|Hello, I am Debra Neiman, RN BSN.
I have worked in Neonatal Care, at Beauregard Memorial Hospital, DeRidder for over four years. My college experience at Louisiana State University at Alexandria, resulted in a great deal of research papers, which are gathering dust in my office. My curriculum at Northwestern State University also added to this wealth of information.
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HIV Infection and AIDS:
Patient Resources in Vernon Parish, Louisiana
Divided into several pages
Debra Neiman, RN, BSN, 1 April 1995
Prepared for Community Health Nursing
Northwestern State University
Survey the resources available to clients infected with Human Immunodeficiency Virus (HIV) and diagnosed with Acquired Immune Deficiency Syndrome (AIDS) in Vernon Parish, Louisiana. Examine attitudes toward the impact of HIV and AIDS in Vernon Parish. Identify projected needs in Vernon Parish to meet the health care needs of persons infected with HIV or AIDS. Summarize a list of resources to be provided to health care workers in Vernon Parish. This list would be useful when counseling family caretakers or a patient with HIV infection or AIDS.
Vernon Parish is mostly a rural community with an estimated population of 53,000 based on 1990 census figures. Cattle and forestry provide the parish economic base. Fort Polk, the 198,356 acre Army post seven miles from Leesville, provides an estimated payroll of $366,600,000 to boost the economic base of Vernon Parish (SC Bell, 1993). The transient population of military personnel and their families also have a significant impact on the public health requirements of Vernon Parish.
Vernon Parish has two hospitals, a mental health unit, a 102 bed nursing home and a new elderly housing project. The city of Leesville is the site of the parish health unit. Fort Polk has federally regulated disease prevention and surveillance departments under USAMEDDAC. Vernon Parish has a medically underserved rating with insurance carriers.
III. Attitudes toward HIV and AIDS
The public schools in Vernon Parish do not include information about sexually transmitted disease in the junior or senior high curriculum. There is a mandatory class for military and federal employees at Fort Polk on HIV and AIDS prevention currently in progress. This class is directed from the office of the President of the United States and is presented by a private contractor. Comments from employees range from "informative" to "offensive and unnecessary."
Since health care workers are part of the community, their attitudes impact and are impacted on by those of the community. The telephone survey of Vernon Parish hospitals, home health agencies, health unit, and community action or support agencies was accomplished (see Appendix A). A surprising negative attitude was found among some health care workers during the survey. Some were unaware of the requirement to provide pre and post test counseling for those receiving HIV testing, although all knew the test required a signed consent. Others were unaware of procedures for notification of a positive test, "I don't know, but we never get a positive test."
One person relayed the tale of a "local doctor" who refused to treat a patient's son. This young man had come back to his home in Vernon Parish to die with AIDS only a few years ago. Most surveyed did not believe there was much incidence in Vernon Parish. However, all had received instruction on universal precautions and HIV transmission through their medical agencies.
Persons engaging in heterosexual activity and the children born from this activity comprise the growing risk group for HIV infection. Teenagers face the greatest risk. This is due to their developmental stage's predisposition toward risk taking. Sexual activity is occurring at much lower age, some as early as 12 years off age. Statistics cited by Crawford state that 43% of 12 to 17 year olds are current users of alcohol and over 50% will have used an illegal drug by the time they graduate from high school (1995). The prevalence of alcohol use and recreational drugs also increase the risk of HIV infection by lowering inhibitions toward risky sexual activity. Sexually transmitted disease trends are higher in this age group, further increasing the risk of HIV transmission (Cates, 1991).
According to the Morin Model, before risky behavior is changed, the person must believe they are at risk (Crawford, 1995). A survey at a maternity center of low risk women's attitudes towards AIDS determined that over half supported voluntary testing. Another 21.1% supported mandatory testing, but less than half requested the test. 8% of those surveyed would not want to know if they had the virus, and 17.5% were not sure (Glenn et al., 1991).
IV. Disease Definition
HIV is found in the body's fluids; vaginal secretions, seminal fluid, and blood. HIV is spread by sexual contact with an infected person, by needle sharing among injectable drug users, or through transfusions of infected blood or blood clotting factors. Babies born to HIV infected women may become infected before or during birth, or through breastfeeding after birth. Sexually transmitted diseases potentiate transmission of HIV through the breakdown of the skin and mucous membranes, the body's first line of defense (Schmid, 1990).
Once infection occurs, the disease is divided into four stages for medical management.
Stage 1 is the time from infection until the person produces enough antibodies to produce a positive result on the Elisa or Western Blot tests. The time period ranges from 3 weeks to 6 months, with an average time of 3 to 12 weeks. A person can be infectious as early as 72 hours after exposure, due to the rapid increase of the viral load in the acute stage of infection. One long term study cited by Crawford indicates that 70-80% of HIV infected patients report symptoms of fatigue and influenza-like malaise during this stage (1995).
Stage 2 is reached when the antibodies are detectable by Elisa or Western Blot testing and continues until symptoms of illness occur. During this time the viral load is greatly reduced and the level of antibodies also decline. The virus continues to multiply during this period, but does not reach the levels of early infection again until stage 4. HIV is a Lenti virus and can remain dormant inside cells for a long time. The asymptomatic period averages 10 years, but can range from 6 months to over 17 years (Crawford, 1995).
Stage 3 is defined when the person begins to experience symptoms and continues until the diagnosis of AIDS is made. The average time is 4 to 5 years, but can range from months to years. A person can continue to function in school or work in Moderate Stage 3 and may experience only intermittent flareups of illness. Acute Stage 3 is defined when the person is disabled and unable to work or attend school, but has not met the criteria for AIDS diagnosis. Death can occur at this stage without meeting the diagnostic criteria for AIDS, such as: gastroenteritis with severe neuropathy (Crawford, 1995).
Stage 4 occurs when the person meets specific criteria for AIDS diagnosis. The diagnosis of AIDS is made when the person has HIV infection plus a case definition. The case definition list has been altered several times, but currently includes CD-4 cell count <200, any of the listed opportunistic infections, Kaposi's sarcoma, aids dementia complex, or wasting syndrome. The average time from infection to this stage is 44 months, however the range can be months to years. The end of this stage is death. Approximately 90% of persons infected with HIV in the United States have their first HIV test at this stage and die within two months of an AIDS diagnosis (Crawford, 1995).
V. Disease Impact and Projections:
AIDS was followed as an unknown syndrome for several years before being recognized in 1981 as a clinical syndrome. By 1993, 253,648 adult cases had been reported in the United States (CDC, 1993).
The trend of the disease was discussed by Jeanne Dumestre at a recent seminar for health care workers. The infection growth has shifted from gay males and injectable drug users toward women and children. Children become infected through blood products, sexual abuse, and maternal vertical transmission before or at birth. Women with AIDS now total over 58,000 or 18% of the U.S. cases in 1994. The breakdown of associated risk factors for women infected with AIDS, as published in a 1995 Morbidity and Mortality Weekly Report (1995), is 41% injectable drug users, 38% heterosexual sex, 2% blood transfusions, and 19% undetermined/under investigation. AIDS has become the 4th leading cause of death for women in the age group 25 to 44 in the United States. Women of color, including blacks and hispanics, comprise 19% of the U.S. population, but account for 77% of the total number of women with HIV (Dumestre, 1995).
Resources and care facilities have been established by the efforts and models of the gay male community and are not equipped to deal with the demographic change of the disease to women and children. Many women are unaware they have HIV and may not discover their own infection until they have a child born with HIV (CDC, 1991). The mismatch of testing and reporting prevents a definitive estimate of the full impact of the spread of HIV and AIDS.
Disease Impact and Projections:
According to CDC and State of Louisiana surveillance report on January 31, 1995 there are 6,689 cases of AIDS in Louisiana with 23 reported in Vernon Parish. Louisiana counts a total of 3,897 deaths, representing a 58% case fatality rate. This does not include the number of persons infected with HIV and not meeting the diagnostic criteria for AIDS.
Currently the state of Louisiana is facing a financial crisis in the Medicaid program. A change in the federal funding of Medicaid is causing a $750 million shortfall in the state's budget ("Medicaid cuts", 1995). The impact this will have on existing programs has not been defined at this date. However, Medicaid finances most of the care for HIV infected and AIDS diagnosed patients in Louisiana. Most of these patients seek treatment of the Louisiana Health Care Authority hospitals which is the charity hospital system in Louisiana. Whenever the prescribed medication is not covered by the charity program, the second line of defense is the Medicaid program or private insurance carrier ("AIDS drugs", 1992). Community based support groups provide assistance after these resources have been used. The cost of this treatment was unavailable or unknown to the providers surveyed. However a recent case study published by the Centers for Disease Control cited the cost of tracking contacts of an HIV infected prisoner. Fifty persons were linked through sex or needle sharing and over half were unaware of their infection. The partner notification process took five months and cost $13,969 ("Fifty exposed", 1995). The financial impact on the community and taxpayers to provide care for those affected by this disease comprises a significant part of the total health care cost. Included in this impact is the loss of the persons disabled during peak productive years, Medicaid and social security disability projections, volunteers, and community programs. CLASS (Central Louisiana Aids Support Service) reports a total annual budget of $175,000 annually to serve an eight parish area. Incidental expenses such as the cost of latex gloves used in health care for the implementation of universal precautions has caused an increase in health care costs for all types of patients.
VI. Survey of Vernon Parish Resources
The telephone survey of Vernon Parish health care providers determined that home health agencies were more likely to be aware of the services needed to care for the HIV infected patient. Physician offices report they did not test many persons for HIV and denied having any HIV patients. A call to the nearest obstetric group determined that they test maternal patients after obtaining written consent, but the point of contact was unaware of the protocol for pre and post test counseling or notification procedures in the case of a positive test. The parish health unit provides anonymous or confidential testing with pre and post test counseling. None of the agencies surveyed utilize volunteers for support, counseling, or care of HIV/AIDS patients. CLASS has made attempts to enlist the use of volunteer care teams in this parish without success. Those patients with positive HIV tests or AIDS diagnosis are finding treatment and support through the agencies and clinics in Rapides Parish.
VII. Resources in Use
AIDS drugs available in Rapides. (1992, January 13). The Alexandria Town Talk, p. D1.
Cates, W. J. (1991). Teenagers and sexual risk taking: The best of times and the worst of times. Journal of Adolescent Health, 12(2), 84-94.
Centers for Disease Control. (1991). Women and AIDS: The growing crisis. HIV/AIDS Prevention Newsletter, 2(1), 1.
Centers for Disease Control. (1993, February). HIV/AIDS and Health Care Workers. CDC: HIV/AIDS Prevention Newsletter.
Centers for Disease Control. (1993). Summary - cases of specified notifiable diseases. US cumulative week ending February 13, 1993. Morbidity and Mortality Weekly Report, 42(6), 114.
Centers for Disease Control. (1995, January 31). Acquired Immunodeficience Syndrome Cases, cumulative: Louisiana. CDC Surveillance Report.
Crawford, B. (1995, March). Pre and post test counselor training. HIV Counselor Training Workshop. Symposium conducted at the Central Louisiana Aids Support Service, Alexandria, Louisiana.
Dumestre, J. (1995, March). Women and HIV. Care of HIV Disease: A Community's Response. Seminar conducted at the Ramada Inn Convention Center, Alexandria, Louisiana.
Fifty exposed to AIDS tracked down. (1995, March 24). Alexandria Town Talk, p. A4.
Glenn, P., Nance-Spronson, L. McCartney, M., & Yesalis, C. (1991). Attitudes toward AIDS among a low-risk group of women. Journal of Obstetric, Gynecologic, and Neonatal Nursing, 20, 398-405.
Medicaid cuts: Budget proposal calls for slashing more than $500 million. (1995, March 31). The Alexandria Town Talk, p. A1.
South Central Bell.(1993).About your community: Leesville, Louisiana. South Central Bell Telephone Book: Leesville - DeRidder, p. Y1.
Schmid, G. P. (1990, September). Sexually transmitted diseases and HIV: A primary care approach. Journal of Osteopathic Medicine, supplement, 4(8), 14-20.
Copyright, ©1997 Debra Kay Neiman,
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