Medication Persistence in the Treatment of HIV Infection, Case Study Example

Case Narrative: Chronic Care Visit

This case describes the care I provided for Ms. R., a 33 Year old African American single female with Medicaid insurance, who presents to the outpatient clinic as a walk in for HIV with complaints of a new rash and fever.  The case narrative focuses on a single encounter which occurred in the outpatient clinic. This case narrative demonstrates my ability to meet the following University of St. Francis School of Nursing Doctoral for Comprehensive Direct Patient Care.

Domain 1. Competency 1

Evaluate the patient needs based on age, developmental age, family history, ethnicity, and individual risk including genetic profile to formulate plans for health promotion, anticipatory guidance, counseling, and disease prevention services for healthy or sick patients and their families in any clinical setting.

Performance Objective C. Evaluate individual patient needs based on age, developmental stage, family history, ethnicity and individual risk.

Performance Objective D. Formulate a plan that addresses health promotion, anticipatory guidance and/ or disease prevention for the individual.

Domain 1. Competency 3.

Formulate differential diagnoses and diagnostic strategies and therapeutic interventions with attention to scientific evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and efficacy for patients who present with new conditions and those with ambiguous or incomplete data, complex illnesses, comorbid conditions, and multiple diagnoses in all clinical settings.

Performance Objective A. Formulate a differential diagnosis for a patient who presents with ambiguous or incomplete data, complex illness, comorbid conditions and potential multiple diagnoses.

Performance Objective C.  Discuss the rationale for the differential diagnosis.

Performance Objective D.  Discuss the rationale for the diagnostic evaluation with attention to scientific evidence, safety, cost, invasiveness, simplicity, acceptability, adherence and efficacy.

Performance Objective E.  Discuss the rationale for the therapeutic intervention with attention to scientific evidence, safety, cost, invasiveness, simplicity, acceptability, adherence and efficacy.

Domain2. Competency 1.

Assemble a collaborative interdisciplinary network; refer and consult appropriately while maintaining primary responsibility for comprehensive patient care.

Performance Objective A.  Initiate referral to other health care professionals while maintain primary responsibility for patient care.

Domain 3 competency 1.

Synthesize the principles of legal and ethical decision-making and analyze dilemmas that arise in patient care, interprofessional relationships, research or practice management to improve outcomes.

Performance Objective A.  Synthesize ethical principles to address a complex practice dilemma.

Performance Objective B. Apply ethical principles to resolve the dilemma.

Summary of Care

Ms. R. is a 33 year old single African American female who first entered the practice on March 15, 2000.  Ms. R was referred by her PCP for management of HIV.She acquired HIV from a new partner that she had been dating for one month.  She has history of histoplasmosis. During the past 15 years her HIV has been managed by this outpatient clinic. She was last seen in the clinic for HIV follow up on last Friday September 4, 2015 in which she was started on a new HIV medication Prezista 800 mg 1 tab oral daily. She was seen in the emergency room for conjunctivitis on Sunday September 6, 2015. She presents to the clinic today as a walk in for newly developed rash and fever. The onset of the rash was September 7, 2015. The severity is extreme. The course is worsening. Associated symptoms: cough and rash. She denies any changes in food, lotions, perfumes and soaps.

Encounter Context

nitial Evaluation

Doctor of Nursing Practice (DNP) Role:  I am a Family Nurse Practitioner (FNP) and DNP student evaluating this patient.

Identifying Information

Site: Ambulatory Care

Setting: HIV Clinic

Reason for Encounter: Walk In for complaints of rash and fever.

Informant: Patient and previous outpatient records. Patient is a reliable historian.

Chief Complaint: Patient presents to clinic with complaints of new rash and fever.

History of Present Illness:

Ms. R arrives to the office anxious and afraid that her HIV has turn into full blown AIDS.  Her last visit occurred on Friday September 4, 2015.  At that time her CD4 count 5 and viral load 1423.She has been noncompliant with taking her prescribed HIV medications regularly. She misses multiple doses and she blames her missing doses of her medications on her being too busy to remember to take her medications. Patient was instructed by the provider the importance

of her taking her medications daily as prescribed in order to suppress the HIV virus. The goal is to have her viral load less than forty in which she will be undetected for the HIV virus. She was started on a new medication Prezista to assist with her other HIV medications to get her viral load undetected.

It is of critical importance for the patient to take her medications on a regular basis in order to prevent the growth of her viral load and CD4 counts, and this reflects a need to use medications that will provide a means of reducing her viral load to almost undetectable levels to prolong her health. Prescribing Prezista (Darunavir) attempts to suppress her viral load, although the dosage must be monitored in order to be most successful in managing HIV, while also aiming to prevent complications such as rash (Rakhmanina, Neely, & Capparelli, 2012). This reflects the importance of developing an environment whereby patient needs will be met and viral load will be better managed without a high risk of developing side effects or other complications (Rakhmanina et.al, 2012). In addition, it is known that for patients who are allergic to sulfonamide, it is not necessarily required that they discontinue use of the drug, particularly because the benefits of the drug outweigh the risks and provide a greater ability to manage viral load more effectively (Nishjima et.al, 2014). In this context, the use of Prezista should continue to be used, even if there are side effects such as rash, because its benefits are instrumental in managing viral load and other complications related to HIV.

Critical Appraisal      

The treatment of HIV requires an understanding of the symptoms and challenges of the disease, as well as its impact on viral load and other concerns that influence how patient care is managed by healthcare providers. Viral load is a critical component of this process and promotes an opportunity to examine the different areas where medications are prescribed in an effort to better understand how the disease is affected by these treatments. Medication persistence is a critical component of HIV treatment, as it enables a patient to address concerns regarding viral load and the overall ability to adhere to medication prescribing requirements (Bae, Guyer, Grimm, & Altice, 2011). From this perspective, it is important to identify the ever-changing nature of HIV therapies and what is required to ensure that patients receive the appropriate treatments in a timely manner (Bae et.al, 2011). Viral suppression is a critical objective in this process; however, other factors must also be considered that will have a lasting impact on outcomes and create a means of supporting patient needs effectively and consistently (Bae et.al, 2011). In general, antiretroviral therapies are used extensively in the treatment of HIV; therefore, they must be better understood and must provide a means of recognizing the value of these treatments to promote greater health and wellbeing for this patient population, along with the determination of other factors that influence HIV treatment effectively and consistently to achieve the desired outcomes. In the context of Prezista, for example, there must be an emphasis on its side effects, such as rash, but must also consider other factors that influence the manner in which treatment is able to continue so that the patient is able to manage her viral load but also experience side effects that are tolerable (Livingston, 2014). If this is not the case, other alternatives must be considered in order to be successful in treating the disease without additional limitations.

Immunizations:

Influenza- September 4, 2015

For patients with HIV, it is important to develop an understanding of the benefits of the influenza vaccine in the course of treatment, as this reflects a greater need to improve the immune response relative to this process. To be specific, a study by Crum-Cianflone et.al (2011) notes that there is a potential higher risk of contracting influenza for HIV patients, even with the use of the vaccine, particularly when patients have elevated CD4, and T/B cell counts. However, a study by McKittrick et.al (2013) demonstrates that a standard vaccine protocol may not be sufficient to improve immunity against the disease, and a higher dose trivalent vaccine may be necessary for this patient population. It is also important to consider the risk of pneumonia as related to HIV, as this requires an improved understanding of the nature of the disease and its level of risk, particularly with the bacterial version (Gohil, Heo, Schoenbaum, Celentano, & Pirofski, 2013). Patients with HIV possess a 25 times higher risk of developing bacterial pneumonia; therefore, this condition must be addressed more closely to ensure that patients receive the best possible care and treatment in order to prevent bacterial and other forms of the disease (Gohil et.al, 2013). It is important for patients to receive the appropriate treatment to better manage the risk of pneumonia and to be mindful of their risk relative to their HIV diagnosis and treatment strategy. All vaccinations related to influenza and pneumonia, therefore, must be addressed in a timely manner and enable patients to have an improved opportunity to prevent both conditions as best as possible.

Medications:

Multivitamin 1 tab oral daily

Vitamin D3 5000 intl units 1 capsule oral daily

Norvir 100 mg 1 tab oral daily

Prezista 800 mg 1 tab oral daily

Truvada 200 mg-300mg 1 tab oral daily

Atovaquone 750 mg/5ml oral suspension: 1500 mg, 10 ML oral daily for 30 days

Erythromycin ophthalmic 0.5% ointment 0.5 inch in right eye four times a day for 5 days

Prednisone 20 mg take 2 tabs oral daily for 3 days

Hydrocortisone Ointment 1% apply to affected areas twice a day as needed

Past Medical History: Histoplasmosis

Past Surgical History:  Denies

Family Medical History:

Mom – Diabetes, Hypertension, Breast Cancer

Dad- Hypertension, Diabetes, Prostate Cancer, Congestive Heart Failure

Sister- Hypertension

Sister- Alive and well

Brother-Bipolar, diabetes

Maternal Grandmother- Diabetes, Hypertension, Lung Cancer (Deceased)

Social History: Denies tobacco, alcohol and illicit drug use.

Review of Systems

General: Complains of fever and chills for 2 days. Denies weight loss, night sweats, weakness and acute pain.

Integumentary: Reports of rash that is itchy.

Eyes: Complains of exudates and tearing. Denies blurred vision and changes in vision.

Ears: denies tinnitus, hearing loss, vertigo, or excessive cerumen.

Nose: Denies nasal discharge, irritation or epistaxis.

Mouth and throat: Denies gum changes, bleeding sore throat, dysphagia, halitosis or oral lesions

Cardiovascular: Denies chest pain and tightness, shortness of breath, orthopnea, palpitations, peripheral edema or intermittent cladication

Respiratory: Complains of nonproductive cough. Denies shortness of breath, wheezing. Denies history of TB.

Gastrointestinal: Denies abdominal pain, excessive bloating, dyspepsia, pyrosis, diarrhea, constipation, nausea, and vomiting.  Bowel movements are regular, daily brown and formed.

Genitourinary: Denies frequency, urgency, dysuria, incontinence or polyuria. Denies being in a sexual relationship. Pelvic exam one year ago and within normal limits.

Musculoskeletal: Ambulates with steady gait. Denies pain.

Neurological: Denies numbness, tingling, radiation, parathesia, neuropathic symptoms, weakness or increased forgetfulness or changes in thought processes.

Psychiatric: Denies

Allergies: Penicillin, Dapsone, Bactrim

Physical Exam

General: Alert and oriented to person, place and time. No apparent distress.

Vital Signs: Temperature 100.8 oral, Pulse 116 beats per minute, Respirations 20 breaths per minute, Blood Pressure 122/76, Height 62 inches, Weight 123 Kilograms, BMI 44, Pain is 0/1-10 numerical scale.

Skin: Warm and dry, Generalized Rash to arms, legs back and chest (Macular, Papular, Consistent with an allergic reaction).Bilateral palm of hands erythema.

HEENT: Head: Normacephalic. Eyes PERRLA, Bilateral conjunctiva injected, erythema surrounding bilateral periphery, EOMS intact. Ears: Hearing equal bilaterally. Nose: Straight without deviation, no discharge, enlarged turbinates or lesions. Oropharynx: without redness or exudates.

Neck: Supple, trachea midline, no lymphadenopathy, no thyromegalyno JVD.

Respiratory: Bilateral lungs clear to auscultation. No crackles, no rhonchi, no wheezing.

Heart: S1S2 heard regular rate and rhythm, no murmurs, gallops or rubs.

Abdomen: Soft, nontender, Obese, no masses, no rebound tenderness, no organomegaly.

Geniturinary: Deferred.

Rectal: Deferred.

Extremities: FROM, No edema, cyanosis or clubbing, pedal pulses 2+ bilateral.

Neurological: No focal deficits.

Impression

Based upon an evaluation of the patient and her current condition, her rash appears to be a product of a standard allergic reaction and requires further analysis and treatment in order to minimize symptoms and further risk. This reflects the importance of understanding the nature of the disease and the overall use of Prezista in the treatment of HIV, while also balancing its side effects and how they impact the patient’s current health status. There must be a greater emphasis on balancing the patient’s medication-related needs, current health status, and symptoms with respect to her long-term care and treatment, as this is an important step in determining how this balance will prolong her quality of life and improve her overall health and wellbeing for as long as possible. This is an important step towards the discovery of a protocol that will have a lasting impact the patient’s physical, mental, psychological, and emotional health.

ICD-9 Codes

Rash

HIV

Conjunctivitis

Obesity

Plan: 

Instructed to discontinue all meds until rash resolves.

Start Prednisone 40 mg oral daily for 3 days.

Start Benadryl 25 mg 1 tab oral three times a day.

Hydrocortisones 1% apply to affected area twice a day as needed.

Discussed and consulted with Sonja PharmD that Prezista is most likely the suspect of causing the allergic reaction.

The plan is to restart Truvada, Reyataz, and Norvir when patient returns in two weeks.

One week later restart Itraconazole.

Patient instructed to go to the Emergency room for fever greater than 101, blisters and oral lesions.

Follow up in two weeks.

Competency Defense

Domain 1. Competency 1

Evaluate the patient needs based on age, developmental age, family history, ethnicity, and individual risk including genetic profile to formulate plans for health promotion, anticipatory guidance, counseling, and disease prevention services for healthy or sick patients and their families in any clinical setting.

 Defense. Domain 1 Competency 1, was met with the

Domain 1. Competency 3.

Formulate differential diagnoses and diagnostic strategies and therapeutic interventions with attention to scientific evidence, safety, cost, invasiveness, simplicity, acceptability, adherence, and efficacy for patients who present with new conditions and those with ambiguous or incomplete data, complex illnesses, comorbid conditions, and multiple diagnoses in all clinical settings.

Defense. Domain 1 Competency 3, has been met because the treatment plan has been largely effective in managing the patient’s condition to date; however, the patient must be able to better manage her health by taking her medication in a timely manner in order to ensure that its effectiveness is optimized at all times. There are many factors that influence HIV patient care and treatment; therefore, these considerations must be made in order to effectively manage the disease and to recognize the limitations that may exist in terms of treatment and in support of patient needs at the highest possible level. Factors such as costs and length of treatment must be considered and supported by a dynamic that is likely to influence a greater understanding of the dynamics of treating the disease, the complications that may arise, and the overall outlook for this patient population and quality of life (Meyer-Rath & Over, 2012). This process must be considered more closely and aim to provide a framework that supports the patient’s overall ability to manage an HIV diagnosis effectively and with as few limitations as possible.

Domain2. Competency 1.

Assemble a collaborative interdisciplinary network; refer and consult appropriately while maintaining primary responsibility for comprehensive patient care.

Defense. Domain 2 Competency 1, has been met because prior data regarding modeling HIV diagnoses and treatment have been successful in addressing the comprehensive nature of the disease and its impact on patients. This reflects the importance of developing a treatment regimen that will have lasting and meaningful benefits for patients, while also considering the factors that influence outcomes and support treatments that will contribute to effective outcomes. This strategy requires a comprehensive plan of care that is contingent upon communication and collaboration among colleagues in order to provide a supportive and relevant environment for the patient in which to manage HIV effectively and on a consistent basis. Therefore, communication among caregivers is integral to a successful plan of care and provides the patient with the tools that are required to ensure that all patient needs are met in a timely and efficient manner.

Domain 3 competency 1.

Synthesize the principles of legal and ethical decision-making and analyze dilemmas that arise in patient care, interprofessional relationships, research or practice management to improve outcomes.

Defense. Domain 3 competency 1 has been met because there is a strong emphasis on developing and maintaining a plan of care that will have a lasting impact on outcomes and on patient wellbeing. This process is instrumental in shaping an environment whereby the patient’s needs are supported above all other needs and whereby there are significant opportunities for growth and change. At the same time, an ethical framework must be achieved that will be effective in supporting the long-term care and treatment of the patient, along with other factors that influence outcomes and support a strong dynamic of care and treatment at a high level. This process will demonstrate the importance of recognizing ethical decision-making in supporting this patient and in providing her with the best possible opportunity to manage her recovery in an effective manner. Although this is a challenging process, it nonetheless provides a basis for examining the different constructs of care that influence change and which provide a patient with an additional level of support and guidance to meet her needs in a positive manner.

References

Bae, J. W., Guyer, W., Grimm, K., & Altice, F. L. (2011). Medication persistence in the treatment of HIV infection: a review of the literature and implications for future clinical care and research. Aids, 25(3), 279-290.

Benea, O. E., Streinu-Cercel, A., Dorob??, C., Rugin?, S., Negru?iu, L., Cup?a, A., … & Iosif, I. (2014). Efficacy and safety of darunavir (Prezista®) with low-dose ritonavir and other antiretroviral medications in subtype F HIV-1 infected, treatment-experienced subjects in Romania: a post-authorization, open-label, one-cohort, non-interventional, prospective study. Germs, 4(3), 59.

Crum-Cianflone, N. F., Eberly, L. E., Duplessis, C., Maguire, J., Ganesan, A., Faix, D., … &

Burgess, T. (2011). Immunogenicity of a monovalent 2009 influenza A (H1N1) vaccine in an immunocompromised population: a prospective study comparing HIV-infected adults with HIV-uninfected adults.Clinical Infectious Diseases, 52(1), 138-146.

Delva, W., Wilson, D. P., Abu-Raddad, L., Gorgens, M., Wilson, D., Hallett, T. B., & Welte, A. (2012). HIV treatment as prevention: principles of good HIV epidemiology modelling for public health decision-making in all modes of prevention and evaluation. PLoS medicine, 9(7), 938.

Gohil, S., Heo, M., Schoenbaum, E., Celentano, D., & Pirofski, L. A. (2012). CD8+ T cells and risk for bacterial pneumonia and all-cause mortality among HIV-infected women. Journal of acquired immune deficiency syndromes (1999),60(2), 191.

Livingston, S. (2014). Fundamentals of Antiretroviral Therapy. Meyer-Rath, G., & Over, M. (2012). HIV treatment as prevention: Modelling the cost of antiretroviral treatment-state of the art and future directions. PLoS medicine, 9(7), 881.

McKittrick, N., Frank, I., Jacobson, J. M., White, C. J., Kim, D., Kappes, R., … & Tebas, P. (2013). Improved immunogenicity with high-dose seasonal influenza vaccine in HIV-infected persons: a single-center, parallel, randomized trial. Annals of internal medicine, 158(1), 19-26.

Nishijima, T., Gatanaga, H., Teruya, K., Mizushima, D., Aoki, T., Watanabe, K., … & Oka, S. (2014). Skin rash induced by ritonavir-boosted darunavir is common, but generally tolerable in an observational setting. Journal of Infection and Chemotherapy, 20(4), 285-287.

Wilson, D. P. (2012). HIV treatment as prevention: natural experiments highlight limits of antiretroviral treatment as HIV prevention. PLoS medicine,9(7), 922.