IMPROVING TREATMENT COMPLIANCE FOR HIV 1

Public Health Department Follow-Up on Positive HIV Test Results: Improving Treatment

Compliance

Sara R. Bolton, BSN, RN

School of Nursing, University of North Carolina at Greensboro

NUR 609: The Role of the Nurse Leader in Advanced Quality and Safety

Dr. Cindy Bacon, PhD, RN, CNE, NE-BC

October 8, 2021

I have abided by the UNC-G academic integrity policy on this assignment

Sara Bolton 10/8/2021

IMPROVING TREATMENT COMPLIANCE FOR HIV 2

Public Health Department Follow-Up on Positive HIV Test Results: Improving Treatment

Compliance

Human immunodeficiency virus (HIV) is a communicable disease that originated in

Africa that attacks the immune system and may lead to acquired immunodeficiency syndrome

(AIDS) if untreated (CDC, 2021a). HIV cannot be cured, but it can be controlled with medical

care (CDC, 2021a). HIV must be tracked, maintained, and reported by local public health

departments (PHDs). The purpose of this paper is to describe the XYZ County Public Health

Department role in contacting patients with positive HIV test results, the reporting of patients

that they are unable to contact, the scope of the quality issue of HIV treatment non-compliance,

and strategies for quality improvement. Data has been gathered from XYZ County Public Health

Department, the region that this public health department (PHD) is included in, and the state of

North Carolina. Recommendations for quality improvement at XYZ County Public Health

Department will follow the presentation of this data.

Scope of the Issue: Statistics

In the United States (US), at year-end 2019, there were 1,059,784 documented

individuals living with HIV (CDC, 2021b). In the US, in 2019, 36,740 individuals were

diagnosed with HIV (CDC, 2021b). In North Carolina (NC), in 2018, there were 364.4

individuals per 100,000 population documented to be living with HIV (Kaiser Family

Foundation [KFF], n.d.). In NC, in 2018, there were 16 individuals per 100,000 population

diagnosed with HIV and 5.8 individuals per 100,000 population diagnosed with AIDS (KFF,

n.d.). In 2018, the documented population for NC was 10.38 million (Data Commons, n.d.b).
IMPROVING TREATMENT COMPLIANCE FOR HIV 3

In North Carolina in the first quarter of 2019, there were 333 newly diagnosed

individuals with HIV and 143 newly diagnosed individuals with AIDS (NCPH, 2021a) and by

the second quarter there were 692 newly diagnosed individuals with HIV and 275 newly

diagnosed individuals with AIDS (see Table 2) (NCPH, 2021b). The number of newly diagnosed

individuals with HIV more than doubled and the number of newly diagnosed individuals with

AIDS almost doubled. In the first quarter of 2020, there were 287 newly diagnosed individuals

with HIV and 144 newly diagnosed individuals with AIDS (NCPH, 2021a) and in the second

quarter there were 530 newly diagnosed individuals with HIV and 273 newly diagnosed

individuals with AIDS (NCPH, 2021b). The number of newly diagnosed individuals with HIV

more than doubled and the number of newly diagnosed individuals with AIDS was barely less

than double. In the region of NC that XYZ County Public Health Department is located in, the

number of documented individuals living with HIV was 4,733 and the number of documented

individuals living with AIDS was 3,567 (see Table 1) (NCPH, 2020b).

In XYZ County, in 2019, there were 744 documented individuals living with HIV (North

Carolina Public Health (see Table 1) ([NCPH], 2020b). In XYZ County, in 2019, there were 32

individuals diagnosed with HIV and 10 individuals diagnosed with AIDS (NCPH, 2020b). In

2019, the documented population for XYZ County was 224,529 (Data Commons, n.d.a). In XYZ

County in the first quarter of 2019 there were five newly diagnosed individuals with HIV and

zero newly diagnosed individuals with AIDS (NCPH, 2021a) and by the second quarter there

were six newly diagnosed individuals with HIV and five newly diagnosed individuals with AIDS

(see Table 2) (NCPH, 2021b). In the first quarter of 2020 there were four newly diagnosed

individuals with HIV and zero newly diagnosed individuals with AIDS (NCPH, 2021a) and by

the second quarter there were nine newly diagnosed individuals with HIV cases and four newly
IMPROVING TREATMENT COMPLIANCE FOR HIV 4

diagnosed individuals with AIDS (NCPH, 2021b). In the first quarter of 2021 there was one

newly diagnosed individual with HIV and zero newly diagnosed individuals with AIDS (NCPH,

2021a) and by the second quarter there were seven newly diagnosed individuals with HIV and

one newly diagnosed individual with AIDS (NCPH, 2021b).

These numbers may not seem significant but in NC, XYZ County is ranked number 17

out of 87 counties, in having the highest number of newly diagnosed individuals with HIV in

2019 (NCPH, 2020b). A comparison of XYZ County average numbers and the North Carolina

county average numbers show a more detailed representation of the significance of this issue for

XYZ County Public Health Department (see Table 3). The North Carolina county average

number of documented positive individuals with HIV in 2019 was 342, and the XYZ County

number of documented positive individuals with HIV in 2019 was more than double at 744

(NCPH, 2020b). The North Carolina county average number of documented positive individuals

with AIDS in 2019 was 153, and the XYZ County number of known positive individuals with

AIDS in 2019 was more than double at 363 (NCPH, 2020b). The North Carolina county average

number of new positive individuals with HIV in 2019 was 14, and the XYZ County number of

newly diagnosed positive individuals with HIV in 2019 was more than double at 32 (NCPH,

2020b). The NC county average number of newly diagnosed positive individuals with AIDS in

2019 was 52, and the XYZ County number of newly diagnosed positive individuals with AIDS

in 2019 was significantly lower at ten (NCPH, 2020b).

Looking at the first and second quarters of 2019, 2020, and 2021, the number of newly

diagnosed positive individuals with HIV and AIDS for both the North Carolina county average

and the XYZ County average increased from the first quarters to the second, and significantly

more often than not (see Table 3) (NCPH, 2021a) (NCPH, 2021b). In the first quarter of 2019,
IMPROVING TREATMENT COMPLIANCE FOR HIV 5

the North Carolina county average number of newly diagnosed positive individuals with HIV

was three (NCPH, 2021a) and by the second quarter it was seven (NCPH, 2021b), while the

XYZ County number was five in the first quarter (NCPH, 2021a) and six by the second quarter

(NCPH, 2021b). In the first quarter of 2019, the North Carolina county average number of newly

diagnosed positive individuals with AIDS was one (NCPH, 2021a) and by the second quarter it

was three (NCPH, 2021b), while the XYZ county number was zero in the first quarter (NCPH,

2021a) and five by the second quarter (NCPH, 2021b).

In the first quarter of 2020, the North Carolina county average number of newly

diagnosed positive individuals with HIV was three (see Table 3) (NCPH, 2021a) and by the

second quarter it was five (NCPH, 2021b), while the XYZ County number was four in the first

quarter (NCPH, 2021a) and nine by the second quarter (NCPH, 2021b). In the first quarter of

2020, the North Carolina County average number of newly diagnosed positive individuals with

AIDS was one (NCPH, 2021a) and by the second quarter it was three (NCPH, 2021b), while the

XYZ County number was zero in the first quarter (NCPH, 2021a) and four by the second quarter

(NCPH, 2021b). In the first quarter of 2021, the North Carolina county average number of newly

diagnosed positive individuals with HIV was three (NCPH, 2021a) and by the second quarter it

was seven (NCPH, 2021b), while the XYZ County number was one in the first quarter (NCPH,

2021a) and seven by the second quarter (NCPH, 2021b). In the first quarter of 2021, the North

Carolina county average number of newly diagnosed positive individuals with AIDS was one

(NCPH, 2021a) and by the second quarter it was three (NCPH, 2021b), while the XYZ county

number was zero in the first quarter (NCPH, 2021a) and one by the second quarter (NCPH,

2021b). If HIV positive patients do not seek treatment, they are (a) more likely to develop AIDS
IMPROVING TREATMENT COMPLIANCE FOR HIV 6

themselves, and (b) more likely to spread HIV to others. This cycle continues and represents why

XYZ County, NC, the US, and the world are still fighting to stop HIV transmission in 2021.

Importance in Nursing and Nursing Administration

This issue is important to nursing because nurses’ primary passion is to improve health.

HIV is a communicable disease contributing to the number of sick patients to care for long-term.

Now, during the COVID-19 pandemic this presents a bigger problem, as resources are limited.

Nurses also must consider their risk for HIV infected needle sticks, due to job hazard. Public

health nursing has a role in the reporting of HIV cases. HIV is important to nursing

administration because nurse leaders and managers must consider evidence-based practice and

quality improvement strategies to ultimately decrease the amount of new HIV cases and HIV

cases developing into AIDS cases.

HIV in XYZ County

While the XYZ County Public Health Department goal is to contact 100 percent of

individuals with positive HIV test results to attempt to initiate treatment, they have an agreement

addendum with the state of North Carolina that says they must make contact, and attempt to

initiate treatment, with 85 percent of individuals with positive HIV test results (P. Black,

personal communication, October 28, 2021). In 2019, there were 32 new individuals documented

to have positive HIV test results and there were four that XYZ County Public Health Department

were unable to contact, despite following through with procedure to attempt contact three times

before documenting that they were unable to be contacted (See Table 4) (P. Black, personal

communication, October 28, 2021). Since 85 percent of the 32 new individuals with positive

HIV test results is 27, and the health department was able to contact 28 of the 32 individuals,
IMPROVING TREATMENT COMPLIANCE FOR HIV 7

they met their contractual agreement. However, they did not meet their goal of 100 percent of

individuals contacted.

The total numbers of new individuals with positive HIV test results for 2020 and 2021

are estimated based on multiplying quarterly data to equal a full year, as full year documentation

has not yet been published for 2020 and 2021 (See Table 4). There were approximately 18 new

individuals with positive HIV test results in 2020 and approximately fourteen in 2021 (NCPH,

2021a) (NCPH, 2021b). XYZ County Public Health Department has reported being unable to

contact two patients from 2020 and two patients from 2021 (P. Black, personal communication,

October 28, 2021). This indicates that in 2020 and in 2021 the health department has met and

will meet, respectively, their contractual agreement of 85 percent, but still have not met or will

not meet their goal of 100 percent.

Theoretical Framework

Wellness motivation theory, a conceptual framework, generated by Fleury, assists in

understanding the process through which motivated action may be initiated and sustained over

time (Fleury, 1996). This framework is based upon patient empowerment to facilitate individual

growth and positive health patterns. Three stages in a process of individual motivation to initiate

and sustain positive health patterns were identified through the constant comparative method: (a)

individual appraisal of readiness to initiate health behavior change, (b) an intention to initiate

behavioral change, and (c) transformation of behavioral intentions into personalized actions.

These three stages represent movement toward sustained risk factor modification and

maintenance of an ongoing lifestyle change. Two categories were identified throughout the

process of empowering potential. Imaging reflected the individual representation of valued

IMPROVING TREATMENT COMPLIANCE FOR HIV 8

health outcomes and social support systems enabled and limited risk modification efforts during

the health behavior change process.

An evaluation, through structured interviews, of how health behavior change takes place

culturally included health values, community orientation, and traditional health beliefs as

motivational factors in the health behavior change process (Fleury, 1996). Interviewees

communicated a lack of understanding between themselves and their health care providers. For

some, physicians’ instructions were beyond the needed level of knowledge and for others,

instructions did not match the social and economic realities of their everyday lives. Some

difficulties faced include understanding medical referral systems, adhering to dietary and

medication regimens and ability to afford medical care. “An awareness of cultural context and

health value is essential to understanding the pre- and post-decisional processes that guide

individual health behaviors” (Fleury, 1996, Discussion section, para. 8).

Perez and Fleury (2009) discuss the use of wellness motivation theory in Hispanic

women, to facilitate lifestyle change. They state that motivation has been used in health guides

for Hispanic women, as self-knowledge leads to understanding motivational factors, reasons for

planning and incorporating physical activity into their daily life. The theory focuses on

motivation for health behavior change, including formation of intentions and positive health

patterns stemming from goal-directed behaviors. The theory acknowledges the individual

interacting with their environment through social influences, behavior change processes, and

risk-reducing health behavior.

Early education will allow individuals with positive HIV test results to understand the

importance of HIV treatment. Wellness motivation theory can assist in understanding what

motivates these individuals to stay healthy and adhere to HIV treatment. Focusing on the
IMPROVING TREATMENT COMPLIANCE FOR HIV 9

individuals’ motivation to improve their health and formation of goals to guide this health

behavior change can decrease the number of individuals that are positive for HIV that do not

initiate or adhere to treatment. Acknowledging the individual, their daily environment, what is

most important to them, and how to realistically meet them where they are to improve their

health will assist them in making the decision to change their health behavior and maintain

positive health patterns.

Regulations

Public Health Law

NC public health law mandates that the local PHDs must report positive HIV test results

from tests administered by the local PHD to the state via the NC electronic disease surveillance

system (NC EDSS) (NCPH, n.d.). County providers report positive HIV tests results from tests

administered at their organizations to the local PHD who reports these results to the state via the

NC EDSS system (NCPH, n.d.). County providers must report results to the local PHD within 24

hours of the positive result and the local PHD must report results to the state within seven days

(NCPH, n.d.).

Local PHDs must follow regulations for positive HIV test result follow-up and report

attempts to contact and if contact is not achieved (NCPH, 2014). At least three methods should

be utilized to assure a patient is notified regarding the need for treatment. If these efforts do not

result in treatment, the attempts must be documented in the NC EDSS. If test results were

reported to the local PHD by a private provider, three attempts, one being a letter signed by the

health director, must be made to obtain treatment information. If this information is not

attainable the case must then be submitted to the State Registrar for closure and documentation
IMPROVING TREATMENT COMPLIANCE FOR HIV 10

stating, “No response from MD (medical doctor) or client. Unable to complete investigation.

Closed to follow-up in accordance with agency policy and procedure.” should be noted in the NC

EDSS.

Performance Measures and Reporting Requirements

While HIV can be transmitted several different ways, it can be sexually transmitted, and

is therefore considered within the sexually transmitted disease (STD) category. PHDs must

follow STD performance measures and reporting requirements when working with HIV.

Performance measures, and reporting requirements within them, related to sexually transmitted

diseases (STDs) within the health department, focus primarily on public health employee

education surrounding STDs (NCPH, 2020a). Performance measure two states that new local

PHD STD clinical providers must participate in required trainings with reporting requirements to

the regional communicable disease branch (CDB) nurse consultant. Performance measure three

states that the local PHD will ensure STD enhanced role registered nurse (ERRN) training is

completed and maintained by all registered nurses who manage STDs with reporting

requirements to the regional CDB nurse consultant. Performance measure four states that the

local PHD must provide specific information about its STD clinical services with reporting

requirements of all STD medical providers and STD ERRNs to the regional CDB nurse

consultant, annually (NCPH, 2020a).

Evidence-Based Practice

Treatment Initiation

There is little literature surrounding HIV treatment initiation or challenges surrounding it.

Sued et al. (2018) state that linkage to care and early initiation of antiretroviral therapy (ART)
IMPROVING TREATMENT COMPLIANCE FOR HIV 11

are two factors to optimize health of HIV-infected patients and to reduce HIV transmission. They

go on to discuss, in detail, adherence and retention in treatment of HIV.

Treatment Adherence

Sued et al. (2018) discuss HIV prevention, diagnosis, and treatment in Argentina. They

state that “dropout” of HIV treatment occurs at various stages of the treatment process. “An

estimated 110,000 individuals are HIV-infected in Argentina; of these, 70% have been diagnosed

and 54% were linked to care. However, only 36% have achieved viral suppression and 31% of

those diagnosed delayed entry to care” (Sued et al., 2018, Background section, para. 2). Sued et

al. (2018) discuss providers utilizing motivational interviewing (MI) to enhance motivation and

commitment in treatment adherence. With MI, the patient’s personal motivation is assessed, and

the patient participates in creating their own care plan. Results from their pilot study showed that

patient engagement ultimately led to the intervention outcome of viral suppression.

Mukamba et al. (2020) studied HIV patient satisfaction in Lusaka, the capital of Zambia,

in Africa. They note that while HIV infection prognosis has improved, long-term retention in

HIV treatment is a challenge. They state that patient satisfaction may affect engagement in HIV

treatment. They use a patient satisfaction tool to assess satisfaction among patients previously

lost to follow-up from HIV treatment in Lusaka. Results suggested that patient satisfaction is

related to re-engagement in treatment and may be important to monitor with HIV patients.

Lin et al. (2019) analyzed research completed on HIV treatment adherence and found a

correlation between low adherence to treatment and “hard-to-reach” status in HIV patients. They

state that HIV disproportionately impacts “hard-to-reach” socially disadvantaged groups

including drug users, sex workers, and homeless individuals. Analysis results indicate that “hard-
IMPROVING TREATMENT COMPLIANCE FOR HIV 12

to-reach” populations have suboptimal adherence to ART for HIV due to social exclusion. They

conclude that the findings have implications for public health and medical service provision, and

they list developing strategies and policies to address extreme health inequities as suggestions for

improvement in providing sustainable assistance and support.

Piercy et al. (2019) discuss disengagement from HIV treatment in England. They state

that the disengagement is strongly associated with poor health outcomes and reduced life

expectancy. It also results in continued disease transmission. They describe patients who

disengage from treatment as complex with a range of psychosocial problems. Therefore, re-

engagement interventions must be individualized. They completed a study to develop and test a

nursing intervention to prevent disengagement from HIV treatment. They found that a structured

and theoretically informed intervention may potentially reduce disengagement from HIV

treatment. This evidence suggests that Fleury’s Wellness Motivation Theory may assist in the

reduction of disengagement from HIV treatment. Using this theoretical framework to ensure

individuals are ready and willing to commit to positive health patterns before initiating HIV

treatment, will increase the likelihood that these individuals will maintain continued HIV

treatment adherence (Fleury, 1996).

Improvement of Care

Rural Health

Ziller and Milkowski (2020) write about rural health disparities. They discuss infectious

disease in rural areas, health care access, and public health nursing.

Infectious Disease.
IMPROVING TREATMENT COMPLIANCE FOR HIV 13

Infectious disease has been known to be prevalent in urban areas for many years (Ziller

and Milkowski, 2020). However, the awareness of this has led to increased sanitation and

maintenance that rural areas have not seen. Therefore, infectious disease has now become a

bigger issue for rural areas. Opioid-related injection drug use has contributed to new HIV

infections and similar outbreaks in rural communities. Most communities vulnerable to rapid

spread of HIV among intravenous drug users are rural.

Health Care Access.

Rural areas face challenges with access to health care including insufficient facilities and

providers, barriers to transportation, lower education and literacy levels, and higher rates of the

uninsured or underinsured. Hospitals within rural areas of the US are closing critical services

within the facility, or sometimes closing altogether (Ziller and Milkowski, 2020). “In 2019, 64%

of nonmetropolitan counties were designated primary care Health Professional Shortage Areas,

compared with 41% of metropolitan counties” (Ziller and Milkowski, 2020, Health Care Access

section, para. 2).

Public Health Nursing.

Public health nurses (PHNs) are essential in providing rural health care services (Ziller

and Milkowski, 2020). Rural PHNs often serve large geographically dispersed populations,

filling numerous, varied responsibilities. They contribute to improved health outcomes in the

underserved and isolated rural communities. There are some areas looking to increase the

recruitment and retention of rural PHNs by offering loan forgiveness for working in designated

high-need rural areas or offering Rural Health Scholar programs allowing health profession

students to gain experience working in rural areas.

IMPROVING TREATMENT COMPLIANCE FOR HIV 14

Physician Advocates for Infectious Disease Policy

Brito et al. (2021) highlight the importance of physician and other healthcare

professionals in federal policy regarding infectious disease and HIV. Physicians have a unique

ability, due to the trust and respect they earn, to inform policymakers that have the power to

develop policies that improve patient health. Infectious disease physicians’ efforts have led to

increased funding for HIV treatment and programs such as the Ryan White HIV/AIDS Program

and the President’s Emergency Plan for AIDS Relief. These physicians have also highlighted

disparities in healthcare resulting from the cost of HIV pre-exposure prophylaxis (PrEP) and

other critical HIV medications. They have made a difference in HIV patient insurance coverage

and prevention of discrimination for preexisting conditions like HIV and they have provided

information and support for HIV research.

Limitations

Limitations to the validity of this research, that investigates the difficulty of following up

with HIV positive patients, include the fact that patients may seek treatment outside of XYZ

county PHD, therefore there is no way to know if some of the “non-compliant” patients did

receive treatment. The COVID-19 pandemic may also provide skewed data for the years of 2019

to 2021. Due to stay-at-home orders and mandatory quarantines, it is possible that an increase of

people engaged in risky behaviors out of boredom, which may increase new HIV case numbers.

It is possible that, due to the same reasons, people who suspected HIV may have chosen not to

seek testing or treatment, as this may require exposure to large amounts of people in public

places. It is also notable that XYZ county PHD has a significant role in COVID-19 testing and

vaccination, and it is possible that during the added tasks and stress, opportunities for HIV
IMPROVING TREATMENT COMPLIANCE FOR HIV 15

testing decreased. This may result in suspected HIV positive people seeking testing outside of

XYZ county or not at all.

Conclusion

HIV is a global health issue of which outcomes have significantly improved over the

years, however there are still improvements to be made. Ensuring HIV positive patients seek

treatment and adhere to treatment is important in reducing the transmission of HIV and in

improving the outcomes of HIV infected patients. Effective communication and early,

accessible, education is important in HIV treatment. Rural, underserved, and socially

disadvantaged populations must have individualized, holistic, patient-centered care that is

appropriate for their unique situation. Strong provider-patient relationships influence patient

satisfaction and long-term treatment adherence. Proper education about HIV including testing

and treatment processes is imperative to create accurate understanding and gain patients’ trust.

Eradicating HIV transmission has been a global health care goal for a long time, and it is

possible with strong and consistent patient care.

IMPROVING TREATMENT COMPLIANCE FOR HIV 16

References

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physician ambassadors: Advancing policy to improve health. Journal of the Pediatric

Infectious Diseases Society, 10(4), 432-439.

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profile.html#Diagnoses

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IMPROVING TREATMENT COMPLIANCE FOR HIV 19

Table 1

Documented Individuals Living with HIV and AIDS and Number of Newly Diagnosed Cases

2019 NC State XYZ Region XYZ County

# Positive HIV 34,460 4,733 744

# New HIV 1,383 32

# Positive AIDS 15,473 3,567 363

# New AIDS 519 10

Note: Data not available for number of newly diagnosed individuals with HIV and AIDS in 2019 in XYZ

Region.
IMPROVING TREATMENT COMPLIANCE FOR HIV 20

Table 2

Newly Diagnosed Individuals with HIV and AIDS in First and Second Quarters for Three Years

New HIV Jan-Mar Jan-Mar Jan-Mar Jan-Jun Jan-Jun Jan-Jun

2019 2020 2021 2019 2020 2021

NC State 333 287 322 692 530 701

XYZ County 5 4 1 6 9 7

New AIDS Jan-Mar Jan-Mar Jan-Mar Jan-Jun Jan-Jun Jan-Jun

2019 2020 2021 2019 2020 2021

NC State 143 144 135 275 265 273

XYZ County 0 0 0 5 4 1
IMPROVING TREATMENT COMPLIANCE FOR HIV 21

Table 3

Documented Individuals Living with HIV and AIDS and Number of Newly Diagnosed Cases

Over One Year and the First and Second Quarters of Three Years

NC 2019 Jan-Mar Jan-Mar Jan-Mar Jan-Jun Jan-Jun Jan-Jun

County 2019 2020 2021 2019 2020 2021

Average

# Positive 342

HIV

# Positive 153

AIDS

# New HIV 14 3 3 3 7 5 7

# New 52 1 1 1 3 3 3

AIDS

XYZ 2019 Jan-Mar Jan-Mar Jan-Mar Jan-Jun Jan-Jun Jan-Jun

County 2019 2020 2021 2019 2020 2021

# Positive 744

HIV

# Positive 363

AIDS

# New HIV 32 5 4 1 6 9 7

# New 10 0 0 0 5 4 1

AIDS

Note: Data are not available for number of documented individuals living with HIV and AIDS in XYZ county or for

a NC county average, per first and second quarter of 2019 through 2021.
IMPROVING TREATMENT COMPLIANCE FOR HIV 22

Table 4

Number of Newly Diagnosed Individuals with HIV and Number of These Individuals That

Cannot Be Contacted for Treatment

XYZ County 2019 2020 2021

# New HIV 32 ~18 ~14

# Unable to Contact 4 2 2

Note: The data for number of newly diagnosed individuals with HIV for 2020 and 2021 are estimated

based on multiplying quarterly data to equal a full year, as full year reporting is not yet published

for 2020 or 2021.