Counseling

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Counseling HIV-infected patients can present great challenges to their physicians. Many HIV-infected persons enter the physician-patient relationship with significant emotional distress and numerous complicating circumstances. These complicating circumstances can include issues of sexual orientation and sexuality, the need for risk reduction, substance abuse, societal discrimination, and increasing poverty as the epidemic evolves in the United States. The physician must enter this relationship prepared to address these issues with knowledge and compassion and without becoming judgmental about their content.

A crucial component involved in counseling HIV-infected persons is education concerning HIV disease, its transmission, and its potential treatments. This process should continue for the duration of the physician-patient relationship; and given the extensive knowledge base of many persons with HIV infection, there may be a mutual exchange of important information. The best medical interventions will not succeed unless HIV-infected persons have been carefully counseled regarding their potential benefits, costs, and acquisition. 

A well-informed patient can be a strong ally in tackling difficult therapeutic decisions, and many therapeutic decisions are currently not straightforward, such as the optimal time to initiate antiretroviral therapy. A well-informed patient will be more adherent with prescribed medications and may better recognize the early manifestations of HIV-related clinical complications and potential drug toxicities. Finally, a well-informed patient can constructively guide decisions regarding advance directives for his or her care if HIV disease progresses.

Education regarding the transmission of HIV and alterations in risk behavior is another important goal of counseling. Efforts to encourage behavioral changes resulting in temporarily decreased HIV transmission have succeeded in homosexual men in San Francisco, although recent evidence suggests an increasing number of new infections, especially among young individuals. Intensive efforts to decrease HIV transmission have also succeeded in smaller populations of injecting drug users and high-risk heterosexuals. All patients should be well informed regarding safer sex precautions and the avoidance of needle sharing. This information must be presented in language appropriate to the culture of the patient. Significant behavioral changes are frequently not accomplished during a single visit, and enduring change requires ongoing re-education and support from the physician.

Treating substance abuse is crucial in decreasing the risk of HIV transmission through needle sharing and sexual contact and in avoiding the medical and psychological consequences of continued substance abuse. Physicians must advocate for their patients in seeking access to frequently inadequate and overwhelmed drug treatment programs. Physicians also must acknowledge the high recidivism rates associated with substance abuse and continue to treat their recidivous patients firmly and without judgment. Finally, physicians should reinforce positively those recovering addicts who have succeeded in treatment and struggle to avoid relapse on a daily basis.

The clinical course of persons with HIV infection is frequently complicated by significant anxiety and depression. Pharmacologic measures may prove useful in their management, although physicians should be cautious about the potential for drug interactions with protease inhibitors. In the circumstance of late-stage HIV infection complicated by HIV encephalopathy and depression, ritalin may be of benefit. Physicians should identify AIDS service organizations in their community that may provide support services such as patient education, case management, transportation, shelter, food, medications, or support groups to their clients. Formal psychiatric referral may also be necessary in individual patients. Patients may experience depression throughout the course of HIV infection--in early infection, during successful treatment, and in disease progression. Past coping strategies may be useful in such instances. A careful history may provide assistance in identifying these strategies.

References:
_{Bartlett JG: Medical Management of HIV Infection. Glenview, IL, Physicians and Scientists Publishing Co, 1997. A review for health care professionals describing the medical management of HIV-infected persons.}

Carpenter CJ, Fischl MA, Hammer SM, et al: Antiretroviral therapy for HIV infection in 1997: Updated recommendations of the International AIDS Society--USA Panel. JAMA 227:1962-1969, 1997. A review of the continually evolving recommendations for antiretroviral therapy.

Kitahata MM, Koepsell TD, Deyo RA, et al: Physician’s experience with acquired immunodeficiency syndrome as a factor in patient survival. N Engl J Med 334:701-706, 1996. Increased experience of physicians in treating AIDS improves survival.

Royce RA, Sena A, Cates W, Cohen MS: Sexual transmission of HIV. N Engl J Med 336:1072-1078, 1997. A review of the factors affecting the sexual transmission of HIV, the predominant mechanism of continuing spread.

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