SCENERIO:
You are working in a community health clinic and you have just taken C.Q., a 38-year-old woman, into the consultation
room. C.Q. has been divorced for 5 years, has two daughters (ages 14 and 16), and works full time as a legal secretary.
She is here for her yearly routine physical examination C.Q. states she is in a serious relationship, is contemplating
marriage, and just wants to make certain she is "okay." No abnormalities were noted during C.Q.'s physical examination.
Blood was drawn for routine blood chemistries and hematology studies; since she has never been tested, C.Q. agrees to
a human immunodeficiency virus (HIV) test. The physician requests you perform a rapid HIV test, which is an antibody
test. Within 20 minutes, the results are available and are positive.
1.
2.
Does a positive rapid HIV test mean that C.Q. definitely has HIV? If it is negative, does it mean she definitely
does not have HIV?
a. A rapid test can give false negatives or false positive results. C.Q. will need to come back to get a
western blot test to confirm the diagnosis.
What counseling do you need to provide to C.Q.?
a. C.Q. will need to know that the rapid test is inconclusive and that a blood sample will be needed to
perform the western blot test to confirm the diagnosis of HIV. She should take precautions to avoid
transmitting the virus.
CASE STUDY PROGRESS:
C.Q. returns to the clinic two days later. The physician informs you that C.Q.'s Western blot test results confirm that she
is HIV positive; he requests that you be present when he talks to her. Before leaving C.Q.'s room, the physician requests
that you give C.Q. verbal and written information about local HIV support groups and help C.Q. call a friend to
accompany her home this evening. She looks at you through her tears and states, "I can't believe it. J. is the only man
I've had sex with since my divorce. He told me I had nothing to worry about. I can't believe he would do this to me."
3.
4.
5.
6.
7.
C.Q.'s statement is based on three assumptions: (1) J. is HIV positive; (2) he intentionally withheld the
information from her; and (3) he intentionally transmitted the HIV to her through unprotected sex. Based
on your knowledge of HIV infection, how would you counsel C.Q.?
a. I would ask her if she got a blood transfusion between 1978 and 1985; if she's gotten surgery or dental
work between the past few years; if shes used needles to inject drugs or medication into her body; or
is shes had sex with anyone who later learned he was infected. I would suggest that she speak to J.
about getting tested for HIV as he could be unaware that he is infected.
In addition to offering alternative explanations and exploring options, what is your most important role at
this time?
a. It is important to provide compassion and emotional support, remain non judgemental, and allow her
to vent her frustrations.
C.Q. asks you whether she has AIDS. What do you tell her?
a. I would explain that AIDS is diagnosed when CD4 t-cell count is less than 200 cells and the patient has
an opportunistic infection such as candidal esophagitis.
Why is it a good idea for C.Q. to have someone she trusts transport her home this evening?
a. Since she just heard disturbing news she is at risk for injury if she drives herself. She needs the
emotional support of someone who cares about her.
C.Q. gives you the name and phone number of a relative she wants you to call. You remain with her until
she leaves with her relative. Has C.Q.'s right to privacy been violated? Explain why or why not.
a. No, permission was given to call said relative and her HIV status was not disclosed.
CASE STUDY PROGRESS
C.Q. returns to the clinic 4 days later to discuss her diagnosis.
8.
9.
What are your goals for C.Q. at this time?
a. Goals are to maintain her health, manage the disease and prevent transmission, and prevent infectious
complications.
What additional laboratory tests would you anticipate for C.Q. and why?
a. CD4 count, viral load testing, CBC, chemistry panel and urinalysis
10. C.Q. asks whether there is any treatment available. How would you respond?
a. Antiretroviral medication can reduce HIV viral load to undetectable within 6 months, but there is no
cure
11. C.Q. asks why she has to take so many drugs instead of a "big dose" of one drug. What would you tell her?
a. Many drugs have to be taken throughout the day to make the drug therapy more effective and prevents
resistance against the drugs.
12. The physician starts C.Q. on a regimen of Truvada (tenofovir and emtricitabine) and efavirenz (Sustiva).
What general information will you give C.Q. about ART therapy?
a. She should be instructed to take the drugs as prescribed in the exact intervals, not to skip a dose,
follow fluid and meal requirements, contact the provider if experiencing side effects, store drugs as
instructed, check with the provider before taking OTC meds, and keep follow up appointments to
monitor labs.
13. What other issues will you discuss with C.Q. at this visit?
a. Discuss who should be told about her positive result, explain how to reduce risk of transmission, she
should be referred to a dietitian for nutrition therapy, emphasize the importance of staying active, and
describe signs and symptoms of infection.
14. C.Q. asks if she has to tell J. of her HIV status. Does she have a legal responsibility to inform him?
a. Depending on the state/city there are laws that require the informing of partners that they have been
exposed to HIV
15. What reporting obligations does the clinic have?
a. Depending on the state, laws require the clinic to report to the partner of the HIV infected patient
about the positive diagnosis.
16. Before C.Q. leaves the clinic, you recognize the need for further teaching when she says:
a. "Joining a support group can help me deal with my HIV diagnosis."
b. "I will not use any other medications without checking with my health care provider."
c. "If my viral load becomes undetectable, I will not have to worry about transmitting HIV to someone
else."
d. "If my skin turns yellow, I have unusual muscle pain or feel dizzy or weak, I will call the provider
immediately."
CASE STUDY PROGRESS:
Two weeks later, C.Q. visits the office and asks to speak to you in private. She thanks you for talking to her the day she
received the news of her diagnosis. She tells you that J. confessed to her that he has hemophilia and tested positive for
HIV after having been infected through contaminated recombinant factor VIII products. He was afraid to tell her about
his diagnosis because she might leave him. C.Q. tells you that she is angry with J. They are going through counseling and
the wedding is "off" at the moment.