SAN FRANCISCO – In assessing an adolescent newly diagnosed with HIV, establishing a productive doctor-patient relationship can be every bit as important as determining viral loads, Dr. Andrew T. Pavia said at a meeting on HIV management sponsored by the University of California, San Francisco.
With adolescents, “one of the difficulties is getting to the point where the conversation starts,” said Dr. Pavia of the University of Utah, Salt Lake City. “Sometimes a lot of the visit is spent while the kid is examining her shoes and not answering questions and speaking in monosyllables. And as you reach the end of the visit and you're running out of time, suddenly the floodgates open.”
Few clinicians have the luxury of the five-visit assessment model pioneered by Children's Hospital of Philadelphia. There, the initial visit is entirely devoted to relationship building and to determining the teen's psychological profile. Only at the second visit does the initial medical intake examination begin, including blood draws for STD testing and HIV staging.
The third visit involves mental health screening, including cognitive testing and screening for depression. During the fourth visit the physician reviews the patient's CD4 counts and viral loads, and at the fifth visit those tests are repeated.
“We don't have the luxury of doing a five-visit evaluation, but it's actually been very surprising how much tests like the Beck Depression Inventory can help open up a range of conversations,” Dr. Pavia said. Starting the visit with this and discussing the results with the patient immediately can be a shortcut to developing a productive therapeutic relationship.
The physician should try to understand the patient's psychosocial situation. It's important to know whether the teen's basic needs for housing, food, clothing, child care, and education are being met.
It's important to know whether the adolescent has mental health issues or is a substance abuser. It's also important to know what legal issues the teen may be facing.
For example, Dr. Pavia discovered that after he sent them off for referrals, some adolescents simply failed to show up. When he questioned them, some mentioned that they were on probation or had outstanding warrants, and while they trusted him not to turn them in, they couldn't be so sure about other health care workers.
It's important to determine whether the adolescent has an adequate support system, and if so, how to engage it. It's important to determine whether the adolescent has any special needs, such as language translation, hearing impairment, reading impairment, and the like.
And it's important to determine where the patient stands on disclosing his or her HIV status or sexual orientation to parents or guardians.