HIV-AIDS can affect treatment for chronic, catastrophic diseases

Work closely with a specialist for optimum outcomes

If you’re managing the care of a patient who has a comorbidity of HIV or AIDS, keep in mind that the patient is likely to have issues that other patients with the same condition do not.

"AIDS puts a different spin on how to manage most comorbidities. It is a disease that overshadows other illnesses, and it takes a lot of maneuvering to manage it effectively," says Donna Stidham, chief of managed care for the AIDS Healthcare Foundation, with headquarters in Los Angeles.

Patients with HIV-AIDS who have chronic comorbid conditions or catastrophic illnesses are set up for developing opportunistic infections, says Morris Harper, MD, chief medical officer of HIV-AIDS & Hepatitis Associates in Waynesburg, PA.

For instance, a patient with congestive heart failure who experiences a buildup of fluid in his or her lungs is at risk for developing pneumonia. A patient with a spinal cord injury and HIV-AIDS is at high risk for pressure ulcers.

"If patients have comorbidities, along with HIV-AIDS, they need to be especially careful to take their medicines," says Harper, suggesting that case managers come up with ways to help them remember, such as pillboxes.

Stidham suggests connecting patients who have AIDS with providers who understand the disease and the toll it takes on the body’s systems. For instance, if the patient has diabetes, he or she will get the best care from an endocrinologist who has some experience with HIV.

"The way a disease presents is complicated by HIV. If a physician has had some experience with HIV, he or she is better equipped to diagnose and treat patients," she says.

Harper recommends that patients with HIV-AIDS be followed medically by a clinical specialist certified by the American Academy of HIV Medicine.

"An HIV-positive patient needs to be followed closely and should have an excellent rapport with the primary care physician. Caring and sensitive mental health professionals definitely need to be involved in the patient’s care," he says.

Case managers should develop a good relationship with the patient’s primary care physician or the HIV-AIDS clinical specialist and alert them if they have any concerns about the patient, Harper suggests.

"If the patient seems to be acting a little different, the case manager should communicate these differences in attitude and/or behavior to the physician. HIV-positive patients oftentimes have financial, social, mental, and housing-associated issues and problems. These accompanying problems can cause some patients to miss taking their medications. When this happens, it does not take much for them to get into trouble. It is better to err on the side of being cautious," he says.

It is essential that case managers build their base of knowledge about AIDS so they can work closely with the patients. It’s especially important for case managers who work with patients in rural areas to be familiar with the disease so they can help educate the physicians, Stidham says.

"In rural areas, physicians are likely to have only one or two patients with AIDS and may not be managing those patients according to best practice standards. It’s not that they’re bad physicians, but they usually don’t have access to the latest updates, and the case manager can be invaluable in helping the physician access information on the Internet. Case managers can be a helpful link between the patient and the provider if they know what the resources are," she says.

The cornerstone of good management of a patient with HIV-AIDS is developing a plan of care and helping the patient stay adherent to the prescribed medication regime, Stidham says.

With the advent of new drugs, adherence is easier than it used to be when it was necessary for patients to take as many as 40 pills a day, but it’s still imperative that patients are compliant, Harper says.

"We now have 21 different drugs to treat HIV-positive patients. Some patients can take medication only once or twice daily," he adds.

The drugs used to treat AIDS are so complicated, the regime is so sensitive to resistance, and the drugs have so many interactions with other drugs that someone with expertise needs to be managing these patients, " Stidham says.

Case managers should make sure the patient is adherent to the treatment plan and be aware of what medications the patient is taking.

"People with AIDS need someone who is good at coaching them to be adherent. The drugs aren’t easy to take, and the patients may get ill on them, especially when they are first starting. The toughest part is to keep taking something that makes you feel terrible," she says.

Medications for people who are HIV-positive will work if the diagnosis is made early and the patient stays on his or her medication, Harper says.

"We have known for some time that if patients miss taking 10% of their medications, they began to develop resistance, and if the appropriate medications are not changed, the resistance will continue to grow. We now believe that if patients miss 5% of their medications, they can develop a low-grade resistance," he says.

Patients who have HIV-AIDS may have adverse drug interactions, Harper points out.

Get a pharmacist involved in managing the patient’s care to ensure that the drugs the patient is taking for the disease or condition you are managing are not contraindicated for his or her HIV-AIDS medication, he suggests.

This becomes even more critical for the HIV-positive patient on a salvage or deep salvage regimen (a treatment regimen for people who have few or limited anti-HIV drug options) and at the same time is being treated for multiple comorbidities and/or opportunistic infections," Harper adds.

It’s important for patients with HIV-AIDS to feel as though someone cares about them, Harper says.

"So much of the outcome of HIV care revolves around the patient feeling good about himself or herself and feeling like someone cares if he or she lives or dies," he says.

That’s where a case manager can make a lot of difference, particularly with patients who don’t have a support system at home.

Monitor your patient’s lab reports to make sure their immune system and other factors are within a normal range, suggests Gene Bundrock, MS, RN, CCM, statewide director for AIDS Healthcare Foundation’s Positive Healthcare Florida disease management program.

"Lab data are a very good gauge. As the immune system weakens and the CD4 comes down to 350, people with AIDS need to be on antiviral therapy," Bundrock says.

CD4 levels, or T-Cell counts also are important to monitor. A person with AIDS can develop a serious opportunistic infection once the count drops below 50.