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HIV: Therapeutic Strategies for Guilt, Uncertainty, and Taking Control
HIV: Therapeutic Strategies for Guilt, Uncertainty, and Taking Control

Section 10
Treating Psychosocial Issues in HIV Positive Clients

Question 10 | Answer Booklet | Table of Contents | HIV/AIDS CEU Courses
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

Unpredictability: Although counselors working with persons impacted by HIV/AIDS have been dealing with the unpredictability of this illness and the resulting lack of control that persons in the spectrum feel, newVirus HIV Therapeutic Strategies mft CEU course treatments have added another dimension to this theme (Kalichman et al., 1998; Kelly, Otto-Salaj, Sikkema, Pinkerton, & Bloom, 1998; Rabkin & Ferrando, 1997). For example, it is still too early to know just how long these new treatments will continue to fight a virus that often mutates (Carpenter et al., 1997; Fatkenheuer et al., 1997). Further, recent studies have suggested that long-term use of HIV medications can have some very serious and severe consequences (Carpenter et al., 1997). Finally, when and how HIV will resurface as an active virus is still an unknown.

Difficulties in Undertaking Treatment:  The new medical treatments can be quite challenging. Frequently, clients are taking medications that can make them very ill, require stringent regimens, and are expensive. Moreover, many clients have been subjected to exhilarating hopes followed by desolation and disappointments. Understandably, some decide to withdraw from medical interventions. They may be going through the process of preparing to die and are thus not willing to go back to a different stage in the process. Clients often report, "I cannot be disappointed one more time." Alternately, they may refer to being tired of being "a guinea pig" or proclaim that "I am ready for it all to end."

Denial as a Coping Method: Some clients use denial as their primary way of coping with the unpre-dictability of the new medical treatments. This can be especially true for people whose viral load is undetectable. It can become seductive to return to the lifestyle they lived prior to HIV infection. "I feel fine, so I must be fine. Thus, I will live as if HIV did not exist in me," which may result in excessive use of alcohol, drugs, or unprotected sex. Denial keeps them "safe" from recognizing some returning symptoms that may indicate the new treatments are not working quite as effectively.
Alternatively, the new treatments may force clients who were in denial about their disease to face and accept their HIV status. For example, clients who had quit or ignored medical treatment when newly diagnosed are now hearing the news about promising new medications and the importance of early treatment. Consequently, revisiting medical treatments means that once again they have to deal with the reality of having the HIV virus--medical tests, viral loads, medication, side effects, and the unpredictability of treatment. Moreover, some of these clients may have been symptom free, yet now are taking medications that may have very unpleasant side effects.

Life/career Planning: Clients benefiting from the new treatments may have corresponding career issues (Brooks & Klosinski, 1999). Now that they are feeling better and have new hope, they need to explore what they will do with their lives. However, these are complex decisions. People on disability may be getting healthier, but have fears about terminating their disability benefits, as they might then lose medical benefits. They may desire to return to work, but at the same time they can't afford to give up government assistance. They may be concerned that if they return to work their health may suffer or they may lose their benefits due to improved health status. "I could make decisions if I had some sense of what was going to happen to me." Questions as to employability and necessity of disclosure of HIV status appear as well. Life planning may mean a change in identity. For some, especially those who are considered long-term survivors, AIDS has become an integral part of their self-concept. These people have spent much of their lives finding ways to treat, manage, and live with this insidious disease. The advent of new treatments and the possibility of a more healthy lifestyle may create a loss of identify related to being sick and having AIDS, as evident from statements such as, "AIDS has been my life for so long; I don't really know what to do without it."

Nonresponsiveness: There are some individuals who do not respond to the new treatments in positive ways. Some are unable to tolerate the side effects. For others, the drugs do not control the replication of the virus (Gilden, 1996). Still others find the new treatment interferes with the effectiveness of other medications (e.g., psychotropic medications or other life-sustaining treatments) (Nemeroff, DeVane, & Pollick, 1996; Shader & Greenblatt, 1996; Van Cleef, Fisher, & Polk, 1997). A deep sense of anger, frustration, and helplessness may result (Kalichman et al. 1998). Nonresponding can be especially difficult when others in their lives (e.g., a partner) are responding positively to the treatments. Where once everyone in the HIV spectrum had a common bond, now there can be a sense of separation in those nonresponding from those who are doing well. Clients may report a sense of personal failure, "Perhaps I was not good enough" (Rabkin & Ferrando, 1997) or guilt,"I am letting my partner and loved ones down by not getting better."

Adherence Issues: Adherence to the new treatments is imperative, or they may become quickly resistant to the medications and perhaps others in the same family (Deeks et al., 1997; Kuritzkes, 1996; Mellors, 1997). Moreover, persons may end up with a medication resistant strain of HIV that potentially can infect others, who also will not be able to benefit from the new treatments (Bangsberg, Tulsky, Hecht, & Moss, 1997; Gwadz et al., 1999).  With such severe consequences, it may be difficult to understand why noncompliance may be so pervasive. However, there are some compelling reasons why persons may choose not to adhere to the medication regimes (Aversa & Kimberlin, 1996; Besch, 1995; Mehta, Moore, & Graham, 1997). Potent side effects can be very debilitating; especially difficult to tolerate when, prior to the medications, the client may have been symptom free. Medication interactions can alter the impact of other salient medications (Shader & Greenblatt, 1996; Van Cleef et al., 1997). The strict dietary restrictions and rules make taking the protease inhibitors very arduous. For example, some need to take pills one hour before eating and two hours after. Coupled with severe diarrhea, it can be a regimen too stressful for some. Persons with chemical dependency issues or severe mental illness may be in positions of not being able to manage such complex medication protocols. Additionally, for clients who have adapted a wellness paradigm in terms of treatment (i.e., regular exercise, medication, and substance free), the toxicity of the protease treatment may be quite contradictory to the manner in which they have dealt with this disease. For those whose primary coping mechanism includes denial, taking medications is a constant reminder of being "sick." Additionally, it is difficult to adhere to a medication after witnessing someone's failure with the same medications. Finally, as these medications are so costly (Holtgrave & Pinkerton, 1997), economic concerns may interfere with adherence.
- Britton, Paula; Staying on the Roller Coaster with Clients: Implications of the New HIV/AIDS Medical Treatments for Counseling; Journal of Mental Health Counseling; Jan 2000; Vol. 22 Issue 1
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #4
The preceding section contained information about treating psychosocial issues in HIV positive clients.  Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 10
According to Britton, what are six psychosocial issues common to HIV positive clients? Record the letter of the correct answer the Answer Booklet

 
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The article above contains foundational information. Articles below contain optional updates.
Cocaine use associated with poor adherence to PrEP and dropping out of care - February 22, 2019
Cocaine users have poorer adherence to HIV pre-exposure prophylaxis (PrEP) and engagement with care, according to research published in the online edition of the Journal of Acquired Immune Deficiency Syndromes. Even light cocaine use doubled the odds of having blood levels of tenofovir, a key PrEP drug, that were insufficient to protect against infection
In the USA, only two in five PrEP users keep taking it over two years - February 21, 2019
Real-world data from a large American chain of retail pharmacies show that only two in five people keep on taking pre-exposure prophylaxis (PrEP) for two years after starting, researchers report in the Journal of the International AIDS Society this week.Most studies of PrEP persistence have been for shorter periods of time, but it has
Shifting social norms around what “safer” sex is: perspectives of HIV-negative men in Canada - February 20, 2019
HIV-negative men who have sex with men (MSM) living in Vancouver, Canada are redefining ways to negotiate sexual safety and risk, according to qualitative research recently published by Dr Benjamin Klassen and colleagues in BMC Public Health. Condoms are no longer seen as the only means of preventing HIV infection. Biomedical prevention strategies –  including
Gay men in New York rate an undetectable viral load as less effective than PrEP - February 19, 2019
Gay, bisexual and other men who have sex with men in New York City rate daily pre-exposure prophylaxis (PrEP) as the most effective HIV prevention strategy when condoms aren’t used, and considerably more effective than treatment as prevention or event-based PrEP, according to survey results published in AIDS and Behavior. Men rated these biomedical approaches
Nicotine metabolised at a faster rate among HIV-positive smokers – implications for quitting smoking - February 18, 2019
HIV-positive smokers metabolise nicotine at a significantly higher rate than HIV-negative individuals, investigators from the United States report in the online edition of AIDS. The finding could explain why people with HIV have more difficulty quitting smoking than their HIV-negative peers. A second study involving the same HIV-positive smokers and published in the Journal of Acquired Immune

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