proportions.
Group counseling groups for HIV individuals can be a tremendous help in reducing social isolation, increasing coping resources and providing support for making positive changes. The average patient feels a sense of relief when hearing others describe similar experiences and emotional reactions to a HIV test result. Many benefit from involvement in such a group concurrently with individual counseling whereas others prefer only one on one sessions. In some communities, there may be a variety of types of groups from which to choose, including short-term topic-focused groups, drop-in support groups, longer-term closed-membership support groups, and psychotherapy groups. Short-term topic-focused groups, often intense six to ten weeks of sessions and tend to have the dual objective of offering interpersonal support as well as information relevant to coping with HIV and protecting oneself and others. Drop-in support groups generally offer the individual an opportunity for group support and educational information without having to make an ongoing commitment to attend. Such groups are particularly helpful to those with limited experience in therapeutic groups and who want to test the water before considering a longer-term support group. More traditional psychotherapy groups for individuals who are HIV positive can offer an opportunity for greater depth of exploration of personal and interpersonal concerns than is possible in short-term groups. The health care professional should consult the patient while providing suggestions about which type of therapy will be best for the patient.
HIV AND EMOTIONS?
Anger, guilt, depression, fatigue and fear are some of the reactions to HIV. These feelings and reactions do not come in a particular order and are also not felt by everyone at the same intensity. Some people experience each feeling differently and sometimes they are felt at different times and sometimes they are all felt at once. These emotions are reasonable reactions that HIV infected patients feel.
JUSTIFICATION
No matter how someone was infected with HIV they feel that did not ask for it nor do they deserve it. Some of the common thoughts experienced during this situation include but are not limited to:
ANGER?
Some people can easily express their anger, while others keep it inside. Some people with HIV may not feel any anger due to their medical condition. In any case, anger is a reasonable response to HIV.
Anger also is derived from the lack of control over one's body and health. An independent person can quickly become dependent on their caretakers when they become ill and unable to tend to their daily functions.
People express anger differently. Some people express anger directly and openly. Other people keep their anger bottled up inside until it is released in an appropriate or inappropriate way. Some people express anger at whatever or whoever is within reach and at most times they get angry at their caregivers. Some people are uncomfortable with expressing their anger and in these cases anger acknowledgment and anger management training would benefit the individual.
If one cannot express their anger in any way then they turn their anger inward and they feel depressed, guilty or they dislike themselves. Some people rely heavily on drugs or alcohol to cope with their medical condition. This option is detrimental in many ways as they lose control, are more likely to be reckless. Also drugs and alcohol are horrible for their health and being under the influence most likely will put the person back into the behavior that put them at risk for the virus in the first place.
People usually realize that they are treating themselves badly and before long they start to realize their wrong doing and work on treating themselves better. At other times friends and relatives intervene and point out that the individual needs help and suggests it to the person affected with HIV. In this situation mental health professionals can help an individual identify and understand the anger and help the anger find its appropriate target. Additionally, an alcohol or drug rehabilitation, outpatient or inpatient program would also benefit an abuser.
People need to be allowed to deal with their anger and to be angry. They need to learn how to express their anger in a safe and appropriate setting. Directing anger at the wrong target is at best ineffective and at the worst harmful. Even anger turned outward can be overwhelming. Certain attitudes and actions help people deal with their anger and these actions need to be identified and the anger needs to be redirected appropriately.
Each person also needs to find the appropriate mechanisms to discharge their anger. Some people scream while others exercise or write in journals. Caretakers need to understand that the person affected with HIV is angry at the medical condition and the disease is the target, not the caretaker. They feel anger not hatred and they don't blame the care taker, however the care taker is the closest to them and he is the current release for their anger. Until the anger is redirected in an appropriate way the patients will continue to abuse their caretakers, family, friends and themselves. Acknowledge the struggle that they have and the family, friends or care giver should understand that they are not angry at them
Energy from anger can be used to form support groups, telephone hot lines, newsletters, fund raising, and political action groups. It is important to explain to the patient that it is easy to sit and complain about a situation, however, if his health allows him to redirect the energy into positive activities it will allow him to feel good about himself and less angry, depressed, hopeless or guilty.
DEATH OF A LOVED ONE
Grief is an expected human response to the loss of a loved one. Grief can cause extreme physical and emotional pain. An individual grieving from a single, uncomplicated loss may experience sadness, crying, disorientation, anger, anxiety, loss of concentration, physical discomforts and may also feel pain in their chest or a sense of emptiness. These symptoms may last a year or more and by themselves suggest no pathology. Even with social support, though, survivors are faced with the personal challenge of adjusting to a new life without the loved one. After death survivors may experience stress related to inheriting new and unanticipated responsibilities or experiencing changes in social role.
In the case of death due to HIV disease, mourning, the public display of one's grief, may be hampered by the societal stigma and blame associated with AIDS. Survivors may not receive support and compassion from their friends, family and church during the painful grieving period. For others, such as gay partners, relationships may go unrecognized or invalidated and may obstruct opportunities to talk about the death. Such disenfranchisement from one's grief may impede the process of bereavement. In the months and years following the death of a loved one, survivors face the challenge of leaving the deceased behind, learning to live with the absence, and reinvesting in the future; resolving grief is an ongoing process.
AIDS and Multiple Losses ?Members of communities that have been heavily affected by the HIV pandemic may suffer new losses before recovering from old ones. Kastenbaum coined the term "bereavement overload" to describe a potentially unhealthy response to a series of consecutive, often overlapping losses and the accumulation of unresolved bereavements which may cause an individual to become emotionally overwhelmed, physically exhausted, and spiritually demoralized [Kastenbaum R. Death and Bereavement 1969; Springfield, IL:Charles C. Thomas].
The inability to resolve one's grief can be devastating. Unresolved bereavement has been found to produce significant risk for the development of adverse health outcomes. It is characterized by a myriad of symptoms ranging from emotional distress, such as depression, to somatic disorders, such as insomnia, and even suicide. Bereavement may be complicated by a variety of circumstances that have the potential to interfere with its resolution. Conditions, which may complicate mourning, are identified as those associated with the current death, such as social stigma or secrecy, as well as antecedent variables such as previous, un accommodated losses or lingering feelings of guilt. All of these conditions are commonly seen with death due to AIDS.
Bereaved people may wonder how to get through their grief. The grief process is like a journey running from the starting point of bereavement to a new life. Progress is made through grief as the feelings are worked through. Freud called this grief work.
Some strategies for dealing with grief:
Some people find it helpful to spend fifteen to twenty minutes alone every day. They put on the answering machine so they won't be disturbed. This time acts as a safety valve. In it they deal with any emotions they have stored up during the day. There are different ways of grieving at these times: thinking, crying, praying, meditating, writing or drawing talking to the dog!
Some people like to keep a diary. They write down their feelings and the memories of the loved one. They can then see how their grief changes over a period of weeks and months. This is proof of progress. If the diary is kept in a safe place the written memories become precious in the future. Alternatively some people feel more comfortable with pictures or diagrams. Many people feel less alone by also grieving with other family members, including the children.
Many people find crying a relief. Rather than being an indication of weakness, tears are often a sign of strength and show that the bereaved person is prepared to work through their grief. Some people find it difficult to cry, and yearn for tears to release their grief.
Enlisting help can seem long and lonely; so many people find someone whom they can confide in, for example, a relative or friend. Some people find the experience of another person who has been through a similar situation invaluable, and so contact a support group.
Some other useful strategies
Self care is important to prevent further stress to the body. The following have been found to be helpful in coping with grief:
Depression has been associated with people who are infected with HIV. Depression seems like the only possible response to an illness that can devastate psychological, social, health and integrity. Some people find solace in despair or becoming entirely indifferent while others seem to come alive, manifesting an inner strength and resolve.
HIV infection initiates a long and complicated emotional process during which there are often moments of despair, of denial, but also of strength, even heroism. This process includes moments of sadness and personal loss. But when does such a depressive response become significant enough to warrant mental health intervention? One cannot work with clients with HIV and be insensitive to the inevitability of profound loss. But this sensitivity cannot blind providers to the possibility of intervention.
One cause of depression is a sense of being stuck in a frustrating situation. At some point, most people must face something in which they cannot fix, to which they can only adjust. People with HIV usually do not know what is coming next. This loss of control is overwhelming and thus depressing. Another cause of depression is predisposition. People who have been depressed before their diagnosis are more likely to be depressed afterward. Some of the medications to treat HIV can cause depression.
Alcohol, which is a depressant, can cause a cycle that causes a person to feel better about their depression and then causes the person to feel more depressed and out of control after the alcohol wears off. Occasionally, depression may be caused by the virus itself since depression can be a symptom of dementia, which is a condition when the virus enters the brain.
Depression that is unexpressed anger will disappear when the anger is recognized and dealt with. Anger is difficult to express, especially when the situation is out of one's control. People who do not express such anger either consciously restrain it or unconsciously ignore it and hence they unknowingly turn their anger inward on themselves and become depressed.
Depression that is associated with sadness, loneliness and hopeless usually runs its course and after a few days or weeks gradually fades away. For some people this happens without intervention and for others there need to be someone to intervene to help the person cope with their depression.
Physical activity is one way to permanently end depression. Researches indicate that 20 minutes of exercise can have the same effect as 20 milligrams of anti depressant medicine. The counselor should tell the patient to go outside, go for a walk, cook a meal, bicycle riding, bowling fishing or going shopping and buying himself a treat are all ways to alleviate depression. A sense of accomplishment can come from doing something small like cleaning out a closet, writing a letter, or painting a picture and each small accomplishment can give him hope continue leading a normal life.
Mental tasks, such as reading, going to the movies, going to an art gallery, taking pictures, learning to play a musical instrument, taking a trip, gardening, taking up a new hobby or continuing an old hobby or just talking to a friend are just a few ideas to lessen depression. These activities should help restore hope and lessen or alleviate the person's depression.
For some people, the depression is too severe or it doesn't seem to go away. They feel alienated from everyone, very apathetic and hopeless. Severe depression is often best treated with medication. Sometimes medications that are treating some other illness can also cause depression. If this happens a certified doctor can either change the medication or change the dosage to one that is more effective for the symptoms that it is suppose to be treating and does not cause depression. If the depression is due to dementia then medication should be prescribed by the patient's doctor.
Due to the severity of HIV most people will have some level of depression. This depression can be managed with medications and support. A psychiatrist should be part of the treatment team to prescribe medication that restored sleep, appetite and mood. The drugs prescribed for depression are very successful. About 80% of severely depressed clients with HIV get better while 50% of them are cured of their depression. For most people the treatment of depression is critical but it is also temporary.
Psychiatrists, psychologists and social workers can help talk the person through whatever is blocking the healing process, though only psychiatrists are trained medically and can prescribe medications. Therapy can concentrate on the overwhelming problems people must face and feel that they cannot solve.
SUICIDE AND HIV
Suicide and HIV are linked and will definitely present as an issue for any provider working with HIV-infected patients. Many reviews in the psychiatric and medical literature have looked at the link between suicide and HIV infection and all report indicate a higher incidence of suicidal ideation, suicide attempts, and actual suicide in the HIV-infected than in the general population.
For the healthcare provider the possibility of suicide of any patient can provoke great anxiety and pose medical and ethical dilemmas. There are several risk factors for suicide in patients across the entire spectrum of HIV infection from learning one is HIV-positive to having end-stage AIDS. Familiarity with these factors can help the provider in making an office assessment and forming a treatment plan.
Providers in the office may see a patient who has just made an attempt, reported suicidal thinking spontaneously or answered positively to an inquiry about suicidal ideation during a review of symptoms. Asking about suicide will not cause a person to attempt suicide and is not likely to suggest something to the person with HIV infection that he has not already considered. Patients will usually be relieved to be able to talk about feelings that they might think need to be hidden, and will take comfort in learning that suicidal thoughts are common or even expected in HIV cases.
If the questions can be comfortably asked by the provider, patients with suicidal intent, with or without a plan will usually talk openly and will be much less likely to act on the feelings. Patients may develop a trust and rapport with the provider and are more likely to seek help in the future if faced with frustration, hopelessness, and despair or disturbing suicidal feelings. A suicide assessment includes a thorough mental status evaluation, a thorough history especially of psychiatric problems or suicide attempts, a current psychosocial assessment, a review of current and past alcohol and other drug use or abuse and an assessment of current medical status including current medications.
The provider can be more direct and assertive in asking about suicidal ideation in patients with patients with the following problems.
If the provider believes the patient is open and honest about the suicidal thinking and has no immediate plan to act on the feelings then education, support, reassurance and the offer to be available in the future or to provide a future referral will usually suffice. Most patients are able to control the desire to act on immediate feelings, will promise to call someone if the suicidal intent recurs and will feel reassured that the provider is listening and taking them seriously.
The option for an extra visit or a referral to a mental health provider can be offered if there are factors that cause the provider to doubt the patient's promise or any factors will interfere with the patient's ability to control impulsive behavior like evidence of current alcoholism, substance abuse, or a history of prior attempts while intoxicated, a severe depression and a diagnosis of a borderline personality disorder the provider should then intervene in some way.
When appropriate, the provider can counsel the patient about reducing and stopping substance abuse or assess him for a medical intervention to treat the depression. It is most likely that the patient will need to be referred to a mental health or substance abuse counselor, provider or program. In the rare instance when a patient clearly intends to act on suicidal feelings and will not contract to seek help from a psychiatric or mental health provider, the provider with the patient should arrange for an emergency psychiatric assessment before allowing the patient to leave the office. Enlisting the help of a lover, spouse, close friend or family member may be a crucial and necessary step.
Although ethical and legal issues are beyond the scope of this discussion of anxiety and depression in the HIV-infected patient such matters as confidentiality, safety, informed consent, involuntary commitment to a psychiatric facility and the duty to warn others who may be at risk of harm by an HIV-infected patient need to be considered in all treatment interactions.
The provider can serve as a constant source of hope for the patient with AIDS or other HIV related illness. The provider can improve the quality of life, possibly add to longevity, reduce suicidal accidents if anxiety and depression are noted and can also advice appropriate treatment.
The possibility of substance abuse must be included in all assessments and treatment interventions due to the role of substance use and abuse in the transmission of HIV, both through direct routes of infection and through failure to use proper precaution and judgment in avoiding high-risk behavior when intoxicated. The patient will benefit from proper assessment and diagnosis of anxiety and depression, since he will feel relieved to be cared for and have painful symptoms treated. The provider may see a dramatic improvement in the patient and the care provider will help contributing greatly to an improved quality of life and enhanced compliance with the overall treatment plan.
An individual's HIV status whether it is positive or negative raises special concerns for individuals in primary relationships whether it is with spouses, partners or lovers. Providing initial and long-term emotional support, disclosing test results and practicing safe sex, in particular are complicated when added to the psychological context of a committed emotional and sexual relationship. While counselors are unable to fully explore their clients' relationships within single, time-limited sessions, it is important for them to consider the effects of antibody test results on the dynamics of relationships and the effects of relationships on their clients' capacities to cope with test results.
Among the support-related topics counselors may discuss are the range of emotions clients may experience, the impact of test results on current or future primary relationships, and how views of health care may affect this relationship.
Clients should evaluate and perhaps discuss with their partners the long-term effects of test results on their primary relationships. Some clients may tell counselors that they are uncertain about the future of their relationships, or that they want to end their relationships. In other cases, clients may not question the problems in their relationships, but counselors may identify in these relationships destructive qualities that may affect clients' responses to being infected. Counselors should remember that, in some cases, ending a relationship may be more beneficial than staying in one.
The counselors who do brief HIV counseling pre and post test cannot evaluate particular relationships but they can suggest that clients themselves consider the reasons they are in their relationships, the support they receive from their partners, and the support they expect to receive in light of their test results. In addition to general issues of emotional support, counselors should consider other ways for example, partners' attitudes toward medical intervention and history of substance use in which primary relationships affect clients. Clients may have already examined their beliefs about early medical intervention, experimental treatments, and alternative health care, but may not have considered how their partners' beliefs support or contradict their own. When informal discussion between partners does not resolve health care conflicts, formal counseling may be necessary.
When either their clients or partners have problems with substance use, they challenge the abilities of the relationship to offer support and they challenge counselors to evaluate the availability of emotional support. In many cases, substance users may be unwilling to discuss their infection with others, may be more susceptible to engaging in unsafe sexual activities, and are likely to withdraw emotionally from their partners. As always, counselors should be prepared to take a substance use history and have substance use counseling referrals available for clients in relationships where this is an issue.
Losing someone close through suicide can lead to a whole range of emotions including shock, sorrow, confusion, guilt, depression and even relief. The question 'Why did they take their life?' is often complex and may never be resolved. There is no easy answer - the most honest answer is we don't know. The factors that can result in a person suicide are varied and may include:
Many people who are bereaved through suicide have feelings of guilt. They may feel they should have seen the suicide coming. Thoughts like these are common, 'If only I had done this' or 'If only I had not done that.' Parents may feel there was something wrong with their parenting. Brothers, sisters and partners may feel responsible particularly when there has been family stress or conflict. It is important for bereaved people to remember that they acted with the information they had at the time. With hindsight it is often easy to see signs of the person's distress and to criticize what was or was not done. Some people feel others blame them for the suicide, and some are blamed in a suicide note. These notes are usually written when the mind is disturbed and are unlikely to be a true expression of a person's thoughts and feelings about their family and friends.
Anger is a common reaction to suicide, even towards the person who took their life for the pain they caused others. It may be difficult to understand how the person who committed suicide was so intent on getting relief from their distress that they could not think of the hurt it would give others. It is common to experience feelings of inadequacy and loss of self-esteem. Sometimes people doubt their own values and judgment and find it difficult to make decisions and carry on with normal day to day tasks.
Some bereaved people may experience symptoms of post-traumatic stress, particularly if they discovered the body. Symptoms of depression may also be experienced. At times there may seem little meaning or purpose in life. These thoughts pass but if they are strong, prolonged, or of significant concern, it is important to seek help from a professional. Many people feel deserted, rejected, or even betrayed by the person who committed suicide and may be afraid to begin new relationships. For many reasons, friends may not be able to give the support that is needed. It can be a very lonely experience and a support group may help.
In some families a suicide occurs without any warning, whereas in others it is obvious the person who later suicides is suffering from a mental illness, and the death may not be unexpected. When this is the case, feelings of guilt and rejection may be less strong or even absent. After the suicide there may be feelings of relief that the person is released from their mental suffering. In situations where there were repeated threats or attempts at suicide, or in which the relationship with the deceased person was difficult, the family may experience relief that the suicide is over. The death may ease the tension and resolve the family problems so that life can settle down again.
Bereaved people may feel there were many things they would have liked to say to the person they lost, but were unable to because of the suddenness of the death. They may yearn to tell them they were loved, or to settle misunderstandings. It is common to feel sadness about the waste of a life, but it may help to recognize the person's contributions and influences during their life and to remember the time spent together.
Comprehensive care
While access to medicines is extremely important, the needs of people with HIV/AIDS extend far beyond drugs and health care. HIV/AIDS care strategies therefore need to be comprehensive. Comprehensive care and support rest on several pillars, and need to include voluntary HIV counseling and testing so that people can know their HIV status and deal effectively with it.
Comprehensive care must include psychological support to help people cope with the implications of having a life-threatening disease. It requires social support to help HIV-positive people; their families and their communities cope with the economic and social consequences of sickness and death due to AIDS.
The role of communities and community organizations especially those involving people living with HIV/AIDS-is especially important. Their work promotes social solidarity with HIV-affected individuals and their families, provides them with emotional support, and helps protect them against discrimination and violations of their rights. Often their activism helps prompt governments to devote more resources to the AIDS response and spurs companies to lower drug prices.
Comprehensive care and support depends upon improved health systems to boost access to comprehensive care and support services, including to the life-saving drugs people living with the virus need. In Africa, where two-thirds of the world's HIV-positive people live, health care systems were already weak and under-financed before the advent of AIDS. They are now buckling under the added strain of millions of new patients. In many places, facilities for diagnosis are inadequate and drug supplies are erratic, even for HIV-related conditions that are easy to diagnose and inexpensive to treat. Access will remain uneven and compromised until countries are able to afford AIDS-related drugs and diagnostic equipment and equip their health systems with the necessary infrastructure and adequately trained staff.
Many developing countries, however, struggle to allocate sufficient portions of their national budgets to the health sector. In Africa, governments are spending considerably more on servicing foreign debts than they spend on health and education. Increased debt relief and international development assistance can help countries invest more in poverty alleviation and AIDS prevention and care. In places unable to mobilize sufficient resources (health staff, infrastructure and funding), people living with HIV/AIDS must have access to basic pain relief and treatment for "simpler" opportunistic infections such as pneumonia and tuberculosis.
Care and treatment boosts prevention?and care and support for people living with HIV can help to protect the health of the public at large by making prevention more effective. The vast majority of people living with HIV do not know their HIV status. Greater use of voluntary counseling and HIV testing is an important key to encouraging changes in risky behavior and in turn to more effective prevention. The availability of HIV care and treatment is a source of hope and can be a powerful incentive for people to come forward and find out their HIV status.
People who know they are infected and have access to care can break through the denial about HIV that so often impedes prevention efforts. Care providers who look after HIV-positive people demonstrate to others that there is no need to fear being infected through everyday contact and thus help dispel misguided beliefs about HIV transmission.
Providing diagnosis and treatment for tuberculosis and sexually transmitted infections, common among people with HIV, also helps decrease the spread of infections among people who are HIV-negative. For these reasons, AIDS-related care is increasingly recognized as a good investment that directly benefits people with HIV/AIDS, while also boosting AIDS prevention.
Drug prices?
The prices of a number of important drugs for people living with HIV/AIDS, including a number of antiretroviral, have decreased dramatically in recent months. Price reductions have been achieved through a combination of efforts. They have included advocacy (to draw attention to the enormous impact of the epidemic and the treatment gap in developing countries), pressure from activists and civil society and competition from generic drug manufacturers. Also important have been differential or discounted prices from pharmaceutical companies for use exclusively in developing countries, as well as ventures like the Accelerating Access Initiative.
Some companies have also offered donations of drugs, for instance an antiretroviral to prevent mother-to-child transmission and an antifungal to treat certain opportunistic infections. Price has been an obstacle to expanding access to treatment but other important conditions for expanding access to drugs include mobilizing sustainable financing for bringing medicines and equipment to developing countries, and strengthening health facilities and personnel so that the drugs can be prescribed and used safely.
Proper prescription and monitoring of compliance with drug regimes is essential for the benefit of patients and for avoiding the serious potential of drug resistance.
Even with greatly reduced drug prices, drugs sometimes remain out of reach for the vast majority of people who need them. For example, current prices being offered in developing countries to treat one patient for a year are still much higher than the annual per capita of many of the hardest hit countries. In addition to advocating the pricing of HIV medicines in line with the purchasing power of countries, other avenues are being pursued. They include reducing or eliminating import duties and taxes; encouraging patent-holder companies to grant voluntary licenses that allow other manufacturers to produce their products at lower cost; and the use of safeguards in international trade agreements that can help governments expand access to medicines and protect public health. New funding mechanisms are also being devised to channel more private and public sector resources towards care and support programs.
LEGAL AND ETHICAL ISSUES
It is extremely important that the patient's privacy or confidentiality is protected. The patient's HIV status is to be considered the most confidential of information and must be protected at all times. Counseling must be conducted in private where the conversation between the participant and counselor cannot be overheard. All record forms, even those identified only with a participant number, must be kept in locked file drawers at all times when they are not in use.
Discussions between counselors and counselor supervisors, including case discussions in supervision, will protect the privacy of participants by not referring to the participant by name. A patient's confidentiality should also be protected in conversations between counselors and other project staff. Breeches in participant confidentiality may be grounds for dismissal of counselors and other staff.
The HIV epidemic poses two powerful, and conflicting, legal and ethical obligations. The first obligation is to respect the privacy of persons with HIV infection. The threat of stigma and discrimination has had a profound impact on the extent to which persons with HIV/AIDS demand legal protections of confidentiality. The Hippocratic Oath admonishes physicians "to tell no secret" obtained in the course of the therapeutic relationship.
The second obligation is the duty to inform persons who may be exposed to HIV. The partner claims the right to know if their sexual or needle-sharing partners are infected with HIV. People have a legitimate ethical claim that they not be exposed to significant danger without their knowledge and consent.
Nearly two decades ago the California Supreme Court, in the landmark case of Tarasoff vs the Regents of California, found that physicians have a legal duty to inform known third parties of significant risks posed by their patients. An international survey of AIDS legislation undertaken for the World Health Organization found that 33 countries had specific confidentiality provisions related to HIV or AIDS. Many of these countries had very brief reported provisions for confidentiality of information contained in reports of communicable diseases. Few countries had enacted legislation specifying a duty to inform third party.
Compelling ethical reasons exists for protecting the privacy of a person with HIV infection. An important justification for privacy resides in the principle of respect for autonomy. To respect the privacy of people with HIV/AIDS is to respect their wishes not be observed or to have intimate information about themselves made available to others. Privacy also enhances the development of trust in the physician. One of the defining characteristics of the doctor/patient relationship involves the sharing - freely given - of private information. Failure to respect the confidentiality of patients drives patients away from HIV testing, counseling, and treatment, and discourages patients from confiding in their physicians. Healthcare facilities that treat persons with HIV argue fiercely that compelling physicians to disclose HIV infection to sexual or needle-sharing partners would mean they would lose the trust of their clients. Ultimately, they argue, a "duty to warn" would seriously undermine public health efforts.
Unwanted disclosure of intimate health information can cause patients a great deal of emotional, social, and economic harm. Stigmatization may be a consequence of such disclosure, particularly when HIV infection reveals the person's sexual orientation or use of illegal drugs. Disclosure can cause embarrassment, social isolation, and loss of self-esteem. A breach of privacy can result in loss of employment or employability, insurance or insurability or housing.
Many developed countries spell out legal and ethical duties to protect the confidentiality of persons with HIV/AIDS. For example, virtually all jurisdictions in the United States have HIV-specific confidentiality laws. The World Health Organization and the Council of Europe both emphasize that HIV testing and screening should be undertaken only with the person's informed consent and consistent with the principles or confidentiality.
Meanwhile, political bodies in the United States and elsewhere are clamoring for a right to know a person's HIV status. Imagine a variety of circumstances where the right to know is asserted: Should a person who has sex or shares injection equipment with an intravenous drug user be informed? Should a surgeon, obstetrician, or emergency room nurse who risks exposure to a patient's blood be informed? Should a police officer, prison guard, or other emergency worker be informed, particularly if he or she has sustained a needle-stick injury? Should a person who has been sexually assaulted be informed of the accuser's HIV status?
Many confidentiality statutes in the United States have been amended to grant a right to know for all these groups. Some statutes have so many exceptions to the principle of confidentiality that the exceptions swallow the rule. Healthcare professionals who support a right to know should consider another perspective like many patients claim the right to know if their healthcare workers are infected with HIV.
The Centers for Disease Control prevention guidelines, and many state statutes and court decisions, give patients the right to know if their physicians are HIV-positive, particularly if they are engaged in invasive, "exposure-prone" procedures.
Is there any principled way to reconcile the dual obligations of the right to privacy and the right to know? If one takes the ethical and legal right to privacy seriously, then it ought to yield only where absolutely necessary to avert a serious harm. The World Health Organization and the Council of Europe both recognize the need to inform persons at serious risk of HIV infection in "extreme cases." Accordingly, the right to confidentiality ought to be near absolute in cases where the risk of contracting HIV is remote. Thus, claims by healthcare professionals, emergency workers, prison guards, and others for this sensitive information ought to be denied if the patient refuses to consent to the disclosure.
The strongest claim to a right to know exists where there is an ongoing sexual or needle-sharing relationship. In such cases, the law would give healthcare professionals a power, not a duty to disclose if in their judgment it is necessary to avert a significant risk of transmission. Healthcare professionals should first counsel the patient to make the disclosure him or herself. Framing the law in this way permits healthcare professionals to exercise their judgment and decide whether maintenance of the confidence and trust of patients overrides the rights of their partners. If the healthcare professional exercises a diligent good faith judgment, he or she ought not to risk legal liability in a case where society itself is unable to resolve this powerful ethical and legal dilemma.
What's legal, what's not? ?
It is important to realize what is protected under the law and what is not. Most of the California laws regarding confidentiality of a person's HIV status were written before we knew as much about HIV and before a lot of the current tests and treatments were available. Therefore, the laws prohibit the unauthorized release of HIV test results. In contrast, the laws do not cover the release of viral load tests, what medications you are taking, or even an AIDS diagnosis. All of these things, of course, essentially give away the fact that you are HIV-positive.
If you tested at an anonymous test site, you are the only person who knows that you are HIV-positive. If you tested in a doctor's office, a clinic or another confidential test site, your doctor and possibly some of the office personnel know you are HIV-positive. If the HIV test was submitted to your insurance carrier for payment, your insurance carrier may now know that you are HIV-positive. The insurance company will report this information to the Medical Information Bureau (MIB) in Massachusetts, which is something like a credit reporting agency for health care information.
Already, your HIV status may have been disseminated further than you imagined and without you telling a soul. Once the MIB has this information, you may have difficulty obtaining life insurance, disability insurance, or health insurance coverage.
Limited disclosure
There may be several points in your life when you will need to reveal that you are HIV-positive in order to get the assistance you need.
When you join an AIDS-service organization, such as AIDS Project Los Angeles, you must present a copy of your diagnosis in order to become enrolled as a client. AIDS-service organizations will keep this information confidential unless you give permission to the contrary.
If your case manager is to help you obtain housing, public benefits or many other types of necessary services, he or she may need to share your HIV status to someone at another agency. Before this can be done, however, your case manager or other advocate must get your specific permission in writing.
Generally, your doctor may reveal your HIV status to another of your health care providers or people in your chain of treatment without your written permission. Currently, doctors in California must report AIDS diagnoses to the state Department of Health, but there is no requirement for a doctor to report a positive HIV test to anyone, including your sexual partner. There is possible legislation coming up in the near future which would require doctors to report HIV-positive results to the state.
Confidentiality in the workplace
Many people with HIV are in the process of returning to work or have continued to work despite HIV. For most people, there is absolutely no need to reveal your HIV status at work. If you are interviewing for a job, you have no need to reveal that you are HIV-positive or have AIDS. If a person is asked about this on a job application or during an interview, this is probably illegal discrimination, and he should consult an attorney about your rights.
A person's HIV status should have nothing to do with his qualifications to perform a job. The only time that an HIV-positive person may run into legal trouble on the job would be if you are a health care worker who performs invasive procedures on patients.
If a person is having health problems which may affect your work, he may wish to reveal to a supervisor or human resources person that you have a disabling condition so that your employer is on notice that you may be a disabled person who is protected by law from discrimination and possibly entitled to reasonable accommodations on the job so that you may continue working.
Coping with HIV?- speaking to your client
Preserving ones emotional health with HIV is a task that may seem hard but can be done. Preservation tactics - as some HIV + people call them - allow them to function in their daily routine to endure the pain and loss, on choosing how to live and to find pleasure in the process. Mental Health Professionals have no firm rules for maintaining emotional wellness.
Preservation tactics fall into two categories.
First you have your support system and the second is to take control of your life.
To people who are infected with HIV, a good support system is as important to their mind as medications are to their bodies. When people are feeling ill or depressed they have a greater need for people. Even when they are alone they know that they have people who care about them and without their support they might as well give up. This is not true for all people. Some people are more private than others. There are also times when people need to be alone and to rely on their own resources.
A self-care plan should involve making any lifestyle changes you need to make to promote overall health and well-being: making sure you have a balanced diet, plenty of rest, and regular exercise and relaxation. Avoid doing the sorts of things that put a strain on your immune system -- acquiring other sexually transmitted diseases, for example, or using recreational drugs. If you're hooked on drugs, get yourself into a detoxification or methadone program. If you only consider yourself a "recreational" drug user, consider doing something else for recreation. Alcohol, heroin, cocaine, and other chemicals inflict their own forms of havoc, even among the healthy, and may speed up the progression to AIDS. If you haven't done it already, make sobriety a cornerstone of your healthy-living, HIV-survival strategy. Your immune system is balanced too precariously to take any unnecessary tilting.
Finding out you've been exposed to HIV is not easy. They take the news hard and die a little every day. For others, though, it's something else altogether. They take the news as an ultimate challenge to get busy with their lives and the lives of the people they care about -- in spite of the way they may feel.
Interestingly, it's this group that contains virtually all of the long-term AIDS survivors identified thus far. It's a special group of people, united by a common theme: That life is more important than a disease that can only take life away. They know a secret that's as old as time and as timely as tomorrow's headlines: That living without purpose is giving up. And with AIDS, giving up can be a real killer.
The critical first step in any plan for living with HIV is to find a knowledgeable doctor or clinic that you feel comfortable with and confidence in. Start with your family doctor, if you have one, or contact an AIDS helpline for referral to a specialist in your area. After that, get serious about getting on top of your life and your infection. HIV is not an automatic death sentence. Thousands of people have lived with HIV for years, and some say they didn't really start living until they got their test results back and decided to begin right then and there. What they also started doing, then and there -- or shortly after -- was to take care of themselves.
Diet plays a main role in any HIV survival plan. That's because people with AIDS are vulnerable to food-borne micro-organisms. And food-related infections can be life-threatening. According to the U.S. Centers for Disease Control, people with AIDS are 20 times more likely to contract salmonella, a contaminant of under-cooked poultry and eggs, and 200-300 times more likely to develop listeria infections from poultry, meat, and raw fish. Since animal foods -- including cheese, milk, and eggs -- are a main source of food infections, experts offer the following advice:
Eat meats well-done. Use a thermometer to insure that poultry, fish, and other meats are well-done, and pre-cook grilled meats. Avoid sushi, shrimp, and other raw meats.
Cook eggs thoroughly. Avoid dishes containing raw eggs, including Hollandaise sauce, egg nog, and Caesar salad.
Drink pasteurized milk. Raw, unpasteurized dairy products can also be a problem. Better keep your distance. Clean utensils after handling raw meat. Infectious organisms can spread to other foods and dishes, and to uncovered cuts or sores on the hands. Also, you may want to consider soy and vegetable protein substitutes for meat, milk, and cheese that are available at health food and grocery stores. ??
Notification | Partner notification is most effective when medical professionals gain the trust of those whose partners are to be contacted; requiring the provision of a name is likely to discourage such trust. Currently, California provides partner notification services without HIV name reporting. This approach makes sense because the name of the "index case" is not needed in order to elicit the names of an individual's partners. Furthermore, people could be more willing to provide their partners' names if they know their own names are not documented in any way.
Assure that a private, safe and confidential discussion can occur. Remain sensitive to special needs and considerations of especially vulnerable individuals (e.g., minors, pregnant women, immigrants, seniors, individuals with disabilities, individuals who are unstably housed, individuals in residential or institutional settings, substance users in and out of treatment, and persons who are gay, lesbian, trans-gender or bisexual). In no cases are names of HIV-infected individuals provided to partners, or others, by public health staff. Respond to questions about the process. Review the benefits of partner notification. Request that the individual consider partner notification.
DOMESTIC VIOLENCE
Assess domestic violence risk to the HIV-infected individual. Screen for risk on a partner-by-partner basis for any partners voluntarily identified and for any partners who are already known to the provider like a spouse.
Note: The name or other information about the infected individual is never disclosed during partner notification, use simple screening questions. Raise the issue of domestic violence risk associated with notifying partners. Keep questions simple and specific. Avoid using the phrases "domestic violence" and "victim".
Suggested script: "There are some routine questions that I ask all my clients because some of them are in relationships where they are afraid their partners may hurt them." Provide assurances that: Any information provided will be kept strictly confidential and be used only to help make decisions about whether partner notification should proceed and to offer referrals for domestic violence services.
Suggested script: "What response would you anticipate from this partner if he/she were notified of possible exposure to HIV?" Follow-up questions can be used to explore any indication of a history of domestic violence or anticipated consequences of HIV partner notification. "Have you ever felt afraid of your partner or ex-partner? "Has a partner or ex-partner currently or ever: Pushed, grabbed, slapped, choked or kicked you? Forced you to have sex or made you do sexual things you didn't want to? Threatened to hurt you, your children or someone close to you? Stalked, followed or monitored you? "Based on what you've just told me, do you think that the notification of this partner will have a severe negative effect on your physical health and safety, or that of your children or someone close to you?" "Are you afraid of what might happen to you or someone close to you, for example your children, if this partner were notified?" "Have you ever been afraid about harming your partner or someone close to you?"
Rely on the perception, if any, of the HIV-infected individual as to whether or not notification could result in domestic violence. Characterize the type of domestic violence like physical, sexual, economic, emotional, social and psychological if any.
Explore the severity of anticipated domestic violence to the HIV-infected individual. Assess any domestic violence risks to each partner. Elicit the infected individual's knowledge of the partner's current situation, if it is known, when the partner is other than the current partner. "If you know whether our notifying a previous partner of their possible HIV exposure might put them at risk of being harmed by, or harming, someone they are currently involved with, it is important that you tell us about it."
Explore severity of anticipated domestic violence outcomes to the partner/contact. Move forward with action plan for HIV partner notification Review options and work with the client to identify the optimal partner notification strategy for each partner. Provide the HIV-infected individual for whom notification of a specific partner is deferred based on a risk of severe domestic violence with information enabling them to contact the Department of Health Notification Assistance Program at any point in the future. Ask the HIV-infected individual if they are willing to sign a release form for domestic violence information to enable future follow-up to determine if the domestic violence risk has been alleviated. Ask the HIV-infected individual whether or not he/she would consent to follow-up contact by public health staff for purposes of ascertaining the continued deferral of partner notification and how such contact can most safely be made.
Routinely, throughout the provision of medical care and support services, remind individuals that HIV partner notification and assistance services and referrals to domestic violence service providers remain available and encourage their use throughout the continuum of care. This should be incorporated into ongoing discussion to reduce behavior that may transmit HIV to partners.
Refer HIV-infected individuals to HIV case management services which assure ongoing discussion of HIV partner notification services, including those cases in which risk of domestic violence which may have a severe negative effect on the physical health and safety of the HIV-infected individual, his/her children, someone who is close to them, or to his or her contact(s). Help ensure that HIV partner notification assistance services are accessed in the event that the previously identified domestic violence concerns are resolved.
Counter Transference
One of the most significant issues for each psychotherapist is how to make the most disciplined use of self while remaining empathetically connected to the patient. The literature is full of discussions about how not to allow the therapist's counter transference to harm the treatment. Issues of counter transference become more complicated when therapists treat patients with whom they may easily identify. Since the onset of gay and lesbian affirmative psychotherapy the professional literature has continued to address the impact on therapy when the gay or lesbian patient knows that his or her therapist is also lesbian or gay. When both therapist and patient are dealing with virtually identical life crises at the same time the potential for therapeutic mistakes is enormous. Extraordinarily skilled therapeutic interaction is necessary between therapist and patient to avert these mistakes.
While the literature contains a few articles about the illness or imminent death of the therapist (Rosner, 1986), literature on the therapist and patient sharing the same life-threatening condition appears to be just emerging. There are certain unique factors in this situation that may prove troublesome for the therapist and detrimental to the treatment he provides if left unaddressed. For example, how does the therapist cope with the constant reminder of his own health status and impending death when his practice is full of patients facing identical issues? The therapist's access to and utilization of clinical supervision, consultation and psychotherapy and his ability to remain self-examining during his personal crisis will largely determine whether or not he is able to continue to provide good treatment so stressful a period.
The therapist's level of acceptance of his own condition and possible death will determine how emotionally available he is to work with patients needing to discuss their struggles and feelings about the same illness. A therapist who is in a great deal of denial about his own physical condition will most likely not be able to begin discussions with patients who need help initiating discussions about their situations. If the therapist is in denial about his own illness he is certain to re-enforce any denial that his patients may be experiencing, and will not be able to confront the patient's denial when it would be best to do so.
The question, "How much time do I have left before I get sick or before I die?" has a powerful influence on both the therapist and the patient. The therapist has to be able to assess if and when it is appropriate to bring the patient's thoughts and feelings about this into the open for exploration. The patient with HIV enters therapy wanting to be "healed" emotionally before he becomes too debilitated to do this difficult psychic work. The therapist feels the pressure of limited time to accomplish the healing before he, himself, gets too ill to continue working. It takes great skill to acknowledge the therapist's illness without intruding into the patient's treatment.
The therapist's experience of death and dying can shape his work with patients susceptible to the same illness as he. Does the therapist believe that death is the end of it all, or does he envision some kind of life following death? If the therapist is not able to understand his own beliefs and feelings surrounding death, he will not be able to initiate discussions about this with patients. A therapist's inability to discuss these issues creates a sense of secrecy or shame in the patient who may not have anyone else with whom to discuss these feelings.
One of the interesting questions is whether the counter transference issues that arise from being HIV positive and doing this work are in fact different than those every therapist faces during the course of his or her daily work. There is the potential to view the feelings and concerns of many of these patients as having an urgency that must be responded to immediately. Any tendencies the therapist has towards grandiosity can be highlighted by the apparent urgency of the impending mortality of both the patient and therapist. Even if the urgency does stem from the patient, is it good treatment to respond to and thus validate a patient's urgency rather than explore it? Does the fact that the issues being explored, defended against, denied or acted out are connected to the patient's and therapist's responses to illness and mortality justify conducting the treatment any differently than if the presenting problem were different?
The therapist needs to know from his own experience what the patient is experiencing. Yet the potential for the therapist to make clinical mistakes is enormous when he or she is simultaneously experiencing many of the identical situations and feelings as the patient. I have learned that just because my patients are experiencing very similar situations to the ones that I am living through, I cannot assume that they will or should react in the same ways that I do.
Terminal illness usually causes individuals to regress, at least in some areas of their lives. Thus the therapist who is dying, or living with a life threatening illness has to work with patients who are regressing. Perhaps the patients' regression mirrors the therapist's own struggles with regression. Sometimes a patient's regression will serve as permission for the therapist to regress in a similar fashion.
When a person begins therapy he or she does so expecting to continue the process and relationship with the therapist until the goals for therapy have been met. In the case when the patient has a life threatening illness he must have a willingness to embark upon the therapeutic journey with the knowledge that this process could be abruptly terminated by his own death. The therapist with a life threatening illness has the obligation to evaluate realistically whether or not the issues a new patient is presenting can be worked on effectively within the uncertain amount of time he has left. Correspondingly, the therapist must be able to know when he is reaching the point of not being able to continue to practice. Thus the therapist with a terminal illness must be able to distinguish between his own narcissistic needs to deny the severity of his own condition, and his needs to continue working, and what is in the best interest of his patients. Knowing when to let go of one's career, patients and the identity that have been so significant a part of one's life, and knowing when to refer patients to a respected colleague is difficult and yet crucial. It is a clear indication of both the personal and professional development of the therapist and of the quality of the professional assistance he is receiving. It is improper for the therapist to place the decision of whether or not to continue working together in the hands of patients. For many patients it may be impossible to place their own needs for ongoing treatment above the needs of the "helpless, dying, and beloved" therapist who has helped them so much.
A common feeling among counselors of HIV positive clients is frustration over the tremendous ambiguity that must be faced in the work about HIV disease itself and about the appropriate therapeutic approaches to take. This ambiguity that client is facing can sometimes increase the empathy felt for the client. For the counselor who has particular difficulty accepting ambiguity, the risk of inhibiting the client's freedom to recognize and experience the uncertainty of the situation must be carefully watched. Often clients resist the painful awareness of this uncertainty by looking for clear-cut, instant answers. The counselor may, in turn, feel pulled to respond to this pressure by offering "quick fix" solutions. Related to this is the pressure many counselors feel to become experts on HIV as a way to be better prepared to provide answers whenever the client expresses confusion. This can lead to spending considerable time and energy attempting to stay current about research and treatment issues. The overwhelming amount of information available places such a counselor at risk of becoming seriously overextended, and the counselor must be willing to accept his or her own limitations, including the limits of one's expertise. Often a critical element of being informed about HIV involves knowing which people or organizations to refer clients to for further information.
Counselors who are in so-called "high-risk groups" themselves face special counter transference issues. The gay counselor, for instance, is likely to have been directly affected in his personal life by the epidemic, thereby increasing the likelihood of a strong identification with the client's situation. This can both enhance and detract from the counseling relationship. It can serve to increase the capacity for empathy and the degree to which the client as a potentially understanding helping figure perceives the counselor. It can also lead to the counselor's becoming over-invested in the work, and eventually unable to continue the work because of emotional strain. The antibody status of the counselor introduces another level of complexity. It is not uncommon for a HIV negative counselor, whether gay or straight, to experience feelings of "survivor guilt." The client's anger and resentment at those who do not share the burden of being HIV infected may fuel these feelings.
The antibody status of the counselor has implications in terms of perceived capacity for empathy and level of personal investment, which are similar to those described above in the discussion about counselors' personal risk. An additional issue the counselor must consider is whether, and under which circumstances, to disclose his antibody status to clients who ask. Finally, it is important that counselors be aware of the personal meanings attached to HIV as a result of their own past experiences, so as to decrease the likelihood of imposing these meanings on clients. For example, counselors who have friends recently deceased or ill with HIV disease may attribute more significance to a client's recent HIV positive test result than the client is prepared to hear. It is also important that counselors carefully examine their own attitudes and assumptions regarding such issues as homosexuality, IV drug use, and death and dying, so as to minimize the chances of colluding unconsciously with any self-ridicule their clients may feel in terms of these issues.
BURNOUT
It is important to acknowledge that HIV counseling can be stressful and to encourage counselors to be aware of signs that they are overworking or not coping well. Counselors must also be aware that they are not expected to help clients deal with all of their needs. Clients may be referred to referral sources in the community as needed; it is important that counselors be familiar with these resources. It is important for counselors to ask for help when they need help, use supervision to discuss their concerns about the work, be aware of their own biases and stereotypes, learn to be assertive and to set limits with clients, and to continue learning new skills and requesting feedback on their work with their clients.
Not all stresses and strains come from difficult clients. More often than you prefer, you will feel utterly helpless. You will see a client in pain, want so badly to help, and yet feel that what you have to offer is not nearly enough. The abused child you are offering comfort to is about to go back to the abusing home by court order. The grieving widow you are talking to sees no other way out except suicide. The AIDS client you are working with screams out the indignity and injustice of it all, and then looks to you for solace. How will you handle all of this? How will you metabolize the pain of others without driving yourself crazy? How will you stay focused on that which is within your power to do something about?
Conclusion
While counselors should remember that many issues may need to be addressed further, and should be prepared to offer appropriate referrals to individual and group therapy, counselors can nevertheless offer insights to their clients. The counselors have to be patient and provide information but remember not to push their viewpoints too strongly.
HIV and Older People There is growing evidence that older people are increasingly being infected by HIV/AIDS, but available data does not often explain how the epidemic is affecting this population group. For example, although 83% of all AIDS deaths in the world have occurred in sub-Saharan Africa, very little is known about the epidemiology of HIV/AIDS among older people in this region. In the United States, 10% of all reported AIDS cases occur among people over the age of 50, with a quarter of these over 60. In Western Europe, nearly 10% of new infections declared between January 1997 and mid-June 2000 were among the over-50 group, with these figures dropping at 4.3% in Central Europe and 0.7% in Eastern Europe. Older women appear to have higher incidence than older men, and during a recent five-year period the number of new cases in this group increased by 40%. More than half of the infected over 50 are of African American and Hispanic origin, indicating greater risks among minority groups. However, available figures do not reflect at what age this population group was infected, and many of those over 50 were probably infected when they were younger and may have had the virus for years before being tested. By the time they are diagnosed, their infection may be in its most advanced stages.
Risk and vulnerability of older people
The dominant risk factor among the 50+ age group is the same as for other age groups - heterosexual sex. Specific risk behaviors, such as unprotected sex, multiple sexual partners, sexually transmitted infections, and substance abuse are also present in this age group.
According to the US-based Centers for Disease Control and Prevention (CDC), age accelerates the progress of HIV to AIDS and blunts CD4 cell response to antiretroviral therapy. Age-related conditions, such as osteoporosis, increase the risk of severe complications.
Older people tend to view condoms primarily as a contraceptive measure, and women who no longer fear unwanted pregnancy may not insist on their use. Women also undergo physical changes with age that affect their vulnerability to HIV. In the post-menopausal stage, their vaginal walls are thinner and lubrication is often reduced. Many doctors believe older women are more vulnerable to vaginal trauma during intercourse, and thus at greater risk of contracting HIV.
Early symptoms of HIV infection - fatigue, poor memory, shortness of breath, sleeplessness, weight loss - may be mistaken for signs of aging, thus preventing those infected from seeking early medical interventions that would help them stay healthy and avert HIV transmission risk.
Health providers often fall into the trap of age stereotypes, which can be a problem in prevention and diagnosis. Health care workers are less likely to ask older patients about their sexual behavior and do not provide the prevention information they would routinely offer younger patients. Nor do prevention education programs target older people. Social barriers to discussions on sexuality become even stronger with age, because of an increasing denial of sexual needs. Consequently, there are few effective strategies for this population group. Older people also have less knowledge about the basic facts on HIV/AIDS and its prevention. In a CDC study of a hot-line service, only 6% of callers were from the older population, and nearly 50% wanted more information about HIV/AIDS risks.
In addition, coping mechanisms among older people are weaker, as they are more prone to depression and less inclined to join support groups.
Impact of HIV/AIDS on the elderly
The advent of HIV or AIDS imposes caring responsibilities upon older people, which they might not otherwise have to contend with. AIDS causes changes in family structures due to the death of young parents. This in turn often leaves grandparents as the sole authority figures in a family, with the added burden of providing economic support and psycho-social care to orphaned children. In many societies, the opposite is supposed to happen. There is also inadequate support for grandparents and other older family members and friends in many societies. Governments do not usually provide economic support or subsidies for grandparents forced to care for sick or orphaned children. In addition, there is a significant lack of legislation on care for the elderly, such as pensions and other forms of assistance for grandparents, adding to the broader social burden carried by societies already hard hit by an AIDS epidemic.
Actions to be taken
A number of strategies and behaviors can be adopted to help mitigate the risk of HIV to older people and the impact of HIV/AIDS on those already infected:
Reducing stigma surrounding the sexual needs of older people to enable them to discuss these issues more easily with their health providers and families.
Integrating HIV programming into services for the aging, including the integration of secondary prevention education (prevention among HIV-positive people) into specialized care services. Educating HIV service providers regarding aging and the provision of age-sensitive services. Identifying areas of research specifically looking into the interactions between age and HIV. Involving older persons in research on prevention and care.
Discrimination
All over the world, the epidemics of HIV and AIDS are having a profound impact, bringing out the best and the worst in people. They trigger the best when individuals group together in solidarity to combat government, community and individual denial, and to offer support and care to people living with HIV and AIDS. They bring out the worst when individuals are stigmatized and ostracized by their loved ones, their family and their communities, and discriminated against individually as well as institutionally. The nature of stigma and discrimination
The "undesirable differences" and "spoiled identities" that HIV/AIDS-related stigma causes do not naturally exist, they are created by individuals and by communities. Stigmatization describes this process of devaluation.
HIV/AIDS-related stigma builds upon, and reinforces, existing prejudices. It also plays into, and strengthens, existing social inequalities - especially those of gender, sexuality and race. HIV/AIDS-related stigma and discrimination play a key role in producing and reproducing relations of power and control. They cause some groups to be devalued and others to feel that they are superior. Ultimately, stigma creates and is reinforced by social inequality.
Stigma, discrimination and human rights
Prejudiced and stigmatizing thoughts frequently lead people to do (or not do) something that denies services or entitlements to another person. For example, they may prevent health services being used by a person living with HIV/AIDS, or terminate their employment on the grounds of their HIV status. This is discrimination.
Discrimination occurs when a distinction is made against a person that results in their being treated unfairly and unjustly on the basis of their belonging, or being perceived to belong, to a particular group.
Due to stigma and HIV/AIDS-related discrimination, the rights of people living with HIV/AIDS and their families are frequently violated simply because they are known, or presumed, to have HIV/AIDS. This violation of rights hinders the response and increases the negative impact of the epidemic.
Freedom from discrimination is a fundamental human right founded on principles of natural justice that are universal and perpetual. The basic characteristics of human rights are that they inhere in individuals because they are human, and that they apply to people everywhere.
The Principle of Non-discrimination is central to human rights thinking and practices. All international human rights instruments prohibit discrimination based race, color, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, fortune, birth or other status.
Discrimination against people living with HIV/AIDS, or those thought to be infected, is therefore a clear violation of their human rights.
The forms of stigma and discrimination faced by people with HIV/AIDS are multiple and complex. Individuals tend to not only be stigmatized and discriminated against because of their HIV status, but also because of what this connotes. Recent UNAIDS-sponsored research in India and Uganda shows that women with HIV/AIDS may be doubly stigmatized - both as 'women' and as 'people living with HIV/AIDS' when their sero-positivity becomes known.
States have obligations to respect protect and fulfill human rights. In relation to stigma and discrimination, for example, the obligation to respect requires States not to directly or indirectly discriminate in law, policy or practice. The obligation to protect requires States to take measures that prevent third parties from discriminating, and the obligation to fulfill requires States to adopt appropriate legislative, budgetary, judicial, promotional and other measures to ensure that strategies, policies and programs are developed that address the discrimination, and ensure that compensation is paid to those who suffer discrimination.
Action to address stigma and discrimination
The human rights framework provides access to existing procedural, institutional and other monitoring mechanisms for enforcing the rights of people living with HIV and AIDS, and for countering and redressing discriminatory action.
Appropriate reporting and enforcement mechanisms (ranging from legal aid services to hot-lines for reporting acts of discrimination and violence) have provided powerful and rapid means of mitigating the worst affects of HIV/AIDS-related stigmatization and discrimination.
Experience has shown that two complementary kinds of alleviation strategies are necessary to address stigma and discrimination: (I) strategies that prevent stigma or prejudicial thoughts being formed and (II) strategies that address or redress the situation when stigma persists and is acted upon through discriminatory action, leading to negative consequences or the denial of entitlements or services.
Ultimately, it is at the community and national levels that HIV/AIDS-related stigma and discrimination are most effectively combated. Communities and community leaders must advocate for inclusiveness and equality irrespective of HIV status.
EXERCISES FOR THE COUNSELOR
EXERCISE #1 The purpose of this exercise is to practice listening and paraphrasing opinions, even if these opinions are different from your own. If you have access to a colleague you can share with each other opinions about the following controversial statements and why you hold these opinions. The role of the listener in this exercise is to listen to the other counselor's opinions without speaking, and then to paraphrase what was said. Reassure counselors that they will not be required to share their personal opinions with the entire group. Each counselor spends 15 minutes in the role of listener and 15 minutes in the role of sharing his or her opinions. Consider these statements for discussion:
EXERCISE #2 HIV counseling requires explicit discussion of sexual behavior. In this exercise the counselor makes a list all of the various sexual behaviors that are practiced in this country. These may be sexual behaviors the counselor knows of personally or behaviors that they have read about or heard about from clients in the past. List all behaviors on a piece of paper. When you have exhausted your knowledge of sexual behaviors, ask yourself the following questions.
AVERT is an international AIDS charity
AIDS & HIV information from AVERT.org
Sources:Centers for Disease Control and Prevention (2009), HIV/AIDS Surveillance Report 2007, (Vol. 19)
References:
District of Columbia Department of Health (2009), 'District of Columbia HIV/AIDS Epidemiology Update 2008'
Morbidity and Mortality Weekly Report (2008, 3rd October), 'HIV Prevalence Estimates - United States, 2006 Centers for Disease Control and Prevention', US Centers for Disease Control and Prevention
At the end of 2007, an estimated 455,636 people were living with AIDS in America (50 states plus the District of Columbia). The highest numbers were in California, Florida, New York State and Texas. Among the 50 states, the lowest numbers were in North Dakota, South Dakota, Montana and Wyoming.
In 2007, the District of Columbia reported a far higher rate of AIDS diagnoses than any other area (though the rate in the wider Washington area was surpassed by other metropolitan areas). A 2009 local government report found the capital city had an HIV prevalence rate of 3%, including figures as high as 7.2% for 40-49 year olds, and 6.5% for black males.1
AIDS diagnosis rates in New York State, Florida and Maryland were much higher than the national average of 12.7 cases per 100,000 population per year.
In the 39 areas that have a history of confidential name-based HIV reporting, an estimated 263,936 people were living with HIV infection that had not progressed to AIDS. This number only includes people whose infection has been diagnosed and reported through the confidential name-based system.
According to the number of AIDS cases reported to the CDC, the 34 states with a history of confidential name-based HIV reporting represent approximately 66% of the US epidemic. For this reason, and because many HIV infections remain undiagnosed (or anonymously diagnosed and unreported) within the 39 areas, the total number of people living with HIV (and not AIDS) in the USA must be much higher.
The CDC estimates that around 1.1 million adults and adolescents are living with HIV in the USA, including those not yet diagnosed, and including those who have already progressed to AIDS.2
Estimated numbers of persons living with HIV (not AIDS) or with AIDS at the end of 2007, and reported AIDS case rates, by state and dependent area
* Persons reported from areas with confidential name-based AIDS reporting, who are residents of other areas - data unavailable through the confidential name-based reporting system
AIDS statistics by city
Over one million AIDS cases have been reported in the 50 states of the USA, the District of Columbia and Puerto Rico. Of those with known residence, 85% were reported in major metropolitan areas.
New York has accounted for around a fifth of all cases, with Los Angeles (60,583 cases), and Miami (58,554) also providing substantial numbers.
In 2007, the highest rates of new AIDS diagnoses were in Miami (33.1 per 100,000 people), New Orleans (31.5), Baton Rouge (31.4) and Washington (30.5).
Reported AIDS cases by USA metropolitan area of residence
Notes
The latest statistics on AIDS & HIV in the USA were published in February 2009 by the US Centers for Disease Control and Prevention (CDC).
There is often a delay between the time of diagnosis of HIV or AIDS, or the time of death, and the time at which the event is reported. For this reason the CDC estimates the number of people living with HIV or AIDS by adjusting for reporting delays. No adjustment is made for incomplete reporting.
The term "living with AIDS" includes every living person who has ever received an AIDS diagnosis, regardless of their current state of health. The term "living with HIV (and not AIDS)" includes every living person who has been diagnosed with HIV through the confidential name-based system, but has not been diagnosed with AIDS.
The statistics by city table contains data for Metropolitan Statistical Areas (MSAs) as defined by the Office of Management and Budget.
Resources
AIDS/HIV Treatment Directory (1995) Published by the American Foundation for AIDS Research
BETA (1995) Published by the San Francisco AIDS Foundation ?HIV Adult Standard of Care (1996) Published by ACT/UP Philadelphia Latino AIDS Project (323) 661-6752 ?Catalyst Foundation for AIDS Awareness/Care (805) 948-8559 ?Foothill AIDS Project (800) 448-0858 ?Jeffrey Goodman Special Care Clinic (323) 993-7500 ?Jewish AIDS Services (323) 761-8770 ?L.A. Gay & Lesbian CENTER (323) 993-7400 ?City AIDS/HIV Discrimination Unit (213) 485-4579 ?City AIDS Coordinator (213) 485-6320 ?L.A. Family AIDS Network (323) 669-5616 ?L.A. Shanti (323) 962-8197 ?Minority AIDS Project (323) 936-4949 ?Mountains AIDS Foundation (310) 264-9790 ?Northeast Valley Health Corp. (818) 988-6335 ?Pacific CENTER for HIV/AIDS Counseling and Psychotherapy at APLA (323) 993-1621 ?PAWS/L.A. (323) 876-PAWS ?Project Angel Food (323) 845-1800 ?Ron Shipton HIV Information CENTER (310) 652-5340 ?Santa Monica AIDS Project (310) 586-7627 ?T.H.E. Clinic for Women Inc. (323) 295-6571 ?Valley HIV/AIDS CENTER (818) 908-3840 ?Women Alive (323) 965-1564 ?Women at Risk (310) 204-1046
Where do AIDS Drugs Come From? Published by the National Institute of Allergy and Infectious Diseases
References?Rosner, S: The seriously ill or dying analyst and the limits of neutrality, in Psychoanalytic Psychology, 3(4), 357-371. 1986. Where to Find Help for HIV/AIDS in Los Angeles?Aid for AIDS (323) 656-1107 ?AIDS Education Services for the Deaf (323) 550-4250 voice/TTY ?AIDS Healthcare Foundation (323) 860-5200 ?AIDS Prevention Team (323) 964-7820 ?AIDS Project Los Angeles (323) 993-1600 ?AIDS ReSEARCH Alliance (310) 358-2423 ?AIDS Service CENTER (626) 441-8495 ?AltaMed HIV Services (323) 881-2232 ?American Foundation for AIDS Research (323) 857-5900 ?Asian Pacific AIDS Intervention Team (213) 553-1830 ?Being Alive (310) 289-2551 ?Bienestar Latino AIDS Project (323) 660-9680 ?California HIV/AIDS Hotline (800) 367-2437 ?Cara a Cara Latino
AIDS is an acronym used for acquired immune deficiency syndrome. AIDS is a disease that slowly destroys the body's immune system and a person with a suppressed immune system can't fight off germs, infections and diseases. AIDS is caused by a virus known as the Human Immunodeficiency Virus (HIV) that is a member of the retrovirus group. The virus responsible for causing AIDS in a person is the lentivirus.
The lentivirus kills an important kind of blood cell -- the CD4 T lymphocyte, or T cell. These T cells are the quarterbacks of the immune system. As the cells die the body becomes weaker and susceptible to other diseases. Microbes and other pathogens take advantage of this situation and infect the body since the body cannot fight off the pathogens. The diseases and infections caused by these pathogens are termed as opportunistic infections. When people infected HIV get these infections; or when their T-cell levels get too low, the people are HIV infected and can get AIDS after a period of time.
Usually it takes many years for HIV to weaken the body's immune system to the point of AIDS. Depending on the spread of the virus it can take up to 10 years or more for the body to be infected with AIDS. It may take that long for damage to the white blood cells to show up. White blood cells are part of the body's immune defense against infection and these cells help fight off any kind of infections.
HIV causes certain white blood cells to become weak or die off hence the body becomes immuno-deficient. This means that the body can no longer fight off infection and the body can be infected by a vast number of pathogens. In this stage the syndrome is called Immuno-deficiency Syndrome and the syndrome is acquired due to the lentivirus because before the attack of the virus the body was healthy. AIDS also known as Auto Immune Deficiency Syndrome gets the name due to this reason. It is important to remember that a person can be infected with HIV and not have AIDS since when a person is HIV infected the white blood cells are not yet completely damaged and the immune system can still fight off infections.
Anti HIV drugs help a person who is suffering from HIV or AIDS live a healthier life and these drugs help the body fight off infections. These drugs help a person stay infection free as long as the person takes the drugs regularly. Although combining HIV drugs can help a person combination of drugs can have side effects such as vomiting, diarrhea and fatigue. These medications are prescribed by a health care professional and these medications need to be taken every day, as long as the person doesn't want to get infected.
Although most AIDS cases are in Africa, but the disease is spreading most rapidly in Eastern Europe and Asia and is becoming a worldwide problem.
HIV is the most feared sexually transmitted disease because there is no cure and it can cause death of the infected person. Currently there is no cure for HIV or AIDS and since the person who is affected by the HIV lentivirus, has a weak immune system without medications the person's immune system cannot fight off pathogens and infections.
The infected person's body starts making anti bodies soon after the person is infected and he can be tested for HIV infection after 3 months of being infected. Although 3 months is the regular time frame for most HIV tests, a person may not test positive for up to 6 months to 1 year, hence repeated testing may be required.
There is no cure for HIV and AIDS but anti-HIV drugs keep infections in check however, 95% of the world's HIV infected people cannot afford this medicine. Certain health care professionals and scientists say that HIV does not cause AIDS but there is no scientific proof to support their claims. Overwhelming medical and scientific evidence shows that HIV is the AIDS virus and every major health organization in the world says that HIV eventually causes AIDS which can cause death in the person who is infected.
HIV AND PREGNANCY
New born babies can get infected with the HIV virus by coming in contact with vaginal fluids or blood that is infected with HIV during or before birth. They can also contract HIV by HIV infected breast milk. If the mother takes medications during her delivery and while breast feeding there are good chances that the child will not get an HIV infection. The children who are born before 1985 have a good chance of being infected if their mothers were carrying the virus due to lack of medications available at that time.
It is crucial to remember that a baby born to an HIV positive woman will test positive for the HIV antibody. The mother passes her antibodies, which includes the antibodies for HIV to her unborn child. Although the baby may not be infected with the HIV virus, the antibodies will induce a positive HIV test and the baby will need to be tested over time until they reach 24 months. Since children lose their mothers' antibodies within 9 to 15 months after birth there is a good chance that some children will not have the infection.
Babies and children with HIV disease can suffer from the following:
- Weight loss
- Persistent diarrhea
- Recurrent fevers
- Recurrent ear or sinus infection
- Swollen lymph glands
- Thrush - which is a yeast infection in the mouth or in the diaper area
- Bacterial infections
- Failure to thrive
- Heart liver or skin problems
- Damages nervous system
- Slower growth
- Opportunistic infections
HOW DOES A HIV TEST WORK?
Testing for HIV is a simple process and it is possible to get home tests. It is also possible to get tested at professional labs that keep the person's identity discreet or the person can get tested by his doctor and at the public health department.
If the result is positive in a home test or lab test it is important to go to a doctor and confirm the test results and to start medication.
If the person knows that he is at high risk of HIV infection and come down with a bad case of the flu, it is important for him to see a doctor right away as this could be the early signs of HIV infection. It is crucial that he tells his doctor about the test and any symptoms.
Before getting tested it is important to understand why he is taking this test. If he tests negative he may want to understand about how to reduce your future risk since you were concerned about the risk in the first place. There are many private AIDS organizations that can give you this kind of help and usually these organizations have experienced counselors that may or may not have encountered a similar experience.
If he tests positive, he will need help deciding what to do next. HIV infection isn't a death sentence but it does mean that he will need to take special care of his health. It also means that he will have to take special care not to infect anybody else with the AIDS virus.
If he tests positive for HIV, he must have proper medical care and he should get some help from a person you trust or a medical counselor. The person he chooses should accompany him to the doctor to provide support.
If he tests positive, he will have to tell his sex or needle-sharing partners that they too need to be tested. If he has children then it may be important to also get his children tested after his test is confirmed.
HIV TESTING - DECISIONS
Here are some things the person will need to decide before and after he takes the HIV test:
- Deciding whether to take the test: their right to decide whether to be tested anonymous versus confidential testing
- How and when to get test results
- Who will see the results if the test is done here
- Alternate sites for being tested if he does not want to take the home test.
If infected the person is infected he will need to do the following things.
- Begin treatments for HIV and HIV-related problems
- Prevent transmission to others; make informed childbearing decisions
- Diagnose illness or symptoms
- Access government assistance programs
- Telling sex or needle-sharing partners
- Possible relationship difficulties with partner, family, friends
- Possible loss of job; difficulty getting or keeping insurance
- Few experienced care providers in some locales
- Antibody tested positive
- The person is infected
- He can pass the virus on to other people
- Antibody tested negative
- The person is not infected, or
- He is infected but his body has not yet made enough antibodies for the test to detect them and register as "positive" and he will need to test again.
- Abstain from unprotected sex. If his partner is also infected then they will still need to avoid unprotected sex as each of the partners may have a different strain of virus.
- Avoid pregnancy unless the women is taking medications and the doctor gives a go ahead
- Avoid donating blood, sperm, or body organs
- Have mutually monogamous sex only with uninfected persons
- Avoid drug use that lowers sexual inhibitions/ impairs judgment (e.g. alcohol, crack cocaine)
- Abstain from sharing of IV drug needles or works
- Delay pregnancy plans until he has received counseling about medications that can reduce the chance of HIV transmission to his baby
- Use barriers to protect each person's mucous membranes and bloodstream from contact with their sexual partner's blood, semen, or vaginal fluid.
HIV TESTING - REACTIONS
These are the common reactions a person can encounter after being tested positive:
- Numbness
- Relief
- Denial - may be mild or profound
- Fear of social isolation
- Fear of loss of sexual relationship
- Fear of loss of childbearing potential
- Fear of discovery of risk behavior
- Fear of loss of job, housing, insurance
- Fear of punishment from provider, partner, family, God
- Fear of terminal illness
- Anger about having become infected
- Anger at provider's inability to define current health status and predict future illness outcomes
- Anxiety about medical confidentiality
- Anxiety about access to medical care services
- Difficulty in incorporating safer sex guidelines
- Trigger for addictive behaviors
It is important for the care giver to give the test results promptly. The care giver or medical health care professional should not overload the patient with information and give him some time to cope with the new situation. The care giver should mildly encourage the patient to opt for supportive counseling about his feelings and the patient's personal concerns then move on to education and counseling when the time is appropriate. Information can be given in print or at a later appointment when the person has started accepting the new situation and is ready for advice or information.
The health care professional should ask the patient to learn more about HIV and AIDS since knowledge can help the person avoid any further problems. He should also ask the person to visit a care provider who is experienced in the HIV field. The care provider will further on test the infected person for various things such as a T- cell count, Tuberculosis test, virus load test and may prescribe any medications that are needed.
The health care professional should also tell the patient that since the immune system may weaken over time with medications and the virus it is important that the person stops consuming drugs, nicotine, alcohol and other unhealthy substances that can cause complications. Adequate rest, exercise and a healthy diet will help the body fight off secondary infections with the help of the medication.
It is important for the health care professional to remind the infected person that he has to inform the people he is having sexual relations with or sharing infected needles with. It is also important for the person to ask those people to get tested and seek the required medical care.
HIV tests under rare circumstances can be incorrect; the chance is less than 1 in a thousand. However, if the person does want to re test he should be asked to use a different laboratory or testing company.
If the test came back negative it is important for the health care professional to tell the person who was tested that the test was to search for antibodies created by the body to combat the virus and the test was not for the virus itself. It is also important to tell the person that these tests are accurate but if the person has performed any questionable activity within the last 1- 3 months he will need to wait for another 3- 6 months to take another test since these test only counts for any activity that happened 3 - 6 months ago.
If the test came back negative the health care professional will need to inform the person that he may not have been exposed or may have been exposed but not infected. He should also inform the person that he was fortunate at this time but to be cautious in the future as he can be infected later on if he continues indulging in similar activities.
The health care professional should keep in mind that the HIV test does not determine how long the person has been infected or if the person has moved on to the latter stage known as AIDS. The health care professional should also keep in mind that this test does not determine if the person can or cannot get AIDS and the status of the person's current immune system.
AIDS SYMPTOMS
A person who is infected with HIV may not show symptoms of AIDS for many years depending on how long his immune system can manage to fight off secondary infections. HIV and AIDS symptoms include but are not limited to fever, night sweats and swollen lymph glands. These symptoms can show up anywhere from several weeks to several months after being infected with the virus. These symptoms can last for a month or so and then they will go away although these early symptoms are not present in all cases. Since they resemble the flu then many people may experience these symptoms without thinking that it may be anything more than the flu.
Kaposi's Sarcoma - ?The immune system helps protect our bodies from contracting certain types of cancers. When a person has AIDS their body is unable to fight off such cancers and the person becomes susceptible and vulnerable to such cancers. One type of cancer that an AIDS patient can contract is Kaposi's Sarcoma. This type of cancer affects the skin and other body organs. The marking on the skin from this type of cancer looks like a bruise or black and blue mark and these markings are permanent. This type of cancer has been a leading cause of death among AIDS patients.
TREATMENT
In a controlled environment these drugs can help a person who is infected live a longer and healthier life, but in real situations when a person forgets to take his anti retroviral medications, these medicines can be less effective. For the HIV and AID S treatment drugs to have effect it is important for the person to take the prescribed drugs in the right quantity at the right time every day. Although most doctors agree that the treatment and medication should be started at the first stage of being infected, at times people are not diagnosed until their systems have already been badly infected.
Majority of the scientists and health care professionals agree that the drugs should be started when a CD4 test that helps determine the T cell count states that the cell count is below 350 cells /mm. Other considerations such as opportunist infections and viral overload may also be taken into account.
Combination drugs are often prescribed to patients with the most common combinations being two NRTIs (Nucleoside/Nucleotide Reverse Transcriptase Inhibitors) combined with a NNRTI (Non-Nucleoside Reverse Transcriptase Inhibitors) or a boosted protease inhibitor. When the antiretroviral drugs have been combined into one pill or medicine these drugs are known as fixed dose combination drugs. The main benefit of these drugs is that the person infected has to take a lesser amount of drugs every day.
Since HIV has to get into a T cell and latch on to the cell to fuse its outer membrane to the T cells, new and improved drugs known as attachment inhibitors or fusion inhibitors are being tested in humans to help tackle this virus.
Interluekin - 2 or IL- 2 are chemicals that help the body's immune system stronger to fight the virus more effectively. Constant clinical trials are conducted to reach a conclusion however no decision regarding this drug has been finalized yet.
Antisense drugs help for a mirror image of the HIV's genetic code that helps shut down cellular factories that are creating disease causing proteins. Although these drugs are not released to doctors yet due to continuous testing, scientists agree that these drugs will not have side effects.
Anti retroviral drugs can cause side effects until the body gets used to the medications. Possible side effects of anti retroviral drugs are mentioned below.
- Nausea and Vomiting - Common in the first two weeks after starting medications.
- Diarrhea - Common side effect. The patient should call his doctor if this side effect lasts for more than 3 days.
- Rash - This side effect usually goes away by itself but can also be caused as an allergic reaction to a drug. Rashes happen when some patients take Ziagen, Rescriptor, Sustiva or Viramune.
- Insomnia
- Fatigue
- Dry skin or ingrown toe nails - Can happen with the medication Crixivan.
- Kidney stones - can happen with the medication Crixivan.
- Lipodystophy syndrome - This syndrome causes the body to store fat in various places and the symptoms may include a roll of fat between the shoulders, enlarged breasts and loss of fat in the body.
HIV Dementia/ HIV-Associated Dementia Complex (also known as AIDS Dementia Complex) is a progressive neurological disorder that can affect people who are infected with the Human Immunodeficiency Virus (HIV). HIV-Associated Dementia Complex (HAD) is thought to be a subcortical dementia and is characterized by cognitive, motor and behavioral impairments severe enough to interfere with an individual's ability to function occupationally or socially.
Although the precise incidence and prevalence of HIV-Associated Dementia Complex is uncertain, it has been estimated that as many as two-thirds of the individuals with AIDS will develop dementia or related neurological disorders at some point of time. The leading hypothesis regarding HIV Associated Dementia is that it is caused by direct infection of the brain by the Human Immunodeficiency Virus (HIV) which is the cause of AIDS. In 1987 the Centers for Disease Control included HIV-Associated Dementia Complex as a primary diagnostic condition that warrants a diagnosis of AIDS.
Symptoms of HIV Dementia The early manifestations of HIV-Associated Dementia Complex ) (HAD)may include:
- Memory loss (difficulty recalling appointment times, telephone numbers, or names), impaired concentration (trouble keeping track of conversations or completing thoughts), and mental slowing (not as "quick" as usual, slower at responding to questions).
- Difficulty with gait, balance, coordination, leg weakness, clumsiness and deteriorating handwriting.
- Impaired judgment (impulsive behavior, poor decision making), personality changes (apathy, social withdrawal, irritability), mood changes (extreme highs and lows, anxiety, emotional outbursts), and occasionally psychotic behavior (hallucinations, suspiciousness, grandiose thoughts).
Adolescent and adult clients should be advised about risk factors for STDs and counseled appropriately about effective measures to reduce risk of infection. Counseling should be tailored to the individual risk factors, needs, and abilities of each client. Assessment of risk should be based on a careful sexual and drug use history and consideration of the local epidemiology of STDs. Sexual history should include questions about number and nature of current and past sex partners including same-sex partners or partners who have injected drugs, any history of past STD infections, the use of condoms or other barrier protection and particular high-risk sexual practices such as anal intercourse.
People at risk of STDs should receive information on their risk and be advised about measures to reduce their risk. Effective measures include abstaining from unprotected sex, maintaining a mutually faithful monogamous sexual relationship with a partner known to be uninfected, regular use of latex condoms, and avoiding sexual contact with casual partners and high-risk individuals like intervenes Drug Users, commercial sex workers, and persons with numerous sex partners. People who have sex with multiple partners, casual partners, or other persons who may be infected should be advised to use a latex condom at each encounter and to avoid anal intercourse.
Condoms need not be recommended to prevent infection in long-standing, mutually monogamous relationships in which neither partner is an injection drug user or is infected with HIV. People using condoms should be informed about the importance of using them in accordance with recommended guidelines.
It is beneficial to involve the client in his own education as much as you can. He can repeat instructions in his own words and simulate anticipated conversations with his partner or parent. The average person can absorb about three take-home messages in one educational session. Give your messages careful priority ranking, and don't overload people with data. Pay attention to the person's agenda and allow time for the client to discuss his questions and concerns.
There will almost certainly be questions you haven't thought of and the most important way to show respect for a patient is to give time to his issues. Evaluate your client's learning since you don't know what the client has already learned until you hear what he says. Ask a few keys questions and see how he responds. Education must be ongoing since almost no client can learn all he needs to know in one visit.
Invite calls to the clinic or office or hot-line later as people learn best in an environment that feels safe and calm. A person on the way to a medical exam rarely feels safe and calm hence you should allow time after the exam for more education and discussion and invite clients to call back later with questions. Teens and adults may need a different style of education and understanding intellectual and emotional developmental stages can help you pitch educational messages appropriately.
Information reassures some people and overwhelms others. Not all clients need or want to know every single fact you know. You can do no harm if you do not make decisions for the client. You will almost certainly do harm, sooner or later, if you are extremely authoritative. The best response to "What do you think I should do?" is "What do you think? is that I'll help you sort out all your options, and then we'll look at your ideas about the pros and cons for each option."
Listening is very helpful and listening to concerns and the responding is the best way to answer questions. Often clients need to be understood more than they need anything else. Avoid thinking in me or them terms since the successful counselor recognizes the common human ground he has with each client. Not all people are able to be "compliant" and when you and your clients are face to face, support them and hold them accountable for their actions. Once they leave your office, let it go.
Denial and anger are common, normal responses to trouble. You will need to be skilled at reflecting and discussing these feelings. Anger is usually a sane, healthy response to feelings of vulnerability and loss of control and denial can be given up by the denier, but never forcibly taken away be the counselor. Help preserve hope, even in the face of fatal illness and you can actively help clients have as many good days as possible. That is a worthwhile, valuable goal. Avoid asking "why" questions as reasons for feelings or actions can be murky and complex, and "why" questions are usually difficult or impossible to answer. Clients are likely to feel attacked or embarrassed so offer the option of including others in counseling. Partners, parents, and best friends may be helpful in reducing anxiety for some clients and for others privacy in counseling is absolutely essential. The ultimate choice belongs to the client and your opinion should not be forced.
Assure the client you only want to know what he wants to tell you. This powerful phrase returns control of the encounter to the client, and often results in a remarkably candid discussion. Be open to the broad variety of healthy, effective human coping styles. Your way will almost never be the only way. People solve their own problems! Assume nothing and discipline yourself to forestall labeling, categorizing, and stereotyping. Just listen. Accept your client where he is right now and the client knows what he wants from you. Just ask!
Here are some practical tips the health care professional can ask their clients to use if they feel that their families are having a hard time coping with the situation.
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" Don't avoid me. Be the friend, the loved one, you've always been.
" Touch me. A simple squeeze of my hand can tell me you still care.
" Call me to tell me you're bringing my favorite dish and what time you are coming. Bring food in disposable containers, so I won't worry about returns.
" Take care of my children for me. I need a little time to be alone with my loved one. My children may also need a little vacation from my illness.
" Weep with me when I weep. Laugh with me when I laugh. Don't be afraid to share this with me.
" Take me out for a pleasure trip, but know my limitations.
" Call for my shopping list and make a "special" delivery to my home.
" Call me before you visit, but don't be afraid to visit. I need you. I am lonely.
" Help me celebrate holidays and life by decorating my hospital room or home or bringing me tiny gifts of flowers or other natural treasures.
" Help my family. I am sick, but they may be suffering. Offer to come and stay with me to give my loved ones a break. Invite them out or take them places.
" Be creative! Bring me a book of thoughts, taped music, a poster for my wall, cookies to share with my family and friends...an old friend who hasn't come to visit me.
" Let's talk about it. Maybe I need to talk about my illness. Find out by asking me: "Do you feel like talking about it?"
" Don't always feel we have to talk. We can sit silently together.
" Can you take me or my children somewhere? I may need transportation to a treatment...to the store ...to a doctor.
" Help me feel good about my looks. Tell me I look good, considering my illness.
" Please include me in decision making. I've been robbed of so many things. Please don't deny me a chance to make decisions in my family...in my life.
" Talk to me of the future. Tomorrow, next week, next year. Hope is so important to me.
" Bring me a positive attitude. It's catching!
" What's in the news? Magazines, photos, newspapers, verbal reports, keep me from feeling the world is passing me by.
" Could you help me with some cleaning? During my illness, my family and I still face: dirty clothes, dirty dishes, dirty house.
" Water my flowers
" Just send a card to say "I care."
" Tell me what you'd like to do for me and, when I agree, please do it!
Listed below are some social and emotional stressors that people who are infected with HIV or AIDS can feel and go through.
- Facing a terminal illness: fear for self, partner, child
- Family rejection: drug use, sexual style, or fear of infection
- Unpredictable illness: maybe fine today, sick two days from now
- Isolation and discrimination: fear losing job, housing, friends
- Few benefits, services, or support groups for infected families
- Fear that child will be abandoned or abused when parent dies
- Fear that child will be taken away by social agencies
- Guilt and fear if child has become infected
- Anger if child was infected by transfusion or because partner used drugs or had sex outside the relationship
- Multiple losses: job, insurance, relationship, self-esteem, body image, friends, child, strength
- Shortage of affordable housing
- Medical care may be expensive, far away, involve long waits and many clinic visits, be painful or stressful and offer few answers
- Anxiety about child's school attendance and community reaction
- Drug abuse issues: lack of treatment facilities for women, continuing compulsion to use drugs, perception by service providers that drug user is "manipulative" or a "bad patient"
- Hopelessness
- Please Don't Judge Me.
- I know that some people believe I deserve this illness because of my past behavior.
- Like all people, I have done the best I am able to do in my life with the circumstances that I have been given.
- Please Don't Talk About Me.
- I know that you need to discuss my case with people who are involved in my care.
- I also know that HIV is an interesting topic of discussion at other times as well.
- Your talking compromises my confidentiality and could have serious consequences for me if word of my illness got around.
- Please Explain Things To Me. I know that you are very busy, but please understand that the procedures and drugs you discuss are like foreign languages to me. It will help me accept and understand what I am going through if I have your help.
- Please Understand How Emotionally Difficult This Is For Me.
- I am too young to be thinking about the end of my life!
- I am worried about my young children.
- I am worried about my partner. I have kept a very big secret from many people, and this illness threatens to expose me.
- Please Acknowledge The People I Consider My Family.
- I may not have lived near my biological family for many years, but I have a wonderful, loving support group who are my "family of choice."
- I may have a spouse to whom I am not married, or a spouse who is the same gender as I am. Treat this person as my spouse, I do.
- Please Follow My Lead With My Biological Family. I may not have told my family why I am ill.
- I may have reasons to avoid seeing them or to avoid their calls. Honor my wishes.
- Please Understand My Need To Be Involved In My Care. So many things in my life now feel out of control. I want to be involved in making decisions about my care and I want to be told what is going on.
- I am losing my dignity all the time, and your respectful treatment can help me feel self respect.
- Please Treat Me Like Other Patients. Signs on my door and flags on my chart reinforce the stigma I feel. Please educate the dietary and housekeeping staffs so my room and meals will be handled in a sensitive way.
- Please Don't Reject Me. I need love now more than ever in my life. You will not become infected by listening to who I am, or by holding my hand or giving me a hug. Thank you for doing a very difficult job!
Sexually Transmitted Diseases (STD's) can cause serious illness, sterility and even death. Safe Sex means ways of having sex that reduce or eliminate a person's risk from STD infection. Body fluids such as blood, semen and vaginal fluid can carry many STD's including the HIV virus, which can lead to AIDS. Never letting body fluids transfer from one partner to another during sex will greatly reduce the risk of catching STD's. So, if engaging in intercourse whether it is vaginal or anal, always use a condom. A condom properly used is an effective barrier against most STD's including HIV, but not against herpes or genital warts if the infected area is not covered by the condom. Only lubricate a condom with water based lube and not Vaseline which will cause the condom to tear.
Other forms of Safe Sex include any non penetrative activity such as mutual masturbation, kissing, massage or using dildos or vibrators but never share them without cleaning them first. These can be great fun too - talk to your sexual partner about protecting yourselves and only having safe sex.
Oral Sex (mouth to genitals) is thought to be only a very low risk from HIV, but higher risk from other STD's such as Herpes, Genital Warts or Gonorrhea. To reduce the risk further, avoid semen in the mouth and consider using a condom for oral sex on a man and a dental dam on a woman. Don't have oral sex if either partner has cuts or sores on the mouth, lips or genitals.
While injection-drug use once accounted for most new cases of AIDS in women, the latest data show that the majority of females are now infected through heterosexual sex with an HIV-positive partner. While injection-drug use once accounted for most new cases of AIDS in women, the latest data show that the majority of females are now infected through heterosexual sex with an HIV-positive partner.
The best protection is to follow these guidelines:
Do not share needles. If you share needles clean them with bleach and water after every use. Practice only safe or "Possibly" safe sex.
Talk with your sexual partner(s). Take the time to discuss how each of you can reduce the risk of exposure to the HIV virus.
SAFE ACTIVITIES:
- Massage
- Body to body rub
- Hugging
- Dry kissing
- Masturbation
- Mutual masturbation
- Possibly safe activities:
- French kissing
- Vaginal or anal sex using a condom
- Oral sex on a man wearing a condom
- Oral sex on a woman using a latex square (dental dam) that covers the vaginal area.
- oral sex on a woman without a latex square
- oral-anal contact
- finger-anal contact
- sharing sex toys or douching equipment
- blood contact of any kind, including menstrual blood
- sharing intravenous needles
- Sexual activity while under the influence of mind altering drugs that can cloud your judgment.
COUNSELING
Using alcohol or drugs can lead to high-risk sexual behavior. People who inject drugs should be referred to available drug treatment facilities, warned against sharing drug equipment and where possible referred to sources for uncontaminated injection equipment and condoms. Drug users should be advised of the importance of being tested for HIV, of using condoms regularly with both casual and steady partners, and of following specific steps to reduce the risk of transmitting infection during preparation and injection of drugs.
HIV counseling requires explicit discussion of death and dying. Counselors are likely to encounter clients who hold opinions and values very different from their own, and will be challenged to become aware of their own biases and stereotypes that could interfere with effective counseling. HIV counseling requires that the counselor consider the reactions and needs of partners and other family members as well as those of the client.
COUNSELING COUPLES AND GROUP COUNCELING
In all cases the counselor's role includes assisting each member of the couple to cope with their emotional reactions to their HIV status and to the HIV status of their partner. In the case of concordant seropositive couples or discordant couples, it is not uncommon for one partner to blame the other for behavior that may have resulted in infection.
While the expression of emotional reactions is necessary and often helpful in risk reduction, counselors must set limits to prevent partners from verbally or physically abusing each other and re-focus them away from assigning blame to developing a plan for living positively with their couple serostatus.
Couples being counseled together should be encouraged to discuss their plans regarding pregnancy and family planning. Counselors are reminded that the question of whether discordant or seropositive couples should have more children is a complicated issue that involves considerations of their health status, resources, family circumstances, spiritual beliefs, etc. While it is not the role of the counselor to tell the couple what to do, the counselor raises the discussion for the purpose of providing information and encouraging communication within the couple.
Couples should be referred for family planning services and medical evaluations. It is the responsibility of the counselor to keep referral information current.
In some cases, it may be harmful to discuss antibody status immediately after receiving a test result or when a person is reluctant to do so. Individuals need time to develop an understanding about how they feel and about the health, psychological, financial, and relationship implications of their results. This process may be aided by disclosing to a partner, but clients first need to acknowledge these concerns by themselves. At the same time, counselors should encourage clients who are uncomfortable about disclosing to partners at all. They may need to explore further their concerns, possibly through individual or group therapy, or by first talking to a friend or family member other than their partner.
Partners may accompany patients to test sites and patients may ask that partners join the counseling session. With both partners present, a counselor can help the couple acknowledge HIV as a "third party" in the relationship, an element that will affect their lives and plans together. By acknowledging this, partners may better accept and deal with infection, and diminish the effects of its intrusion in their relationship.
For some couples a shared session may encourage open discussion of certain concerns, such as safe sex, health care, and emotional support. However, counselors should be aware that shared sessions may be unproductive especially if they result from unequal power-sharing in the relationship for instance, if one partner has demanded to be part of the session. A partner's presence may inhibit a client's emotional response, and partners may limit their discussion to protect each other. Counselors should acknowledge these concerns before asking or allowing partners to join in sessions.
To facilitate joint sessions, counselors should make sure that they address their clients' primary concerns before partners attend. When partners are present, counselors should encourage both individuals to freely express their thoughts but counselors should remember that while they are offering support to both partners, their primary counseling responsibility remains with partners to whom they have disclosed test results.
For the client who has recently tested positive and who is experiencing a flurry of disturbing and disorganizing emotions some form of crisis intervention is frequently indicated. This means providing support and validation for feelings, mobilizing resources for coping, providing educational information, and helping the client solve pressing situational demands.
The counselor can begin by normalizing the emotional "roller coaster" that is so commonly experienced. As many of these clients have had little if any opportunity to discuss their situation with anyone in depth, the experience of feeling heard and understood, and accepted by an empathic counselor who actively listens can be a significant starting point. Learning that many others have experienced similarly severe reactions to testing positive can also help reduce their sense of isolation.
The counselor should be sensitive to the possibility of suicidal ideas, though actual hospitalization of suicidal HIV clients has been a rare occurrence in medical experience. A useful initial response to such thinking is to normalize it by pointing out its commonness among HIV individuals. When present, suicidal ideas should be monitored carefully and can be expected to subside as the client begins to adjust to the information and the sense of immediate crisis is alleviated.
Helping the patient find resources for coping can include identifying internal strengths and abilities as well as external supports such as friends, family and social services in the community. Identifying effective coping strategies that the patient may have used in the past during high stress or crisis is also useful. Teaching coping strategies ranging from controlled breathing, visualization, or taking a walk in the park, to problem-solving approaches such as "taking things one step at a time," ensuring frequent rest periods or "mini vacations," and remembering other successes in coping with past adversity have all been used effectively.
Often friends and family as supports are underutilized in the case of HIV infections. This is because of the fear to a negative reaction or fear or overburdening them. The counselor can assist the client in helping the patient decide which friends or family members would be the most likely to respond in an accepting and supportive way. Referral to support services in the community, such as emotional support groups and AIDS informational centers, contributes further to the sense of having a range of resources from which the patient can draw support from.
Finally, reminding clients who have recently tested HIV that the emotional turmoil of the initial adjustment period is hard but once the patient gets used the situation life can become normal again if the patient has strength and determination. It is critical that the counselor provides an opportunity for clients to recognize, express, and eventually accept the full range of feelings that are sparked by facing a life-threatening illness. When negative thinking predominates, however, and clients become trapped in a downward spiral of hopelessness, cognitive techniques can help to replace some of the dysfunctional thought patterns with more constructive ways of thinking. For instance, clients who repeatedly think that they are going to die so there is no sense trying or they are exempted from the joys of life because they are HIV positive can be helped to examine the dysfunctional nature of these thoughts and to recognize the potential for changing them. Through support and therapy the client can realize that life is not yet over and he has to be happy and healthy for himself, his family and his friends.
The negative thoughts should be converted to positive thoughts over a period of time and the patient should not be rushed but should be encouraged to think of all the positive things that life holds for him. Often patients feel that this is the worse situation and they are doomed for life. The patients should be told that there are better off than many people who face a lot of problems and if they take their medications on time they still have a chance of leading a normal life. The words used to convey positive messages should be altered according to the severity of the patient's mindset and the therapist should refrain from using any negative words that may cause the patient to think that he has no chance of living a normal life.
Often the client's difficulty in disclosing antibody status to friends or family reflects problems with self-esteem associated with being HIV positive. In such cases, it may be important to first address negative feelings before encouraging disclosure to others.
It is not uncommon for the counselor to encounter a client who is continuing to engage in potentially self-destructive behaviors such as drug or alcohol abuse, unsafe sexual activity, or poor daily health habits involving diet, sleep patterns, and so on. If these behaviors do not change during the course of counseling, firm but gentle confrontation of the behaviors is recommended. Sometimes providing information about the potential harm of such behaviors to an already vulnerable immune system can help motivate the client who is poorly informed.
For others, being pushed to seriously to examine such behaviors requires confronting the potential seriousness of the situation in a way which may have been avoided out of fear. Such fears need to be examined and explained with careful timing and in an atmosphere of respect. In other cases unhealthy patterns such as those involving diet, sleep, or substance use may reflect an underlying depression or crippling anxiety, which inhibits the client from making important changes. In such instances, a referral to a psychiatrist for evaluation for medication should be made if the person does not respond to regular therapy.
Throughout the sessions it is important that the counselor conveys a sense of hope and encouragement while at the same time allowing space for experiencing emotional pain and loss. The re-examination of basic values and priorities in life that many HIV positive clients undergo can be framed by the counselor as an opportunity to enrich the quality of life. Giving examples of others in similar circumstances who have managed to survive and make progress over time can be inspiring. Supporting the patient's right to engage in "healthy" denial like regularly taking breaks from dealing with emotionally painful realities can also help the patient heal.
The crisis which most clients experience following an antibody-positive test result can be a source not only of emotional turmoil, but also of motivation for making significant positive changes. The confrontation with potential mortality brought on by the test result leads many individuals to a commitment to work through troubling personal issues which they previously lacked ability or motivation to address effectively. For such clients, a decision to enter longer-term psychotherapy may be an important step towards turning the crisis into a profoundly life-enhancing transition.
HIV positive clients must cope with a range of painful emotions which typically accompany an antibody-positive test result which include fear, grief, anger, and sadness. They must also deal with decision-making in a number of important areas of their lives in which there is a great deal of uncertainty. This includes uncertainty about medical prognosis, health care options, how best to spend one's time and plan for the future, and how to share the news of being HIV positive with others. Furthermore, social restrictions and the strain often imposed by the antibody-positive test result on important interpersonal relationships may contribute to a plummeting self-esteem.
Counselors who choose to work with this client population face a demanding set of challenges. They must struggle with a high degree of ambiguity and with the difficulty of identifying clear guidelines for how to address the client's needs and how to measure progress. The counselor's own attitudes and anxieties about AIDS and HIV must also be channeled in a healthy direction. Ultimately the counselor, along with the patient, has an opportunity to develop an enhanced sense of purpose and meaning within a situation of crisis proportions.
Group counseling groups for HIV individuals can be a tremendous help in reducing social isolation, increasing coping resources and providing support for making positive changes. The average patient feels a sense of relief when hearing others describe similar experiences and emotional reactions to a HIV test result. Many benefit from involvement in such a group concurrently with individual counseling whereas others prefer only one on one sessions. In some communities, there may be a variety of types of groups from which to choose, including short-term topic-focused groups, drop-in support groups, longer-term closed-membership support groups, and psychotherapy groups. Short-term topic-focused groups, often intense six to ten weeks of sessions and tend to have the dual objective of offering interpersonal support as well as information relevant to coping with HIV and protecting oneself and others. Drop-in support groups generally offer the individual an opportunity for group support and educational information without having to make an ongoing commitment to attend. Such groups are particularly helpful to those with limited experience in therapeutic groups and who want to test the water before considering a longer-term support group. More traditional psychotherapy groups for individuals who are HIV positive can offer an opportunity for greater depth of exploration of personal and interpersonal concerns than is possible in short-term groups. The health care professional should consult the patient while providing suggestions about which type of therapy will be best for the patient.
HIV AND EMOTIONS?
Anger, guilt, depression, fatigue and fear are some of the reactions to HIV. These feelings and reactions do not come in a particular order and are also not felt by everyone at the same intensity. Some people experience each feeling differently and sometimes they are felt at different times and sometimes they are all felt at once. These emotions are reasonable reactions that HIV infected patients feel.
JUSTIFICATION
No matter how someone was infected with HIV they feel that did not ask for it nor do they deserve it. Some of the common thoughts experienced during this situation include but are not limited to:
- Why me?
- Did I deserve this?
- I never hurt anyone.
- I didn't do anything wrong.
- I will not get to fulfill my dreams.
ANGER?
Some people can easily express their anger, while others keep it inside. Some people with HIV may not feel any anger due to their medical condition. In any case, anger is a reasonable response to HIV.
Anger also is derived from the lack of control over one's body and health. An independent person can quickly become dependent on their caretakers when they become ill and unable to tend to their daily functions.
People express anger differently. Some people express anger directly and openly. Other people keep their anger bottled up inside until it is released in an appropriate or inappropriate way. Some people express anger at whatever or whoever is within reach and at most times they get angry at their caregivers. Some people are uncomfortable with expressing their anger and in these cases anger acknowledgment and anger management training would benefit the individual.
If one cannot express their anger in any way then they turn their anger inward and they feel depressed, guilty or they dislike themselves. Some people rely heavily on drugs or alcohol to cope with their medical condition. This option is detrimental in many ways as they lose control, are more likely to be reckless. Also drugs and alcohol are horrible for their health and being under the influence most likely will put the person back into the behavior that put them at risk for the virus in the first place.
People usually realize that they are treating themselves badly and before long they start to realize their wrong doing and work on treating themselves better. At other times friends and relatives intervene and point out that the individual needs help and suggests it to the person affected with HIV. In this situation mental health professionals can help an individual identify and understand the anger and help the anger find its appropriate target. Additionally, an alcohol or drug rehabilitation, outpatient or inpatient program would also benefit an abuser.
People need to be allowed to deal with their anger and to be angry. They need to learn how to express their anger in a safe and appropriate setting. Directing anger at the wrong target is at best ineffective and at the worst harmful. Even anger turned outward can be overwhelming. Certain attitudes and actions help people deal with their anger and these actions need to be identified and the anger needs to be redirected appropriately.
Each person also needs to find the appropriate mechanisms to discharge their anger. Some people scream while others exercise or write in journals. Caretakers need to understand that the person affected with HIV is angry at the medical condition and the disease is the target, not the caretaker. They feel anger not hatred and they don't blame the care taker, however the care taker is the closest to them and he is the current release for their anger. Until the anger is redirected in an appropriate way the patients will continue to abuse their caretakers, family, friends and themselves. Acknowledge the struggle that they have and the family, friends or care giver should understand that they are not angry at them
Energy from anger can be used to form support groups, telephone hot lines, newsletters, fund raising, and political action groups. It is important to explain to the patient that it is easy to sit and complain about a situation, however, if his health allows him to redirect the energy into positive activities it will allow him to feel good about himself and less angry, depressed, hopeless or guilty.
DEATH OF A LOVED ONE
Grief is an expected human response to the loss of a loved one. Grief can cause extreme physical and emotional pain. An individual grieving from a single, uncomplicated loss may experience sadness, crying, disorientation, anger, anxiety, loss of concentration, physical discomforts and may also feel pain in their chest or a sense of emptiness. These symptoms may last a year or more and by themselves suggest no pathology. Even with social support, though, survivors are faced with the personal challenge of adjusting to a new life without the loved one. After death survivors may experience stress related to inheriting new and unanticipated responsibilities or experiencing changes in social role.
In the case of death due to HIV disease, mourning, the public display of one's grief, may be hampered by the societal stigma and blame associated with AIDS. Survivors may not receive support and compassion from their friends, family and church during the painful grieving period. For others, such as gay partners, relationships may go unrecognized or invalidated and may obstruct opportunities to talk about the death. Such disenfranchisement from one's grief may impede the process of bereavement. In the months and years following the death of a loved one, survivors face the challenge of leaving the deceased behind, learning to live with the absence, and reinvesting in the future; resolving grief is an ongoing process.
AIDS and Multiple Losses ?Members of communities that have been heavily affected by the HIV pandemic may suffer new losses before recovering from old ones. Kastenbaum coined the term "bereavement overload" to describe a potentially unhealthy response to a series of consecutive, often overlapping losses and the accumulation of unresolved bereavements which may cause an individual to become emotionally overwhelmed, physically exhausted, and spiritually demoralized [Kastenbaum R. Death and Bereavement 1969; Springfield, IL:Charles C. Thomas].
The inability to resolve one's grief can be devastating. Unresolved bereavement has been found to produce significant risk for the development of adverse health outcomes. It is characterized by a myriad of symptoms ranging from emotional distress, such as depression, to somatic disorders, such as insomnia, and even suicide. Bereavement may be complicated by a variety of circumstances that have the potential to interfere with its resolution. Conditions, which may complicate mourning, are identified as those associated with the current death, such as social stigma or secrecy, as well as antecedent variables such as previous, un accommodated losses or lingering feelings of guilt. All of these conditions are commonly seen with death due to AIDS.
- Addressing Grief ?Health care providers have a unique opportunity, if not a clear responsibility, to support patients and their loved ones by addressing the effects of grief and loss. Adverse health outcomes are a potential danger to both HIV negative and HIV positive individuals. Unfortunately, our own discomfort may keep us from raising the topic. There are, however, many approaches to facilitating the exploration of grief:
- Acknowledge the death: "I understand that your partner died last week. How is it going for you?" Often, survivors reflect upon their grief throughout the course of a day. When interacting with others, who are unaware or unaffected by the loss, a grieving person may feel isolated. Recognizing the loss may provide the survivor a chance to talk.
- Validate the importance to the survivor: "You knew him a long time, and the two of you were very close. What was he like?" Describing one's relationship with the deceased may authenticate relationships that are frequently disenfranchised.
- Speak of the deceased when appropriate: "I remember when Tommy was first born. This would have been his second birthday this week. How are you feeling?" Remember that after a death, celebration dates, such as birthdays and holidays, can be particularly difficult for survivors. Acknowledging the importance of an anniversary can assure survivors that others remember and care about the death and their loss.
- Note the existence of multiple losses: "Since you have been coming to clinic, you have lost your partner, your best friend and, now, your friend Will. I can't imagine what that is like. How do you handle the grief?" Besides the loss of friends, many of the bereaved senses the loss of close confidants, the loss of community, and, frequently, the loss of sexual intimacy. Overwhelming and overlapping bereavements may eventually contribute to a loss of hope and a loss of the joy in one's life.
- Learn about grief and loss. Taking courses, attending workshops, and reading the research literature allows health care workers to acquire therapeutic communication skills, acknowledge signs and symptoms of grief and develop effective alternatives to "I didn't know what to say," or "I was afraid I might make him/her cry."
- Assess for signs and symptoms of clinical depression. Although depression is not necessarily an outcome of ongoing bereavement, it must be seriously considered. Take notice of behaviors, statements, and mood that may indicate the need for an in-depth work-up. Treating depression appropriately should be an integral part of standard health care.
Bereaved people may wonder how to get through their grief. The grief process is like a journey running from the starting point of bereavement to a new life. Progress is made through grief as the feelings are worked through. Freud called this grief work.
Some strategies for dealing with grief:
Some people find it helpful to spend fifteen to twenty minutes alone every day. They put on the answering machine so they won't be disturbed. This time acts as a safety valve. In it they deal with any emotions they have stored up during the day. There are different ways of grieving at these times: thinking, crying, praying, meditating, writing or drawing talking to the dog!
Some people like to keep a diary. They write down their feelings and the memories of the loved one. They can then see how their grief changes over a period of weeks and months. This is proof of progress. If the diary is kept in a safe place the written memories become precious in the future. Alternatively some people feel more comfortable with pictures or diagrams. Many people feel less alone by also grieving with other family members, including the children.
Many people find crying a relief. Rather than being an indication of weakness, tears are often a sign of strength and show that the bereaved person is prepared to work through their grief. Some people find it difficult to cry, and yearn for tears to release their grief.
Enlisting help can seem long and lonely; so many people find someone whom they can confide in, for example, a relative or friend. Some people find the experience of another person who has been through a similar situation invaluable, and so contact a support group.
Some other useful strategies
- Live a day at time
- Do something special for yourself every day
- Do not make any major decisions, such as selling the house, in the first year if possible
- Talk to a caring friend
- Join a bereavement support group
- Read books on grief.
- Write letters to the person you have lost to express your feelings or as a way of saying goodbye. You can then keep these in a safe place, or bury them under a bush you plant in their memory, or scatter the pieces in a significant place.
- Keep a journal as a record of your own journey of grief.
- Create a memorial for the person who died: plant a tree, create a memory book or photo album. Children often like to collect items for a memento box.
- Commemorate the person you lost on special days, such as birthdays, Christmas, Father's Day. Light a candle, drink their favorite bottle of win, and talk about them. Then go and do something special for yourselves- you deserve it! Plan these activities with the rest of the family.
Self care is important to prevent further stress to the body. The following have been found to be helpful in coping with grief:
- A regular daily routine. Have set times for getting up, meals and going to bed.
- A balanced diet. Include: breads and cereals; meat, fish and dairy products; fruit and vegetables.
- Avoid too much coffee and tea to help you sleep at night.
- Outdoor activities, such as going for a walk or gardening take you away from the stress, and refresh you mentally.
- Exercise, such as swimming, walking and team games, will produce chemicals called endorphins in the body which help to counteract depression and make you feel good. The exercise does not need to be strenuous. If you have doubts about your fitness consult your doctor.
- Relaxation: meditation, massage, music.
- A relaxing pre-sleep routine: winding down before bed and not watching television.
- Avoiding seeking relief through alcohol, smoking, medication and other drugs
- Consulting the doctor about physical symptoms, for a blood pressure check, for practical help, for medical certificates, and for help with the grief.
Depression has been associated with people who are infected with HIV. Depression seems like the only possible response to an illness that can devastate psychological, social, health and integrity. Some people find solace in despair or becoming entirely indifferent while others seem to come alive, manifesting an inner strength and resolve.
HIV infection initiates a long and complicated emotional process during which there are often moments of despair, of denial, but also of strength, even heroism. This process includes moments of sadness and personal loss. But when does such a depressive response become significant enough to warrant mental health intervention? One cannot work with clients with HIV and be insensitive to the inevitability of profound loss. But this sensitivity cannot blind providers to the possibility of intervention.
One cause of depression is a sense of being stuck in a frustrating situation. At some point, most people must face something in which they cannot fix, to which they can only adjust. People with HIV usually do not know what is coming next. This loss of control is overwhelming and thus depressing. Another cause of depression is predisposition. People who have been depressed before their diagnosis are more likely to be depressed afterward. Some of the medications to treat HIV can cause depression.
Alcohol, which is a depressant, can cause a cycle that causes a person to feel better about their depression and then causes the person to feel more depressed and out of control after the alcohol wears off. Occasionally, depression may be caused by the virus itself since depression can be a symptom of dementia, which is a condition when the virus enters the brain.
Depression that is unexpressed anger will disappear when the anger is recognized and dealt with. Anger is difficult to express, especially when the situation is out of one's control. People who do not express such anger either consciously restrain it or unconsciously ignore it and hence they unknowingly turn their anger inward on themselves and become depressed.
Depression that is associated with sadness, loneliness and hopeless usually runs its course and after a few days or weeks gradually fades away. For some people this happens without intervention and for others there need to be someone to intervene to help the person cope with their depression.
Physical activity is one way to permanently end depression. Researches indicate that 20 minutes of exercise can have the same effect as 20 milligrams of anti depressant medicine. The counselor should tell the patient to go outside, go for a walk, cook a meal, bicycle riding, bowling fishing or going shopping and buying himself a treat are all ways to alleviate depression. A sense of accomplishment can come from doing something small like cleaning out a closet, writing a letter, or painting a picture and each small accomplishment can give him hope continue leading a normal life.
Mental tasks, such as reading, going to the movies, going to an art gallery, taking pictures, learning to play a musical instrument, taking a trip, gardening, taking up a new hobby or continuing an old hobby or just talking to a friend are just a few ideas to lessen depression. These activities should help restore hope and lessen or alleviate the person's depression.
For some people, the depression is too severe or it doesn't seem to go away. They feel alienated from everyone, very apathetic and hopeless. Severe depression is often best treated with medication. Sometimes medications that are treating some other illness can also cause depression. If this happens a certified doctor can either change the medication or change the dosage to one that is more effective for the symptoms that it is suppose to be treating and does not cause depression. If the depression is due to dementia then medication should be prescribed by the patient's doctor.
Due to the severity of HIV most people will have some level of depression. This depression can be managed with medications and support. A psychiatrist should be part of the treatment team to prescribe medication that restored sleep, appetite and mood. The drugs prescribed for depression are very successful. About 80% of severely depressed clients with HIV get better while 50% of them are cured of their depression. For most people the treatment of depression is critical but it is also temporary.
Psychiatrists, psychologists and social workers can help talk the person through whatever is blocking the healing process, though only psychiatrists are trained medically and can prescribe medications. Therapy can concentrate on the overwhelming problems people must face and feel that they cannot solve.
SUICIDE AND HIV
Suicide and HIV are linked and will definitely present as an issue for any provider working with HIV-infected patients. Many reviews in the psychiatric and medical literature have looked at the link between suicide and HIV infection and all report indicate a higher incidence of suicidal ideation, suicide attempts, and actual suicide in the HIV-infected than in the general population.
For the healthcare provider the possibility of suicide of any patient can provoke great anxiety and pose medical and ethical dilemmas. There are several risk factors for suicide in patients across the entire spectrum of HIV infection from learning one is HIV-positive to having end-stage AIDS. Familiarity with these factors can help the provider in making an office assessment and forming a treatment plan.
Providers in the office may see a patient who has just made an attempt, reported suicidal thinking spontaneously or answered positively to an inquiry about suicidal ideation during a review of symptoms. Asking about suicide will not cause a person to attempt suicide and is not likely to suggest something to the person with HIV infection that he has not already considered. Patients will usually be relieved to be able to talk about feelings that they might think need to be hidden, and will take comfort in learning that suicidal thoughts are common or even expected in HIV cases.
If the questions can be comfortably asked by the provider, patients with suicidal intent, with or without a plan will usually talk openly and will be much less likely to act on the feelings. Patients may develop a trust and rapport with the provider and are more likely to seek help in the future if faced with frustration, hopelessness, and despair or disturbing suicidal feelings. A suicide assessment includes a thorough mental status evaluation, a thorough history especially of psychiatric problems or suicide attempts, a current psychosocial assessment, a review of current and past alcohol and other drug use or abuse and an assessment of current medical status including current medications.
The provider can be more direct and assertive in asking about suicidal ideation in patients with patients with the following problems.
- Current symptoms of depression
- A psychiatric history of depression
- Anxiety
- Alcohol or substance abuse
- Organic mental disorders
- An experience with someone who committed suicide
- A history of several losses due to AIDS
- A limited or absent social support system
- The inability to work, financial worries
- Guilt or shame at having HIV infection
- Progression in the HIV illness
- A large drop in CD4+ count;
- Limited future medical treatment options
- Pain that is increasing or difficult to treat
- Mild neuro-cognitive impairment
- Hopelessness about feeling better.
If the provider believes the patient is open and honest about the suicidal thinking and has no immediate plan to act on the feelings then education, support, reassurance and the offer to be available in the future or to provide a future referral will usually suffice. Most patients are able to control the desire to act on immediate feelings, will promise to call someone if the suicidal intent recurs and will feel reassured that the provider is listening and taking them seriously.
The option for an extra visit or a referral to a mental health provider can be offered if there are factors that cause the provider to doubt the patient's promise or any factors will interfere with the patient's ability to control impulsive behavior like evidence of current alcoholism, substance abuse, or a history of prior attempts while intoxicated, a severe depression and a diagnosis of a borderline personality disorder the provider should then intervene in some way.
When appropriate, the provider can counsel the patient about reducing and stopping substance abuse or assess him for a medical intervention to treat the depression. It is most likely that the patient will need to be referred to a mental health or substance abuse counselor, provider or program. In the rare instance when a patient clearly intends to act on suicidal feelings and will not contract to seek help from a psychiatric or mental health provider, the provider with the patient should arrange for an emergency psychiatric assessment before allowing the patient to leave the office. Enlisting the help of a lover, spouse, close friend or family member may be a crucial and necessary step.
Although ethical and legal issues are beyond the scope of this discussion of anxiety and depression in the HIV-infected patient such matters as confidentiality, safety, informed consent, involuntary commitment to a psychiatric facility and the duty to warn others who may be at risk of harm by an HIV-infected patient need to be considered in all treatment interactions.
The provider can serve as a constant source of hope for the patient with AIDS or other HIV related illness. The provider can improve the quality of life, possibly add to longevity, reduce suicidal accidents if anxiety and depression are noted and can also advice appropriate treatment.
The possibility of substance abuse must be included in all assessments and treatment interventions due to the role of substance use and abuse in the transmission of HIV, both through direct routes of infection and through failure to use proper precaution and judgment in avoiding high-risk behavior when intoxicated. The patient will benefit from proper assessment and diagnosis of anxiety and depression, since he will feel relieved to be cared for and have painful symptoms treated. The provider may see a dramatic improvement in the patient and the care provider will help contributing greatly to an improved quality of life and enhanced compliance with the overall treatment plan.
An individual's HIV status whether it is positive or negative raises special concerns for individuals in primary relationships whether it is with spouses, partners or lovers. Providing initial and long-term emotional support, disclosing test results and practicing safe sex, in particular are complicated when added to the psychological context of a committed emotional and sexual relationship. While counselors are unable to fully explore their clients' relationships within single, time-limited sessions, it is important for them to consider the effects of antibody test results on the dynamics of relationships and the effects of relationships on their clients' capacities to cope with test results.
Among the support-related topics counselors may discuss are the range of emotions clients may experience, the impact of test results on current or future primary relationships, and how views of health care may affect this relationship.
Clients should evaluate and perhaps discuss with their partners the long-term effects of test results on their primary relationships. Some clients may tell counselors that they are uncertain about the future of their relationships, or that they want to end their relationships. In other cases, clients may not question the problems in their relationships, but counselors may identify in these relationships destructive qualities that may affect clients' responses to being infected. Counselors should remember that, in some cases, ending a relationship may be more beneficial than staying in one.
The counselors who do brief HIV counseling pre and post test cannot evaluate particular relationships but they can suggest that clients themselves consider the reasons they are in their relationships, the support they receive from their partners, and the support they expect to receive in light of their test results. In addition to general issues of emotional support, counselors should consider other ways for example, partners' attitudes toward medical intervention and history of substance use in which primary relationships affect clients. Clients may have already examined their beliefs about early medical intervention, experimental treatments, and alternative health care, but may not have considered how their partners' beliefs support or contradict their own. When informal discussion between partners does not resolve health care conflicts, formal counseling may be necessary.
When either their clients or partners have problems with substance use, they challenge the abilities of the relationship to offer support and they challenge counselors to evaluate the availability of emotional support. In many cases, substance users may be unwilling to discuss their infection with others, may be more susceptible to engaging in unsafe sexual activities, and are likely to withdraw emotionally from their partners. As always, counselors should be prepared to take a substance use history and have substance use counseling referrals available for clients in relationships where this is an issue.
Losing someone close through suicide can lead to a whole range of emotions including shock, sorrow, confusion, guilt, depression and even relief. The question 'Why did they take their life?' is often complex and may never be resolved. There is no easy answer - the most honest answer is we don't know. The factors that can result in a person suicide are varied and may include:
- current stresses and social pressures
- long-term problems associated with early abuse or trauma
- chronic pain
- physical disability
- having a lethal disease (cancer or HIV/AIDS)
Many people who are bereaved through suicide have feelings of guilt. They may feel they should have seen the suicide coming. Thoughts like these are common, 'If only I had done this' or 'If only I had not done that.' Parents may feel there was something wrong with their parenting. Brothers, sisters and partners may feel responsible particularly when there has been family stress or conflict. It is important for bereaved people to remember that they acted with the information they had at the time. With hindsight it is often easy to see signs of the person's distress and to criticize what was or was not done. Some people feel others blame them for the suicide, and some are blamed in a suicide note. These notes are usually written when the mind is disturbed and are unlikely to be a true expression of a person's thoughts and feelings about their family and friends.
Anger is a common reaction to suicide, even towards the person who took their life for the pain they caused others. It may be difficult to understand how the person who committed suicide was so intent on getting relief from their distress that they could not think of the hurt it would give others. It is common to experience feelings of inadequacy and loss of self-esteem. Sometimes people doubt their own values and judgment and find it difficult to make decisions and carry on with normal day to day tasks.
Some bereaved people may experience symptoms of post-traumatic stress, particularly if they discovered the body. Symptoms of depression may also be experienced. At times there may seem little meaning or purpose in life. These thoughts pass but if they are strong, prolonged, or of significant concern, it is important to seek help from a professional. Many people feel deserted, rejected, or even betrayed by the person who committed suicide and may be afraid to begin new relationships. For many reasons, friends may not be able to give the support that is needed. It can be a very lonely experience and a support group may help.
In some families a suicide occurs without any warning, whereas in others it is obvious the person who later suicides is suffering from a mental illness, and the death may not be unexpected. When this is the case, feelings of guilt and rejection may be less strong or even absent. After the suicide there may be feelings of relief that the person is released from their mental suffering. In situations where there were repeated threats or attempts at suicide, or in which the relationship with the deceased person was difficult, the family may experience relief that the suicide is over. The death may ease the tension and resolve the family problems so that life can settle down again.
Bereaved people may feel there were many things they would have liked to say to the person they lost, but were unable to because of the suddenness of the death. They may yearn to tell them they were loved, or to settle misunderstandings. It is common to feel sadness about the waste of a life, but it may help to recognize the person's contributions and influences during their life and to remember the time spent together.
Comprehensive care
While access to medicines is extremely important, the needs of people with HIV/AIDS extend far beyond drugs and health care. HIV/AIDS care strategies therefore need to be comprehensive. Comprehensive care and support rest on several pillars, and need to include voluntary HIV counseling and testing so that people can know their HIV status and deal effectively with it.
Comprehensive care must include psychological support to help people cope with the implications of having a life-threatening disease. It requires social support to help HIV-positive people; their families and their communities cope with the economic and social consequences of sickness and death due to AIDS.
The role of communities and community organizations especially those involving people living with HIV/AIDS-is especially important. Their work promotes social solidarity with HIV-affected individuals and their families, provides them with emotional support, and helps protect them against discrimination and violations of their rights. Often their activism helps prompt governments to devote more resources to the AIDS response and spurs companies to lower drug prices.
Comprehensive care and support depends upon improved health systems to boost access to comprehensive care and support services, including to the life-saving drugs people living with the virus need. In Africa, where two-thirds of the world's HIV-positive people live, health care systems were already weak and under-financed before the advent of AIDS. They are now buckling under the added strain of millions of new patients. In many places, facilities for diagnosis are inadequate and drug supplies are erratic, even for HIV-related conditions that are easy to diagnose and inexpensive to treat. Access will remain uneven and compromised until countries are able to afford AIDS-related drugs and diagnostic equipment and equip their health systems with the necessary infrastructure and adequately trained staff.
Many developing countries, however, struggle to allocate sufficient portions of their national budgets to the health sector. In Africa, governments are spending considerably more on servicing foreign debts than they spend on health and education. Increased debt relief and international development assistance can help countries invest more in poverty alleviation and AIDS prevention and care. In places unable to mobilize sufficient resources (health staff, infrastructure and funding), people living with HIV/AIDS must have access to basic pain relief and treatment for "simpler" opportunistic infections such as pneumonia and tuberculosis.
Care and treatment boosts prevention?and care and support for people living with HIV can help to protect the health of the public at large by making prevention more effective. The vast majority of people living with HIV do not know their HIV status. Greater use of voluntary counseling and HIV testing is an important key to encouraging changes in risky behavior and in turn to more effective prevention. The availability of HIV care and treatment is a source of hope and can be a powerful incentive for people to come forward and find out their HIV status.
People who know they are infected and have access to care can break through the denial about HIV that so often impedes prevention efforts. Care providers who look after HIV-positive people demonstrate to others that there is no need to fear being infected through everyday contact and thus help dispel misguided beliefs about HIV transmission.
Providing diagnosis and treatment for tuberculosis and sexually transmitted infections, common among people with HIV, also helps decrease the spread of infections among people who are HIV-negative. For these reasons, AIDS-related care is increasingly recognized as a good investment that directly benefits people with HIV/AIDS, while also boosting AIDS prevention.
Drug prices?
The prices of a number of important drugs for people living with HIV/AIDS, including a number of antiretroviral, have decreased dramatically in recent months. Price reductions have been achieved through a combination of efforts. They have included advocacy (to draw attention to the enormous impact of the epidemic and the treatment gap in developing countries), pressure from activists and civil society and competition from generic drug manufacturers. Also important have been differential or discounted prices from pharmaceutical companies for use exclusively in developing countries, as well as ventures like the Accelerating Access Initiative.
Some companies have also offered donations of drugs, for instance an antiretroviral to prevent mother-to-child transmission and an antifungal to treat certain opportunistic infections. Price has been an obstacle to expanding access to treatment but other important conditions for expanding access to drugs include mobilizing sustainable financing for bringing medicines and equipment to developing countries, and strengthening health facilities and personnel so that the drugs can be prescribed and used safely.
Proper prescription and monitoring of compliance with drug regimes is essential for the benefit of patients and for avoiding the serious potential of drug resistance.
Even with greatly reduced drug prices, drugs sometimes remain out of reach for the vast majority of people who need them. For example, current prices being offered in developing countries to treat one patient for a year are still much higher than the annual per capita of many of the hardest hit countries. In addition to advocating the pricing of HIV medicines in line with the purchasing power of countries, other avenues are being pursued. They include reducing or eliminating import duties and taxes; encouraging patent-holder companies to grant voluntary licenses that allow other manufacturers to produce their products at lower cost; and the use of safeguards in international trade agreements that can help governments expand access to medicines and protect public health. New funding mechanisms are also being devised to channel more private and public sector resources towards care and support programs.
LEGAL AND ETHICAL ISSUES
It is extremely important that the patient's privacy or confidentiality is protected. The patient's HIV status is to be considered the most confidential of information and must be protected at all times. Counseling must be conducted in private where the conversation between the participant and counselor cannot be overheard. All record forms, even those identified only with a participant number, must be kept in locked file drawers at all times when they are not in use.
Discussions between counselors and counselor supervisors, including case discussions in supervision, will protect the privacy of participants by not referring to the participant by name. A patient's confidentiality should also be protected in conversations between counselors and other project staff. Breeches in participant confidentiality may be grounds for dismissal of counselors and other staff.
The HIV epidemic poses two powerful, and conflicting, legal and ethical obligations. The first obligation is to respect the privacy of persons with HIV infection. The threat of stigma and discrimination has had a profound impact on the extent to which persons with HIV/AIDS demand legal protections of confidentiality. The Hippocratic Oath admonishes physicians "to tell no secret" obtained in the course of the therapeutic relationship.
The second obligation is the duty to inform persons who may be exposed to HIV. The partner claims the right to know if their sexual or needle-sharing partners are infected with HIV. People have a legitimate ethical claim that they not be exposed to significant danger without their knowledge and consent.
Nearly two decades ago the California Supreme Court, in the landmark case of Tarasoff vs the Regents of California, found that physicians have a legal duty to inform known third parties of significant risks posed by their patients. An international survey of AIDS legislation undertaken for the World Health Organization found that 33 countries had specific confidentiality provisions related to HIV or AIDS. Many of these countries had very brief reported provisions for confidentiality of information contained in reports of communicable diseases. Few countries had enacted legislation specifying a duty to inform third party.
Compelling ethical reasons exists for protecting the privacy of a person with HIV infection. An important justification for privacy resides in the principle of respect for autonomy. To respect the privacy of people with HIV/AIDS is to respect their wishes not be observed or to have intimate information about themselves made available to others. Privacy also enhances the development of trust in the physician. One of the defining characteristics of the doctor/patient relationship involves the sharing - freely given - of private information. Failure to respect the confidentiality of patients drives patients away from HIV testing, counseling, and treatment, and discourages patients from confiding in their physicians. Healthcare facilities that treat persons with HIV argue fiercely that compelling physicians to disclose HIV infection to sexual or needle-sharing partners would mean they would lose the trust of their clients. Ultimately, they argue, a "duty to warn" would seriously undermine public health efforts.
Unwanted disclosure of intimate health information can cause patients a great deal of emotional, social, and economic harm. Stigmatization may be a consequence of such disclosure, particularly when HIV infection reveals the person's sexual orientation or use of illegal drugs. Disclosure can cause embarrassment, social isolation, and loss of self-esteem. A breach of privacy can result in loss of employment or employability, insurance or insurability or housing.
Many developed countries spell out legal and ethical duties to protect the confidentiality of persons with HIV/AIDS. For example, virtually all jurisdictions in the United States have HIV-specific confidentiality laws. The World Health Organization and the Council of Europe both emphasize that HIV testing and screening should be undertaken only with the person's informed consent and consistent with the principles or confidentiality.
Meanwhile, political bodies in the United States and elsewhere are clamoring for a right to know a person's HIV status. Imagine a variety of circumstances where the right to know is asserted: Should a person who has sex or shares injection equipment with an intravenous drug user be informed? Should a surgeon, obstetrician, or emergency room nurse who risks exposure to a patient's blood be informed? Should a police officer, prison guard, or other emergency worker be informed, particularly if he or she has sustained a needle-stick injury? Should a person who has been sexually assaulted be informed of the accuser's HIV status?
Many confidentiality statutes in the United States have been amended to grant a right to know for all these groups. Some statutes have so many exceptions to the principle of confidentiality that the exceptions swallow the rule. Healthcare professionals who support a right to know should consider another perspective like many patients claim the right to know if their healthcare workers are infected with HIV.
The Centers for Disease Control prevention guidelines, and many state statutes and court decisions, give patients the right to know if their physicians are HIV-positive, particularly if they are engaged in invasive, "exposure-prone" procedures.
Is there any principled way to reconcile the dual obligations of the right to privacy and the right to know? If one takes the ethical and legal right to privacy seriously, then it ought to yield only where absolutely necessary to avert a serious harm. The World Health Organization and the Council of Europe both recognize the need to inform persons at serious risk of HIV infection in "extreme cases." Accordingly, the right to confidentiality ought to be near absolute in cases where the risk of contracting HIV is remote. Thus, claims by healthcare professionals, emergency workers, prison guards, and others for this sensitive information ought to be denied if the patient refuses to consent to the disclosure.
The strongest claim to a right to know exists where there is an ongoing sexual or needle-sharing relationship. In such cases, the law would give healthcare professionals a power, not a duty to disclose if in their judgment it is necessary to avert a significant risk of transmission. Healthcare professionals should first counsel the patient to make the disclosure him or herself. Framing the law in this way permits healthcare professionals to exercise their judgment and decide whether maintenance of the confidence and trust of patients overrides the rights of their partners. If the healthcare professional exercises a diligent good faith judgment, he or she ought not to risk legal liability in a case where society itself is unable to resolve this powerful ethical and legal dilemma.
What's legal, what's not? ?
It is important to realize what is protected under the law and what is not. Most of the California laws regarding confidentiality of a person's HIV status were written before we knew as much about HIV and before a lot of the current tests and treatments were available. Therefore, the laws prohibit the unauthorized release of HIV test results. In contrast, the laws do not cover the release of viral load tests, what medications you are taking, or even an AIDS diagnosis. All of these things, of course, essentially give away the fact that you are HIV-positive.
If you tested at an anonymous test site, you are the only person who knows that you are HIV-positive. If you tested in a doctor's office, a clinic or another confidential test site, your doctor and possibly some of the office personnel know you are HIV-positive. If the HIV test was submitted to your insurance carrier for payment, your insurance carrier may now know that you are HIV-positive. The insurance company will report this information to the Medical Information Bureau (MIB) in Massachusetts, which is something like a credit reporting agency for health care information.
Already, your HIV status may have been disseminated further than you imagined and without you telling a soul. Once the MIB has this information, you may have difficulty obtaining life insurance, disability insurance, or health insurance coverage.
Limited disclosure
There may be several points in your life when you will need to reveal that you are HIV-positive in order to get the assistance you need.
When you join an AIDS-service organization, such as AIDS Project Los Angeles, you must present a copy of your diagnosis in order to become enrolled as a client. AIDS-service organizations will keep this information confidential unless you give permission to the contrary.
If your case manager is to help you obtain housing, public benefits or many other types of necessary services, he or she may need to share your HIV status to someone at another agency. Before this can be done, however, your case manager or other advocate must get your specific permission in writing.
Generally, your doctor may reveal your HIV status to another of your health care providers or people in your chain of treatment without your written permission. Currently, doctors in California must report AIDS diagnoses to the state Department of Health, but there is no requirement for a doctor to report a positive HIV test to anyone, including your sexual partner. There is possible legislation coming up in the near future which would require doctors to report HIV-positive results to the state.
Confidentiality in the workplace
Many people with HIV are in the process of returning to work or have continued to work despite HIV. For most people, there is absolutely no need to reveal your HIV status at work. If you are interviewing for a job, you have no need to reveal that you are HIV-positive or have AIDS. If a person is asked about this on a job application or during an interview, this is probably illegal discrimination, and he should consult an attorney about your rights.
A person's HIV status should have nothing to do with his qualifications to perform a job. The only time that an HIV-positive person may run into legal trouble on the job would be if you are a health care worker who performs invasive procedures on patients.
If a person is having health problems which may affect your work, he may wish to reveal to a supervisor or human resources person that you have a disabling condition so that your employer is on notice that you may be a disabled person who is protected by law from discrimination and possibly entitled to reasonable accommodations on the job so that you may continue working.
Coping with HIV?- speaking to your client
Preserving ones emotional health with HIV is a task that may seem hard but can be done. Preservation tactics - as some HIV + people call them - allow them to function in their daily routine to endure the pain and loss, on choosing how to live and to find pleasure in the process. Mental Health Professionals have no firm rules for maintaining emotional wellness.
Preservation tactics fall into two categories.
First you have your support system and the second is to take control of your life.
To people who are infected with HIV, a good support system is as important to their mind as medications are to their bodies. When people are feeling ill or depressed they have a greater need for people. Even when they are alone they know that they have people who care about them and without their support they might as well give up. This is not true for all people. Some people are more private than others. There are also times when people need to be alone and to rely on their own resources.
A self-care plan should involve making any lifestyle changes you need to make to promote overall health and well-being: making sure you have a balanced diet, plenty of rest, and regular exercise and relaxation. Avoid doing the sorts of things that put a strain on your immune system -- acquiring other sexually transmitted diseases, for example, or using recreational drugs. If you're hooked on drugs, get yourself into a detoxification or methadone program. If you only consider yourself a "recreational" drug user, consider doing something else for recreation. Alcohol, heroin, cocaine, and other chemicals inflict their own forms of havoc, even among the healthy, and may speed up the progression to AIDS. If you haven't done it already, make sobriety a cornerstone of your healthy-living, HIV-survival strategy. Your immune system is balanced too precariously to take any unnecessary tilting.
Finding out you've been exposed to HIV is not easy. They take the news hard and die a little every day. For others, though, it's something else altogether. They take the news as an ultimate challenge to get busy with their lives and the lives of the people they care about -- in spite of the way they may feel.
Interestingly, it's this group that contains virtually all of the long-term AIDS survivors identified thus far. It's a special group of people, united by a common theme: That life is more important than a disease that can only take life away. They know a secret that's as old as time and as timely as tomorrow's headlines: That living without purpose is giving up. And with AIDS, giving up can be a real killer.
The critical first step in any plan for living with HIV is to find a knowledgeable doctor or clinic that you feel comfortable with and confidence in. Start with your family doctor, if you have one, or contact an AIDS helpline for referral to a specialist in your area. After that, get serious about getting on top of your life and your infection. HIV is not an automatic death sentence. Thousands of people have lived with HIV for years, and some say they didn't really start living until they got their test results back and decided to begin right then and there. What they also started doing, then and there -- or shortly after -- was to take care of themselves.
Diet plays a main role in any HIV survival plan. That's because people with AIDS are vulnerable to food-borne micro-organisms. And food-related infections can be life-threatening. According to the U.S. Centers for Disease Control, people with AIDS are 20 times more likely to contract salmonella, a contaminant of under-cooked poultry and eggs, and 200-300 times more likely to develop listeria infections from poultry, meat, and raw fish. Since animal foods -- including cheese, milk, and eggs -- are a main source of food infections, experts offer the following advice:
Eat meats well-done. Use a thermometer to insure that poultry, fish, and other meats are well-done, and pre-cook grilled meats. Avoid sushi, shrimp, and other raw meats.
Cook eggs thoroughly. Avoid dishes containing raw eggs, including Hollandaise sauce, egg nog, and Caesar salad.
Drink pasteurized milk. Raw, unpasteurized dairy products can also be a problem. Better keep your distance. Clean utensils after handling raw meat. Infectious organisms can spread to other foods and dishes, and to uncovered cuts or sores on the hands. Also, you may want to consider soy and vegetable protein substitutes for meat, milk, and cheese that are available at health food and grocery stores. ??
Notification | Partner notification is most effective when medical professionals gain the trust of those whose partners are to be contacted; requiring the provision of a name is likely to discourage such trust. Currently, California provides partner notification services without HIV name reporting. This approach makes sense because the name of the "index case" is not needed in order to elicit the names of an individual's partners. Furthermore, people could be more willing to provide their partners' names if they know their own names are not documented in any way.
Assure that a private, safe and confidential discussion can occur. Remain sensitive to special needs and considerations of especially vulnerable individuals (e.g., minors, pregnant women, immigrants, seniors, individuals with disabilities, individuals who are unstably housed, individuals in residential or institutional settings, substance users in and out of treatment, and persons who are gay, lesbian, trans-gender or bisexual). In no cases are names of HIV-infected individuals provided to partners, or others, by public health staff. Respond to questions about the process. Review the benefits of partner notification. Request that the individual consider partner notification.
DOMESTIC VIOLENCE
Assess domestic violence risk to the HIV-infected individual. Screen for risk on a partner-by-partner basis for any partners voluntarily identified and for any partners who are already known to the provider like a spouse.
Note: The name or other information about the infected individual is never disclosed during partner notification, use simple screening questions. Raise the issue of domestic violence risk associated with notifying partners. Keep questions simple and specific. Avoid using the phrases "domestic violence" and "victim".
Suggested script: "There are some routine questions that I ask all my clients because some of them are in relationships where they are afraid their partners may hurt them." Provide assurances that: Any information provided will be kept strictly confidential and be used only to help make decisions about whether partner notification should proceed and to offer referrals for domestic violence services.
Suggested script: "What response would you anticipate from this partner if he/she were notified of possible exposure to HIV?" Follow-up questions can be used to explore any indication of a history of domestic violence or anticipated consequences of HIV partner notification. "Have you ever felt afraid of your partner or ex-partner? "Has a partner or ex-partner currently or ever: Pushed, grabbed, slapped, choked or kicked you? Forced you to have sex or made you do sexual things you didn't want to? Threatened to hurt you, your children or someone close to you? Stalked, followed or monitored you? "Based on what you've just told me, do you think that the notification of this partner will have a severe negative effect on your physical health and safety, or that of your children or someone close to you?" "Are you afraid of what might happen to you or someone close to you, for example your children, if this partner were notified?" "Have you ever been afraid about harming your partner or someone close to you?"
Rely on the perception, if any, of the HIV-infected individual as to whether or not notification could result in domestic violence. Characterize the type of domestic violence like physical, sexual, economic, emotional, social and psychological if any.
Explore the severity of anticipated domestic violence to the HIV-infected individual. Assess any domestic violence risks to each partner. Elicit the infected individual's knowledge of the partner's current situation, if it is known, when the partner is other than the current partner. "If you know whether our notifying a previous partner of their possible HIV exposure might put them at risk of being harmed by, or harming, someone they are currently involved with, it is important that you tell us about it."
Explore severity of anticipated domestic violence outcomes to the partner/contact. Move forward with action plan for HIV partner notification Review options and work with the client to identify the optimal partner notification strategy for each partner. Provide the HIV-infected individual for whom notification of a specific partner is deferred based on a risk of severe domestic violence with information enabling them to contact the Department of Health Notification Assistance Program at any point in the future. Ask the HIV-infected individual if they are willing to sign a release form for domestic violence information to enable future follow-up to determine if the domestic violence risk has been alleviated. Ask the HIV-infected individual whether or not he/she would consent to follow-up contact by public health staff for purposes of ascertaining the continued deferral of partner notification and how such contact can most safely be made.
Routinely, throughout the provision of medical care and support services, remind individuals that HIV partner notification and assistance services and referrals to domestic violence service providers remain available and encourage their use throughout the continuum of care. This should be incorporated into ongoing discussion to reduce behavior that may transmit HIV to partners.
Refer HIV-infected individuals to HIV case management services which assure ongoing discussion of HIV partner notification services, including those cases in which risk of domestic violence which may have a severe negative effect on the physical health and safety of the HIV-infected individual, his/her children, someone who is close to them, or to his or her contact(s). Help ensure that HIV partner notification assistance services are accessed in the event that the previously identified domestic violence concerns are resolved.
Counter Transference
One of the most significant issues for each psychotherapist is how to make the most disciplined use of self while remaining empathetically connected to the patient. The literature is full of discussions about how not to allow the therapist's counter transference to harm the treatment. Issues of counter transference become more complicated when therapists treat patients with whom they may easily identify. Since the onset of gay and lesbian affirmative psychotherapy the professional literature has continued to address the impact on therapy when the gay or lesbian patient knows that his or her therapist is also lesbian or gay. When both therapist and patient are dealing with virtually identical life crises at the same time the potential for therapeutic mistakes is enormous. Extraordinarily skilled therapeutic interaction is necessary between therapist and patient to avert these mistakes.
While the literature contains a few articles about the illness or imminent death of the therapist (Rosner, 1986), literature on the therapist and patient sharing the same life-threatening condition appears to be just emerging. There are certain unique factors in this situation that may prove troublesome for the therapist and detrimental to the treatment he provides if left unaddressed. For example, how does the therapist cope with the constant reminder of his own health status and impending death when his practice is full of patients facing identical issues? The therapist's access to and utilization of clinical supervision, consultation and psychotherapy and his ability to remain self-examining during his personal crisis will largely determine whether or not he is able to continue to provide good treatment so stressful a period.
The therapist's level of acceptance of his own condition and possible death will determine how emotionally available he is to work with patients needing to discuss their struggles and feelings about the same illness. A therapist who is in a great deal of denial about his own physical condition will most likely not be able to begin discussions with patients who need help initiating discussions about their situations. If the therapist is in denial about his own illness he is certain to re-enforce any denial that his patients may be experiencing, and will not be able to confront the patient's denial when it would be best to do so.
The question, "How much time do I have left before I get sick or before I die?" has a powerful influence on both the therapist and the patient. The therapist has to be able to assess if and when it is appropriate to bring the patient's thoughts and feelings about this into the open for exploration. The patient with HIV enters therapy wanting to be "healed" emotionally before he becomes too debilitated to do this difficult psychic work. The therapist feels the pressure of limited time to accomplish the healing before he, himself, gets too ill to continue working. It takes great skill to acknowledge the therapist's illness without intruding into the patient's treatment.
The therapist's experience of death and dying can shape his work with patients susceptible to the same illness as he. Does the therapist believe that death is the end of it all, or does he envision some kind of life following death? If the therapist is not able to understand his own beliefs and feelings surrounding death, he will not be able to initiate discussions about this with patients. A therapist's inability to discuss these issues creates a sense of secrecy or shame in the patient who may not have anyone else with whom to discuss these feelings.
One of the interesting questions is whether the counter transference issues that arise from being HIV positive and doing this work are in fact different than those every therapist faces during the course of his or her daily work. There is the potential to view the feelings and concerns of many of these patients as having an urgency that must be responded to immediately. Any tendencies the therapist has towards grandiosity can be highlighted by the apparent urgency of the impending mortality of both the patient and therapist. Even if the urgency does stem from the patient, is it good treatment to respond to and thus validate a patient's urgency rather than explore it? Does the fact that the issues being explored, defended against, denied or acted out are connected to the patient's and therapist's responses to illness and mortality justify conducting the treatment any differently than if the presenting problem were different?
The therapist needs to know from his own experience what the patient is experiencing. Yet the potential for the therapist to make clinical mistakes is enormous when he or she is simultaneously experiencing many of the identical situations and feelings as the patient. I have learned that just because my patients are experiencing very similar situations to the ones that I am living through, I cannot assume that they will or should react in the same ways that I do.
Terminal illness usually causes individuals to regress, at least in some areas of their lives. Thus the therapist who is dying, or living with a life threatening illness has to work with patients who are regressing. Perhaps the patients' regression mirrors the therapist's own struggles with regression. Sometimes a patient's regression will serve as permission for the therapist to regress in a similar fashion.
When a person begins therapy he or she does so expecting to continue the process and relationship with the therapist until the goals for therapy have been met. In the case when the patient has a life threatening illness he must have a willingness to embark upon the therapeutic journey with the knowledge that this process could be abruptly terminated by his own death. The therapist with a life threatening illness has the obligation to evaluate realistically whether or not the issues a new patient is presenting can be worked on effectively within the uncertain amount of time he has left. Correspondingly, the therapist must be able to know when he is reaching the point of not being able to continue to practice. Thus the therapist with a terminal illness must be able to distinguish between his own narcissistic needs to deny the severity of his own condition, and his needs to continue working, and what is in the best interest of his patients. Knowing when to let go of one's career, patients and the identity that have been so significant a part of one's life, and knowing when to refer patients to a respected colleague is difficult and yet crucial. It is a clear indication of both the personal and professional development of the therapist and of the quality of the professional assistance he is receiving. It is improper for the therapist to place the decision of whether or not to continue working together in the hands of patients. For many patients it may be impossible to place their own needs for ongoing treatment above the needs of the "helpless, dying, and beloved" therapist who has helped them so much.
A common feeling among counselors of HIV positive clients is frustration over the tremendous ambiguity that must be faced in the work about HIV disease itself and about the appropriate therapeutic approaches to take. This ambiguity that client is facing can sometimes increase the empathy felt for the client. For the counselor who has particular difficulty accepting ambiguity, the risk of inhibiting the client's freedom to recognize and experience the uncertainty of the situation must be carefully watched. Often clients resist the painful awareness of this uncertainty by looking for clear-cut, instant answers. The counselor may, in turn, feel pulled to respond to this pressure by offering "quick fix" solutions. Related to this is the pressure many counselors feel to become experts on HIV as a way to be better prepared to provide answers whenever the client expresses confusion. This can lead to spending considerable time and energy attempting to stay current about research and treatment issues. The overwhelming amount of information available places such a counselor at risk of becoming seriously overextended, and the counselor must be willing to accept his or her own limitations, including the limits of one's expertise. Often a critical element of being informed about HIV involves knowing which people or organizations to refer clients to for further information.
Counselors who are in so-called "high-risk groups" themselves face special counter transference issues. The gay counselor, for instance, is likely to have been directly affected in his personal life by the epidemic, thereby increasing the likelihood of a strong identification with the client's situation. This can both enhance and detract from the counseling relationship. It can serve to increase the capacity for empathy and the degree to which the client as a potentially understanding helping figure perceives the counselor. It can also lead to the counselor's becoming over-invested in the work, and eventually unable to continue the work because of emotional strain. The antibody status of the counselor introduces another level of complexity. It is not uncommon for a HIV negative counselor, whether gay or straight, to experience feelings of "survivor guilt." The client's anger and resentment at those who do not share the burden of being HIV infected may fuel these feelings.
The antibody status of the counselor has implications in terms of perceived capacity for empathy and level of personal investment, which are similar to those described above in the discussion about counselors' personal risk. An additional issue the counselor must consider is whether, and under which circumstances, to disclose his antibody status to clients who ask. Finally, it is important that counselors be aware of the personal meanings attached to HIV as a result of their own past experiences, so as to decrease the likelihood of imposing these meanings on clients. For example, counselors who have friends recently deceased or ill with HIV disease may attribute more significance to a client's recent HIV positive test result than the client is prepared to hear. It is also important that counselors carefully examine their own attitudes and assumptions regarding such issues as homosexuality, IV drug use, and death and dying, so as to minimize the chances of colluding unconsciously with any self-ridicule their clients may feel in terms of these issues.
BURNOUT
It is important to acknowledge that HIV counseling can be stressful and to encourage counselors to be aware of signs that they are overworking or not coping well. Counselors must also be aware that they are not expected to help clients deal with all of their needs. Clients may be referred to referral sources in the community as needed; it is important that counselors be familiar with these resources. It is important for counselors to ask for help when they need help, use supervision to discuss their concerns about the work, be aware of their own biases and stereotypes, learn to be assertive and to set limits with clients, and to continue learning new skills and requesting feedback on their work with their clients.
Not all stresses and strains come from difficult clients. More often than you prefer, you will feel utterly helpless. You will see a client in pain, want so badly to help, and yet feel that what you have to offer is not nearly enough. The abused child you are offering comfort to is about to go back to the abusing home by court order. The grieving widow you are talking to sees no other way out except suicide. The AIDS client you are working with screams out the indignity and injustice of it all, and then looks to you for solace. How will you handle all of this? How will you metabolize the pain of others without driving yourself crazy? How will you stay focused on that which is within your power to do something about?
Conclusion
While counselors should remember that many issues may need to be addressed further, and should be prepared to offer appropriate referrals to individual and group therapy, counselors can nevertheless offer insights to their clients. The counselors have to be patient and provide information but remember not to push their viewpoints too strongly.
HIV and Older People There is growing evidence that older people are increasingly being infected by HIV/AIDS, but available data does not often explain how the epidemic is affecting this population group. For example, although 83% of all AIDS deaths in the world have occurred in sub-Saharan Africa, very little is known about the epidemiology of HIV/AIDS among older people in this region. In the United States, 10% of all reported AIDS cases occur among people over the age of 50, with a quarter of these over 60. In Western Europe, nearly 10% of new infections declared between January 1997 and mid-June 2000 were among the over-50 group, with these figures dropping at 4.3% in Central Europe and 0.7% in Eastern Europe. Older women appear to have higher incidence than older men, and during a recent five-year period the number of new cases in this group increased by 40%. More than half of the infected over 50 are of African American and Hispanic origin, indicating greater risks among minority groups. However, available figures do not reflect at what age this population group was infected, and many of those over 50 were probably infected when they were younger and may have had the virus for years before being tested. By the time they are diagnosed, their infection may be in its most advanced stages.
Risk and vulnerability of older people
The dominant risk factor among the 50+ age group is the same as for other age groups - heterosexual sex. Specific risk behaviors, such as unprotected sex, multiple sexual partners, sexually transmitted infections, and substance abuse are also present in this age group.
According to the US-based Centers for Disease Control and Prevention (CDC), age accelerates the progress of HIV to AIDS and blunts CD4 cell response to antiretroviral therapy. Age-related conditions, such as osteoporosis, increase the risk of severe complications.
Older people tend to view condoms primarily as a contraceptive measure, and women who no longer fear unwanted pregnancy may not insist on their use. Women also undergo physical changes with age that affect their vulnerability to HIV. In the post-menopausal stage, their vaginal walls are thinner and lubrication is often reduced. Many doctors believe older women are more vulnerable to vaginal trauma during intercourse, and thus at greater risk of contracting HIV.
Early symptoms of HIV infection - fatigue, poor memory, shortness of breath, sleeplessness, weight loss - may be mistaken for signs of aging, thus preventing those infected from seeking early medical interventions that would help them stay healthy and avert HIV transmission risk.
Health providers often fall into the trap of age stereotypes, which can be a problem in prevention and diagnosis. Health care workers are less likely to ask older patients about their sexual behavior and do not provide the prevention information they would routinely offer younger patients. Nor do prevention education programs target older people. Social barriers to discussions on sexuality become even stronger with age, because of an increasing denial of sexual needs. Consequently, there are few effective strategies for this population group. Older people also have less knowledge about the basic facts on HIV/AIDS and its prevention. In a CDC study of a hot-line service, only 6% of callers were from the older population, and nearly 50% wanted more information about HIV/AIDS risks.
In addition, coping mechanisms among older people are weaker, as they are more prone to depression and less inclined to join support groups.
Impact of HIV/AIDS on the elderly
The advent of HIV or AIDS imposes caring responsibilities upon older people, which they might not otherwise have to contend with. AIDS causes changes in family structures due to the death of young parents. This in turn often leaves grandparents as the sole authority figures in a family, with the added burden of providing economic support and psycho-social care to orphaned children. In many societies, the opposite is supposed to happen. There is also inadequate support for grandparents and other older family members and friends in many societies. Governments do not usually provide economic support or subsidies for grandparents forced to care for sick or orphaned children. In addition, there is a significant lack of legislation on care for the elderly, such as pensions and other forms of assistance for grandparents, adding to the broader social burden carried by societies already hard hit by an AIDS epidemic.
Actions to be taken
A number of strategies and behaviors can be adopted to help mitigate the risk of HIV to older people and the impact of HIV/AIDS on those already infected:
Reducing stigma surrounding the sexual needs of older people to enable them to discuss these issues more easily with their health providers and families.
Integrating HIV programming into services for the aging, including the integration of secondary prevention education (prevention among HIV-positive people) into specialized care services. Educating HIV service providers regarding aging and the provision of age-sensitive services. Identifying areas of research specifically looking into the interactions between age and HIV. Involving older persons in research on prevention and care.
Discrimination
All over the world, the epidemics of HIV and AIDS are having a profound impact, bringing out the best and the worst in people. They trigger the best when individuals group together in solidarity to combat government, community and individual denial, and to offer support and care to people living with HIV and AIDS. They bring out the worst when individuals are stigmatized and ostracized by their loved ones, their family and their communities, and discriminated against individually as well as institutionally. The nature of stigma and discrimination
The "undesirable differences" and "spoiled identities" that HIV/AIDS-related stigma causes do not naturally exist, they are created by individuals and by communities. Stigmatization describes this process of devaluation.
HIV/AIDS-related stigma builds upon, and reinforces, existing prejudices. It also plays into, and strengthens, existing social inequalities - especially those of gender, sexuality and race. HIV/AIDS-related stigma and discrimination play a key role in producing and reproducing relations of power and control. They cause some groups to be devalued and others to feel that they are superior. Ultimately, stigma creates and is reinforced by social inequality.
Stigma, discrimination and human rights
Prejudiced and stigmatizing thoughts frequently lead people to do (or not do) something that denies services or entitlements to another person. For example, they may prevent health services being used by a person living with HIV/AIDS, or terminate their employment on the grounds of their HIV status. This is discrimination.
Discrimination occurs when a distinction is made against a person that results in their being treated unfairly and unjustly on the basis of their belonging, or being perceived to belong, to a particular group.
Due to stigma and HIV/AIDS-related discrimination, the rights of people living with HIV/AIDS and their families are frequently violated simply because they are known, or presumed, to have HIV/AIDS. This violation of rights hinders the response and increases the negative impact of the epidemic.
Freedom from discrimination is a fundamental human right founded on principles of natural justice that are universal and perpetual. The basic characteristics of human rights are that they inhere in individuals because they are human, and that they apply to people everywhere.
The Principle of Non-discrimination is central to human rights thinking and practices. All international human rights instruments prohibit discrimination based race, color, sex, language, religion, political or other opinion, national, ethnic or social origin, property, disability, fortune, birth or other status.
Discrimination against people living with HIV/AIDS, or those thought to be infected, is therefore a clear violation of their human rights.
The forms of stigma and discrimination faced by people with HIV/AIDS are multiple and complex. Individuals tend to not only be stigmatized and discriminated against because of their HIV status, but also because of what this connotes. Recent UNAIDS-sponsored research in India and Uganda shows that women with HIV/AIDS may be doubly stigmatized - both as 'women' and as 'people living with HIV/AIDS' when their sero-positivity becomes known.
States have obligations to respect protect and fulfill human rights. In relation to stigma and discrimination, for example, the obligation to respect requires States not to directly or indirectly discriminate in law, policy or practice. The obligation to protect requires States to take measures that prevent third parties from discriminating, and the obligation to fulfill requires States to adopt appropriate legislative, budgetary, judicial, promotional and other measures to ensure that strategies, policies and programs are developed that address the discrimination, and ensure that compensation is paid to those who suffer discrimination.
Action to address stigma and discrimination
The human rights framework provides access to existing procedural, institutional and other monitoring mechanisms for enforcing the rights of people living with HIV and AIDS, and for countering and redressing discriminatory action.
Appropriate reporting and enforcement mechanisms (ranging from legal aid services to hot-lines for reporting acts of discrimination and violence) have provided powerful and rapid means of mitigating the worst affects of HIV/AIDS-related stigmatization and discrimination.
Experience has shown that two complementary kinds of alleviation strategies are necessary to address stigma and discrimination: (I) strategies that prevent stigma or prejudicial thoughts being formed and (II) strategies that address or redress the situation when stigma persists and is acted upon through discriminatory action, leading to negative consequences or the denial of entitlements or services.
Ultimately, it is at the community and national levels that HIV/AIDS-related stigma and discrimination are most effectively combated. Communities and community leaders must advocate for inclusiveness and equality irrespective of HIV status.
EXERCISES FOR THE COUNSELOR
EXERCISE #1 The purpose of this exercise is to practice listening and paraphrasing opinions, even if these opinions are different from your own. If you have access to a colleague you can share with each other opinions about the following controversial statements and why you hold these opinions. The role of the listener in this exercise is to listen to the other counselor's opinions without speaking, and then to paraphrase what was said. Reassure counselors that they will not be required to share their personal opinions with the entire group. Each counselor spends 15 minutes in the role of listener and 15 minutes in the role of sharing his or her opinions. Consider these statements for discussion:
- It is acceptable for men to have many sexual partners.
- It is acceptable for women to have many sexual partners.
- A woman who tests positive for HIV should not have any more children.
- Parents should not allow their daughters as much sexual freedom as they allow their sons.
- Children should be taught about sexually transmitted diseases and AIDS in school.
- It is acceptable to have sex for pleasure only.
- It is acceptable for a man to have extramarital sex.
- It is acceptable for a women to have extramarital sex.
- People with HIV should not have sex.
- Parents should teach their teenage children how to use condoms.
- If a wife wants to use condoms for HIV prevention, but her husband does not want to use condoms, the wife has a right to refuse sex with her husband.
- It is acceptable for men to have sex with other men.
- It is acceptable for parents to encourage their sons to have sex before they are married.
- Consider these questions for discussion:
- What was your experience of sharing your opinions with your partner?
- What was your experience of hearing and paraphrasing opinions that differ from your own?
- Did you become aware of any of your own values and attitudes that may affect your HIV counseling?
EXERCISE #2 HIV counseling requires explicit discussion of sexual behavior. In this exercise the counselor makes a list all of the various sexual behaviors that are practiced in this country. These may be sexual behaviors the counselor knows of personally or behaviors that they have read about or heard about from clients in the past. List all behaviors on a piece of paper. When you have exhausted your knowledge of sexual behaviors, ask yourself the following questions.
- What was it like for you to hear and say these words?
- Were you aware of any reactions?
- Do you know what all of these words mean?
- Would you be willing to ask what these words mean if you did not know?
- How likely is it that each of these behaviors would transmit HIV?
AVERT is an international AIDS charity
AIDS & HIV information from AVERT.org
Sources:
Morbidity and Mortality Weekly Report (2008, 3rd October), 'HIV Prevalence Estimates - United States, 2006 Centers for Disease Control and Prevention', US Centers for Disease Control and Prevention
At the end of 2007, an estimated 455,636 people were living with AIDS in America (50 states plus the District of Columbia). The highest numbers were in California, Florida, New York State and Texas. Among the 50 states, the lowest numbers were in North Dakota, South Dakota, Montana and Wyoming.
In 2007, the District of Columbia reported a far higher rate of AIDS diagnoses than any other area (though the rate in the wider Washington area was surpassed by other metropolitan areas). A 2009 local government report found the capital city had an HIV prevalence rate of 3%, including figures as high as 7.2% for 40-49 year olds, and 6.5% for black males.1
AIDS diagnosis rates in New York State, Florida and Maryland were much higher than the national average of 12.7 cases per 100,000 population per year.
In the 39 areas that have a history of confidential name-based HIV reporting, an estimated 263,936 people were living with HIV infection that had not progressed to AIDS. This number only includes people whose infection has been diagnosed and reported through the confidential name-based system.
According to the number of AIDS cases reported to the CDC, the 34 states with a history of confidential name-based HIV reporting represent approximately 66% of the US epidemic. For this reason, and because many HIV infections remain undiagnosed (or anonymously diagnosed and unreported) within the 39 areas, the total number of people living with HIV (and not AIDS) in the USA must be much higher.
The CDC estimates that around 1.1 million adults and adolescents are living with HIV in the USA, including those not yet diagnosed, and including those who have already progressed to AIDS.2
Estimated numbers of persons living with HIV (not AIDS) or with AIDS at the end of 2007, and reported AIDS case rates, by state and dependent area
| Area of residence | Living with HIV (not AIDS) |
Living with AIDS | AIDS cases per 100,000 population in 2007 |
| Alabama | 5,740 | 4,046 | 8.4 |
| Alaska | 289 | 343 | 4.7 |
| Arizona | 6,226 | 5,110 | 9.2 |
| Arkansas | 2,425 | 2,286 | 6.9 |
| California | - | 65,582 | 13.5 |
| Colorado | 6,067 | 4,286 | 7.3 |
| Connecticut | - | 6,930 | 15.1 |
| Delaware | - | 1,844 | 19.8 |
| District of Columbia | - | 8,895 | 148.1 |
| Florida | 39,686 | 48,059 | 21.7 |
| Georgia | - | 18,011 | 19.7 |
| Hawaii | - | 1,316 | 6.1 |
| Idaho | 409 | 318 | 1.5 |
| Illinois | - | 17,075 | 10.5 |
| Indiana | 3,939 | 4,019 | 5.2 |
| Iowa | 644 | 917 | 2.5 |
| Kansas | 1,370 | 1,390 | 4.8 |
| Kentucky | - | 2,826 | 6.9 |
| Louisiana | 7,738 | 8,491 | 20.5 |
| Maine | - | 537 | 3.5 |
| Maryland | - | 15,682 | 24.8 |
| Massachusetts | - | 9,181 | 9.5 |
| Michigan | 6,501 | 7,088 | 6.2 |
| Minnesota | 3,380 | 2,439 | 3.8 |
| Mississippi | 4,376 | 3,341 | 12.1 |
| Missouri | 5,139 | 5,725 | 9.2 |
| Montana | - | 205 | 2.6 |
| Nebraska | 708 | 835 | 4.5 |
| Nevada | 3,564 | 2,997 | 13.1 |
| New Hampshire | - | 588 | 3.9 |
| New Jersey | 17,612 | 17,671 | 13.4 |
| New Mexico | 962 | 1,339 | 5.7 |
| New York | 46,390 | 75,253 | 24.9 |
| North Carolina | 13,122 | 9,129 | 11.3 |
| North Dakota | 87 | 80 | 1.3 |
| Ohio | 8,557 | 7,426 | 6.1 |
| Oklahoma | 2,237 | 2,274 | 7.3 |
| Oregon | - | 2,951 | 6.4 |
| Pennsylvania | - | 19,236 | 14.1 |
| Rhode Island | - | 1,350 | 6.2 |
| South Carolina | 6,626 | 7,510 | 16.8 |
| South Dakota | 207 | 147 | 1.9 |
| Tennessee | 7,154 | 6,834 | 10.7 |
| Texas | 26,605 | 34,940 | 12.4 |
| Utah | 954 | 1,207 | 2.6 |
| Vermont | - | 239 | 1.0 |
| Virginia | 10,577 | 8,872 | 8.2 |
| Washington | - | 5,629 | 6.6 |
| West Virginia | 670 | 785 | 4.2 |
| Wisconsin | 2,432 | 2,296 | 3.6 |
| Wyoming | 98 | 106 | 2.5 |
| Subtotal | 256,363 | 455,636 | 12.4 |
| American Samoa | 1 | 1 | 0 |
| Guam | 61 | 35 | 0 |
| Northern Mariana Islands | 7 | 3 | 0 |
| Puerto Rico | 7,261 | 11,503 | 21.5 |
| U.S. Virgin Islands | 243 | 331 | 31.4 |
| Other* | - | 0 | 0 |
| Total | 263,936 | 468,578 | 12.5 |
Over one million AIDS cases have been reported in the 50 states of the USA, the District of Columbia and Puerto Rico. Of those with known residence, 85% were reported in major metropolitan areas.
New York has accounted for around a fifth of all cases, with Los Angeles (60,583 cases), and Miami (58,554) also providing substantial numbers.
In 2007, the highest rates of new AIDS diagnoses were in Miami (33.1 per 100,000 people), New Orleans (31.5), Baton Rouge (31.4) and Washington (30.5).
Reported AIDS cases by USA metropolitan area of residence
| Area of residence | Rate per 100,000 population in 2007 | Cumulative cases |
| Akron, OH | 3.3 | 787 |
| Albany-Schenectady-Troy, NY | 7.9 | 2,349 |
| Albuquerque, NM | 7.8 | 1,473 |
| Allentown-Bethlehem-Easton, PA-NJ | 11.3 | 1,458 |
| Atlanta-Sandy Springs-Marietta, GA | 23.0 | 23,241 |
| Augusta-Richmond County, GA-SC | 14.6 | 1,961 |
| Austin-Round Rock, TX | 13.1 | 5,068 |
| Bakersfield, CA | 20.7 | 1,748 |
| Baltimore-Towson, MD | 29.6 | 21,371 |
| Baton Rouge, LA | 31.4 | 3,991 |
| Birmingham-Hoover, AL | 8.0 | 2,726 |
| Boise City-Nampa, ID | 2.0 | 293 |
| Boston, MA-NH | 8.3 | 14,013 |
| Bridgeport-Stamford-Norwalk, CT | 15.6 | 3,922 |
| Buffalo-Niagara Falls, NY | 9.0 | 2,598 |
| Cape Coral-Fort Myers, FL | 14.2 | 1,797 |
| Charleston-North Charleston, SC | 15.7 | 2,153 |
| Charlotte-Gastonia-Concord, NC-SC | 15.7 | 3,524 |
| Chattanooga, TN-GA | 9.1 | 1,037 |
| Chicago, IL-IN-WI | 13.2 | 31,488 |
| Cincinnati-Middletown, OH-KY-IN | 6.2 | 2,886 |
| Cleveland-Elyria-Mentor, OH | 6.4 | 4,416 |
| Colorado Springs, CO | 3.8 | 604 |
| Columbia, SC | 25.3 | 3,481 |
| Columbus, OH | 8.3 | 3,284 |
| Dallas, TX | 13.1 | 21,023 |
| Dayton, OH | 7.8 | 1,301 |
| Deltona-Daytona Beach-Ormond Beach, FL | 12.6 | 1,535 |
| Denver-Aurora, CO | 11.0 | 7,196 |
| Des Moines, IA | 4.8 | 560 |
| Detroit, MI | 9.2 | 10,852 |
| El Paso, TX | 18.4 | 1,619 |
| Fresno, CA | 10.9 | 1,555 |
| Grand Rapids-Wyoming, MI | 5.0 | 860 |
| Greensboro-High Point, NC | 9.2 | 1,342 |
| Greenville, SC | 8.1 | 1,347 |
| Harrisburg-Carlisle, PA | 14.7 | 1,338 |
| Hartford-West Hartford-East Hartford, CT | 17.0 | 5,363 |
| Honolulu, HI | 6.1 | 2,189 |
| Houston-Baytown-Sugar Land, TX | 17.8 | 26,954 |
| Indianapolis, IN | 7.1 | 3,969 |
| Jackson, MS | 26.0 | 2,585 |
| Jacksonville, FL | 23.1 | 6,392 |
| Kansas City, MO-KS | 15.0 | 4,999 |
| Knoxville, TN | 6.6 | 932 |
| Lakeland, FL | 13.4 | 1,911 |
| Las Vegas-Paradise, NV | 15.1 | 4,951 |
| Little Rock-North Little Rock, AR | 11.1 | 1,474 |
| Los Angeles, CA | 15.0 | 60,583 |
| Louisville, KY-IN | 14.3 | 2,476 |
| Madison, WI | 5.4 | 554 |
| McAllen-Edinburg-Pharr, TX | 7.7 | 700 |
| Memphis, TN-MS-AR | 19.9 | 5,401 |
| Miami, FL | 33.1 | 58,554 |
| Milwaukee-Waukesha-West Allis, WI | 7.1 | 2,639 |
| Minneapolis-St. Paul-Bloomington, MN-WI | 5.2 | 4,453 |
| Modesto, CA | 7.0 | 717 |
| Nashville-Davidson-Murfreesboro, TN | 14.7 | 4,091 |
| New Haven-Milford, CT | 16.8 | 4,780 |
| New Orleans-Metairie-Kenner, LA | 31.5 | 9,227 |
| New York, NY-NJ-PA | 27.1 | 202,305 |
| Ogden-Clearfield, UT | 1.5 | 277 |
| Oklahoma City, OK | 9.4 | 2,370 |
| Omaha-Council Bluffs, NE-IA | 7.2 | 1,100 |
| Orlando, FL | 22.7 | 9,202 |
| Oxnard-Thousand Oaks-Ventura, CA | 4.3 | 1,049 |
| Palm Bay-Melbourne-Titusville, FL | 8.4 | 1,567 |
| Philadelphia, PA-NJ-DE-MD | 21.9 | 29,791 |
| Phoenix-Mesa-Scottsdale, AZ | 10.8 | 7,914 |
| Pittsburgh, PA | 6.2 | 3,342 |
| Portland-South Portland, ME | 4.7 | 586 |
| Portland-Vancouver-Beavertown, OR-WA | 8.6 | 5,016 |
| Poughkeepsie-Newburgh-Middletown, NY | 10.0 | 3,255 |
| Providence-New Bedford-Fall River, RI-MA | 6.5 | 4,051 |
| Raleigh-Cary, NC | 14.6 | 2,166 |
| Richmond, VA | 8.0 | 3,500 |
| Riverside-San Bernadino-Ontario, CA | 10.5 | 9,139 |
| Rochester, NY | 11.8 | 3,280 |
| Sacramento-Arden-Arcade-Roseville, CA | 6.3 | 4,181 |
| St. Louis, MO-IL | 8.2 | 6,260 |
| Salt Lake City, UT | 4.4 | 1,802 |
| San Antonio, TX | 12.0 | 5,253 |
| San Diego-Carlsbad-San Marcos, CA | 16.1 | 13,554 |
| San Francisco, CA | 26.0 | 41,596 |
| San Jose-Sunnyvale-Santa Clara, CA | 8.4 | 3,939 |
| San Juan-Caguas-Guaynabo, PR | 22.7 | 22,272 |
| Sarasota-Bradenton-Venice, FL | 8.9 | 2,068 |
| Scranton-Wilkes-Barre, PA | 8.6 | 592 |
| Seattle, WA | 9.4 | 9,496 |
| Springfield, MA | 15.5 | 2,216 |
| Stockton, CA | 8.9 | 1,158 |
| Syracuse, NY | 6.8 | 1,378 |
| Tampa-St Petersburg-Clearwater, FL | 17.2 | 11,754 |
| Toledo, OH | 6.1 | 869 |
| Tucson, AZ | 8.7 | 2,085 |
| Tulsa, OK | 11.4 | 1,604 |
| Virginia Beach-Norfolk-Newport News, VA | 12.7 | 4,986 |
| Washington, DC-VA-MD-WV | 30.5 | 32,809 |
| Wichita, KS | 5.0 | 882 |
| Worcester, MA | 7.9 | 1,861 |
| Youngstown-Warren-Boardman, OH-PA | 9.5 | 576 |
| Metropolitan areas with 500,000 or more population | 15.6 | 871,192 |
| Metropolitan areas with 50,000 to 499,999 population | 7.7 | 97,658 |
| Nonmetropolitan areas | 5.1 | 57,604 |
| Total (including persons of unknown residence) | 12.5 | 1,028,991 |
Notes
The latest statistics on AIDS & HIV in the USA were published in February 2009 by the US Centers for Disease Control and Prevention (CDC).
There is often a delay between the time of diagnosis of HIV or AIDS, or the time of death, and the time at which the event is reported. For this reason the CDC estimates the number of people living with HIV or AIDS by adjusting for reporting delays. No adjustment is made for incomplete reporting.
The term "living with AIDS" includes every living person who has ever received an AIDS diagnosis, regardless of their current state of health. The term "living with HIV (and not AIDS)" includes every living person who has been diagnosed with HIV through the confidential name-based system, but has not been diagnosed with AIDS.
The statistics by city table contains data for Metropolitan Statistical Areas (MSAs) as defined by the Office of Management and Budget.
Resources
AIDS/HIV Treatment Directory (1995) Published by the American Foundation for AIDS Research
BETA (1995) Published by the San Francisco AIDS Foundation ?HIV Adult Standard of Care (1996) Published by ACT/UP Philadelphia Latino AIDS Project (323) 661-6752 ?Catalyst Foundation for AIDS Awareness/Care (805) 948-8559 ?Foothill AIDS Project (800) 448-0858 ?Jeffrey Goodman Special Care Clinic (323) 993-7500 ?Jewish AIDS Services (323) 761-8770 ?L.A. Gay & Lesbian CENTER (323) 993-7400 ?City AIDS/HIV Discrimination Unit (213) 485-4579 ?City AIDS Coordinator (213) 485-6320 ?L.A. Family AIDS Network (323) 669-5616 ?L.A. Shanti (323) 962-8197 ?Minority AIDS Project (323) 936-4949 ?Mountains AIDS Foundation (310) 264-9790 ?Northeast Valley Health Corp. (818) 988-6335 ?Pacific CENTER for HIV/AIDS Counseling and Psychotherapy at APLA (323) 993-1621 ?PAWS/L.A. (323) 876-PAWS ?Project Angel Food (323) 845-1800 ?Ron Shipton HIV Information CENTER (310) 652-5340 ?Santa Monica AIDS Project (310) 586-7627 ?T.H.E. Clinic for Women Inc. (323) 295-6571 ?Valley HIV/AIDS CENTER (818) 908-3840 ?Women Alive (323) 965-1564 ?Women at Risk (310) 204-1046
Where do AIDS Drugs Come From? Published by the National Institute of Allergy and Infectious Diseases
References?Rosner, S: The seriously ill or dying analyst and the limits of neutrality, in Psychoanalytic Psychology, 3(4), 357-371. 1986. Where to Find Help for HIV/AIDS in Los Angeles?Aid for AIDS (323) 656-1107 ?AIDS Education Services for the Deaf (323) 550-4250 voice/TTY ?AIDS Healthcare Foundation (323) 860-5200 ?AIDS Prevention Team (323) 964-7820 ?AIDS Project Los Angeles (323) 993-1600 ?AIDS ReSEARCH Alliance (310) 358-2423 ?AIDS Service CENTER (626) 441-8495 ?AltaMed HIV Services (323) 881-2232 ?American Foundation for AIDS Research (323) 857-5900 ?Asian Pacific AIDS Intervention Team (213) 553-1830 ?Being Alive (310) 289-2551 ?Bienestar Latino AIDS Project (323) 660-9680 ?California HIV/AIDS Hotline (800) 367-2437 ?Cara a Cara Latino
