Physicians must first establish a trusting relationship with HIV patients who struggle with both physical and social stressors.
Patients infected with HIV struggle not only with fear about their physical health, but social stresses, as well. These struggles can make it difficult for patients to gain the trust and comfort with their physician that they need in order to be receptive to communication and education from the care team.
Bob C. Mulder, PhD, of Wageningen University and Research in the Netherlands, told Medical Economics that the key to effective communication and education with HIV-infected patients is a solid, trusting relationship with a physician.
“Having a positive HIV status is very threatening to people, both physically and socially. People experience a physical threat because they want to avoid getting AIDS and dying prematurely. But having HIV also threatens people in a social way, because they are at risk of being stigmatized and excluded from their social groups, including their friends, family and coworkers,” said Mulder, co-author of “Communications Between HIV Patients and Their Providers: A Qualitative Preference Match Analysis,” published in Health Communication. “This social threat sometimes exceeds their fear of dying, because being related to other people is at the core of human nature. Without actually being stigmatized, people with HIV can even stigmatize themselves, because they feel such guilt and shame of being HIV positive.”
These psychosocial elements of an HIV diagnosis extend not just to the patient’s social life, but also to their relationship with their providers.
“These issues have clear implications for effective provider communication with HIV patients. Patients look for ways to deal with their disease, to control it and the worries and concerns that result from it,” Mulder said. “As a consequence, effective communication supports patients in getting control over their disease, including the psychological and social consequences. More specifically, recommendations can be made in three areas in which communication is pivotal: relationship establishment, information exchange and decisional involvement.”
Looking for long-term support
The foundation for all effective communication is a good and trustful patient-provider relationship, Mulder said, but patients with HIV in particular are looking for long-term relationships with their provider where they feel their history is known, they can be taken seriously and treated as equals.
“Furthermore, patients like to talk with a provider who is not only knowledgeable, but also genuinely involved in their well-being, and who shows overall support,” Mulder said. “Building a relationship can be disturbed when providers convey-verbally or through body language-that they have little time, pity or judge the patient or in any other way [that] let the patient feel that he or she is not taken seriously.”
When there is a good provider-patient relationship, patients also have trust in the physician’s competence and integrity, which results in a high level of trust and ultimately disclosure of any issues the patient has or worries about that would otherwise hamper compliance and engagement, Mulder said.
Patients naturally want to talk about their medical status, Mulder said. Keeping patients informed of their viral load and CD4 count provides them with assurance that they are in good health and that treatments are working. Patients are also inclined to discuss psychosocial and behavioral issues-including sexual health and behaviors, and disclosure of their HIV status in relationships-and providers are instrumental in providing support to deal with the practical side of these issues, as well as to provide emotional support that will facilitate a continued open dialogue.
Physicians also need to explore how the patient wants to go forward in decision-making, Mulder said. There is a lot of variation in how patients choose a treatment path, and good communication is key in developing a good care plan.
“Few patients prefer being the one who decides, because they feel they do not have the ability to take full responsibility for medical decisions. Therefore, many patients want decisions to be taken by the provider, with the provider explaining and justifying treatment decisions to the patient,” Mulder said. “More patients want to be more involved when it comes to decision making about behaviors such as determining the medication intake schedule, treatment adherence, and sexual behavior. That is probably because such behavioral decisions offer much more choice, and the patient is the one in control of behavior.”