UPDATE MANAGEMENT OF HIV – AIDS

IN THE IMPLEMENTATION
OF ASEAN ECONOMIC COMMUNITY
By:
Nursalam

Guru Besar Ilmu Keperawatan

Fakultas Keperawatan Universitas Airlangga Surabaya
email: nursalam@fkp.unair.ac.id , Hp. 081 3396 50000

nursalam-2014
 CURRICULUM VITAE

Name : Prof. Dr. Nursalam, M.Nurs (Hons) 081339650000

Address : Jl. Keputih Tegal Timur 62 Surabaya 60111
E-mail : nursalam@fkp.unair.ac.id

HIGHER, EDUCATION:
1. Doctor, Model of Nursing Care for HIV-AIDS, Postgraduate Programme,
Airlangga University, 2005
2. Honours Master of Nursing,, University of Wollongong, New South
Wales, Australia, 1997
3. Master of Nursing (Coursework), Univ. Wollongong, NSW, Australia,1996
4. Med. Surgical Nursing, Lambton College, Sarnia Ontario Canada, 1991
5. Diploma III in Nursing, Sutoma Surabaya 1988

ORGANISATION AND WORKING EXPERIENCES :

1. Dean, Faculty of Nursing Airlangga University (2008 – 2010) & (2015 – 2020)
2. Chaiman, AIPNI Regional JAWA TIMUR (2015-2017)
3. Chairman, PPNI Jawa Timur (2015-2020)
4. Head, Education and Training, Dewan Pengurus Pusat PPNI
5. Nursing Manager, Airlangga University Hospital (2011-2015)
6. Head, School of Nursing, Faculty of Medecine, UNAIR (2007 – 2008)
7. Vice Head, Educatin & Training, PPNI East Java Nursing Association (2000 – 2010)

PUBLICATION :
1. Books = 20
2. Acredited journal & (national & international)= 115 nursalam-2014
 OUTLINE

1. INTRODUCTION
2. ASEAN NURSE COMPETENCIES
3. CARING AS HOLISTIC
4. NURSE ROLE
5. NURSING PROCESS APPROACH
A. ASSESSMENT
B. DIAGNOSIS
C. INTERVENTION
D. EVALUATION
6. CONCLUSION
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 1
INTRODUCTION
7 Trends
Affecting Health Care Workforce
Demography Systems

Culture

Globalization
Technology

Disequalibrium
Market-based
 Global Epidemiology
 More than 39.5 million people living with
HIV/AIDS in 2010
– 4.3 million newly infected with HIV (more than
half are younger than 25)
– 2.9 million people died from AIDS

 More than 25 million people have died from

AIDS since 1981
 Africa has over 12 million AIDS orphans
Global Trends
 Xtending Hope

What can you do in Indonesia to

address the global AIDS
epidemic
?
 2
ASEAN NURSE COMPETENCIES
 5 Domains of the ASEAN
Nursing Common
Core Competencies
1. Ethic and Legal Practice
2. Professional Nursing Practice
3. Leadeship & Management
4. Education & Research
5. Professional, Personal and Quality
Development
11
 12 KOMPETENSI DASAR
NERS
1. Pemeriksaan fisik.
2. Prosedur pemberian obat
secara 12 benar.
3. Pemberian oksigen,
suksion, nebulisasi,
fisioterapi dada dan
postural drainage.
4. Prosedur pemasangan
infus dan enteral.
5. Prosedur pemasangan
kateter urin.
6. Prosedur pemasangan
selang naso gastrik
(NGT). Nursalam-08
7. Prosedur pencegahan
cedera.
8. Resusitasi Jantung
Paru (basic life support =
BLS).
9. Perawatan luka
10. Pemberian transfusi
darah dan produknya.
11. Prosedur pencegahan
infeksi nosokomial.
12. Pendokumentasian
dan pelaporan.
 IMPLICATION on Quality
- “STEEEP”
 Safe: avoiding injuries to patients from the care that is intended to help them
 Timely: reducing waits and sometimes harmful delays for both those who
receive and those who give care
 Effective: providing services based on scientific knowledge to all who could
benefit and refraining from providing services to those not likely to benefit
(avoiding underuse and overuse)
 Efficient: avoiding waste, in particular waste of equipment, supplies, ideas, and
energy
 Equitable: FAIR, providing care that does not vary in quality because of
personal characteristics such as gender, ethnicity, geographic location, and
socioeconomic status
 Patient-Centered: providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide all clinical decisions

“STEEEP” Framework outlined by the Institute of Medicine (“IOM”)

13
 ASEAN Declaration of Commitment:Getting to
Zero New HIV Infections, Zero Discrimination,
Zero AIDS-Related Deaths.

We, the Heads of State/Government of theAssociation of Southeast

Asian Nations(hereinafter referred to as “ASEAN”), namely Brunei
Darussalam, the Kingdom of Cambodia,the Republic of Indonesia,
the Lao People’s Democratic Republic, Malaysia, the Republicof
the Union of Myanmar, the Republic of the Philippines, the
Republic of Singapore,the Kingdom of Thailand and the Socialist
Republic of Viet Nam, on the occasion of the19th ASEAN Summit
in Bali, Indonesia reviewing comprehensively the progress
achieved in the decade since the adoption of the 2001 ASEAN
Declaration on AIDS and the implementation of the 2007 ASEAN
Commitments on HIV and AID”
 ASEAN Declaration of Commitment:Getting to
Zero New HIV Infections, Zero Discrimination,
Zero AIDS-Related Deaths.

Article 19. “Continue to support Global Fund toFight AIDS,

Tuberculosis and Malaria as apivotal mechanism for achieving
access to prevention, treatment, care and supportby 2015;
recognize the programme for17reform of the Global Fund, and
encourageMember States, ASEAN Dialogue Partners,the
private sector, business community,including foundations and
philanthropiststo provide the highest level of supportfor the
Global Fund, taking into accountthe funding targets to be
identified at the2012 midterm review of the Global Fund.
 Prevention: Policy
 Societycontributes to HIV
transmission!
– Empowering women
– Promoting Justice
– Addressing Poverty
– Providing Education
– Addressing Stigma
 3
CARING AS
HOLISTIC CARE IN NURSING
APPROACHES
 N-U-R-S-E
N = Nurture - Asuhan
U = Understand
R = Responsive /review
S = Serve
E = Ethic / educate
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 C A R E-needs
C = Communication
A = Activity (Pattients’ Need )
R =Responsiveness
Responsibility &

E = Education
ENTERPREUNER
/ ETHIC
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COMMUNICATION
Smile and
be happy
while you
can, life will
go on…
PRINCIP GST:
Ha Ha Ha
• GREETING;
!!!
• SORRY&
•THANKS
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CHALLENGE OF CARING
 You may have decided to go into
nursing because you care
 You will have the responsibility to maintain
the caring nature of nursing
 Begin here by developing that
relationship with other and the carry that
over into your career
21
 Caring is Universal
 Influences theway people think, feel and act
 Many nursing theorists have tired to “define”
caring – Nightingale was first

Caring is the heart of nursing

…“Caring is a nurturing way of relating to a

valued other toward whom one feels a
personal sense of commitment and
responsibility” (Swanson)
 Nursing Responsibilities in Patient-
Centered Approaches (Faye Abdellah)
Effective communication between patient
and caregiver. Information is accurate, timely and
appropriate.

Do everything possible to

alleviate patients’ pain and make them feel
comfortable.

We provide emotional support and alleviate fears and

anxiety.

We involve family and friends in every phase of our

patients’ care.

We ensure a smooth transition and continuity from one

focus of care to another.

We guarantee every member of our community has access

to our care (BPJS / poor / general)
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 SHIFTING THE CULTURE OF
CARING

Everyone’s For Every Everyday

Responsibility Patient

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 4
WHAT?
ROLE OF NURSE – HIV & AIDS
PATIENT

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Two Key Goals of HIV Treatment

• LOW Viral Load

• HIGH CD4 Cell Count

26
CARE & SUPPORT
• PROVIDING PRESENCE
• COMFORTING
• TOUCH
• LISTENING
• KNOWING THE PATIENT
• SPIRITUAL CARING
• FAMILY SUPPORT
 How to ..... ?
• Care includes ongoing prevention to reduce risk of
transmission of HIV and other disease
• Care includes prophylaxis for OIs and, if an OI occurs,
aggressive treatment of the infection
• Care includes palliation beginning at disease diagnosis
• Care moves from primarily the acute healthcare setting to
the ambulatory healthcare and home settings
Nursalam_Holistic_Unair_09
A

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 COMPREHENSIVE
CARE ON PWHIV-AIDS
Goals of Nursing in Comprehensive Care
1.Reducing morbidity and mortality and increasing the
quality of life of people at risk for HIV and those affected by
the disease

2. These goals are achieved through a focus on assessment

and implementation of interventions, including education on
both prevention and care
 USAID

COMPREHENSIVE CARE OF HIV (1)

To address the many factors involved in HIV disease, a
comprehensive and multidisciplinary approach is used to assist
patients and families:
– HIV testing and counseling
– Regular medical care including OI treatment and
prophylaxis, palliative care, and ART, either in the clinic or
home (or both)
– Social work
– Nutrition support
– Spiritual and psychosocial support
– Economic support
– PLHA support
– Ongoing prevention support
– Adherence counseling and ongoing support
COMPREHENSIVE CARE OF HIV (2)

• HIV not only affects the patient, but the family and household
as well. For example, children with HIV may be cared for by
ill parents. Nurses must think beyond the patient and include
the context of the patient’s family and household as a unit.
• Assess: Have household members been tested?
Do they need assistance in accessing care and
treatment for themselves or the patient? What
challenges do they face within the home?
• Intervene: Refer to testing and other services,
counsel on issues related to care of whole
family/household.
 5
NURSING PROCESS
APPROACH
 #1 – Free virus
#2 – Virus binds to CD &
ASSESSMENT fuses to T4 helper cell
#3 – Infectious virus
penetrates cell
#4 – Reverse transcription
#5 – Integration
#6 – Transcription
#7 – Assembly
#8 – Budding
#9 – Immature virus leaves
cell
T4 helper
cells = #10 – Maturation – develop
CD4+ cells new virus

35
 Overview of Pathophysiology
T-4
HIV – GP 120 protein – attaches
to CD4+ receptors on surface of
host T-cell
HIV destroys body’s immune system
by selectively attacking T-4
Lymphocytes, also macrophages & B
cells
HIV indirectly affects CNS by
neurotoxins produced by the infected
macrophages
As CD4+ count , body becomes more
susceptible to opportunistic infections
37
 BIOLOGICAL
Viral Load & CD4+ counts
CD4+
Viral load
1600
10 7
1200
10 6
800 10 5
600 10 4
400 10 3
CD4+ <200
200 10 2

Primary infection Latency AIDS

38
 HIV Wasting Syndrome
Incidence Profound involuntary weight loss
90% of people with HIV with chronic diarrhea, weakness
infection & fever > 30 days

Rx
Cause
Replace low testosterone in men
 food intake & women
Malabsorption Stimulate appetite with megestrol
Altered metabolism & dronabinal
Human growth hormone
TB- Infiltrat interstitial
HERPES SIMPLEK
HERPES SIMPLEK
CANDIDIASIS
SARKOMA KAPOSI
 Four (4) Stages of HIV
1. PRIMARY: Short, flu-like illness - occurs one to six weeks after
infection no symptoms at all. Infected person can infect other
people
2. ASYMPTOMATIC: Lasts for an average of ten years
This stage is free from symptoms
There may be swollen glands
The level of HIV in the blood drops to very low levels
HIV antibodies are detectable in the blood
3. SYMPTOMATIC: The symptoms are mild
The immune system deteriorates emergence of
opportunistic infections and cancers
4. HIV – AIDS: The symptoms are mild
The immune system deteriorates emergence of
opportunistic infections and cancers
 B. NURSING DIAGNOSIS
IDENTIFIKASI MASALAH
KEPERAWATAN
MUMPUNG TIDAK ADA
EMAK…

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Nursalam-08
 NURSING PROBLEMS PATIENT WITH
HIV/AIDS (HOLISTIC)
BIOLOGY:
Psychosocial-Spiritual
1. The decrease of
immunity (Seluler
& Humoral: CD4,
cytokine, Anti-HIV) PSYCHOLOGICAL
and RNA 1. Self SOCIAL-
Concept (-) STIGMA SPIRITUAL
2. Respiration : cough; 1. Isolated 1. Separation
2. Rejection
TBC; Chronic 2. Discriminati 2. Stress -
3. Frustration
Pneumonia on Spiritual
3. Digestive: diarrhea 3. Social
interaction
4. Integument: Allergy
(-)
(Ig E); Herpes;
Steven Johnson;
Kaposi Sarcoma.
5. Neurology:
Encephalopathy;
Nursalam_Holistic_Unair_09
Common symptom (PSYCHOLOGICAL)
symptom PREVALENCIES
– Pain 52%
– Pale 50%
Anxiety 40%
 Sleep disturbance 37%
 Stomatitis 33%
 Sad 32%
 Weight lost 31%
 Anorexia 28%
 Fever 27%
 Cough 27%
 Diarrhea 24%
 Skin problems 24%
 Depression 24%

Source : Larue F, et al (1994) Pain & symptoms during HIV disease. A French national
Nursalam_Holistic_Unair_09
study. Journal Palliative Care: 10(2):95 – referred from Agung (2005)
 SOCIAL - STIGMA
KETAKUTAN LABELING

DISKRIMINASI

BLAME &
COUNTER-BLAME STEREOTYPE

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Nursalam_Holistic_Unair_09
 DISCRIMINATION
SO ...Tender, loving, care!
(Sismulyonto, Nursalam, 2015)

‘You will have a

bath Mr Jensen, it
will make you
feel much better’

From: Every Woman's Encyclopaedia.

nursalam-2014
 Stigma in Nursing Care

 The stigma associated with AIDS has silenced

open discussion, both of its causes and of
appropriate responses

 Stigmatization associated with AIDS includes

lack of understanding of the illness,
misconceptions about how HIV is transmitted,
lack of access to treatment, irresponsible media
reporting on the epidemic, the incurability of
AIDS, and prejudice and fears relating to a
number of socially sensitive issues including
sexuality, disease and death, and drug use

53
 Stigma in Nursing Care
 Global consensus on the importance of tackling
AIDS-related stigma and discrimination is
highlighted by the Declaration of Commitment
adopted by the United Nations General Assembly
Special Session on HIV/AIDS in June 20011

 The Declaration states that confronting stigma

and discrimination is a prerequisite for effective
prevention and care, and reaffirms that
discrimination on the grounds of one’s HIV
status is a violation of human rights

54
http://www.un.org/ga/aids/coverage/
 SPIRITUAL
disintegration
 Nyeri spiritual : merasa dihukum Tuhan
 Pengkucilan spritual : merasa dikucilkan
 Kecemasan spiritual : takut berhadapan Tuhan
 Bersalah spiritual : sadar gaya hidup salah
 Marah spiritual : tidak terima takdir
 Kehilangan spiritual : ditinggalkan Tuhan
 Kesedihan spiritual : kehilangan cinta Tuhan
 C. INTERVENTION
CARING BASED ON
HOLISTIC NURSING CARE MODEL
 “BPIS”

PATIENT-CENTRED
CARE & PATIENT SAFETY
(BILA PASIEN ITU SAYA / SAUDARA....)

PRINCIPLE OF CARING

KARS, 2014
Nursalam_Holistic_Unair_09
 NURSING MODEL APPROACH – Nursalam (2007)

INPUT
Coping Strategy Social Support

Biologis; psikologis; sosial;

spiritual

COGNITIVE / KOGNISI (LEARNING

COGNATOR PROCESS)
RESPONSE PROCESS
Cerebral Cortex LIMBIG SYSTEM
(Cognition: (Emotion: .Amigdala) Emotion (+)
Perception (+)
Astrocyte)

Learning (+) Anxiety(-)

Judgment(+) Social Interaction

COPING STYLE (+)
(+)
-Rationalizations
-Utilizing Social Support
Emotion (+)
-Looking for Silver Lining
 stressor

Coping

Respons to stressor
(STRESS)

Alarm
stage Adaptation
EUSTRESS Exhaustion
DISTRESS
stage stage

taat
 Dasar Tidak ada rotan,
bayi, akarpun jadi.
Susunya
habis dik !! Stresor
belajar Tak ada susu, jari
COPIN tanganpun jadi.
G!!!

persepsi

Coping
Aksis
hipotalamus-pituitari-adrenal
(HPA)

Modulasi
Respons
imun
taat taat
 COPING

Kemampuan mengelola stresor

Terkondisi menjadi coping style

Coping Coping Coping
mechanisme model style
Menentukan kualitas stresor

Memodulasi respons imun

Menekan respons
imun
Meningkatkan
respons imun
taat
 HPA-AXIS
PROCESS
Hypothalamus
(CRF )
BIOLOGICAL
REGULATOR Pituitary
RESPONSE (ACTH)

Cortex Adrenal:
Fasciculate Zone
(Cortical)
OUTPUT
IMMUNE RESPONSE MODULATION

Th
IL-2, IL-10,
Th-1 (CD4 ) IFN-
Th-2 (CD8 )

NKcell & CTL

Anti-HIV
Nursalam_Holistic_Unair_09
AIDS (-) –QUALITY
INTERVENTION FOR hiv - aids
1. BIOLOGYC
2. PSICHOLOGIS
3. SOCIAL
4. SPIRITUAL
Nursalam_Holistic_Unair_09
 1. BIOLOGICAL SUPPORT
1. ARV & I-O
2. NUTRITION: Carbohydrate;
PROTEIN, MULTIVITAMIN,
ANTIOXYDANT
3. REST AND ACTIVITY
4. UNIVERSAL PRECAUTIONS
Nursalam_Holistic_Unair_09
 A. I - O
OPPORTUNISTIC
INFECTION &
PAIN
 B. NUTRITION
 ANTIOKSIDAN-
TKW & TKTP
 MULTIVITAMIN
C. ACTIVITIES

Nursalam_Holistic_Unair_09
D. UNIVERSAL PRECAUTIONS

CUCI TANGAN
APD (ALAT PELINDUNG DIRI)
DEKONTAMINASI
LIMBAH

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nursalam-2014
KEPATUHAN KEBERSIHAN
TANGAN
Media transmisi kuman patogen
tersering di Rumah Sakit
Semmelweis (1861),
Penularan penyakit dari pasien ke
pasien melalui tangan petugas
Boyce dan Larson 1995
Kebersihan tangan baik dan benar
menurunkan insiden HAIs
Boyke dan Pittet 2002
Kegalalan kebersihan tangan
menyebabkan multi resisten, wabah

nursalam-2014
BIOLOGICAL
RESPONSE
 Indicator of Biological Response
Progress
Psychological response (IMMUN response)
1. Cortisol (-)
2. CD4
3. Cytokine (IFN gamma, IL-2)
4. mRNA
- 5. Antigen Antibody - HIV
2. PSYCHOLOGICAL
 PSYCHOLOGICAL INTERVENTION

 SELF POTENTION EMPOWERMENT

 COGNITION TECHNIQUE (LEARNING

PROCESS)

 BEHAVIOR (ACT – HEALTH CONDITION)

 Indicator adaptive psychological
response (psychology)
Psychological response progress
(Acceptance response)
1. Denial
psychology 2. Anger
- Kubler – Ross 3. Bargaining
(Sign. Anger & 4. Depression
Bargaining) 5. Acceptance

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3. SOCIAL SUPPORT (16-19)
EMOTIONAL

MATERIAL
INFORMATION

APPRAISAL

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 We’ll do this together
 Replenish the soul of
experienced nurse
 Learn not to eat the
young.
 Experience (first hand)
generational issues.
 Patients like it

Nursalam-preceptorship-2013 82
 SOCIAL ASPECT
PATIENT WITH HIV & AIDS

Nursalam_Holistic_Unair_09
 Indicator adaptive social response

Social adaptation progress

1. Emotional need
2. Self definition(-)
Social (Emotional)
3. Interpersonal relationship
(+)
4. SPIRITUAL

Pray
Self control
 SPIRITUAL INTERVENTION
 Spiritual : values & religiosity

Hope

Reality

 Life value : Meaningful Life

 Religiosity : Improve
Nursalam_Holistic_Unair_09
 Indicator of Adaptive spiritual
response

Response
1. Realistic expectation
2. Patience
Spiritual 3. Looking for silver
lining (-)

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 SPIRITUAL Principle

ITS

IKHTIAR - IKHLAS, TAWAKKAL, SABAR

Nursalam_Holistic_Unair_09
 Relationship between spiritual and
Correlation
biological response Spearman rho

Social Biological response

response

Cortisol CD4 Interferon Anti HIV

Hopeness r = 0,063 r = -0,424 r = -0,197 r = 0,347

p = 0,793 p = 0,062 p = 0,404 p = 0,134

Patience r = -0,015 r = 0,221 r = 0,144 r = 0,233

p =0,949 p = 0,373 p = 0,545 p = 0,322

Silver lining r = 0,052 r = -0,639 r = -0,504 r = 0,387

p = 0,828 p = 0,002 p = 0,023 p = 0,092

Nursalam_Holistic_Unair_09
EVALUATION

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 Evaluation of treatment
Criteria
–  HIV RNA (viral load) in blood
–  # of T cells
– Appropriate clinical response

Generally, 1st treatment regimen of

ART is Pt’s. BEST CHANCE for
SUCCESS, so Adherence is very
Important!
Treatment Failure
 viral load with  T-cell count
Clinical deterioration
New opportunistic infections
91
 6. Conclusion
MODEL of LEARNING COPING
NCAM PROCESS (+)

HOLISTIC CARE:
Coping strategy Stress
Soc. support PERCEPTION
(-)

RESP. BIOLOGICAL
HPA-AXIS (cortisol -)
ADAPTATION
Immune response
Induce Modulation
Immune response
Nursalam_Holistic_Unair_09 (CD4, IFN-, A-HIV)
 10 Cs
1. CARING
2. COMMUNICATION
3. COLLABORATION
4. CONSITENCE
5. CAREFULNESS
6. COMPASSION
7. COURTESY
8. COMPETENT
9. CONFIDENCE
10. COMMITMENT
THANKS FOR YOUR
ATTENTION

Nursalam_Holistic_Unair_09