August 2011

Dear All,

Thanks to everyone who was able to attend the conference.  For those of you who were not able to make it here is a summary of what we discussed.

Today’s Case: Presented by Swana DeGijsel and Dr. Glover

KR is a 42 yo African American woman with a history of AIDS, depression/anxiety heroin abuse (reports that she has been clean for 12 yrs) and hypothyroidism.  She is a former social worker who recently moved back to NY from out of state.  In January of this year her sister, whom she was very close to and was living with at the time, died unexpectedly of a hemorrhagic stroke.  This was devastating for her.  She lost the apartment and had to live in a shelter briefly.

Her husband is HIV negative and has a history of abusing her physically and verbally.  He disclosed her HIV status to their neighbors by yelling at her in the building hallway.  She has 2 teenage children who are not supportive and her mother lives in South Dakota.

She was started on ARVs a few months back and achieved an undetectable VL within 2 months of starting Atripla.  She then stopped coming to her appointments and became non-adherent with medications.  Swana made a home visit and referred her to Argus Case Management which initially resulted in improvement.

At her most recent clinic visit she had just had a physical argument with her husband and had multiple ecchymoses on her extremities.  Argus has been reaching out to her with home visits.  During one of the home visits the patient answered the door naked and invited the case worker inside, not seeming to care that she did not have any clothes on and despite the fact that other people were also in the home.

She is being treated for depression by Dr. Glover and has been requesting specific psych medications and asking for early refills. 

Her CD4 count is declining and her VL is persistently elevated.  She has now lost the apt she has been living in and needs to find a new one or move back to the shelter.

Recommendations by the group:

This patient is sending a clear message that she is in trouble and in need of help.  We should arrange for a multidisciplinary visit with mental health, medicine and Argus to reach out to her, discuss what has been going on and try to find the help she needs.

Atripla has a low barrier for resistance.  Her ability to adhere to treatment if poor currently.  Discontinue her antiretroviral therapy for now.  Keep her on PCP prophylaxis.  Before considering pillboxing and/or directly observed therapy make sure that her mental health issues are adequately addressed and that she is stable enough and ready to resume therapy and is willing to agree to and comply with pillboxing/DOT.  Increase the frequency of her follow-up visits.  Check a genotype prior to changing or resuming ARV medications.

The event of her sister’s death seems to have been the initial trigger for her life to spiral out of control.  We need to make sure that we are adequately addressing her grief.  Try and find at least one person in her life that can provide some stability for her, possibly one of her children or a close friend.

Her erratic behavior is very concerning for possible ongoing substance abuse.  This pattern could be consistent with cocaine abuse.  Although she reports that she is not using illicit drugs it is important to discuss this as a possibility with her and to check a urine tox screen.  If she is using illicit drugs then we can begin discussing treatment options including residential drug treatment programs. 

Make use of her background as a former social worker.  Ask her if she were seeing a patient with her issues and problems what would she recommend?

Given the ongoing domestic violence in her household consider referring her to an organization that assists victims of domestic violence such as Safe Horizon. 

SAFE HORIZON HOTLINES

Domestic Violence Hotline: 800.621.HOPE (4673)

Crime Victims Hotline: 866.689.HELP (4357)

Rape, Sexual Assault & Incest Hotline: 212.227.3000 OR 866.689.HELP (4357)

Our next case conference is Wed, September 21st from 1-2pm in the CHCC basement conference room.  I am planning to discuss 2 transplant patients on multiple immunosuppressive medications and ARVs.  If anyone has a complex medication interaction case they would like to share or any other cases please let me know.

 

***I posted some HIV resources and basic guidelines in the precepting room.  Please take a look and make suggestions for improvement.***

 

As always you are welcome to contact me with any questions, problems or suggestions.

 

Thanks,

Laura

 

CHCC x424

646-267-4307 cell

917-949-8771 pager

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