HIV Nursing and Home & Community Care Conference
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This joint presentation by Susann Nasewich and Greg Riehl will describe HIV Nursing as it relates to pre and post test counseling, and what is important to know for home and community care nurses and aides.
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HIV Nursing and Home & Community Care Conference
- 1. HIV Nursing & Home Care Greg Riehl, RN Susanne Nasewich, RN Saskatchewan First Nations Home & Community Care Staff HIV /HCV Training Session January 16 & 17, 2014 Hilton Garden Inn, Saskatoon SK
- 2. Learning Objectives • Roles & responsibilities • HIV 101 • HIV Testing • Pre and Post test counseling • Disclosure • Confidentiality • Referrals • Resources
- 3. HIV is a great story…
- 5. HIV 101 • Once a person is infected they are always infected. • Medications are available to prolong life but they do not cure the disease. • Those who are infected are capable of infecting others without having symptoms or knowing of the infection. HIV AIDS
- 6. Natural history of HIV without treatment
- 7. Transmission • Blood contact • Sexual contact • Vertical transmission Remember elements of infection: • Source of infection • Susceptible host • Means of transmission
- 8. Testing – Why? “Evidence shows that most people newly diagnosed with HIV have had many missed opportunities in health care for diagnosis. We can’t stress enough how very crucial early treatment is. While HIV is a chronic infection, early treatment prolongs and improves people’s lives.” Offer HIV test as part of routine care. http://www.health.gov.sk.ca/hiv-strategy-2010-2014 http://www.catie.ca/sites/default/files/EN_HIV-Screening-Guide-2013.pdf
- 9. Testing – Who? • All pregnant women • All tuberculosis (TB)/Hep C patients • All clients assessed in a sexually transmitted infection (STI) clinic or seen in any health care setting for an STI • All patients showing signs/symptoms that may be consistent with HIV-related disease • All clients who have requested an HIV test • All patients aged 13 to 64* receiving primary or emergency health care who do not know their HIV status, or who are sexually active and have not had an HIV test in the last 12 months
- 10. Testing – Who? If you or your partner(s) have ever: • had sex – oral, vaginal anal intercourse – without a latex/polyurethane condom or other protective barrier • had sex while under the influence of alcohol or drugs – you might not have used protection • tested positive for another sexually transmitted an/or blood-borne infection – (e.g. syphilis, gonorrhea, chlamydia, hepatitis B, hepatitis C, etc.) • shared needles, syringes or other drug use equipment when using drugs, including steroids • had tattooing, piercing or acupuncture with unsterilized equipment • had a blood transfusion/received blood products – before November 1986 (in Canada)
- 11. Testing – How? • Requires at MINIMUM: – Consent – Counselling – Confidentiality
- 12. Testing – How? • Testing without consent is an assault in most places in Canada. • The person must know and understand all of the potential consequences of getting tested that a reasonable person would want to know. • Being HIV positive can result in criminal liability • Very important to understand legal implications in pretest counseling, prior to consent being obtained. HIV and the Law Update, Ruth Carey, April 20th, 2004
- 13. Testing – When? • Anyone who does not know their status should be tested when they visit their primary care provider – Knowing you are HIV-negative is as important as knowing you are HIV-positive. • What are some barriers to testing? – Patient/client – Provider
- 14. Testing – When? ~95% of individuals who WILL seroconvert will be detectable (by Western Blot) by 6 weeks Remaining ~5% of individuals who WILL seroconvert will become detectable (by WB) between 6 wks & 3 mo. Maximum Window Period (by Western Blot) Minimum Ab Window Period (approx.) Minimum P24 Window Period 0 ~2 Weeks ~3 Weeks P24 HIV Ab Detected Detected 6 Weeks 12 Weeks
- 15. Testing – When? 4th GENERATION EIA Negative Indeterminate/Positive If routine testing: Re-test annually prn. If targeted risk testing: Re-test q 3 - 6 mos. If suspected/confirmed exposure: Re-test 4 wks. and 3 mos. post-exposure WESTERN BLOT Negative/Indeterminate Re-test in 4 weeks – may still be seroconverting. *If P24 is Negative but client is presenting with S&S of HIV/AIDS, consult with Infectious Disease Specialist or Laboratory Microbiologist. Indeterminate/Negative P24 Positive Contact Microbiologist and submit plasma for Viral Load. Contact Public Health and/or Infectious Disease clinic. Refer to In-Depth Pre and Post Test Counseling Guide. Positive Contact Public Health and/or Infectious Disease Clinic. Refer to In-Depth Pre and Post Test Counseling Guide.
- 16. Testing – After the test? • Post-test counselling is recommended after an HIV test whether the result was negative or positive. • For people living with HIV infection, post-test counselling is not a one-time event but should be ongoing
- 17. Risk of HIV CATEGORIES FOR ASSESSING RISK: • No risk • Negligible (theoretical) risk • Low risk • High risk DISCUSSION: • How do we assess risk? • What is risk? HIV Transmission: Guidelines for Assessing Risk, Fifth Edition, 2005
- 18. Mechanics of HIV Transmission NO RISK • Potential for transmission: None • Evidence of transmission: None • None of the practices in this group has ever led to HIV infection. There is no potential for transmission since all of the basics conditions for viral transmission are not present. Canadian AIDS Society, 2004. http://www.cdnaids.ca/home.nsf/ad7c054e653c96438525721a0050fd60/4d4cf16b70a 7247f0525732500678839/$FILE/HIV%20TRANSMISSION%20Guidelines%20for %20assessing%20risk.pdf
- 19. No Risk Activities Kissing (no blood); masturbation (non-insertive); receiving unshared sex toys; contact with feces (scatophilia) or urine (urolagnia) on unbroken skin; injecting with unshared needles; using drugs with new pipe or straw; sadomasochistic activities (with universal precautions); tattooing, piercing, electrolysis and acupuncture with sterilized and new equipment; manicures or pedicures; fantasizing; handholding; phone sex/cybersex; mutual masturbation; bubble baths; sensual touch and massage; hugging; watching porn; shared utensils, cups, straws (for drinking); mosquitoes
- 20. Mechanics of HIV Transmission NEGLIGIBLE (THEORETICAL) RISK • Potential for transmission: Yes • Evidence of transmission: None • Practices in this group present a potential for HIV transmission because they involve an exchange of bodily fluids, such as semen (including pre-cum), vaginal fluid, blood or breast milk. However, the amounts, conditions and media of exchange are such that the efficiency of HIV transmission appears to be greatly diminished. • No confirmed reports of transmission for these activities Canadian AIDS Society, 2004. http://www.cdnaids.ca/home.nsf/ad7c054e653c96438525721a0050fd60/4d4cf16b70a 7247f0525732500678839/$FILE/HIV%20TRANSMISSION%20Guidelines%20for %20assessing%20risk.pdf
- 21. Negligible (theoretical) Risk Activities Receiving fellatio or cunnilingus (oral sex); performing fellatio or cunnilingus (oral sex) with barrier; anilingus/rimming (oral-anal); fingering; fisting; using shared sex toys with a condom; using disinfected sex toys; sadomasochistic activities; contact with feces or urine (on broken skin); vulva-to-vulva rubbing; docking; taking breast milk into the mouth. Using drugs with shared pipe or straw; tattooing, piercing, electrolysis and acupuncture with shared equipment/ink; fighting; sharing toothbrushes, razors and nail clippers.*
- 22. Mechanics of HIV Transmission LOW RISK • Potential for transmission: Yes • Evidence of transmission: Yes (certain conditions) • Practices in this group present a potential for HIV transmission because they involve an exchange of body fluids, such as semen (including pre-cum), vaginal fluid, blood or breast milk. There are also a few reports of infection attributed to these activities (usually through individual case studies or anecdotal reports, and usually under certain identifiable conditions). Canadian AIDS Society, 2004. http://www.cdnaids.ca/home.nsf/ad7c054e653c96438525721a0050fd60/4d4cf16b70a 7247f0525732500678839/$FILE/HIV%20TRANSMISSION%20Guidelines%20for %20assessing%20risk.pdf
- 23. Low Risk Activities Kissing (with exchange of blood); performing fellatio or cunnilingus (oral sex) without barrier; intercourse (penisanus or penis-vagina) with barrier; injecting with cleaned needles; tattooing with non-professional equipment/ink; taking blood in the mouth; occupational exposure
- 24. Mechanics of HIV Transmission HIGH RISK • Potential for transmission: Yes • Evidence of transmission: Yes • Practices in this group present a potential for HIV transmission because they involve an exchange of body fluids, such as semen (including pre-cum), vaginal fluid, blood or breast milk. In addition, a significant number of scientific studies have repeatedly associated the activities with HIV infection. Even when the exact mechanism of transmission is not completely clear, the results of such studies conclude that activities in this category are high risk. Canadian AIDS Society, 2004. http://www.cdnaids.ca/home.nsf/ad7c054e653c96438525721a0050fd60/4d4cf16b70a 7247f0525732500678839/$FILE/HIV%20TRANSMISSION%20Guidelines%20for %20assessing%20risk.pdf
- 25. High Risk Activities Anal (penis-anus) or vaginal (penis-vagina) intercourse without condom; receiving shared sex toys; injecting with shared needles/using shared equipment
- 26. Risk from Exposure • Risk of HIV transmission after exposure to HIV-infected blood through needle sticks or cuts is approximately 0.3% (or 1 in 300). • The risk from mucocutaneous exposure (e.g., eye, nose or mouth) to HIV-infected blood is approximately 0.1% or (1 in 1000). • Risk of infection varies with the: – type of exposure – amount of blood/fluid involved – amount of virus in the source’s blood at the time of exposure. • Most exposures DO NOT result in infection! CDC(2003), http://www.health.gov.sk.ca/hiv-guidlines
- 28. Disclosure • How to disclose, to whom, when… – Obligations under the Public Health Act • Legal/criminalization – Responsibility is to ensure the client is aware of the larger issue of criminalization of HIV, but not to provide details Do you feel more comfortable knowing that your patient is HIV negative? HIV positive?
- 29. Disclosure • HIV disclosure ruling clarified by Supreme Court, October 2012 – People with low-level HIV and condoms needn't disclose infection – The court ruled Friday that the "realistic possibility of transmission of HIV is negated" provided the carrier of the virus has a low viral load and a condom is used during sexual intercourse. Otherwise… – People living with HIV have to disclose their status to their partners. http://www.cbc.ca/news/canada/story/2012/10/05/supreme-court-hiv-ruling.html http://www.aidslaw.ca/EN/issues/criminal_law.htm
- 30. Confidentiality – more than nice to know… • HIPA identifies several rules that trustees must follow for the collection, use and disclosure of your personal health information. Among them are: – The primary purpose for collecting personal health information must be for the benefit of the INDIVIDUAL. – Trustees should only collect, use or disclose personal health information required to provide the client with a service. – Trustees must also have practices in place that will ensure the safekeeping of personal health information. • Consider: – Who will have access to the information? – Why they would need to know particular information? The Health Information Protection Act (HIPA) Canadian Nurses Protective Society (CNPS®) http://www.cnps.ca/index.php
- 31. Referrals & Resources You do not have to be the expert… Provide support and education. Provide link to care.
- 33. Platinum vs Golden Rule? • Gold – do unto others as you would have them do unto you • Platinum – do unto others as they want done unto them – treat other people how they want to be treated – requires cultural competence • i.e. Position Statement: Cultural Safety for First Nations, Inuit and Métis people
- 34. What Can I Do? • Learn to see through a different lens • Cultural Humility • Work with others to create safe spaces • Be strategic • Look to leadership from the community • Be accountable • Get support • Who do you stand for? • Who do you stand with?
- 35. In Practice… • Recognize complexities of care • Balance individual needs/rights with those of larger community – e.g. community viral load • There is no black and white…only GREY • Consult with experienced colleagues • Understand that there is often more than one choice for similar situations • Client is part of their own circle of care –Driving the bus! • We are nurses…not lawyers • Know your own limitations and when to refer
- 36. Key Messages • The HIV epidemic shows no signs of slowing down. • IDU is the most common mode of HIV transmission in SK. • Women make up a large part of the HIV epidemic. • Aboriginal peoples are: – over-represented in the current HIV epidemic – infected at a younger age than non-Aboriginal persons (PHAC, Dec 2004)
- 37. Finally… • HIV testing is the key to slowing the epidemic. • Early intervention is so important. • Know your status.
- 39. Contact information Greg Riehl RN BScN MA Susanne Nasewich, RN, BA, BScN, ACRN Aboriginal Nursing Student Advisor Aboriginal Nursing Student Achievement Program SIAST Wascana Campus HIV Strategy Coordinator Population & Public Health Services Regina, Saskatchewan greg.riehl@siast.sk.ca susanne.nasewich@rqhealth.ca @griehl
Notes de l'éditeur
- It pushes all the news buttons: it is a health emergency, it has a human face, it has elements of science, medicine, religion, it has deep grief and moments of extreme joy. It often has enemies: governments, the church, religious bodies, the fraudsters and snake-oil salesmen. It has heroes: the people living with HIV, community groups and NGOs fighting on the frontline of the epidemic, the scientists and researchers working for new treatments, a vaccine, a cure, and the doctors and nurses caring for the sick and dying. It is clear that HIV and AIDS is more than a disease that infects individuals. It is a social, economic and, in some countries, security crisis.
- The couple of media reports of HIV being cured, have all be updated, with people having HIV found on subsequent testing
- Diagnosis of AIDS is less common today. More often referred to as advanced HIV, HIV disease or chronic HIV infection. With care and treatment, ability to postpone, even avoid AIDS.
- Sexual Contact - unprotected sexual contact (oral, vaginal, anal) with someone with HIV (sexual health history, drug history, etc, people have to be comfortable with taking a good history wherever they work, and this can be the start of establishing trusting relationships, etc) insertive and receptive sex (pre-cum, semen, vaginal and anal fluids) Vertical transmission - to fetus/infant during pregnancy, at birth or through breast milk (discuss MTCT, term?) Blood Contact - Sharing needles or other drug using equipment with someone with HIV (e.g. spoon, water, filter; crack pipe; roll/bill/tube/straw for snorting) - Shared personal hygiene equipment (razors, nail clippers, toothbrushes, tattoo and piercing equipment) - Occupational exposure (i.e.. needle stick injuries) - Blood transfusions in Canada, in the past (before 1985) Other body fluids can contain HIV but would less commonly account for infection: CSF, amniotic , pleural , pericardial, peritoneal, synovial fluids Inflammatory exudates (pus) Tissues or organs for transplant Other fluids such as tears and saliva may contain HIV, however NOT in quantity enough to infect; http://aids.gov/hiv-aids-basics/hiv-aids-101/how-you-get-hiv-aids/ Still other fluids such as urine or feces would not contain HIV, unless visibly contaminated with blood The basics conditions for HIV transmission to occur include: Source of organism - infected/contaminated fluid(s) – blood, body fluids containing visible blood, semen, vaginal fluids, breast milk Mechanism/Point of entry – open wound, break in skin – poke/puncture, mouth, vagina, anus, penis Activity that brings the infected/contaminated fluid(s) together with the point of entry – IDU, needlestick, sex – oral, vaginal, anal Susceptible Host
- discuss their feelings about getting tested, and again, the stigma of HIV WHY? 1:4 HIV positive people are unaware of their status.1 In spite of UNAIDS/WHO 2004 recommendations, people who should be tested are still being missed. Missed testing opportunities when providers are required to determine need for testing based on risk Missed testing opportunities when testing is mainly client-initiated Who? >13yrs, sexually active – at least once 13-64, but people don’t suddenly stop having sex the day they turn 65. Opt-out testing is considered cost effective if 1/1,000 tests yield a positive HIV result. Stigma and discrimination will lessen when testing is routine. Gives earlier opportunity for services, care. Helps people to live longer, healthier lives with treatment. Decreases worry about possible infection. Helps prevent transmission to others. Avoids the need to identify risks or exposures.
- The Saskatchewan HIV Provincial Leadership Team (SK HIV PLT) recommends that voluntary confidential HIV testing and counselling be conducted in the following circumstance, as close to the individuals’ home community as possible (UNAIDS/WHO, 2004). The type of testing technology used will be determined by the testing situation:
- http://www.phac-aspc.gc.ca/aids-sida/info/4-eng.php
- Note: HIV testing without consent may be justified in the rare circumstance in which a patient is unconscious, his or her parent or guardian is absent, and knowledge of HIV status is necessary for purposes of optimal treatment of the patient themselves. Disclosure without consent is never justified. And this is often what nurses/health managers, want to know. They want to know who is positive, so they can ‘protect’ their community members, or so they can provide the best care possible (which is usually a smoke screen for finding out who is positive)
- Barriers to testing There are several barriers to increasing the uptake of HIV testing and reducing the proportion of people who are undiagnosed in Canada. These barriers include: inability to accurately assess levels of risk for exposure to HIV by some clients and providers lack of comfort discussing HIV testing and lack of knowledge about HIV among clients and providers provider time constraints for risk assessments and pre- and post-test counselling cumbersome consent procedures fear of stigma and discrimination associated with risk behaviors and/or testing HIV positive http://www.catie.ca/en/catienews/2013-05-09/new-phac-testing-guide-includes-recommendations-promote-routine-hiv-testing
- This describes when to get tested, and when to get tested subsequently
- prior to engaging in risky behaviour.
- Canadian AIDS Society also lists “using drugs with shared pipe or straw; tattooing, piercing, electrolysis and acupuncture with shared equipment/ink”. * These variables require some discussion! The level of risk is for these activities (as with most) is influenced by other variables such as where a tattoo was done and by whom, who was involved in the sharing, etc. CDC still indicates there is risk of transmission from these activities. In practice, we would consider the activities in the note here “exposure” and would do testing at 4 wks and 3 months. How much of the “discrepancy” in our treatment of the 2 different portions of this list is related to OUR procedures and what WE ask vs. how much is evidence based.
- Note HBV, HCV, HIV and risk – immunization, prevalence, virulence, post-exposure proph HCV 10x HIV; HBV 10x HCV (100x HIV)
- Standard or Universal Precautions.
- Public Health Act/Health Information Protection Act (HIPA) regulates/impacts: disclosure* age of consent/disclosure responsibilities charting (also comply with agency & professional guidelines) circle of care for client referrals consent for Release of Information storage of results, including access to positive results Acknowledge personal connections in smaller communities (rural, on-reserve, GLBTTIQ*)
- There is no good evidence that the criminal law is effective at preventing HIV transmission. Criminalization of HIV may drive people away from public health initiatives that have proven effective, such as HIV testing, counselling and support, and partner notification. The public attention given to criminal prosecutions may create a false sense of security that the law will protect people from HIV infection. It may also undermine the message that every person is responsible for his or her own sexual health, and lead to human rights abuses by increasing the stigma and discrimination faced by people living with HIV. http://www.aidslaw.ca/EN/issues/criminal_law.htm
- Health records need to be stored in secure environment. Do you think HIV positive individuals should have separate files to ensure they are kept safe? Who is your organizations privacy officer? Do you have a lawyer that you can consult with? http://www.health.gov.sk.ca/hipa-brochure Public Health Act/Health Information Protection Act (HIPA) regulates/impacts: disclosure* age of consent/disclosure responsibilities charting (also comply with agency & professional guidelines) circle of care for client referrals consent for Release of Information storage of results, including access to positive results Acknowledge personal connections in smaller communities (rural, on-reserve, GLBTTIQ*) Section 65 establishes significant penalties for offences under the Act . Individuals (including officers and directors of a corporation) can be punished by a fine of up to $50,000, one year imprisonment, or both. A corporation can be fined up to $500,000. Even information regarding age, ethnicity, gender by themselves can breech confidentiality depending on who hears/sees it.
- You do not have to know everything, but you do have to be honest.
- The Golden Rule “do unto other as you would have them do unto you” or treat others how we would like to be treated – this is what many nurses were taught in training. In Nursing, this is seen as supporting the provider-client relationship. to truly empathize we need to give the power to the client When the client is culturally, ethnically, or spiritually different from the person or group providing care a dilemma evolves. For social justice to support inclusivity, avoid the Golden Rule, and shift our focus to the Platinum Rule, ‘treating others how they want to be treated’. The challenge for the Platinum Rule is evident in practice, and occurs when providers work with clients who are actively engaging in risky, unhealthy behaviours. Harm Reduction creates challenges for nurses, just as morals and personal values can often interfere with providing care to “those” people. The notion of a provider’s belief in a supernatural being who decides on right and wrong can affect interactions with marginalized people, especially those who “choose” harmful behaviours. I/we believe we should not treat everyone the same because we are all different. Patients, families, groups, and communities possess the knowledge to be active consumers and partners in health programming. Acceptance of all clients, with a focus on genuine empathy, regardless of lifestyles and choices, is required for health care providers and educators in today’s dynamic learning and client-first focused environment. Cultural Competence is part of the Platiunm Rule! Cultural safety stresses the importance of reflection & acceptance of differences. We should not treat everyone the same. We do need to recognize and acknowledge our blind spots. It is the position of the Canadian Association of Nurses in AIDS Care that: First Nations, Inuit and Métis people are a diverse, vibrant population who bring strength, fortitude and knowledge to our communities. First Nations, Inuit and Métis people experience unique barriers to health and well being due to a history of colonization and continued racism in both general society and within health care. Racism is a social determinant of health that must be addressed, explored, challenged and changed to ensure that all care is culturally safe. To provide optimal prevention, health promotion and care for First Nations, Inuit and Métis people, nurses require knowledge and skills about indigenous history, colonization, generational trauma and culturally safe practice. Nurses recognize that all interactions with clients are bi-cultural and nurses must understand their role as a ‘bearer of culture’ and examine their own realties, attitudes and beliefs. Nurses must acknowledge the power they posses as a nurse and its impact on others – cultural safety is determined by the person we are providing care to. Nurses should work with their organization to identify and address issues that may affect client’s accessing services. Nursing care should be undertaken whenever possible, with the input of the client and/or whomever the client identifies as their community, family, significant other(s) and support structure. Nurses working in HIV/AIDS care must be committed to ongoing professional development to obtain and maintain cultural competency. To optimize client outcomes, workplaces and nursing education programs should make every effort to recruit and retain nurses with First Nations, Inuit and Métis heritage.
- “We (nurses) don’t have a right to be uninvolved” Cathy Crowe, CANAC 2013 Nurses have a huge capacity to influence policy and politics Advocacy is integral to nursing practice Sharing best practice, skills, tools and knowledge benefits everyone involved Engaging the community in our learning and development benefits everyone and is highly valued by community members Involvement of people living with HIV/AIDS in the education of health professionals is not an ‘add on’ it is essential
- Know the difference between giving advice and sharing information
- Further research is needed on the pattern of HIV/AIDS and HIV testing among Aboriginal peoples to increase our understanding of the specific impact of HIV on Aboriginal peoples to guide prevention and control strategies. Are Aboriginal people more at risk for HIV?