Microsoft word - reflectionsonline2004.doc

About the Author
Dr. Jean Penny is Founder and President of Pennywise Educational Enterprises, a continuing
education firm. She’s a masters prepared clinical specialist in maternal child health and an ARNP
in Women’s Health Care. Her PhD is in Higher Education. Jean has practiced as a staff nurse, a
public health nurse, a supervisor, a nurse practitioner, an educator, a “bureaucrat” (Nursing Board
administrator), a consultant, and now a nurse entrepreneur—publishing and marketing creative
home study courses using storytel ing to teach. Jean’s proud to be a founder of the Northeast FL
Great 100 Nurses and also Distinguished Lecturer for Sigma Theta Tau International. She
recently addressed an international Women’s Health Congress at Khon Kaen University in the
Republic of Thailand about Domestic Violence education for healthcare professionals and was on
the (Jacksonvil e) Mayor’s Task Force Against Domestic Violence. Need a Penny? Cal Jean!
Her company’s motto is: “Get Pennywise!”

REFLECTIONS
(HIV/AIDS UPDATE)

Learning Objectives: After reading this course, you wil be able to
1. Identify some of the current issues surrounding HIV treatment and management.
2. Discuss the increase in rate of HIV infection among groups at or below poverty level. 3. Relate the current focus of treatment and management . 4. Examine the position of “alternative” therapies in symptom management. How must it feel to find out you’re HIV positive? “Positive always meant something good when I was growing up. Now the word seems almost synonymous with despair. Why not another word for being infected with HIV? Like maybe ’subjected’.”18, p148 “You know the feeling you get when you’ve gotten off the bus and you realize you’ve left your wal et on the seat and the bus is taking off? Wel , [for me] the proverbial bus has taken off.”18, p211 Shortly fol owing the September 11 terrorist attacks, an unidentified individual in Florida (after testing negative for HIV) gave blood for the first time and then became a regular donor. But, in May 2002, blood given by this donor tested positive for HIV, making it necessary to track down al recipients of earlier donations. Officials discovered that two patients in the Tampa/St. Petersburg area—a young adult and a mid-60s adult—were now infected with the HIV virus, presumably from contaminated blood.24 What had happened was that the donor’s blood, unbeknownst to anyone including the donor, was actual y positive for HIV in March 2002. But HIV test results in March registered (falsely) negative—due to the fact the timeframe of the test was within the roughly 25 day transition window. The donor’s profile met none of the HIV risk factors and there was (and stil is) no suggestion he or she lied.so, the blood was used. Compared to other things that can happen to a patient in need of a blood transfusion, the risk of contracting HIV is incredibly smal and remote (about 1 in 2 mil ion); so the FDA and the American Association of Blood Banks have determined that the US blood supply should continue to be considered safe. Thankful y, five other recipients of blood from this donor al tested negative for HIV infection. Beginning in 1999, al blood donated in the US has been rigorously tested and only one other instance of accidental infection has been reported.24 Since the implementation of HAART in 1996, the number of people diagnosed with AIDS and the number of AIDS deaths have both declined. On the other hand, the number of people living with AIDS has increased. Although side effects of HAART can range from mild and transient (headaches, nausea, insomnia) to potential y severe (lipodystrophy, heart disease, and osteoporosis), the maximal benefit is only attained through consistent adherence. When adherence is faithful and unwavering, an HIV infected individual’s chances of survival are dramatical y improved; with the most marked improvement is seen in Caucasians, males, men who have sex with men, and people with a high socioeconomic status.20 It is discouraging that probably more than half of those infected in the US are unaware of their HIV status and are thus not seeking treatment.20 As a result, Pneumocystis pneumonia
(PCP), an AIDS defining il ness for which there is highly effective prophylaxis, seems to be on
the rise in some populations. There have also been increases in rates of AIDS dementia
complex (ARC), TB, and non-Hodgkin’s lymphoma (NHL); while the rates of mycobacterium
avium complex (MAC), cytomegalovirus (CMV), and cryptosporidiosis (crypto) have decreased
since the inception of HAART. As people live longer with AIDS, the disease continues to place a
burden on the US healthcare system. Since variables such as wealth and gender influence
outcomes, access to treatment and prevention services must be improved in order to decrease
the overal impact on public health.20 Even with recent clinical successes related to simplified
treatment regimens, the HIV positive numbers continue to climb among susceptible groups;
namely, women, children, and racial and ethnic minorities. Intensive efforts notwithstanding,
there stil remains no real “cure” on the horizon.
PATHOGENESIS
AIDS is caused by the Human Immunodificiency Virus (HIV). HIV, being a retrovirus, often enters a proviral state characterized by slight or absent viral RNA and viral-specific protein production. The HIV infected cel s can remain in the dormant state for years or they can go into an active production cycle, cloning themselves into new copies of HIV. These new editions then use the circulatory system like linking interstate highways to travel to far distant parts of the body, setting up new reservoirs of infection in other organs and body systems. HIV infection is considered to be a chronic il ness. The initial infection leads to a compromised immune system due to viral attacks on the helper cel s which normal y orchestrate the immune response (T-lymphocytes or CD4 cel s). The amount of CD4 cel presence reflects the severity of the infection, as does the viral burden (or viral load), referring to the amount of HIV in the bloodstream. The higher the viral load, the more advanced the disease progression. As the virus continues to kil cel s bearing CD4 receptors, the CD4 cel count drops, signaling progressive immunosuppression.,24 Ultimately, after development of an "AIDS defining" il ness, Acquired Immune Deficiency Syndrome (AIDS) is diagnosed. According to the Centers for Disease Control, (CDC) the current surveil ance definition for AIDS includes a CD4 count of less than 200 cel s/mm3 or development of an opportunistic infection or indicator condition such as pulmonary tuberculosis, recurrent pneumonias, or invasive cervical cancer.8 HIV can "hide" and remain undetected in a person who is feeling wel --and/or is untested and unsuspecting--for as long as ten or more years. Most HIV infected people undergo a gradual decrease in the number of CD4 cel s, denoting a corresponding gradual, yet progressive, deterioration in the immune system. Except.we now know there are a handful of people who have been living with the HIV virus but have never progressed to AIDS, despite 20 years of untreated infection. They’re cal ed long-term nonprogressors (LTNPs).11 Why (and how) they stay wel constitutes the central puzzle in HIV/AIDS care. Theories about why LTNPs don’t get sick include: (a) unusual CD8+ T cel activity involving a mysterious cel antiviral factor (known as CAF); (b) a cel kil ing substance cal ed human alpha defensins; and (c) the presence of a molecule involved with cel division known as perforin.20 Whereas there are many clues, the exact reason LTNPs are able to successful y fight off the HIV virus has yet to be determined conclusively. Such a momentous discovery could lead to development of an effective vaccine for prevention—as wel as a “therapeutic vaccine” that could be used to treat people already infected. As current vaccine trials in humans have been disappointing, researchers continue to search for the key to the LTNP mystery.11 There are stil only three recognized modes of HIV transmission: unprotected sexual intercourse with an infected partner, contact with infected blood or blood products (as in sharing injecting drug equipment and receiving infected organs, tissue or sperm), and perinatal transmission.8. You don’t get “it” from a doorknob, a toilet, a faucet, dishes, mosquitoes, towels, being sneezed on, spit at, hugged or any other indirect method that does not involve contact with
infected semen, vaginal secretions, breast milk, or human blood or blood products.8
LEGAL and ETHICAL ISSUES
Courts can order HIV testing, just as they can order other tests and procedures, but only under very specific and unusual conditions. The conditions vary by jurisdiction. An individual accused of rape in Florida, for example, is automatical y court ordered to be HIV tested. When physician certified “significant exposure” to a healthcare worker (or other individual) occurs, a blood sample that is already available can be tested without the source’s permission. If no sample is available, or the source refuses to be tested, an order for mandatory testing can be obtained.24 In Florida, ranked third in the nation with regard to the number of reported cases of AIDS, positive test results may not be provided to the test subject without a second confirmatory test. Post test counseling must involve: the meaning of test results; any further testing; measures for preventing transmission; location and availability of healthcare (including public health), social, and support services; and benefits of locating and counseling of infected individuals.30 During pretest counseling, people tested in Florida must be informed that positive test results wil be reported to the county health department. Anonymous testing, confidential
counseling, and partner notification services remain available. Florida also requires that pregnant
women be counseled and tested. This must include a discussion of possible treatments. If the
woman refuses testing, efforts must be made to obtain a written statement to that effect and the
statement should be included in the medical record.
PREVENTION
Education about transmission, aimed at risk avoidance or reduction, remains our one truly reliable weapon to prevent HIV. Prevention techniques can be categorized as either “safe” or “risk reducing .” Safe activities eliminate al risk, such as abstinence, saying no to drugs, and preventing HIV infection in pregnant women. “Risk reducing” activities decrease risk, but do not total y eliminate it, such as condom use, “clean” drug paraphernalia, and treating infected mothers and their newborns with ZDV. “High risk” behaviors involve no effective effort to either eliminate or reduce risk. Examples of high risk activities include unprotected intercourse with an infected partner, sharing “dirty” needles, and untreated pregnancy in an infected mother. Attitudes drive behavior. Much of what health education is about is changing attitudes in order to influence “better” behaviors. Harm reduction is an approach to disease prevention based on the concept that any change in the direction of safer behavior wil decrease health risks. Therefore, any movement toward safer practices represents positive progress, even though the ultimate goal of absolute protection may not be not attained. This particular model recognizes that behavioral change is a complex process which might best be achieved through smal , sequential, personal y acceptable, and attainable steps. Since attitudes are notoriously resistant to change, health education efforts aimed at encouraging harm reduction (i.e., promoting risk reducing behaviors) must be repeated over and over. Like an oft-repeated commercial, repetition is singularly important in getting the message heard. It has to be heard, of course, before it can be acted on. We stil have such a long way to go. For instance, we’ve known for some time now that some at risk individuals have relaxed their vigilance about safer sex practices, prompted by over confidence in the efficacy of powerful new therapies. This trend is being closely monitored, but it certainly reinforces that regardless of available treatments, prevention clearly remains our strongest and most effective weapon. RISK GROUPS: Gender and Age
With up to 47% of new cases of HIV infection occurring in women worldwide, women of childbearing age represent a fast growing HIV/AIDS group. In the US, the CDC estimates that 23% of the reported AIDS diagnoses occur in women.15,25 The state of Florida ranks high with regard to heterosexual y acquired cases of HIV in women (over 40%) and second in the nation with regard to the number of AIDS cases among children.8 Perinatal transmission is the source of most pediatric infections. Perinatal transmission can be reduced significantly by treating the mother with HAART, to include zidovudine; initiated at whatever gestational stage she presents to the healthcare system. Even if the mother’s initial contact is at delivery, antiretroviral treatment during the intrapartal period, and antiretroviral treatment of the newborn for six weeks, wil stil reduce transmission rates.24 In the US, heterosexual transmission is the major route by which women acquire HIV infection. African-American and Hispanic women are disproportionately affected by HIV disease, representing over 85% of al AIDS cases in females.25 Two ongoing studies have shown that concerns about reproduction have been pivotal in keeping women out of clinical trials. Among other barriers are: (a) fears that hormonal fluctuations may affect outcomes; (b) gender differences (such as differences in body size, fat content, and enzyme concentrations) that may affect drug metabolism; and (c) lack of transportation and child care.25 Numerous studies have suggested that HIV viral loads among women appear to be significantly lower than for men fol owing seroconversion; but after five years, that difference disappears, with viral loads in women increasing more rapidly.15 This is important because viral loads frequently are used to guide initiation and modification of treatment. We know that men and women differ in access to care, with women less likely to receive appropriate antiretroviral therapy or prophylaxis for opportunistic infections. Given the clear survival benefit of current HIV therapeutics, such treatment differentials may lead to serious disadvantages for women.15 For many reasons, HIV infection continues to be troublesome within the adolescent population of the US. Lack of appropriate education, combined with the unique emotional and developmental turbulence associated with the adolescent years, are factors contributing to the problem.7,19 Abstinence is unquestionably the most effective means of preventing infection. A recent national survey by the Kaiser Family Foundation showed that teaching abstinence until marriage is indeed at the top of parents’ priorities for high school sex education classes. However, despite that, two-thirds of the parents said the overal message to teens should be to postpone sex, but use birth control and practice safer sex if they don’t wait.31 It is disturbing that the federal government provides $100 mil ion annual y (with another $35 mil ion proposed) to fund “abstinence-only-until-marriage” programs that deliberately suppress information about HIV prevention and misleadingly teach that condoms are ineffective.28 While abstinence is the best way to prevent HIV infection, the fact remains that whether adults want to recognize it or not, many adolescents do engage in sexual activity for a variety of complex biological, cultural, social, and economic reasons. They have the highest rate of sexual y transmitted diseases of al age groups.1,6,8 Thus, realistical y, we also need to ensure that education about both abstinence and responsible sex (including accurate information about condom efficacy) are made available to the mil ions of teens who are already sexual y active .1,6,7,19 A recent study of risk behaviors and the incidence of STD and HIV among African American adolescents showed that a careful y designed risk reduction program affects subsequent risk behaviors.19 The study used an intense but brief, cultural y sensitive, skil based, one-on-one (or group) approach employing developmental y appropriate HIV risk reduction interventions for adolescents. The implication is that similarly designed programs could ultimately reduce the risk of HIV transmission and infection. As the HIV epidemic shifts toward increasing numbers of infected women, children, and racial and ethnic minorities, it becomes increasingly important to study the link between poverty and disease progression and to develop appropriate interventions. These same groups make up the majority of the ranks of the US population at or below poverty level.28 Another emerging risk group for HIV infection is “senior” adults over the age of 50. Nearly 10% of diagnosed cases of AIDS occur in people aged 50 and older.14 This group is not targeted
by prevention and education campaigns, and, indeed, may not even be screened or tested. Viagra
is readily available for older men. Post menopausal women, no longer fearing pregnancy, may not
insist upon condoms. Research on the interaction of HIV/AIDS meds and traditional geriatric
meds is lacking.17 Plus, as the death rate from AIDS continues to decline, and with infected
individuals living longer, the numbers of people over 50 living with HIV are expected to increase
sharply.
INFECTION CONTROL
Universal precautions are divided into two tiers. Standard precautions require that each patient, no matter what their diagnosis, be treated as potential y infectious. Transmission-based precautions protect against contact, droplet, and airborne transmission.26 The single best way to comply with al infection control guidelines is to learn them wel and fol ow them conscientiously and consistently. Although hepatitis B virus (HBV) is 100 times more infectious than HIV, and the probability of exposure to HBV is far greater, studies show that caregivers know alarmingly little about HBV and may not even perceive themselves at substantive risk. Today, prevention of viral hepatitis is considered a worldwide public health concern, but many caregivers seem more baffled than frightened by its’ "alphabet soup" aspects: i.e., types A,B,C,D, and E.6,8 Overal , tuberculosis rates are leveling out again in the US, due to the strengthening of TB control activities over the last decade. But in ten states, including Florida, “hot pockets” of TB activity continue—warranting accelerated prevention and control efforts.23 During the mid 1980s and 1990s researchers blamed the spread of TB on improper antibiotic use, an influx of refugees, increased international travel, and the prevalence of AIDS, which makes it easier for opportunistic infections like TB to gain a toehold. Some experts cal ed TB “AIDS with wings.” because, unlike HIV infection, which is tied to avoidable modes of transmission, TB is airborne. Everyone is susceptible, and even with excel ent treatment, TB carries the threat of significant mortality rates. Global y, the TB epidemic continues unabated with 8 mil ion new cases annual y and 2 mil ion deaths.23 Unless US defense systems against TB are careful y maintained, the global epidemic could impact the recent declines in the US. Yet caregivers in this country remain relatively unconcerned. Exaggerated fear of HIV contagion--i.e., fear that is far out of proportion to actual risk--is pervasive.9,22 . High levels of fear lead to heightened stress among staff and lowered standards of care for people with AIDS. This poses the potential for less than optimal care outcomes, and raises questions about the ability of some caregivers to facilitate and maintain a therapeutic environment for HIV infected people. It should be borne in mind that codes of professional ethics, state practice acts, and federal laws (such as the ADA) al specifical y prohibit discrimination against or abandonment of any patient, regardless of diagnosis. Words from a caregiver: “It is important, and it’s about time that people stop treating people with AIDS like they’re lepers. It’s a disease. And it’s not a gay disease. It’s a people disease. I used
to think that only people who used drugs or were gay had AIDS. Now I know better. Years ago I
would have judged. I did judge. No more.”18, p72
MANAGEMENT
Since there stil is (as yet) no cure, much of today’s HIV clinical management necessarily centers on aggressive prophylaxis and early intervention with opportunistic infections such as Pneumocystis pneumonia (PCP), Kaposi's sarcoma (KS), cytomegalovirus retinitis (CMV), Candida albicans, TB, and shigel osis (among many others). Clinical decisions must be made individual y, taking into account the specific infections involved, co-morbidity (which is common), stage of the disease, response to treatment, tolerance of side effects, and quality of life issues. Major clinical advances that literal y have changed the face of HIV/AIDS treatment and management grew out of a better understanding of the pathogenesis of HIV infection and the availability of means to measure plasma viral burden. “Highly Active Antiretroviral Therapy” (HAART) refers to aggressive treatment with combination therapies early in the course of the disease (including the time of seroconversion). Current guidelines have become more conservative, reflecting clinicians' greater experience with antiretroviral drugs and a growing concern regarding short- and long-term toxicities of combination regimens. At present, the Department of Health and Human Services suggests that asymptomatic HIV positive patients not be given drug therapy until their CD4+ counts fal to 350/mm3. The previous recommendation was to initiate therapy at 500/mm3. 27 The goals of antiretroviral therapy are to delay progression, decrease opportunistic complications, and improve survival rates.24 Today, the overal intent of HIV/AIDS therapy is to reduce measurable viral burden to below the level of detection.20 Non-nucleoside reverse transcriptase inhibitors (NNRTI), protease inhibitors (PI), and the fusion inhibitors are agents for managing treatment. Retrovir (zidovudine, AZT, ZDV); Videx (didanosine, ddI); Videx EC (didanosine, ddI); Hivid (zalcitabine, ddC); Zerit (stavudine, d4T); Combivir (ZVD and lamivudine); Trizivir (abacavir, ZDV, lamivudine); Ziagen (abacavir); and Epivir (lamivudine, 3TC) are FDA approved anti-retroviral agents. They are Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs). Many newer NRTIs are being investigated in clinical trials. Used singly or in combination, their beneficial aspects can include prolonging the long-term survival and improving quality of life. Serious potential side effects include nausea, vomiting, headaches, anorexia, and bone marrow suppression. HIV mutations leading to drug resistance and treatment failure are common.8,27 Non-nucleoside reverse transcriptase inhibitors (NNRTIs) are used in combination regimens for treatment of patients who have not received prior antiretroviral therapy. They should not be used as a single agent, as they can readily lead to resistance in a matter of weeks. Viramune (nevirapine, NVP), Rescriptor (delavirdine, DLV), and Sustiva (efavirenz, EFV) are examples of currently available NNRTIs.8,27 Other NNRTIs are under investigation. Approved protease inhibitors (PI) currently in use include Fortovase, Invirase (saquinavir, SQV), Crixivan (indinavir, IDV), Norvir (ritonavir, RTV), Viracept (nelfinavir, NFV), Kaletra (lopinavir/ritonavir, LPV), Agenerase (amprenavir, APV), Reyataz (atazanavir), and Lexiva (fosamprenvir, GW433908, 908). Newer PIs are stil in clinical trials.32 Potential y grave side effects of PIs include severe nausea, vomiting, and diarrhea; peripheral neuropathies; metabolic complications such as fat redistribution (lipodystrophy syndrome), hyperlipidemia and/or hyperglycemia with insulin resistance; and bone marrow suppression.8,20 For a variety of reasons, some HIV infected people do not respond favorably to aggressive multi-drug treatment. People who do not respond wel include those who: • lack access to the most potent drugs. • cannot tolerate the treatment schedule or drug side effects. • “fail” treatment due to resistance to therapy • are unable or unwil ing to adhere to complex regimens4,18 Nonadherence not only harms the individual but also leads to the development resistant strains of HIV. Factors most strongly predictive of non-adherence include active substance abuse and depression. Experiencing more than two side effects also correlates with less adherence, as does higher CD4 cel counts.4 With many chronic diseases, medication adherence rates of 80% are acceptable but with HIV infection, rates below 95% do not produce complete suppression of viral replication. Rates of 95% or better are associated with decreased opportunistic infections and a decrease in the number of inpatient hospital days.16 Nurses in AIDS care have ranked medication adherence as one of the top five priorities for HIV/AIDS nursing research. Keys to adherence are thought to be belief and education, which are integral y related. Education about HIV serves as a foundation for establishing a belief in the need for treatment.4 Patients who believe they can take their medications (high “self-efficacy”) exhibit higher adherence rates that patients who predict they wil have trouble with their drugs. People who trust their health care providers are more likely to be adherent as wel as those with ready access to treatment—which facilitates keeping appointments. A variety of approaches can improve adherence. Obviously treatment for depression and substance abuse should be paramount. Beyond that, simplifying and streamlining drug regimens (i.e., substituting meds with reduced dose frequency, fewer pil s, and simpler food requirements) is a critical issue. A recent six-city study of 300 people taking HAART was designed to identify specific factors most frequently associated with nonadherence. Not surprisingly, the number one issue of importance was found to be taking as few pil s at a time as possible.26 In second place was taking fewer doses per day (without food restrictions) and third was drugs with fewer side effects.26 Several anti HIV drugs have been developed and approved for once daily dosages.12 They are: Agenerase (amprinavir), combined with Norvir (ritonavir); Lexiva (fosamprenavir), combined with Norvir ; Sustiva (efavirenz); Reyataz (atazanavir); Viread (tenofovir DF); Videx EC (ddl); Epivir (3TC), Emtriva (FTC); and Zerit XR (d4t).3 Theoretical y, the current availability of many different once daily drugs would al ow for multiple different once daily regimens. With numerous additional once a day drugs on the way, the possible combinations increase exponential y. Keep in mind that additional research is needed to determine if once daily regimens are as effective as twice or three times daily ones. As in any il ness, management decisions should be made by a qualified clinician and weighed against available guidelines, case by case, based on treatment goals, other health conditions, and individual factors. Lifestyle preferences should not be downplayed since formulations are available now to help tailor regimens to needs.26 Workable strategies to manage the problems of “polypharmacy” are essential to optimal patient care.4 Because of their wel developed interpersonal skil s, nurses can play a major role in counseling people about the crucial nature of consistent adherence to treatment. The goal is to educate and empower patients so they can participate meaningful y in treatment and management decisions. In turn, this can increase the relevance of those decisions and thus the desire to adhere the treatment regimen. Interest in the healing properties of foods and other natural substances, along with the “mind-body-spirit connection,” have been the focus of some ancient cultures for centuries.9,17 The Office of Alternative Medicine can help distinguish between therapeutic interventions in HIV/AIDS care that are safe and helpful and unconventional approaches that are useless, fraudulent, harmful, or dangerous. Careful y selected complementary therapies, based upon a holistic approach to health and healing, can be beneficial adjuncts in an overal plan of care to relieve discomfort from drug side effects. Self-help measures (such as relaxation and imagery) can restore a sense of control and resiliency and decrease feelings of helplessness. Due to their non-invasive nature, many alternative modalities can be used in conjunction with more traditional practices in order to promote healing and increase comfort.10 As a caveat, remember that though herbs, vitamins, minerals, and herbal therapy preparations may be “natural” they stil carry the potential for side effects and adverse interactions. Cases in point: garlic supplements are popular among HIV infected people to combat cholesterol elevations caused by some anti HIV drugs, but garlic has been shown to reduce serum levels of Invirase (saquinavir) by 50%. St. Johns Wort decreases serum levels of Crixivan (indinavir) by 57%. Some US and African researchers suggest that prenatal B,C, and E multivitamins may decrease the risk of vertical transmission from mother to fetus, whereas use of vitamin A supplements alone actual y increases the risk. An Australian researcher suggests that a few drops of lemon or lime juice could protect women from HIV infection because the virus is “extremely susceptible to acidity.” Field tests in Thailand are planned to test this theory which is, as yet, untried in animals or humans2 It goes without saying that discussion of alternative measures to be used in managing symptoms is in no way meant to imply that anyone should bypass conventional medical treatment. Which is exactly what some patients unwisely do—regarding their antiretroviral therapeutics as “too toxic,” some eschew them in favor of unproven modalities, such as col oidal silver mineral supplements. But ideal y, in a holistic approach to planning care, augmenting our array of available noninvasive treatment and management options for people with AIDS should serve to improve pal iative outcomes and enhance overal wel -being. Such a stance is the bedrock of holism, which derives from the Greek word holos, meaning “health,” “entire,” and “whole.”24 CONCLUSION

Florence Nightingale taught that holism is the very essence of nursing. Indeed, she felt that the “basic principles of nursing” and the “scientific laws of health” were one and the same. Nurses are uniquely positioned to further the “cause” of education and early intervention to prevent or reduce risks and to maintain health and wel ness. Or, when it is too late for prevention, they can encourage treatment adherence. Empowering people to participate in planning their care can help them “buy into” it, which encourages fol ow through. Enriching contemporary approaches with proven alternative therapies, including selected self-help measures to reduce a sense of powerlessness, could help to al eviate symptoms, promote adherence, and enhance wel -being. A professional nurse, herself HIV infected, offers an eloquent testimonial to dramatic impact compassionate, caring, and non-judgmental nursing care can make. “Certainly the nurses were polite, respectful, and nice.but no one touched me. They did their job efficiently and moved on.No one took my hand, rubbed my back, gave me support, or did any of the comfort and care measures that we nurses pride ourselves on. [Later] I was very sick again and back in the hospital.I stil felt unclean and untouchable.I was readmitted to the same hospital but to a different unit. This unit was a “healing place” created by the nurses.I believe now these nurses saved my life. [One of them] looked into my eyes. She said gently, ‘Al your life you have cared for people, now let us take care of you. It’s your turn. It’s OK, that’s what we do. Let us take care of you for awhile.’ Simple words from an ordinary woman, but they were magic.I felt my sense of dignity return.The unit was a healing place.I got a glimmer there is life after AIDS.My healing had begun.”21, p86-7 Another HIV positive individual, addressing a group of physicians at a national AIDS conference, says “.until [there’s a cure, until] the day we hold healing in our hands together, I offer you this ancient prayer: grace to you, and peace.”13, p142 To that I would add, may there also be hope –hope in the hearts of those who are travelers on the road to AIDS, and hope in the hearts of those who offer healing and comfort along the way. REFERENCES
1. American Social Health Association (ASHA) http://ASHA.org, 2002. 2. “Australian Reproductive Physiologist Says Lemon Juice Kil s HIV, Sperm.” Kaiser Daily HIV/AIDS report, http://www.kaisernetwork.org, 10/11/2002. 3. “Big Treatment Questions” Article accessed at http://www.aidsmeds.com, 1/18/2004 4. Boyle, B.HAART and Adherence. The AIDS Reader 10 (7):392-396. Cliggott Pub: 2000. 5. Brown, J. (ed.) A Promise to Remember:The Names Project Book of Letters. New York: Avon Books, 1992. 6. Bureau of STD Prevention and Control, “STD Treatment Guidelines, 2002” MMWR Vol 51 (RR-6), 5/10/2002. 7. Caring for the Future. Proceedings of the HIV Nursing Summit. Journal of the American Nurses Association of Nurses in AIDS Care; 1994; 5 (2): 29. 8. Centers for Disease Control and Prevention (CDC) 1-800-342-AIDS (2004). 9. Colombotos, J. Physicians, Nurses, and AIDS--Findings From A National Study. Rockvil e, MD, Agency for Healthcare Administration, 1995. 10. Chopra, Deepak. Creating Health: How to Wake Up the Body’s Intel igence. Houghton Mifflin Company, 1991. 11. DeNoon, D. “Why Some Stay Healthy Despite HIV” WebMD, Inc, 2002. (http://aolsvc.health.webmd.aol.com/content/article1624.52056). 12. “Are Once Daily Regimens Now A Possibility?” http://www.aidsmeds.com, 05/05/03. 13. Fisher, M. I’l Not Go Quietly, New York, Scribner, 1995. 14. Fowler, H. “HIV in the over fifty population,” 14th Annual Conference of the Association of Nurses in AIDS Care,11/2001; Minneapolis. 15. Gandhi, M., et al “Does Patient Gender Affect HIV Levels?” Clinical Infectious Diseases 35: 313-322, 2002. 16. Gracia, S. “From Pil Fatigue to Pil Counts: Medication Adherence in HIV/AIDS,” 14th Conf of the Association of Nurses in AIDS Care, 11/ 2001; 17. “HIV-AIDS Hitting Older Americans” AP article reprinted in Florida Times Union (p A8), 5/12/02 18. Hitchins, N. Voices That Care, Los Angeles, CA, Lowel House, 1992. 19. Sweet-Jemmott, L. “Reducing HIV risk-related behavior among African American adolescents,” Conf of the Assoc of Nurses in AIDS Care, 11/2001 MN. 20. Klevens, R & Neal, J. “Update: AIDS—United States, 2000” JAMA Vol 288 (6), August 2002 21. Lego, S. Fear and AIDS: Empathy and Communication. New York, Delmar, 1994. 22. Meissenhelder, J. Contributing factors to fear of HIV contagion. Image, 1994; 26 (1): 65-69. 23. National Prevention Information Network: US TB Cases Decline printed by CDC Office of Communications, 11/2002 24. Penny, J.The Epic Epidemic: HI/AIDS. Pennywise Educational Enterprises. 1-800-PennyCE, 2004. 25. Squires, K. Managing Women With HIV. The Changing Landscape of HIV: Strategies, Choices. HIV/AIDS Treatment Updates Medscape, 2000. 26. Stone, V. “Reasons for Low Compliance with HAART Regimens Pinpointed” study presented at the 40th Annual Meeting of the Infectious Diseases Society, Reuters Medical News for the Professional, http://www.medscape.com, 11/7/02. 27. Swihart, D., et al. “The HIV Pandemic in 2003.” Advance for Nurses Vol 4 (16), 13-18, 7/21/2003. 28. “What Are the most Common Ways Teens Get AIDS?” HIV/AIDS Facts, American Red Cross, http://www.redcross.org, 11/2002. 29. White House Office Of National AIDS Policy, access via ASHA home page, 2002. 30. “Why Do People Receive Counseling Before and After HIV Testing?” HIV/AIDS Facts, ARC, http://www.redcross.org . 11/2002. 31. Zwil ich, T. Parents Want more Comprehensive Sex Education in Schools Reuters Med News for Professional. Medscape, 9/27/2000. 32.“Fosamprenavir: A New PI Option—Expert Interview with Jeffery Nadler, MD” Medscape: HIV/AIDS MedPulse (from WebMD). http://www.medscape.com/hiv-aidshome. Accessed 1/16/2004.

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