General management of HIV-infected people
One of the most important aspects of dealing with any HIV- infected person is confidentiality (Box 4.6). Maintaining confidentiality might be complicated: for example the patient's family or friends may not know his or her diagnosis or sexual orientation; people at work (or school) may seek medical information (especially if the individual is having time off
Box 4.6 General management of the HIV-infected person
• Protect confidentiality
• Medical issues
• Psychological support (patient, family and friends)
• Avoidance of transmission
• Other issues (dental treatment, insurance, work, or school, etc.) work); or the person may fear that information may inadvertently be given to third parties.
Special precautions may be required, firstly to reassure the patient that confidentiality is protected and, secondly, to limit any unwarranted dissemination of confidential information. Issues related to partner notification are discussed in chapter 13.The routine medical management of these individuals is usually straightforward. They should be seen regularly, for example every three to six months. At each visit the patient's weight should be recorded and special attention given to mouth or skin problems and, if necessary, they should be referred to the appropriate specialist. Screening for STDs and hepatitis viruses should be offered if the individual is at risk and hepatitis A and B vaccines can be safely given. Repeating a full blood count and measuring the CD4 count and viral load every three to six months allows early detection of actual or imminent immune dysfunction. Patients should be advised to reattend if they develop any symptom, especially those suggestive of opportunistic infections or cancers, for example shortness of breath, cough, haemoptysis, pain or difficulty in swallowing, diarrhoea, weight loss, fevers, headaches, fitting, altered consciousness or purple spots on their skin. Other symptoms may indicate increased viral replication and the need to consider treatment.
Psychological and emotional support of the infected individual, the family and friends are a vital aspect of management (see chapter 13). HIV antibody positive persons should also be advised about reducing the risk of transmitting HIV to others and reducing their own risk of receiving different, possibly drug resistant, strains of HIV. Advice concerning safer sex, safer needle use, pregnancy, breastfeeding and children should also be provided (see chapter 16). Patients should be advised to tell their dentists about their infection, and it may sometimes be necessary to refer them to a dental unit with an interest in HIV-related problems.
The physician may also be asked to advise about insurance, work, immigration, travel passes, housing and disability benefit. Patients should be referred to the relevant legal or benefit agency as soon as possible. Infected individuals will often have considerable difficulty in obtaining life insurance as most insurance companies ask specific questions about the infection and either refuse insurance or charge very high premiums. Finally, patients should be told that being positive is no barrier to employment provided there is no chance of their body fluids entering another person or of them transmitting an opportunistic infection, such as tuberculosis, by coughing. It is worth noting that for notifiable diseases such as TB, standard, confidential public health notification procedures still apply. Because of widespread misconceptions about infectivity which are still prevalent, information about the individual's HIV status should never be divulged to employers without their written consent.
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