WORKING WITH CLIENTS WITH HIV/AIDS: THE CASE OF PEDRO

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Pedro is a 58-year-old, heterosexual, Dominican male who is HIV positive. He is married to his second wife and is the father of three sons. Pedro lives with his wife in a modest two-bedroom apartment in a major metropolitan area. Pedro completed high school and has a long work history as the manager of multiple food stores in his community. Pedro is currently on disability. He collects Social Security Disability Insurance (SSDI) and is covered by Medicare and the AIDS Drug Assistance Program (ADAP). ADAP is a state-sponsored insurance program for low-income individuals with HIV/AIDS that provides assistance with access to medication and primary care services in the state. Pedro does some work “off the books” to keep himself busy and earn extra money. While Spanish is Pedro’s dominant language, he is able to communicate well in English. Pedro identifies as a Christian, and his faith is a very important part of his life.

Pedro has a long history of substance abuse, including intravenous drug use (IVDU). Pedro spent a good part of 20 years using both cocaine and heroin. Despite his drug use, Pedro kept a full-time job and provided a safe home and moderate lifestyle for his family. When I met Pedro, he had been clean for more than 15 years. He reported that he stopped using drugs “because I got tired of being strung out.” He stated, “One day I grabbed my Bible and locked myself in a room for a week. I haven’t touched drugs since.” Pedro denied ever attending a formal drug rehabilitation program.

Pedro was diagnosed HIV positive in 1988. His risk factor for contracting HIV was IVDU. Pedro’s first wife contracted HIV from Pedro and died of AIDS. After her death, Pedro raised his sons as a single parent until he remarried about 10 years later. Pedro’s youngest son was infected with HIV through vertical transmission (from mother to baby). His HIV disease was controlled until he was 17. At that time, Pedro’s son developed AIDS and, after a long battle, died before his 19th birthday. Pedro never left his son’s bedside during his illness. Pedro harbors significant guilt about his son’s death. Pedro’s HIV/AIDS is moderately controlled on highly active antiretroviral therapy (HAART), although he has a history of poor compliance with his HAART regimen. HAART should be taken on a consistent schedule, but Pedro stops and starts his HAART, which can be very dangerous. In addition to HIV/AIDS, Pedro is diagnosed with hepatitis C (Hep C). His doctor has indicated that Pedro’s Hep C should be treated, but Pedro is very reluctant to begin treatment.

The treatment setting where I met Pedro was an outpatient comprehensive care clinic affiliated with a city hospital. The clinic was created to provide interdisciplinary care to adult patients living with HIV/AIDS. The backbone of each patient’s clinical team included a social worker and a primary care physician with a specialty in HIV care. For the most part, visits with the social worker were paired with routine doctor appointments. When I met Pedro, he was an established patient at the clinic, having gone there since his initial diagnosis in 1988. As a result, he had worked with a string of social workers over the years.

During our initial visit, Pedro greeted me by saying, “I really don’t need another social worker who is not going to help me, so there’s no point in me talking to you.” I urged Pedro to sit down with me so I could at least introduce myself. During our visit, I validated Pedro’s feelings about having another new social worker and attempted to explain how I viewed my role at the clinic. Pedro “yessed me to death” politely, but his ambivalence and resistance were palpable. This type of exchange continued for several visits. During these visits, I tried to build a rapport with Pedro. We spoke about his family and his social and medical history. The visits were casual, and I was nonconfrontational. After each visit, I thanked Pedro for talking to me and told him that I hoped I would be able to help him if something came up. My intent during this period was to build a clinical assessment of Pedro. Pedro had a strong personality and was reluctant to show his true emotions. His presentation was consistent with machismo, and I realized that Pedro’s Latino cultural background was embedded throughout his life. Pedro was profoundly committed to his family and their well-being, he had strong views toward male and female gender roles, and religion played a very important role in Pedro’s life.

One day, Pedro surprised me by greeting me and saying, “Ok, I need your help.” Pedro was having difficulty filling his prescriptions. In short, Pedro’s Medicare and ADAP had to work together, but neither Pedro nor the pharmacy could figure out how to make the process work. It became plainly obvious that despite Pedro’s ability to manage many complex issues in his life, dealing with this issue was overwhelming and almost paralyzing for him. After multiple phone calls to Medicare, ADAP, the pharmacy, etc., I was able to decipher the process that Pedro needed to follow. I realized the only way Pedro was going to be able to succeed was if I broke the problem down into manageable pieces. Ultimately, Pedro and I figured out a suitable plan that worked for him and got his prescriptions filled. While my initial task was to help Pedro come up with a plan of action, my ongoing role was to provide support and encouragement so that Pedro felt empowered to face a task that was once inapproachable.

Engaging Pedro around this concrete issue opened the door to our future relationship. In his eyes, I was no longer “another worthless social worker,” and he was able to address more emotional issues with me, such as his feelings about his son’s death and the progression of his own HIV/AIDS and Hep C illnesses. In our future work, we spoke about Pedro’s noncompliance to his medication, and while Pedro’s behaviors around his HAART did not change, he did begin and successfully complete treatment for his Hep C.

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