June, 2011

HIV Case Conference Summary June 2011

Case #1
Presented by Dr. Gordon and Dr. Glover

35 yo F w/ h/o HIV diagnosed 2yrs ago during pregnancy, recent CD4 500, VL 700.  During her pregnancy there were concerns about the possibility of substance use vs. mania b/c of hyper, erratic behavior followed by periods of listlessness.  Multiple utox screens during pregnancy were negative.

Now she is being followed by Dr. Glover for feelings of low mood, intense anger, and poor frustration tolerance.  She has not been interested in taking psych medications and has been working on cognitive therapeutic techniques to improve her awareness of her feelings.  Initially did well on antiretrovirals with undetectable VL on atripla, but recently noted to have elevated viral load for past several months.  The patient has many social stressors including caring for her 2yr old, 7yr old, 16yr old with special needs and 18yr old who just had a child herself.

Dr. Gordon has been working on addressing the reasons behind her elevated VL.  At her most recent visit the patient expressed that she has been having side effects to her medication including increased anxiety about her youngest child's safety.  She told Dr. Gordon that she has only been taking the atripla 2-3 times a week b/c of these side effects.  She also admitted to feeling guilty about recent binge drinking, but denied other substance use.

At this visit Dr. Gordon ordered a genotype to check for resistance and advised the patient to stop her atripla.  She also referred the patient for care coordination services with Argus, and sent a utox.  The patient followed through with enrolling with Argus.  Her tox screen came back positive for cocaine and marijuana.  She has since missed a f/u appt with Dr. Glover.  She has an upcoming appt with Dr. Gordon.

Question: How do you address the positive utox with the patient without alienating her or making her defensive?

Recommendations from the group:  In general approach her with a non-confrontational, neutral approach.  Don't apologize for doing the test.  Present the results as a fact.  Let her know that you are concerned about her and want to know how she feels about drug use and her health.  Give her the opportunity to open up to you and let you know what her perspective is, rather than giving her a lecture. 

The goal is to keep her engaged and for you to have a better understanding of where she is coming from.  Once you understand what her barriers are and can work on them together, you can develop a plan to get her back on ARV medications.



Case #2
Presented by Dr. Davis and Angela

33 yo F with h/o HIV and asthma never on ARV therapy in the past presented to CHCC with a CD4 of 206 interested in starting ARV medications.  At her first visit a genotype was drawn.  When she followed up again she asked to start HIV meds.  She was told that she needed to meet with Angela before starting medications.  In the interim she developed severe herpes zoster requiring hospital admission.

 She was seen by Angela to discuss starting ARVs.  Angela noted that she was extremely anxious and had poor adherence with appts and asthma medications and struggled to perform basic ADLs.  Angela felt the patient was not prepared to take ARVs properly and recommended that she begin treatment with psych for her anxiety.

The patient continued to express to Dr. Davis that she was eager to start medication.  This was frustrating for both the patient and Dr. Davis.   Since that time the patient sought treatment at an outside clinic where she was prescribed ARVs.

Questions:
Do we have an official policy on when or how to start patients on ARVs for the first time? 

No, we do not.  This is an individual case-by-case decision.  It is recommended that patients have genotype results and baseline labs including CD4, VL, CBC, chem7 and LFTs available before starting therapy.  Many patients benefit from adherence counseling and education and some patients need additional support with pillboxing and DOT services.  Many of our patients have psychiatric and substance use comorbidities creating additional barriers to successful treatment.  

Residents and fellow preceptors, if you have any questions or concerns, please do not hesitate to contact the HIV preceptors.  Each resident is assigned to an HIV preceptor (Rob, Elliot or me) who is available to provide consultation.  You are welcome to call or page us to discuss cases as you are seeing them in clinic.  Angela is available at x 294 or 917-568-7676.  I am also always available at any time.  You can knock on my door, call or page me with questions.

How can we improve communication between the CICERO team and medical providers?

I would like everyone to share their thoughts with me for how to do this better.

  We are now using phone notes in EMR to document referrals to the CICERO team.   The idea is to improve documentation, communication, follow-up and accountability.   For the following issues send phone messages documenting why you are sending the patient and what you need done to the person(s) listed below and place the note on hold so they can respond to you.

Social Work: Norma Piazza-Howard AND Jose Rodriguez
Adherence/Pillboxing: Angela Giovaniello AND Norma Cordero
Nutrition: Viviana Ramos
Psychology: Veronica Voyages
Psychiatry: Karinn Glover
Patient navigation: Alexandra Bobadilla

FYI every CICERO patient should see Norma Piazza-Howard at least once a year for a needs assessment and every patient should have at least one screening visit with Dr. Voyages for mental health/dementia assessments.

Please share your thoughts and suggestions.

Thank you,
Laura

646-267-4307
917-949-8771
X 424
laguderi@montefiore.org
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