How can PA’s promote medication How can PA’s promote medication compliance/adherence in African compliance/adherence in African American women infected with American women infected with

HIV?HIV?

Tyeshia HalsellTyeshia Halsell

April 6, 2006April 6, 2006

PA Master’s ProjectPA Master’s Project

Advisor: Professor FahringerAdvisor: Professor Fahringer

What is HIV/AIDS?

HIV stands for “human immunodeficiency virus”: HIV stands for “human immunodeficiency virus”: “human”“human” because the virus causes disease only in because the virus causes disease only in people; people; “immunodeficiency”“immunodeficiency” because the immune because the immune system, which normally protects a person from system, which normally protects a person from disease, becomes weak; disease, becomes weak; “virus”“virus” because like all because like all viruses, HIV is a small organism that infects living viruses, HIV is a small organism that infects living things and uses them to make copies of itself.things and uses them to make copies of itself. There are two types of HIVThere are two types of HIV: HIV-1 and HIV-2. HIV-: HIV-1 and HIV-2. HIV-1 is found in all parts of the world but HIV-2 is found 1 is found in all parts of the world but HIV-2 is found mostly in West Africa, but both viruses can be mostly in West Africa, but both viruses can be prevented in the same ways (Granich & Mermin, prevented in the same ways (Granich & Mermin, 1999).1999).

What are the three What are the three barriers identified?barriers identified?

1.1. Physician Assistant-Patient Physician Assistant-Patient RelationshipRelationship

2.2. Dealing with and treating Dealing with and treating psychosocial distress/stress of psychosocial distress/stress of living with HIV/AIDSliving with HIV/AIDS

3.3. The impact of alcohol, and The impact of alcohol, and recreational drug userecreational drug use

PA-Patient RelationshipPA-Patient Relationship

Knowledge of the client’s background will guide which Knowledge of the client’s background will guide which behaviors are appropriate and beneficial to accept in behaviors are appropriate and beneficial to accept in order to gain the favorable rapport that will enhance order to gain the favorable rapport that will enhance treatment (Kelly et al., 1987; Katz et al., 1987; Hunter treatment (Kelly et al., 1987; Katz et al., 1987; Hunter & Ross, 1991).& Ross, 1991).

The PA must appreciate within-group cultural The PA must appreciate within-group cultural diversity and refrain from generalizing knowledge diversity and refrain from generalizing knowledge about one subgroup of a minority population to all about one subgroup of a minority population to all members of that broader population. members of that broader population.

Dealing with & treating psychosocial Dealing with & treating psychosocial distress/stress of living with distress/stress of living with

HIV/AIDSHIV/AIDS““Women living with HIV/AIDS in the community will Women living with HIV/AIDS in the community will usually bear the responsibility for child care, usually bear the responsibility for child care, housekeeping, health and social work appointments, housekeeping, health and social work appointments, and their own illness as well as the illness of their and their own illness as well as the illness of their partner, possibly children and other family members, partner, possibly children and other family members, often their own needs are the least well met” (Berry, often their own needs are the least well met” (Berry, Morrison, & McLachlan, 1992). Morrison, & McLachlan, 1992).

A mother will battle with her own feelings of anxiety, A mother will battle with her own feelings of anxiety, depression, and sadness over her inability to truly be depression, and sadness over her inability to truly be a mother to her family. a mother to her family.

Three Goals for the PA:Three Goals for the PA:

1.1. Initially empower these women to care for Initially empower these women to care for themselves as well as their families, by using themselves as well as their families, by using outside support, AIDS service agencies, and outside support, AIDS service agencies, and support groupssupport groups

2.2. Be with these women, hold their hands, and cry Be with these women, hold their hands, and cry with them as they bury a child or husbandwith them as they bury a child or husband

3.3. Treat the psychological disorders such as Treat the psychological disorders such as depression, anxiety, thoughts of suicide, bipolar depression, anxiety, thoughts of suicide, bipolar disorder, schizophrenia, and many others with disorder, schizophrenia, and many others with pharmaceutical agents before beginning the pharmaceutical agents before beginning the treatment of HIV/AIDS because these disorders treatment of HIV/AIDS because these disorders can contribute to non-adherencecan contribute to non-adherence

The impact of alcohol & The impact of alcohol & recreational drug userecreational drug use

Lifetime prevalence for alcohol use disorders (those Lifetime prevalence for alcohol use disorders (those meeting dependence or abuse criteria) among HIV+ meeting dependence or abuse criteria) among HIV+ persons has ranged from 29% to 60% (Brown et al., persons has ranged from 29% to 60% (Brown et al., 1992; Dew et al., 1997; Kelly et al., 1998; Summers 1992; Dew et al., 1997; Kelly et al., 1998; Summers et al., 1995). et al., 1995).

Studies have shown that impaired judgment, short-Studies have shown that impaired judgment, short-term memory loss, and a decline in cognitive term memory loss, and a decline in cognitive functioning are heightened when substances are functioning are heightened when substances are used (Bondi, Drake & Grand, 1998; Rosseli & Ardilla, used (Bondi, Drake & Grand, 1998; Rosseli & Ardilla, 1996). 1996).

The impact of alcohol & The impact of alcohol & recreational drug userecreational drug use

The use of “club drugs”, such as methamphetamine, The use of “club drugs”, such as methamphetamine, ketamine, and MDMA, posit further danger for people ketamine, and MDMA, posit further danger for people with HIV/AIDS, as club drugs have been shown to with HIV/AIDS, as club drugs have been shown to lead to heightened or focused sensations, euphoria lead to heightened or focused sensations, euphoria and sexual disinhibition, depression, and cognitive and sexual disinhibition, depression, and cognitive dissociation as a means of coping (Bondi, Drake & dissociation as a means of coping (Bondi, Drake & Grand, 1998; Rosseli & Ardilla, 1996). Grand, 1998; Rosseli & Ardilla, 1996).

In particular, dehydration associated with alcohol and In particular, dehydration associated with alcohol and amphetamine use will worsen side effect symptoms amphetamine use will worsen side effect symptoms such as diarrhea and nausea. such as diarrhea and nausea.

Review of LiteratureReview of Literature

Poor adherence contributes to the Poor adherence contributes to the development of drug-resistant HIV, and high development of drug-resistant HIV, and high levels of medication adherence are levels of medication adherence are associated with sustained reductions in viral associated with sustained reductions in viral load, decreased risk of developing AIDS, and load, decreased risk of developing AIDS, and enhanced survival (Natasha et al., 2002). enhanced survival (Natasha et al., 2002). Homeless persons with HIV found that all of Homeless persons with HIV found that all of those who had taken 98-100% of medication those who had taken 98-100% of medication doses had an undetectable viral load doses had an undetectable viral load (Bangsberg et al., 2000). (Bangsberg et al., 2000).

Review of LiteratureReview of Literature

Recent studies have shown that very high Recent studies have shown that very high levels of adherence (at least 90-95% of levels of adherence (at least 90-95% of doses) may be needed to realize superior doses) may be needed to realize superior treatment outcomes (Gifford et al., 2000).treatment outcomes (Gifford et al., 2000).

Improvements in HIV medications have made Improvements in HIV medications have made it easier for some patients to adhere to their it easier for some patients to adhere to their prescribed regimen by reducing the number prescribed regimen by reducing the number of pills that have to be taken or easing dosing of pills that have to be taken or easing dosing restrictions. restrictions.

Review of LiteratureReview of Literature

Twenty studies identified five factors that Twenty studies identified five factors that were most often associated with non-were most often associated with non-adherence: adherence:

1.1. symptoms and medication side effects, symptoms and medication side effects, 2.2. negative life events or stressors, negative life events or stressors, 3.3. lack of family or social support, lack of family or social support, 4.4. treatment regimen complexity, and treatment regimen complexity, and 5.5. low self-efficacy for medication taking low self-efficacy for medication taking

(Ammassari et al., 2002).(Ammassari et al., 2002).

Summary/SynthesisSummary/Synthesis

A consistent theme among the recommendations and A consistent theme among the recommendations and findings in their reports is the interdependent role of findings in their reports is the interdependent role of cultural issues in health care and quality of care. cultural issues in health care and quality of care.

Cultural issues in health care were identified as Cultural issues in health care were identified as important in medical education (Cuff, 2004), in the important in medical education (Cuff, 2004), in the health care work force (Smedley, 2004; Gebbie, health care work force (Smedley, 2004; Gebbie, 2003), in health care disparities (Smedley, 2003), and 2003), in health care disparities (Smedley, 2003), and in health communications (Nielsen-Bohlman, 2004). in health communications (Nielsen-Bohlman, 2004).

Summary/SynthesisSummary/Synthesis

These inquiries suggest the need for core These inquiries suggest the need for core competencies, as reflected in curricular competencies, as reflected in curricular changes as well as new directions in research changes as well as new directions in research and policy. and policy.

Women and the cultural factors related to Women and the cultural factors related to gender are among the issues emphasized by gender are among the issues emphasized by policy makers, researchers, and clinicianspolicy makers, researchers, and clinicians.

Conclusion/RecommendationConclusion/Recommendation

Overall, “to understand and assist women living with Overall, “to understand and assist women living with HIV, it is important to take a systems approach, to HIV, it is important to take a systems approach, to look at the whole to understand the parts, to think in look at the whole to understand the parts, to think in loops rather than in straight line” (O’Connor, 1997).loops rather than in straight line” (O’Connor, 1997).

High quality care for women living with HIV disease is High quality care for women living with HIV disease is best given by addressing not only her medical needs, best given by addressing not only her medical needs, but also her economic needs, her relationships, her but also her economic needs, her relationships, her emotional responses, her culture, and her emotional responses, her culture, and her community: all of the faces of a multifaceted life community: all of the faces of a multifaceted life (Cheever, 1999).(Cheever, 1999).

Thanks for Listening!!!!Thanks for Listening!!!!

Questions???

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