The Complex Importance of Patient Education
Recently our group was consulted in the care of a patient newly diagnosed with HIV. This patient presented to the hospital via the ED with altered mental status. A lumbar puncture was performed and the cerebrospinal fluid was sent off to the microlab for cultures. About 48 hours later, it was positive for Cryptococcus. An HIV test and corresponding viral load and CD4 count were performed. The tests confirmed the patient was HIV positive, the patient's CD4 count was in the 90s and viral load well north of 50,000 copies per milliliter.
The patient's altered mental status in the ED was the direct consequence of cryptococcal meningitis, an unfortunate and pernicious opportunistic infection, seen in patients with low CD4 counts. Luckily this patient was able to access the healthcare necessary to address these problems before any truly irreparable damage had taken place. Once the patient's mental status had returned to baseline and the patient had time to digest the totality of the HIV diagnosis, the patient decided to inform family members. A family meeting was scheduled and I had the great privilege to participate in, but mostly observe, this event.
Each of the family members present appeared appropriately concerned. I did not witness any invective finger pointing or implicit derision of the patient. Rather, this family was interested in what they could do to help improve the patient's health and well being. However, at one point during the meeting, a family member asked if it was possible to transmit the virus by sharing a toothbrush or a razor with someone who is HIV positive. My boss very deftly responded to that inquiry by stating that there has not, to date, been any documented case in which a person contracted HIV through the use of a toothbrush. However, it is always unwise to share a toothbrush or razor with anyone else, irrespective of their health profile. Both the question and answer led me to consider a few things, namely the dissemination of misinformation particularly as it pertains to diseases and treatments.
HIV is transmitted via contact with body fluids from an HIV-infected person. These fluids include blood, semen, vaginal secretions, cerebral spinal fluid and breast milk -- NOT saliva. HIV entry is facilitated by cuts, sores or ulcers in the vagina, penis, rectum or mouth, thus STIs such as herpes and syphilis increase the likelihood of HIV transmission because they abrade the skin's surface and increase the number of potential portals of entry into the body.
In addition to oral, vaginal and anal sex, HIV can be transmitted transplacentally during pregnancy, exposure to genital tract fluids during birth, breastfeeding, via IV drug use, tattooing, piercing, accidental needle sticks or splash on mucous membranes with infected blood or unscreened transfusions. HIV is not transmitted via contact with sweat or tears. It is not airborne, thus it is not contracted via coughs or sneezes, or by sharing eating utensils, phones, clothes or toilet seats.
I assumed that this was common knowledge, but it is foolish to make assumptions. Returning to the idea of disseminated misinformation, as a newbie I have found that health education is an essential component of treatment. People can't be expected to improve upon or maintain good health practices if they are unaware of the modalities of disease transmission and or progression.
The recent controversy associated with insurance coverage for contraception illustrated a robust ignorance of healthcare and treatment. Contraceptive therapy is not tantamount to Viagra. Contraceptive therapy is prescribed for a multitude of reasons beyond contraception, such as menorrhagia, metrorrhagia, migraines and acne. This point was obviously not understood and certainly not discussed.
Moving forward, I intend to initiate conversations with all of my patients about disease prevention and treatment so that they will feel increasingly better equipped to properly care for themselves and their families and become better educated health care consumers.