Telling a Client they have HIV

[BSN317]

Hello, I am in a dilemma. Ok here is the scoop: I am a public health nurse, and I work in Teen Health as well as Women's Health. Working in this role, I have expanded RN functions like I do Pap Smears, STD exams, Breast exams...etc. Anyhow, I also draw blood and order labs like HIV, RPR, etc. Well a client of mine is 16 years old and I just drew his blood Monday. Unfortunately, the HIV test came back reactive. I am so devastated. I look at the teens as my peers, yet my "babies" although I am not too much older than they are. (Im 24). I have only been a RN for a year, and this is my first case. I feel such dread and I even feel sadness about having to give this news. Of course, I will call for back up and have others there with me to handle to counseling piece. But, I am just so sad about this even though I know HIV is a reality and many people have it. I am just struggling because I know this client is going to have a severe meltdown and Im afraid I may react as well. Any thoughts, comments, or suggestions??!

[SweetOldWorld, BSN, RN]

Since this is a minor, what is the role of the parent(s) or guardian? Will they be involved in any way?

[Elvish, BSN, DNP, RN, NP]

Since this is a minor, what is the role of the parent(s) or guardian? Will they be involved in any way?

I think it depends on what state, but in my state, minors do not have to have parental/guardian permission nor involvement for STD testing and results.

[Mexarican]

I thought there were specific privacy laws, and policies regarding telling someone of their reactive HIV status. Also, what responsibilities do you have in first off giving him test results, and his reaction to them? (For all you know he could jump up and run out of the clinic--then what?) I think this is a huge, huge undertaking that I would think be best left to your supervisor, following whatever agency policy you have in place, as there must be one in this type of setting. I would triple check that all my "I's" were dotted and my "t's" crossed especially before telling a child this news. There is no MD that originally ordered the test? Is it policy to retest to be sure it is not a false positive? I understand that the emotional nature of this, and I am sure your feelings of responsibility must be overwhelming, but I do think that someone not as emotionally attached to the patient needs to follow the proper protocol, perhaps the MD that ordered the test to begin with. Additionally, perhaps counseling prior to the test being drawn about "what if it is positive" could be in order, especially if the patient is participating in risky behavior to begin with.

This is true...dot the i's and cross the t's but this is in her job description from what i gather. Therefore it would be inappropriate to hand it off to the supervisor as she needs to start somewhere. I think she has all the players in place and is just seeking advice on how to approach it. I believe in the public health setting their isnt a doctor right there "writing orders". There is a medical director for the whole county somewhere in his/her office who never sees the clinic let alone a patient and there are protocols and standing orders that are followed.

Mex

[Mexarican]

Since this is a minor, what is the role of the parent(s) or guardian? Will they be involved in any way?

I think in almost every state, minors are allowed to access these types of services without parental consent and also recieve the results of those services without parental involvement.

Mex

[BabyLady, BSN, RN]

Hello again

No, no physician ordered the test. The clinet came in requesting an STD screening due to symptoms that they were experiencing. As a part of the STD screening, we have to offer an HIV test, whether they accept it or decline it. The client accepted, so I drew the blood and sent it off. I work under a protocol, and it allows me to do this and other things as well; many things actually. I would like to add that I am not emotionally attached in the sense that I cannot perform my role, but only that I have never dealt with this before and just wanted some pointers. I was only looking for advice from others who may have handled this in the past. I contacted district clinical services and they will be on hand to provide the necessary counseling and serve as a resource as the client will then be a part of district care as an HIV client. I have composed my thoughts and I feel much better, but the Teen Clinic is the only care many of these youth receive and they become regulars, so maybe I came off wrong but I am not overly attached to them; I just care about their well being as I do any other patient.

But my point is that there doesn't seem to be a system in place to handle this type of situation...and that is not good for the nurses on staff or the patients that come in for screening.

If this person is a minor, then the risk for them doing something drastic upon leaving is very high. Chances are they are going to be driving to the facility....it wouldn't be safe to let them back into the car.

They also shouldn't go home alone...and I don't think it's good enough that a resources for counseling is off-site....a minor is going to need counseling whether they think they need it or not...that is a devastating dx to anyone, much less someone that has no capabilty of being able to manage it and a parent, at some point, is going to need to be involved for treatment.

There has to be some physician somewhere that is over something that you can consult with.

The local health department here doesn't have an NP or an MD there 24/7...they do many things under protocol...but there is an MD over the facility that they can call for anything that may come up that is serious enough.

To me, this is as serious as it gets.

Also, I would not give a teen a dx that serious without having them come in and have the test repeated.

[caroladybelle, BSN, RN]

Is this typical in public health?

In the health department here, only the advanced practice nurse or the physicians there disclose HIV or a Herpes dx and counseling is ALWAYS immediately available as well as the client has to come in to get the dx in person.

They delegated this to you??????

This is my question.

In many MANY states, either an MD must counsel a patient before drawing an HIV screen, must consent them and must counsel them on the results. Barring that, the nurses that do HIV must have a specialized course in providing counseling before and after, as well as consenting them for the draw, before being permitted to handle this issue. And this is legal requirement, not an optional facility policy. And, no, the facility consent to treat and draw regular labs does not count - they must sign a consent specific for HIV testing, unless certain specific criteria are met (ex.needle sticks)

Which state is this that does not do that?

[AllSmiles225]

This is my question.

In many MANY states, either an MD must counsel a patient before drawing an HIV screen, must consent them and must counsel them on the results. Barring that, the nurses that do HIV must have a specialized course in providing counseling before and after, as well as consenting them for the draw, before being permitted to handle this issue. And this is legal requirement, not an optional facility policy. And, no, the facility consent to treat and draw regular labs does not count - they must sign a consent specific for HIV testing, unless certain specific criteria are met (ex.needle sticks)

Which state is this that does not do that?

In New York state a MD does NOT have to counsel the patient before or AFTER a blood draw. As long as the Nurse has been trained in handling grief counseling specifically for newly diagnosed HIV positive patients he or she can handle the issue on their own especially in a public health setting. MDs are often uninvolved in this area of medicine. I'm not saying that I think it is right..it just seems to be the way that it is here. Also..the OP stated that the patient consented to an HIV test so what is the issue?

[BabyLady, BSN, RN]

In New York state a MD does NOT have to counsel the patient before or AFTER a blood draw. As long as the Nurse has been trained in handling grief counseling specifically for newly diagnosed HIV positive patients he or she can handle the issue on their own especially in a public health setting. MDs are often uninvolved in this area of medicine. I'm not saying that I think it is right..it just seems to be the way that it is here. Also..the OP stated that the patient consented to an HIV test so what is the issue?

The issue is that she is a nurse working in a facility that doesn't appear to have a policy...at all.

To me, that is a substandard facility...that doesn't have a system in place, not only to disclose an HIV pos status, but no counseling immediately available and the OP doesn't mention having any specialized training in that area.

Then, you have the added issue that this is a minor....who is most likely going to be unable to seek medical treatment for AIDS prevention via antivirals on their own without a parent or guardian to sign a consent to treat.

Correct me if I'm wrong, but I don't believe the HD provides meds for HIV due to the sheer expense...correct?

To me, there is not only one problem, there is a TON of problems.

[BSN317]

I did state that we as RNs in this settingmust be trained on counseling and testing of clients for HIV. I have taken this course as it was required. In reference again to the MDs, Mex is right on target. Things work a little differently in public health than they do in the private sector. YES, there is an MD over this county, but I have only seen him once and he signed off on all the protocols I function under. A lot of my job is autonomous, and required a lot of training, classes, and check offs. This is a health department. You may consider it substandard; but to many this is all the care that they can receive. Minors can come to my clinic without the consent of their parent for STD related services; but due to the severity of this case, of course they will be involved at some point. But for testing purposes, no. I was only stating that this was the first patient of mine to come back HIV positive and I, along with others, have the responsibility to relay this information. I was just seeking a little advice. This is Georgia, and yes the client DID consent for HIV testing; I thought I stated that, but if not I am sorry. Yes, counseling will be available--when I referred to "back up for the counseling piece" that individual will be available as well.

Furthermore, yes the health department does provide HIV meds under the Ryan White clinic. It is its own clinic devoted to the care of these clients. Of course, certain criteria must be met in order to qualify, but the resource is there...Yes of course the test will be repeated but we still must inform the client the first test did indeed come back reactive.

[rn/writer, RN]

Your client is fortunate indeed to have someone like you in his/her corner.

I hope the meeting goes well and the patient goes on to live a long and happy life.

[herecomestrouble]

I'm sure this must be hard for you too,even with your training the first time will be stressful to you.My advice would be to have some support services in the wings for your client,at least a list of places to go if not someone actually there.For some people it takes a while before they are ready to talk face to face with another.There are some on-line sites that are very helpful,two I use a lot are thebody.com and poziam.ning.com.

Don't put off telling the client,s/he needs to start care as soon as possible.Do you have an HIV specialist in your clinic?If not find one you can recommend,it's an awful feeling to be told you have a disease that requires a specialist and not know where to go from there.A PCP is not qualified to care for this pt,there are so many things to be aware of that HIV does require an HIV specialist,remember that not all ID's are HIV specialists either.Your client will need more tests,usually another HIV test is required,along with CD4,viral load and one to see if the virus is resistant to any drugs.(depending on who s/he contracted it from s/he could be resistant to some HIV drugs)

I am a peer educator,diagnosed with AIDS in 2004,if you or your client would like to get in touch with me, contact me via PM.

Good luck to both of you,your client is lucky to have some one who cares so much about their health.

Terry

[BabyLady, BSN, RN]

I did state that we as RNs in this settingmust be trained on counseling and testing of clients for HIV. I have taken this course as it was required. In reference again to the MDs, Mex is right on target. Things work a little differently in public health than they do in the private sector. YES, there is an MD over this county, but I have only seen him once and he signed off on all the protocols I function under. A lot of my job is autonomous, and required a lot of training, classes, and check offs. This is a health department. You may consider it substandard; but to many this is all the care that they can receive. Minors can come to my clinic without the consent of their parent for STD related services; but due to the severity of this case, of course they will be involved at some point. But for testing purposes, no. I was only stating that this was the first patient of mine to come back HIV positive and I, along with others, have the responsibility to relay this information. I was just seeking a little advice. This is Georgia, and yes the client DID consent for HIV testing; I thought I stated that, but if not I am sorry. Yes, counseling will be available--when I referred to "back up for the counseling piece" that individual will be available as well.

Furthermore, yes the health department does provide HIV meds under the Ryan White clinic. It is its own clinic devoted to the care of these clients. Of course, certain criteria must be met in order to qualify, but the resource is there...Yes of course the test will be repeated but we still must inform the client the first test did indeed come back reactive.

I think you are missing the point.

I am very shocked that with all of the specialized training and classes that you have had...that there didn't seem to be anything in the training as far as disclosing the status.

To me, that should have been a vital and integral part of the program, considering some individuals will commit suicide over a dx.