HIV Case Study & Quiz Questions

HIV Case Study & Quiz Questions

by Ginny Bayes

​Millie D. - HIV Case Study

​Millie D. (60 year old female), a former registered nurse, retired from nursing 5 years ago after being an ED nurse for 30 years. Millie spent the majority of her career at a level 1 trauma center (Henry Ford Hospital in Detroit, MI) taking care of critically ill and injured patients.

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​Millie had a routine dental cleaning with her long time dentist when she noticed abnormal findings in Millie's mouth. She diagnosed Millie with oral candidiasis (thrush).

​PMH & Demographics

​PMH: HTN, hyperlipidemia, depression, rheumatoid arthritis, seasonal rhinitis

​PSH: cesarean delivery x2 - second with incidental artery laceration . Right TKA. Bilateral carpal tunnel release (CTR). T&A.

​Social history: divorced x 10 years. 2 healthy adult children who live in neighboring states. Retired RN.

​Family history: mother - alive at 84 years old: HTN, HLD, osteoarthritis. Father - deceased at 76 years old - died of laryngeal cancer after many years of using chewing tobacco. No siblings.

Multiple Select

Considering the discovery of the oral thrush by her dentist, what questions would you like to ask Millie after ascertaining her past medical history and social information? Select all that apply. 

• "Did you receive a blood transfusion after your 2nd c-section?"

• "How many sexual partners have you had since your divorce?"

• "What medications do you take for your RA?"

• "When was your last routine colonoscopy?"

• "How much sleep do you get per night?"

​Diagnostic Work Up

​Millie's thrush is successfully treated after 10 days of nystatin oral suspension therapy. She makes an appointment with her PCP as she is concerned about the thrush.

​Her nurse practitioner makes sure to update her med reconciliation, asks Millie detailed questions about her PMH, PSH and social history. She orders some basic lab work and thinks the thrush is most likely related to the infliximab (Remicade) she receives for treatment of her RA.

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​Millie anxiously awaits the results of her lab work, especially her complete blood count (CBC) with differential.

Multiple Choice

Millie's CBC results reveal a low total WBC count (3.7) as well as below normal levels of lymphocytes. The nurse knows that lymphocytes: 

• Only attack cancerous cells

• Are an immature form of macrophages

• Specialize in the detection and destruction of parasitic infections

• Play an important role in the direct cell-mediated destruction of viruses

​Diagnosis

​After seeing the results of the CBC w/diff, Millie's nurse practitioner is concerned and orders an HIV antigen/antibody combination test as well as a lymphocyte subset differential that includes a CD4+ T cell count.

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​The result of the combo test is positive and the CD4+ T cell count is 276 cells/mm³

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Multiple Choice

After delivering this news it is highly anticipated that Millie will have many questions. Millie states "this seems pretty bad, do I just have HIV or is it considered AIDS?" What is the best response to this question? 

• "Because your CD4 is above 200 cells/mm3 you do not have AIDS."

• "Because your CD4 count is below 500 you have AIDS."

• "Thrush is considered an AIDS-defining condition."

• "Until you develop an AIDS-related cancer, such as Kaposi's sarcoma, you do not have it."

​Treatment

​Millie is immediately started on antiretroviral therapy (ART) that includes 3 different HIV fighting medications. After 6 months of therapy her viral load is undetectable, she reports that the side effects of the medications are not fun but they are tolerable compared to the alternative. She reports fatigue, intermittent diarrhea and peripheral neuropathy in her hands and feet.

Multiple Choice

Millie was started on ART therapy relatively quickly, as compared to some other patients who's HIV immunosuppression is more severe. What primary factor did Millie's provider consider when deciding when to start ART therapy? 

• Millie's CD4 count of 276

• The fact that Millie had developed thrush

• Millie's advanced age

• Millie's readiness and perceived adherence to treatment

​Disease Progression

​Approximately 2 years into treatment Millie's viral load remains undetectable every time her blood is drawn and she continues to tolerate the side effects of her medications fairly well and remains vigilant in taking her medications as directed every single day.

At a follow up visit, she discloses to the nurse at the clinic that she has been "seeing someone" but she is "scared to death" of passing on the HIV to her new boyfriend. She states she cares about her partner very much and would like to be sexually active with him but she is very hesitant. She tells the nurse her partner is aware of her HIV status and he feels comfortable using a condom but she remains concerned. She states she would "rather be safe than sorry" and that she realizes this is the end of her sex life as she knows it.

Multiple Choice

Based on the information in the preceding slide, what is the nurse's best response to Millie's statements regarding sex and intimacy with her partner?

• "If your viral load is undetectable you will not pass HIV onto your partner."

• "As long as you use protection everything will be fine."

• "I completely understand, if I passed a deadly disease onto my husband I would never forgive myself."

• "You may want to focus on intimate activities that do not involve intercourse."

​Conclusion

​This case study was based off of real events, the nurse in this case study actually contracted Hepatitis C in addition to HIV. When asked if she recalled any work-related incidents that may have been responsible for exposure to blood born pathogens she could only recall one incident in which an emergency occurred with an arterial line being inadvertently pulled out. She remembered holding pressure on the site and feeling like she did not have time to put on gloves because the arterial site was bleeding too profusely and she was very concerned about the patient bleeding out if she did not act instantaneously.