Hopkins Nurse Researcher Studies Control of Secondary Infections in HIV-Positive Patients

Deaths from HIV/AIDS are falling worldwide, prompting healthcare providers to focus on controlling the secondary infections that can be life-threatening for immunocompromised individuals. Johns Hopkins University School of Nursing assistant professor Jason Farley, PhD, MPH, is on the forefront of this research, leading several studies both here and abroad on how to protect these patients from additional disease.

Community-Acquired MRSA

Hospital-acquired MRSA the bacteria that causes staph infections is well known. But community-acquired MRSA (CA-MRSA), with a different genetic basis, is more dangerous to HIV/AIDS-affected individuals because its easily transmittable and more likely to recur.
According to Farley, the bacteria are present in only one percent of the general population, but its more common among HIV/AIDS-affected groups. The repeat doctors visits needed to treat the infection augments the patients risk for further sickness, potentially complicating any HIV treatment.

CA-MRSA is highly transmittable within households, he says, so its possible for patients to pass the infection back and forth with their partner. In addition, a CA-MRSA-positive household, with all its surfaces and furniture, provides a ready-made source for reinfection. In fact, based on a molecular-analysis comparison of swabs from seven body sites taken at multiple times, Farley says 80 percent of patients treated for a CA-MRSA infection develop a second one within six months.

The biggest issue for HIV/AIDS-affected patients, Farley says, is the immune response a CA-MRSA infection prompts. The viral load spikes when the body begins to fight CA-MRSA.

We wanted to look at how the bacteria evolved and whether patients had it on different parts of the body, Farley says. Its important to know if a patient is a carrier or has been colonized by the strain especially if they start to develop multiple skin and soft tissue infections. Understanding CA-MRSAs genetic make-up can help create an intervention that prevents bacterial infection between persons or within households, Farley says. A Johns Hopkins Clinical Research Scholars Award funded the study.

Multiple Drug Resistant TB

South Africa has been more affected by HIV/AIDS than any other country. As of 2009, the nation had 5.6 million people living with the virus. Today, however, its the hospital structure itself that increases the risk of death for these individuals admitted with a secondary infection, Farley says. The problem is the high physician-to-patient ratio.

In partnership with the Medical Research Council and the Department of Health in Pretoria, Farley is expanding previous research with multidrug-resistant tuberculosis (MDR-TB) to see if nurse-led care improves outcomes. Currently, 35 percent of South Africas HIV-positive patients who contract MDR-TB die, compared to 16 percent of those who arent HIV-positive. These mortality rates far outpace adjoining countries, Farley says.

Based on our previous research into MDR-TB, we wanted to know why we were seeing such dismal cure rates in South Africa when other countries do well, Farley says. Our research now is looking into whether the physician-based culture is responsible and if these patients would benefit from having a nurse manage their cases.

This change would be a paradigm shift in South Africas physician-centric healthcare system, but Farleys previous research revealed doctors only see each patient once every seven to 10 days. When nurses more actively monitor patients, they catch 25 percent more adverse drug reactions than do physicians alone.

To determine the feasibility of this care model, Farley is collecting data about what job responsibilities South Africas nurses have, what care requirements exist for MDR-TB, what and where the care gaps exist, and upon what services the nurses can improve.

Additionally, in response to mounting pressure on physician time, Farley, with support from the Medical Research Council and South Africas Department of Health, is testing another model in which nurses use the rapid MDR-TB diagnosis test Gene Xpert PCR to initiate care in HIV-positive patients. The test truncates the diagnosis time from almost two months to only a few hours, giving nurses a head start on treating the disease. The first nurse to test this model begins training this month and will finish in January 2012.

Our goal is to develop and evaluate a model to replicate throughout the country, Farley says. Were hoping for good evidence that shows nurses can start these treatments in highly safe and effective ways, expanding the populations access to care.