Nurses are at the heart of achieving HIV treatment and prevention goals, according to the American Nurses Association's 13 updated policies on preventing and caring for HIV and related conditions, which were released in December 2019.
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Tracy Hicks, DNP[/caption] But advanced practice registered nurses and other nurses don't have the necessary authority to do all they can to improve access and reach more patients with preventive education and pre-exposure prophylaxis (PrEP). Nor can they provide the holistic care for which nurses are known, according to Tracy Hicks, DNP, FNP-BC, PMHNP-BC, FIAAN, CARN-AP, a practice owner and program director of the Health AIDS Recovery Program-Special Health Resource, a Ryan White founded clinic in Longview, Texas. Hicks, who reviewed the ANA HIV policy statement, said its recommendation for full practice authority for APRNs is crucial. Hicks previously provided primary care for those living with HIV. She now focuses on patients' mental health needs and treating those who need buprenorphine treatment for opioid abuse. One of the challenges Hicks faces without full practice authority is not being able to prescribe buprenorphine for opioid addiction unless she works with a physician who is Suboxone waivered. Physicians who are waivered are few and far between, said Hicks said, who is on the board of directors for the American Academy of HIV Medicine. "It is crucial we get that full range of care," she said. "For me in my private practice, if I don't have a physician, I can't help combat the crisis."
Leading HIV care teams
Nurses stand poised to lead HIV care teams because they're trained in providing holistic care, take the time to provide that care and are seen by many as trusted providers, according to Hicks. Caring for HIV patients means looking far beyond the diagnosis.
"The cornerstones of nursing are providing safe care, effective care, shared decision-making and letting the patient have a say in their care," she said. "We also need to recognize that we can recommend and educate but we really have to delve in and find out if what we're suggesting is feasible for that client."
Hicks shared a specific example from her career that highlights how nurses can connect with patients. "I had a young lady that came in, and she was seen as somebody that was noncompliant," Hicks said. "She wasn't taking her medicine. Sitting down and talking with her I said, 'You haven't taken your medicine. Your CD4 is 40. You have a viral load of over 50,000. You have two kids at home and you're 22 (with) no job. What is the deal?' She told me she was depressed. She was suicidal. And no one had asked her what the reason was. Once I was able to get her treated for depression and into the therapist, she became adherent."
HIV care comes in many forms
HIV is treatable, yet people are still dying at an alarming rate. The Centers for Disease Control and Prevention reports that about 1.1 million people in the U.S. are living with HIV. About 14% of those people, or 1 in 7, don't know they're infected.
The latest statistics from the CDC suggest an estimated 38,700 Americans became newly infected in 2016. In 2017, there were 16,350 deaths among U.S. adults and adolescents with diagnosed HIV, according to CDC.
The ANA's updated policy statements on prevention and care for HIV and related conditions are meant to help engage nurses in HIV and AIDS advocacy, create awareness about nurses' roles in care and prevention and unite nurses and patients to end the epidemic, according to the ANA. The 13 individual policy statements address support for full practice authority for APRNs to provide care to high-risk groups and lead care teams in high-prevalence geographic areas, but also:
- Voluntary counseling and testing to provide meaningful patient counseling and prevention education.
- Long-term anti-retroviral treatments to prevent transmission and improve health outcomes for people living with HIV and AIDS.
- Access to care among cisgender and transgender women of color, as well as African-American and Latino populations to eliminate disparate health outcomes.
- Patient- and-family-centered care to treat patients' psychosocial concerns and help manage symptoms.
- Review of laws and legal consequences to eradicate HIV-related stigma and discrimination that interfere with appropriate care delivery.
Why safe practice is a must
A big part of harnessing the power of nurses in this epidemic involves keeping them safe and healthy, according to ANA Past President Karen A. Daley, PhD, MPH, RN, FAAN, who in 1998 contracted HIV and hepatitis C from a needle after drawing a patient's blood. Daley, who today speaks about sharps injury prevention and is active in various leadership capacities, said her devastating injury occurred during routine nursing duties. "One of my colleagues asked me to leave the triage area where I was assigned to draw blood on a patient that she was having a difficult time with," she said. Daley got the patient's blood on the first stick, but when she went to put the needle in the box behind her, she felt a sharp stick to her index finger. Needles, which should have been emptied, were protruding in the box, and Daley was fixated on the patient in front of her. "Obviously I was gloved," she said. "I knew it was deep by the way the blood came to the outside of my glove." Daley emphasized that she almost didn't report the injury. In her 26 years of nursing at that point, she had experienced five or six sharps injuries. She reported some but not others based on self-assessments. It was the nurse who asked Daley to draw the blood and saw the injury who encouraged Daley to report it.
"I always think about the fact that I might not have reported the injury and gotten the care I needed, " she said. "You're really depriving not only yourself of the care you might need, but you're also potentially preventing improvement in terms of the safety environment."
In a process filled with lessons she would change today, Daley said the nurse she reported her injury to recommended HIV prevention prophylaxis, based on the injury's depth and the fact there was no way to test the source patient. Daley elected to defer it. The drug cocktail in 1998 was well-defined protocol, but the drugs had a lot of harsh side effects. In the following months, Daley developed symptoms she didn't associate with the injury. About five months after the injury, follow-up lab work revealed Daley had been infected with HIV and hepatitis C. It has indeed been a rough road. Daley's doctors suggested treating the co-infection simultaneously. "I was on daily interferon injections for hepatitis C, which made me really sick, and I was on 16 to 20 oral medications," she said. "My body had been insulted by the viruses, but the drugs were incredibly toxic in those years." Still, Daley started to advocate for sharps prevention a few months into treatment and educated herself about sharps injuries.
"Like every nurse, I thought it was pretty much the cost of doing the work -- that everyone got them," Daley said. "And what I realized as I started doing the reading is that there were some relatively new devices -- probably out for the last 10 years -- that were not being placed in the hands of people that were drawing blood."
Daley, who was president of the Massachusetts ANA chapter at the time, attended a national ANA meeting at which all presidents and executive directors attended to encourage action. "We filed a bill here in Massachusetts that stands today as the strongest legislation in the country," she said. "It requires every hospital in Massachusetts to report any injuries to the department of public health. It allows us to track them, look at trends that might be identified and make recommendations for reducing them." Daley vowed to go anywhere to talk about the issue with anyone willing to listen. "I spoke to legislators, healthcare administrators, nurses in practice -- a wide range of people -- so we could bring attention to the issue," she said. "I saw the power of ANA and collective action." States now have provisions for needle safety legislation, which are listed on the CDC's website.
Work remains on the issue
Today, there's federal legislation, the Needlestick Safety and Prevention Act, which was signed into law Nov. 6, 2000 and went into effect on April 18, 2001. Among other things, the legislation requires that where appropriate safety devices must be placed in the hands of direct users -- people who draw blood, people who put IVs in and people who use sharps. Sharps injuries in the U.S. dropped 33% the first year of the legislation and CDC anticipated within five years, preventable sharps injuries would be all but eradicated, according to Daley. That hasn't happened yet, and sharps injuries continue to be a major concern among nurses. Only two data sources remain that give an indication of what's going on in real-world practice: Massachusetts' data and that from the International Safety Center's Exposure Prevention Information Network surveillance system. "At this point, we've hit a bit of a plateau," Daley said.
What nurses need to know
Nurses should be involved in choosing the safety devices they use in their work environments, so they're more likely to use them and use them correctly.
"In a lot of places, we're still seeing injuries because they're not being used correctly," Daley said. CDC estimates that safety devices could reduce sharps injuries by 60% to 88%, she said.
"Make sure that you have devices that are effective, that you're comfortable with. If you need training, get that training," Daley said. Another safety tip for nurses is to be mindful when using sharps. Pay attention, said Daley, and don't try to do three things at once. "I would say the last piece is when an injury occurs, we should not do our own assessment," Daley said. "I think that's common for providers to do that. Instead, when an injury occurs, each one should be reported because it indicates either a bad process or bad device. There's a potential to improve safety within the work environment once reports are being made." Daley said she wishes she would have taken advantage of the prophylactic drugs. "The drugs are much better tolerated today," she said. "Prophylactic drugs are thought to be up to 80% effective after HIV exposure." Taking care of nurses is important in tackling HIV, according to Daley. "We're never going to solve the HIV epidemic without nurses," she said. Hicks considers it an honor and a privilege to care for her clients and patients. "I do not take it lightly that people trust me with their vulnerabilities and allow me to walk with them on their journey to recovery and healing," she said. "We have to understand that HIV is a treatable disease. When you're dealing with someone, especially those living with HIV, they're already dealing with something that's already stigmatized and that is a life-changer for them. "So, you have to really explain to them that these are disease processes that are treatable, and we can manage this," Hicks said. "Let's share the care together."
Take these courses to learn more about caring for patients with HIV:
Clinical Management of HIV in Adults in the ERA of Highly Active Antiretroviral Therapy (1 contact hr) Newer drugs with fewer adverse effects and more convenient dosing schedules have enabled even more patients to participate in and adhere to these more effective regimens. New combinations of effective therapies, however, contribute to the clinician's arduous task of prescribing antiretroviral medications and educating patients about these therapies. The various combinations and the multitude of possible drug interactions -- both between active antiretroviral therapy medications and any medications used to treat comorbid conditions -- contribute to the complexity of care for the patient with HIV. This module provides information about HIV infection and treatment. Promoting Medication Adherence in HIV Treatment (1 contact hr) With the use of antiretroviral therapies, the progression of HIV infection to AIDS has been slowed, and AIDS deaths have been reduced. However, the bad news is that patients experience numerous difficulties taking these therapies, and adherence to treatment regimens can be challenging for patients. Healthcare providers can help design individualized plans of care to improve adherence. This activity will address barriers to adherence and negative consequences of nonadherence to drug therapy. Sexually Transmitted Diseases: Women Face More Risks (1 contact hr) STDs are a serious problem in the United States. Each year, nearly 20 million Americans, half of them between the ages of 15 and 24, become infected with an STD. The highest rate of infection is among female adolescents. The long-lasting health effects for young people are particularly serious. Consequences of untreated STDs may include infertility, brain and other organ damage, and an increased susceptibility to HIV. Sexually active people need the correct information on preventing STDs so that they can make informed decisions about their sexual activity. All healthcare providers who are knowledgeable about STDs can help provide that information. This course describes common STDs and their treatment.
