Professor of Medicine and Health Behavior
University of North Carolina School of Medicine
Director, Behavior and Technology Lab (BATLab) and UNC
University of North Carolina
Chapel Hill, North Carolina
Lisa Hightow-Weidman, MD, MPH, has no real or apparent conflicts of interest to report.
In this HIV cases series, we highlight common patient case scenarios and the critical decision making that goes into selecting optimal patient management strategies. This case features a Hispanic man who has sex with men (MSM) in his 20s with a stressful life situation, a history of depression, a recent diagnosis of HIV infection, and considerable fear of disclosure and stigma.
The patient is a 26-year-old Hispanic MSM who recently had to move back into his parents’ home after being laid off from his job. He was diagnosed with HIV infection shortly after this move. His parents are not aware that he is gay, and he is very worried that they will not only find out about his HIV status but also about his sexual identity. He has never been formally diagnosed with depression but does report a period of time in his late teens and early 20s when he was “very sad” and had a hard time getting out of bed for weeks at a time. He reports recently breaking up with his partner of 1 year after he discovered his partner was having sex with other people he was meeting online. He feels very alone and does not know how he can deal with his HIV treatment along with all of the other issues going on in his life. Finally, he scores in the depressed range on a clinic-administered depression screener.
Key Considerations and Provider Strategies for Addressing Potential Treatment Challenges
We have all seen clients such as this young man in our practices—those patients who want to take charge of their HIV treatment but have other stressors in life that make it difficult to incorporate daily adherence to ART into their life. Studies have found that stigma related to HIV can be a significant stressor and one that is associated with depression. This may be seen to a greater degree in communities of color. For this young man, active depression may play a role in decreasing adherence. In addition, living with his family and potentially inadvertently disclosing his sexual identity and/or his HIV-positive status is clearly causing him significant stress.
We know that high levels of adherence are associated with maximum suppression of HIV-1 RNA replication, reduced rates of drug resistance, and increased survival. It is important, therefore, to identify and try to address those challenges to adherence that may affect our patients’ ability to adhere.
My approach to this patient would involve trying to address these barriers to adherence, even before (but certainly in concert with) starting him on ART. Providing reassurance, understanding, and some concrete suggestions on how to avoid inadvertent disclosure of his HIV status is a straightforward first step. Medications can be simple; some of the 1-pill, once-daily regimens can be disguised as vitamins, and patients may take them without other family members realizing exactly what they are. Of more importance and thus more challenging for this patient is helping him address some of the psychosocial and structural problems he is facing. Involving a social worker or case manager to help him find a different living situation and employment (if possible) and referring him to a mental health professional who can assist in more formally addressing any depression may, in turn, help with adherence to his HIV treatment. Those of us who have multidisciplinary teams located within our clinics may be able to begin to address these issues within the clinic; others may need to turn to resources in the community. Working with a team may help with relationship building as well. Sometimes one member of the team may “click” more with an individual patient better than others. Patients may not want to admit to their healthcare provider that they have struggled with adherence for fear of disappointing them, but they may admit that to the social worker or nurse, for example. By having other people who can engage with the patient in different ways, we often get a more complete understanding of a patient’s life situation and concerns.
Often we have time pressures in our practices that make holistic care challenging. To address that, I would also increase the frequency of visits for this patient to keep in touch with how he is managing his medications and his life. We often cannot address every issue each time—but it is crucial to identify and act on the ones that are the most pressing and likely to affect adherence and retention in care.
What about you? What strategies have you incorporated into your clinic practice that work with patients similar to this case? Please comment below.