Integration of palliative care throughout HIV disease

Global Assessment of Palliative Care Need: Serious Health-Related Suffering Measurement Methodology

CONTEXT

Inequities and gaps in palliative care access are a serious impediment to health systems especially in low- and middle-income countries and the accurate measurement of need across health conditions is a critical step to understanding and addressing the issue. Serious Health-related Suffering (SHS) is a novel methodology to measure the palliative care need and was originally developed by The Lancet Commission on Global Access to Palliative Care and Pain Relief. In 2015, the first iteration - SHS 1.0 - was estimated at over 61 million people worldwide experiencing at least 6 billion days of SHS annually as a result of life-limiting and life-threatening conditions.

OBJECTIVES

In this paper, an updated methodology - SHS 2.0 - is presented building on the work of the Lancet Commission and detailing calculations, data requirements, limitations, and assumptions.

METHODS AND RESULTS

The updates to the original methodology focus on measuring the number of people who die with (decedents) or live with (non-decedents) SHS in a given year to assess the number of people in need of palliative care across health conditions and populations. Detail on the methodology for measuring the number of days of SHS that was pioneered by the Lancet Commission, is also shared, as this second measure is essential for determining the health system responses that are necessary to address palliative care need and must be a priority for future methodological work on SHS.

CONCLUSIONS

The methodology encompasses opportunities for applying SHS to future policy making assessment of future research priorities particularly in light of the dearth of data from low- and middle-income countries, and sharing of directions for future work to develop SHS 3.0.

Understanding geriatric models of care for older adults living with HIV: a scoping review and qualitative analysis

BACKGROUND

Advances in Human Immunodeficiency Virus (HIV) treatment have reduced mortality rates and consequently increased the number of individuals with HIV living into older age. Despite this, people aged 50 years and older have been left behind in recent HIV treatment and prevention campaigns, and a gold-standard model of care for this population has not yet been defined. Developing evidence-based geriatric HIV models of care can support an accessible, equitable, and sustainable HIV health care system that ensures older adults have access to care that meets their needs now and in the future.

METHODS

Guided by Arksey & O'Malley (2005)'s methodological framework, a scoping review was conducted to determine the key components of, identify gaps in the literature about, and provide recommendations for future research into geriatric models of care for individuals with HIV. Five databases and the grey literature were systematically searched. The titles, abstracts and full texts of the search results were screened independently in duplicate. Data were analyzed using a qualitative case study and key component analysis approach to identify necessary model components.

RESULTS

5702 studies underwent title and abstract screening, with 154 entering full-text review. 13 peer-reviewed and 0 grey literature sources were included. Most articles were from North America. We identified three primary model of care components that may improve the successful delivery of geriatric care to people living with HIV: Collaboration and Integration; Organization of Geriatric Care; and Support for Holistic Care. Most articles included some aspects of all three components.

CONCLUSION

To provide effective geriatric care to older persons living with HIV, health services and systems are encouraged to use an evidence-based framework and should consider incorporating the distinct model of care characteristics that we have identified in the literature. However, there is limited data about models in developing countries and long-term care settings, and limited knowledge of the role of family, friends and peers in supporting the geriatric care of individuals living with HIV. Future evaluative research is encouraged to determine the impact of optimal components of geriatric models of care on patient outcomes.

Patient-centred care: reality or rhetoric—patients’ experiences at ARV clinics located in public hospitals in KwaZulu-Natal, South Africa

Background

The South African public antiretroviral therapy (ART) programme is considered one of the largest and most successful ART programmes worldwide. Hence, a study exploring the patients’ experiences of the public antiretroviral therapy (ART) programme in the second decade of the programme is relevant as no study has been published on patients’ experiences at these sites.

Objectives

To explore patients’ experiences of care in the public ART programme at four ARV clinics within the eThekwini District, KwaZulu-Natal.

Method

A mixed-methods study design with 12 in-depth patient interviews, non-participatory observation, and a stratified random sample of 400 patients completed questionnaires. Qualitative data were thematically analysed. Quantitative data were analysed using a SPSS 24 package to determine frequencies and differences in patients’ responses (p < 0.05). The socio-ecological model framed the study.

Results

All 412 patients reported valuing the provision of free ARVs. Patients’ positive experiences included: routine blood results mostly being available, most staff greeted patients, there were sufficient nurses, patients were satisfied with the time that they spent with doctors, clean clinics, and private and safe counselling areas. The negative experiences included: poor relationships with nurses, negative staff attitudes, disrespectful staff, information was lacking, inadequate counselling at times, varying and inflexible appointments, challenges with data capture and registration systems; varying ARV collection frequencies, routine health tests and processes per site, and the absence of patient committees and representatives.

Conclusion

The results reflected positive and negative experiences which varied between the facilities, as processes and systems differed at each site. Innovative patient-centred processes and programmes could be implemented to ensure patients have mostly positive experiences. As part of continuous improvement, patients’ experiences should be regularly explored to ensure that the ART programme meets their needs and expectations.

Developing Community-Based Palliative Care Services for People Living with HIV in Africa

ABSTRACT

Africa continues to be disproportionately affected by HIV/AIDS. Poor access to medical care, limited access to antiretroviral drugs, and lack of supportive care for persons who are symptomatic lead to disease progression. Community-based palliative care services are effective in providing supportive services throughout the course of the illness, but palliative care services are limited in Africa. This article presents a theoretical approach to developing community-based palliative care services to bridge this gap.

The role of digital health in palliative care for people living with HIV in sub-Saharan Africa: A systematic review

Background

In 2018, 26.6 million people were living with HIV in sub-Saharan Africa. Palliative care services are recommended for people living with HIV at all stages from diagnosis through to end-of-life. However, the provision of palliative care in sub-Saharan Africa is limited, leading to little or no access for the majority of patients. Digital technologies in sub-Saharan Africa present an opportunity to improve access to palliative care for people living with HIV in the region. This review synthesised literature on digital health interventions for palliative care for people living with HIV in sub-Saharan Africa and assessed their effects on patient outcomes.

Methods

Literature searches were conducted in MEDLINE, Embase, PsycINFO and Global Health. Inclusion and exclusion criteria were applied. Two independent reviewers conducted study screening, data extraction and quality appraisal. A narrative synthesis was performed to draw together and report findings across heterogeneous studies. Reporting of this review follows the Preferred Reporting Items for Systematic Review and Meta-Analysis checklist.

Results

Out of 4117 records, 25 studies were included, covering 3592 people living with HIV, across 21 countries. Studies included three randomised controlled trials, three qualitative, three pre- and post-test, two observational, two case series, six cross-sectional and six mixed methods studies. Telemedicine was the most reported digital health intervention, with 12 studies demonstrating the effectiveness of digital health interventions.

Conclusion

Emerging evidence suggests digital health interventions can be effective in facilitating patient-provider communication and health professional decision-making as a part of palliative care for people living with HIV. There is a need for further development and evaluation of digital health interventions alongside determining optimal approaches to their implementation as a part of palliative care provision in sub-Saharan Africa.

Palliative care needs, concerns, and affirmative strategies for the LGBTQ population

The Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning population, also known as sexual and gender minorities, are an incredibly marginalized and vulnerable population that have been disproportionately affected by the provision, delivery, and optimal access to high-quality medical care including palliative, hospice, and end-of-life care. The long-standing and unique experiences shaped by positive and negative historical events have led to a better understanding of significant barriers and gaps in equitable healthcare for this population. The intersection of both internal and external stressors as well as minority identities in the context of discriminatory political and societal infrastructures have resulted in variable health outcomes that continues to be plagued by economic barriers, oppressive legislative policies, and undesirable societal practices. It could not be more urgent and timely to call upon the government and healthcare systems at large to execute reforms in policies and regulations, engage in cultural competency training, and promote cultural shifts in beliefs, attitudes, and practices that will ultimately recognize, prioritize, and address the needs of this population. After all, health care access is a universal right regardless of personal, social, political, and economic determinants of comprehensive medical care.

The Challenges of Caring for People Dying From COVID-19: A Multinational, Observational Study (CovPall)

CONTEXT

Systematic data on the care of people dying with COVID-19 are scarce.

OBJECTIVES

To understand the response of and challenges faced by palliative care services during the COVID-19 pandemic, and identify associated factors.

METHODS

We surveyed palliative care and hospice services, contacted via relevant organizations. Multivariable logistic regression identified associations with challenges. Content analysis explored free text responses.

RESULTS

A total of 458 services responded; 277 UK, 85 rest of Europe, 95 rest of the world; 81% cared for patients with suspected or confirmed COVID-19, 77% had staff with suspected or confirmed COVID-19; 48% reported shortages of Personal Protective Equipment (PPE), 40% staff shortages, 24% medicines shortages, 14% shortages of other equipment. Services provided direct care and education in symptom management and communication; 91% changed how they worked. Care often shifted to increased community and hospital care, with fewer admissions to inpatient palliative care units. Factors associated with increased odds of PPE shortages were: charity rather than public management (OR 3.07, 95% CI 1.81-5.20), inpatient palliative care unit rather than other settings (OR 2.34, 95% CI 1.46-3.75). Being outside the UK was associated with lower odds of staff shortages (OR 0.44, 95% CI 0.26-0.76). Staff described increased workload, concerns for their colleagues who were ill, whilst expending time struggling to get essential equipment and medicines, perceiving they were not a front-line service.

CONCLUSION

Palliative care services were often overwhelmed, yet felt ignored in the COVID-19 response. Palliative care needs better integration with health care systems when planning and responding to future epidemics/pandemics.

Increased Retention in Care After a Palliative Care Referral Among People Living With HIV

BACKGROUND

Early palliative care addresses biopsychosocial needs for people living with HIV in an outpatient setting. We sought to describe patients referred to a palliative care program and compare the medical outcomes of emergency department (ED) visits, hospitalizations, primary care visits, and viral load suppression among patients enrolled in the program, to patients who did not enroll (no-show group).

SETTING

We completed a retrospective cohort study at an urban, academically affiliated HIV primary care clinic.

METHODS

Data were collected from electronic medical records. Descriptive statistics characterized patient demographics at baseline, comorbidities, and reasons for referral to palliative care. Viral load suppression, rates of ED visits, hospitalizations, primary care visits, and retention in care were compared between the palliative and no-show groups.

RESULTS

The most common reasons for referral were chronic pain management and medication/appointment adherence. Median percent of viral load measurements suppressed increased over time, but did not differ statistically between groups (pre: 28.6% and 15.5%, post: 70.8% and 50.0%, palliative and no-show groups, respectively). Median rates of ED visits and hospitalizations were low and were not impacted by palliative care. Rates of primary care visit attendance remained stable in the palliative group (4.6/year) but declined in the no-show group (3.5/year), P < 0.05. Retention in care improved significantly after the palliative intervention (palliative: 85.4%-96.1%, no-show: 94.4%-82.5%), and at high and low palliative engagement, suggesting a threshold effect of the intervention.

CONCLUSION

Outpatient early palliative care is a promising intervention that might impact retention in HIV care.

Palliative care as an essential component of the HIV care continuum

Although antiretroviral therapy has reduced mortality among people with HIV, inadequate treatment coverage, ageing, and the increasing incidence of organ failure and malignancies mean that high-quality care should include care at the end of life. This Review summarises the epidemiology of HIV in relation to mortality, and the symptoms and concerns of people with AIDS and those living with HIV who have either related or unrelated advanced comorbidities. In response to the evidence of a need for palliative care, the principles and practice of palliative care are described, and the evidence for its effectiveness and cost-effectiveness is appraised. The core practices of palliative care offer a mechanism to enhance the person-centred nature of HIV care; I identify the gaps in this type of care, and present evidence for effective models of care to address these. I detail the policies that prompt governments and health systems to respond to the palliative care needs of their population. Finally, I conclude this Review with evidence-based recommendations to improve the delivery of, and access to, high-quality HIV care until the end of life, reducing unnecessary suffering while optimising person-centred outcomes.

Access to palliative care in HIV services in Cape Town

This paper examines access to palliative care (PC) for patients with HIV, part of a study investigating access to PC for patients with chronic diseases. Studies highlight gaps in symptom management and psychosocial care for People living with HIV (PLHIV) and thus the need to integrate PC into HIV services. The aim of the study was to describe the access of patients with advanced chronic illness to PC services.

METHODOLOGY

this was a prospective cohort study conducted over six months. Participants were recruited from patients living with HIV with CD4 counts of <200 cells/mm³, patients with advanced cancer and patients diagnosed with motor neurone disease. All HIV patients were on anti-retroviral treatment. Participants responded to a questionnaire including the APCA African Palliative Outcome Scale (POS), a validated palliative outcome scale, as a measure of care at first visit and telephonically once a month for 6 months.

RESULTS

Seventy-nine HIV patients were recruited to the study. During the study 6 PLHIV died and no HIV patients were referred to PC services. A significant finding is that most patient outcomes improved for HIV patients. Pain reduced from 1.83 to 0.86; symptoms reduced from 2.41 to 0.49; worry reduced from 2.17 to 0.35. Spiritual well-being also improved - life worthwhile from 3.56 to 4.74 and at peace from 3.63 to 4.86; all measures out of 5. A small sub-set of this cohort (7.7%) experienced high pain levels not controlled during the study.

DISCUSSION

Few patients were referred to PC services despite 6 HIV deaths during the study. Patients attending HIV clinics received good PC in conjunction with HAART, suggesting that PC appears to be well integrated into routine HIV care. It is suggested that patients with severe problems including those who died would have benefitted from referral to PC.

Place of death for people with HIV: a population-level comparison of eleven countries across three continents using death certificate data

Background

With over 1 million HIV-related deaths annually, quality end-of-life care remains a priority. Given strong public preference for home death, place of death is an important consideration for quality care. This 11 country study aimed to i) describe the number, proportion of all deaths, and demographics of HIV-related deaths; ii) identify place of death; iii) compare place of death to cancer patients iv), determine patient/health system factors associated with place of HIV-related death.

Methods

In this retrospective analysis of death certification, data were extracted for the full population (ICD-10 codes B20-B24) for 1-year period: deceased’s demographic characteristics, place of death, healthcare supply.

Results

i) 19,739 deaths were attributed to HIV. The highest proportion (per 1000 deaths) was for Mexico (9.8‰), and the lowest Sweden (0.2‰). The majority of deaths were among men (75%), and those aged <50 (69.1%). ii) Hospital was most common place of death in all countries: from 56.6% in the Netherlands to 90.9% in South Korea. The least common places were hospice facility (3.3%–5.7%), nursing home (0%–17.6%) and home (5.9%–26.3%).iii) Age-standardised relative risks found those with HIV less likely to die at home and more likely to die in hospital compared with cancer patients, and in most countries more likely to die in a nursing home. iv) Multivariate analysis found that men were more likely to die at home in UK, Canada, USA and Mexico; a greater number of hospital beds reduced the likelihood of dying at home in Italy and Mexico; a higher number of GPs was associated with home death in Italy and Mexico.

Conclusions

With increasing comorbidity among people ageing with HIV, it is essential that end-of-life preferences are established and met. Differences in place of death according to country and diagnosis demonstrate the importance of ensuring a “good death” for people with HIV, alongside efforts to optimise treatment.

Electronic supplementary material

The online version of this article (10.1186/s12879-018-2951-x) contains supplementary material, which is available to authorized users.

A Population-Based Study of Care at the End of Life Among People With HIV in Ontario From 2010 to 2013

BACKGROUND

Aging and increasing comorbidity is changing the end-of-life experience of people living with HIV (PLHIV) in the developed world. We quantified, at a population level, the receipt of health care services and associated costs across a comprehensive set of sectors among decedents with and without HIV.

METHODS

We conducted a retrospective population-level observational study of all decedents in Ontario and their receipt of health care services, captured through linked health administrative databases, between April 1, 2010 and March 31, 2013. We identified PLHIV using a validated algorithm. We described the characteristics of PLHIV and their receipt of health care services and associated costs by health care sector in the last year of life.

RESULTS

We observed 264,754 eligible deaths, 570 of whom had HIV. PLHIV were significantly younger than those without HIV (mean age of death 56.1 years vs. 76.6 years, [P < 0.01]). PLHIV spent a mean of 20.0 days in an acute care hospital in the last 90 days of life compared with 12.1 days for decedents without HIV (P < 0.01); after adjustment, HIV was associated with 4.5 more acute care days (P < 0.01). Mean cost of care in the last year was significantly higher among PLHIV ($80,885.62 vs. $53,869.77), mostly attributable to acute care costs.

INTERPRETATION

PLHIV in Ontario are dying younger, spending more time and dying more often in hospital, and incur significantly increased costs before death. Greater involvement of community-based palliative care may improve the dying experience for this complex population.

Palliative care for patients with HIV/AIDS admitted to intensive care units

Objective

To describe the characteristics of patients with HIV/AIDS and to compare the therapeutic interventions and end-of-life care before and after evaluation by the palliative care team.

Methods

This retrospective cohort study included all patients with HIV/AIDS admitted to the intensive care unit of the Instituto de Infectologia Emílio Ribas who were evaluated by a palliative care team between January 2006 and December 2012.

Results

Of the 109 patients evaluated, 89% acquired opportunistic infections, 70% had CD4 counts lower than 100 cells/mm³, and only 19% adhered to treatment. The overall mortality rate was 88%. Among patients predicted with a terminally ill (68%), the use of highly active antiretroviral therapy decreased from 50.0% to 23.1% (p = 0.02), the use of antibiotics decreased from 100% to 63.6% (p < 0.001), the use of vasoactive drugs decreased from 62.1% to 37.8% (p = 0.009), the use of renal replacement therapy decreased from 34.8% to 23.0% (p < 0.0001), and the number of blood product transfusions decreased from 74.2% to 19.7% (p < 0.0001). Meetings with the family were held in 48 cases, and 23% of the terminally ill patients were discharged from the intensive care unit.

Conclusion

Palliative care was required in patients with severe illnesses and high mortality. The number of potentially inappropriate interventions in terminally ill patients monitored by the palliative care team significantly decreased, and 26% of the patients were discharged from the intensive care unit.

End-of-life care for HIV-infected patients with malignancies: A questionnaire-based survey

BACKGROUND

The number of HIV-infected patients who require palliative or end-of-life care is increasing, and the status of end-of-life care for HIV patients with malignancies is unclear.

AIM

This study aimed to evaluate the end-of-life care provided to HIV patients with malignancies in Japan.

DESIGN

National cross-sectional questionnaire-based survey.

SETTING/PARTICIPANTS

Questionnaires were delivered to the medical staff of 378 regional core hospitals/core hospitals for AIDS and 285 palliative care units in Japan. Data were collected between August and October 2013.

RESULTS

Overall, 226 regional core hospitals/core hospitals for AIDS (59.8%) responded. A total of 55 institutions (24.3%) provided end-of-life care to HIV patients with malignancies. Regarding the place of death of the patients, 69.1% died at the institution whereas 18.2% were transferred to palliative care units. The requests of 16 (29.1%) institutions to transfer patients to palliative care units were rejected. Of the 378 palliative care units, 179 (62.8%) responded. While 13 palliative care units (4.6%) provided care to hospitalized HIV patients with malignancies, 20 (11.2%) refused to accept these patients for treatment because of a lack of experience in treating these patients and a lack of knowledge regarding HIV infection.

CONCLUSION

Our findings suggest that in Japan, HIV patients with malignancies have difficulties obtaining hospitalization at a palliative care unit, which is likely due to a lack of experience among the professionals in treating such patients as well as a lack of knowledge about HIV.

Implementation of HIV Palliative Care: Interprofessional Education to Improve Patient Outcomes in Resource-Constrained Settings, 2004-2012

Palliative care (PC), introduced early in the management of chronic illness, improves patient outcomes. Early integration of a palliative approach for persons with HIV has been documented to be effective in identifying and managing patient-level concerns over the past decade in African settings. The experience of implementing PC in multiple African and other resource-constrained settings (RCSs) emphasizes the need for essential palliative competencies that can be integrated with chronic disease management for patients and their families facing life-limiting illness. This article is an historical description of how basic palliative competencies were observed to be acceptable for health workers providing outpatient HIV care and treatment during eight years of U.S. implementation of "care and support," a term coined to represent PC for persons living with HIV in RCS. The need for team building and interprofessional education is highlighted. The model is currently being tested in one U.S. city and may represent a mechanism for expanding the palliative approach into management of chronic disease. Such competencies may play a role in the development of the patient-centered medical home, a critical component of U.S. health care reform.

Palliative HIV care: opportunities for biomedical and behavioral change

Advances in treatment are contributing to substantial increases in life expectancy for individuals living with HIV, prompting a need to develop care models for the effective management of HIV as a chronic illness. With many individuals continuing to experience symptoms and complications that add to the disease burden across the spectrum of HIV disease, the discussion herein explores the complementary role that early palliative care can play in HIV primary care as a strategy for enhancing long-term quality of life. After first defining the concept of early palliative care, its scope in the context of current clinical realities in HIV treatment and implications for HIV care models is described. After reviewing the emerging extant research literature on HIV palliative care outcomes, a program description is offered as an illustration of how palliative care integration with HIV primary care can be achieved.

Nurse-led palliative care for HIV-positive patients taking antiretroviral therapy in Kenya: a randomised controlled trial

BACKGROUND

People with HIV accessing antiretroviral therapy (ART) have persistent physical, psychological, social, and spiritual problems, which are associated with poor quality of life and treatment outcomes. We assessed the effectiveness of a nurse-led palliative care intervention on patient-reported outcomes.

METHODS

We did this randomised controlled trial at a clinic in Kenya for adults with HIV, established on ART, and reporting moderate-to-severe pain or symptoms. We randomly assigned participants (1:1) either to a palliative care intervention (including assessments of physical, emotional, and spiritual wellbeing and quality of life) given six times over 4 months, or to usual care. Participants and investigators were not masked to allocation. The primary outcome was pain (scored on the African Palliative Care Association's African Palliative Outcome Scale). This trial is registered with ClinicalTrials.gov, number NCT01608802.

FINDINGS

We screened 2070 patients, of whom we enrolled 120: 60 allocated to each group. In the control group, median pain score improved from 1·0 (IQR 0·0-2·0) at baseline to 5·0 (3·0-5·0) at 4 months; in the intervention group, it improved from 1·0 (0·0-2·0) at baseline to 4·5 (3·0-5·0) at 4 months. Compared with standard care, the intervention had no significant effect on pain (coefficient -0·01, 95% CI -0·36 to 0·34, p=0·95).

INTERPRETATION

A nurse-led palliative care intervention was not effective in reducing pain. However, person-centred assessment and care delivered by staff who have received additional training had positive effects on self-reported mental health related quality of life and psychosocial wellbeing.

FUNDING

Diana Princess of Wales Memorial Fund.

Palliative care in Africa: a global challenge

We are often asked what challenges Rwanda has faced in the development of palliative care and its integration into the healthcare system. In the past, patients have been barred from accessing strong analgesics to treat moderate to severe pain, but thanks to health initiatives, this is slowly changing. Rwanda is an example of a country where only a few years ago, access to morphine was almost impossible. Albert Einsten said 'in the middle of difficulty lies opportunity' and this sentiment could not be more relevant to the development of palliative care programmes. Through advocacy, policy, and staunch commitment to compassion, Rwandan healthcare workers are proving how palliative care can be successfully integrated into a healthcare system. As a global healthcare community, we should be asking what opportunities exist to do this across the African continent. Champions of palliative care have a chance to forge lasting collaborations between international experts and African healthcare workers. This global network could not only advocate for palliative care programmes but it would also help to create a culture where palliative care is viewed as a necessary part of all healthcare systems.

Quality of life and wellbeing among HIV outpatients in East Africa: a multicentre observational study

Background

Global health investment has reduced HIV mortality and transmission. However, little is known of patient-reported outcomes alongside ART rollout. This study aimed to measure wellbeing using patient-reported outcome measures (PROMS) among outpatients at PEPFAR-funded facilities.

Methods

In a multicentre 2 country cross-sectional study, adults attending 12 facilities in Kenya and Uganda gave self-reported data on quality of life (physical and mental wellbeing dimensions), functional and a measure of multidimensional problems (physical, psychological, social and spiritual).

Results

Among the 1,337 participants, multidimensional problems were more common in psychological, spiritual and social domains than in physical. In multivariable analysis using GEE to adjust for facility effect, the mental health subscale of quality of life was lower for people with limited functional status (B = -5.27, 95% CI -5.99, 1. -4.56 p < 0.001) and higher for wealthier people (B = 0.91, 95% CI 0.48, 1.33, p < 0.001). The physical health subscale of quality of life was lower for those with limited functional status (B = -8.58, 95% CI -9.46 to -7.70, p < 0.001) and those who had a caregiver present (B = -1.97, 95% CI -3.72 to -0.23, p = 0.027), higher for wealthier people (B = 1.14, 95% CI 0.65, 1.64, p < 0.001), and positively associated with CD4 count (B = 1.61, 95% CI 1.08-2.14, p < 0.001). Multidimensional problems were more burdensome for people with limited functional status (B = -2.06, 95% CI -2.46 to -1.66, p < 0.001), and less burdensome with more education (B = 0.63, 95% CI 0.25-1.00, p = 0.001) or ART use (B = 0.94, 95% CI 0.34-1.53, p = 0.002).

Conclusions

Multidimensional problems are highly prevalent, and worse with declining function. Importantly, ART use does not appear to be protective for self-reported physical and mental dimensions of quality of life. Assessment and management of self-reported wellbeing must form part of HIV care and treatment services to ensure maximum benefit from ART investment.

A psychometric evaluation of the functional assessment of chronic illness therapy-palliative care (FACIT-Pal) scale with palliative care samples in three African countries

CONTEXT

Although sub-Saharan Africa suffers the greatest burden of progressive illness, there are few outcome measures with adequate properties to measure needs and outcomes.

OBJECTIVES

To examine the psychometric properties of the Functional Assessment of Chronic Illness Therapy-Palliative Care (FACIT-Pal) among people receiving palliative care in three African countries.

METHODS

Adult patients in South Africa, Kenya, and Uganda gave self-reported data to the core FACIT-G plus Pal subscale. Data were subjected to factor analysis, corrected item-total correlations, and Cronbach's α for full scale and subscales.

RESULTS

The resulting four factors bear a strong similarity to the original Functional Assessment of Cancer Therapy-General in our sample of 461: physical symptoms, functional well-being, friends and family, and emotional well-being. Cronbach's α for the full 27-item scale was 0.90 and for the physical well-being, social/family well-being, emotional well-being, and functional well-being subscales, it was 0.83, 0.78, 0.80, and 0.87, respectively. Varimax rotation of the 19-item FACIT-Pal scale showed three clear interpretable factors. Factor 1, a sense of purpose and meaning in life; Factor 2, physical symptoms; and Factor 3, social integration. For the 19-item FACIT-Pal, Cronbach's α was 0.81, and individual corrected item-total correlations ranged from 0.24 to 0.61. Cronbach's α for the eight items comprising Factor 1 (meaning in life) was 0.83. For the other two factors, it was 0.70 (physical symptoms, six items) and 0.68 (social integration, three items).

CONCLUSION

The FACIT-Pal is a reliable multidimensional scale for people with life-limiting incurable diseases in sub-Saharan Africa, and the observed factors are interpretable and clinically meaningful.

Assessing and responding to palliative care needs in rural sub-Saharan Africa: results from a model intervention and situation analysis in Malawi

INTRODUCTION

Palliative care is rarely accessible in rural sub-Saharan Africa. Partners In Health and the Malawi government established the Neno Palliative Care Program (NPCP) to provide palliative care in rural Neno district. We conducted a situation analysis to evaluate early NPCP outcomes and better understand palliative care needs, knowledge, and preferences.

METHODS

Employing rapid evaluation methodology, we collected data from 3 sources: 1) chart review of all adult patients from the NPCP's first 9 months; 2) structured interviews with patients and caregivers; 3) semi-structured interviews with key stakeholders.

RESULTS

The NPCP enrolled 63 patients in its first 9 months. Frequent diagnoses were cancer (n = 50, 79%) and HIV/AIDS (n = 37 of 61, 61%). Nearly all (n = 31, 84%) patients with HIV/AIDS were on antiretroviral therapy. Providers registered 112 patient encounters, including 22 (20%) home visits. Most (n = 43, 68%) patients had documented pain at baseline, of whom 23 (53%) were treated with morphine. A majority (n = 35, 56%) had ≥1 follow-up encounter. Mean African Palliative Outcome Scale pain score decreased non-significantly between baseline and follow-up (3.0 vs. 2.7, p = 0.5) for patients with baseline pain and complete pain assessment documentation. Providers referred 48 (76%) patients for psychosocial services, including community health worker support, socioeconomic assistance, or both. We interviewed 36 patients referred to the NPCP after the chart review period. Most had cancer (n = 19, 53%) or HIV/AIDS (n = 10, 28%). Patients frequently reported needing income (n = 24, 67%) or food (n = 22, 61%). Stakeholders cited a need to make integrated palliative care widely available.

CONCLUSIONS

We identified a high prevalence of pain and psychosocial needs among patients with serious chronic illnesses in rural Malawi. Early NPCP results suggest that comprehensive palliative care can be provided in rural Africa by integrating disease-modifying treatment and palliative care, linking hospital, clinic, and home-based services, and providing psychosocial support that includes socioeconomic assistance.

Integrating early palliative care for patients with HIV: provider and patient perceptions of symptoms and need for services

Increasingly clinicians are using palliative care to address the symptomatic and psychosocial effects of disease often missed by routine clinical care, termed "early" palliative care. Within an inner-city medical center, we began a program to integrate early palliative care into HIV inpatient care. Patient symptom burden and desired services were assessed and compared to provider perceptions of patient's needs. From 2010-2012, 10 patients, with a median CD4+ T-cell count of 32.5 cells/μL, and 34 providers completed the survey. Providers ranked their patients' fatigue, sadness, anxiety, sexual dysfunction, and body image significantly higher than patients it for themselves. Patients ranked medical care, pharmacy, social work, physical therapy, and housing as significantly more important to them than providers estimated them to be. These differences may reflect the fact that physicians often overlook patients' unmet basic needs. Early palliative care may narrow this gap between providers' and patients' perceptions of needs through good communication and targeting barriers, such as housing instability, which are vital to overcome for consistent long-term follow up.

Wellbeing among sub-Saharan African patients with advanced HIV and/or cancer: an international multicentred comparison study of two outcome measures

Background

Despite the high mortality rates of HIV and cancer in sub-Saharan Africa, there are few outcome tools and no comparative data across conditions. This study aimed to measure multidimensional wellbeing among advanced HIV and/or cancer patients in three African countries, and determine the relationship between two validated outcome measures.

Methods

Cross-sectional self-reported data from palliative care populations in Kenya, Uganda and South Africa using FACIT-G+Pal and POS measures.

Results

Among 461 participants across all countries, subscale “social and family wellbeing” had highest (best) score. Significant country effect showed lower (worse) scores for Uganda on 3 FACIT G subscales: Physical, Social + family, and functional. In multiple regression, country and functional status accounted for 21% variance in FACIT-Pal. Worsening functional status was associated with poorer POS score. Kenyans had worse POS score, followed by Uganda and South Africa. Matrix of correlational coefficients revealed moderate correlation between the POS and FACIT-Pal core scale (0.60), the FACIT-G and POS (0.64), and FACIT-G + Pal with POS (0.66).

Conclusions

The data reveal best status for family and social wellbeing, which may reflect the sample being from less individualistic societies. The tools appear to measure different constructs of wellbeing in palliative care, and reveal different levels of wellbeing between countries. Those with poorest physical function require greatest palliative and supportive care, and this does not appear to differ according to diagnosis.

HIV and ageing: what the geriatrician needs to know

The transformation of human immunodeficiency virus (HIV) from a rapidly fatal disease to a chronic manageable illness has resulted in annual increases in the numbers of people living with HIV. The HIV cohort is therefore ageing, with numbers of older adults with HIV climbing, through both prolonged survival and late acquisition of the disease. Associated with ageing is an accumulation of HIV-associated non-AIDS related co-morbidities, creating a complex patient group affected by multi-morbidity along with polypharmacy, functional decline and complex social issues. With this in mind, this review seeks to explore areas where HIV (diagnosed or undetected) may impact on the work of clinical geriatricians.

The presence of CD4 counts for the management of HIV patients in East Africa: a multicentred study

New WHO guidance stipulates six-monthly CD4 testing and treatment initiation at CD4 less than 350. This study aimed to determine the presence of CD4 results in patient records across five care facilities in Kenya, and to identify factors associated with the presence of CD4 count. This is a cross-sectional study of consecutive outpatients. Participants completed self-reported outcomes of demographics, and both physical and mental health dimensions of quality of life and function; charts were reviewed for a CD4 count in the previous 13 months; 548 patients participated. For those diagnosed during the 13-month study period, 7.1% of the sample had no CD4 result on record. For those diagnosed prior to the study, 8.7% had no result. Multivariate logistic regression revealed that 30 days post-HIV diagnosis, facility and antiretroviral therapy use were associated with the odds of having a CD4 result on file. At six months, poverty and prevalence of multidimensional problems were associated with lack of CD4 result. For those diagnosed prior to the observation period, education level was associated with more infrequent CD4 counts, and facility and number of dependants were associated with odds of a CD4 result within six months. Our data suggest inconsistencies in CD4 results availability within and between facilities. Implementation of new guidance will require a shift in practice.

Patterns of pain medication use during last months of life in HIV-infected populations: the experience of an academic outpatient clinic

INTRODUCTION

This article describes the patterns of use of pain medicines of HIV-infected patients during last months of life in an HIV university-affiliated outpatient clinic.

METHODS

We retrospectively reviewed our databases and identified patients who died over the last 12 months in our clinic. Demographic, clinical, and laboratory information were abstracted.

RESULTS

A total of 41 patients died in our HIV outpatient clinic in a period of 12 months. Opioid analgesics were prescribed for 21 (51%) patients, with 10 (48%) of these patients prescribed short-acting opioid analgesics alone, In all, 11 patients (52%) were on a short-acting and long-acting opioid combination, and 30 (73%) patients experienced pain that was not adequately controlled.

DISCUSSION

Pain control during the last months of life for this population appears to be suboptimal. Better strategies are needed.

Antiretroviral therapy at the end of life: the experience of an academic HIV clinic

INTRODUCTION

There are no guidelines regarding the discontinuation of antiretroviral therapy at the end of life.

METHODS

We retrospectively reviewed our databases and identified patients with HIV/AIDS who died over the last 12 months in our HIV clinic.

RESULTS

A total of 41 patients from our HIV clinic died in a period of 12 months. Seventy-three percent of the patients were on antiretroviral therapy during the last clinic visit. During the last 3 months of life, 32% (13 of 41) were off antiretroviral therapy, with 77% (10 of 13) of them having intermittent therapy due to noncompliance. The remaining 23% (3 of 13) decided to stop antiretroviral therapy after discussion among families, patients, and providers.

CONCLUSION

Discussions among providers, patients, and families are encouraged to establish goals of care and role of antiretrovirals during the last months of life.

Management of human immunodeficiency virus infection in advanced age

IMPORTANCE

Human immunodeficiency virus (HIV)-positive patients treated with antiretroviral therapy now have increased life expectancy and develop chronic illnesses that are often seen in older HIV-negative patients.

OBJECTIVE

To address emerging issues related to aging with HIV. Screening older adults for HIV, diagnosis of concomitant diseases, management of multiple comorbid medical illnesses, social isolation, polypharmacy, and factors associated with end-of-life care are reviewed.

EVIDENCE ACQUISITION

Published guidelines and consensus statements were reviewed. PubMed and PsycINFO were searched between January 2000 and February 2013. Articles not appearing in the search that were referenced by reviewed articles were also evaluated.

FINDINGS

The population of older HIV-positive patients is rapidly expanding. It is estimated that by 2015 one-half of the individuals in the United States with HIV will be older than age 50. Older HIV-infected patients are prone to having similar chronic diseases as their HIV-negative counterparts, as well as illnesses associated with co-infections. Medical treatments associated with these conditions, when added to an antiretroviral regimen, increase risk for polypharmacy. Care of aging HIV-infected patients involves a need to balance a number of concurrent comorbid medical conditions.

CONCLUSIONS AND RELEVANCE

HIV is no longer a fatal disease. Management of multiple comorbid diseases is a common feature associated with longer life expectancy in HIV-positive patients. There is a need to better understand how to optimize the care of these patients.

Can palliative care integrated within HIV outpatient settings improve pain and symptom control in a low-income country? A prospective, longitudinal, controlled intervention evaluation

A high burden of pain, symptoms and other multidimensional problems persist alongside HIV treatment. WHO policy indicates palliative care as essential throughout the disease course. This study aimed to determine whether palliative care delivered from within an existing HIV outpatient setting improves control of pain and symptoms compared to standard care. A prospective, longitudinal controlled design compared patient outcomes at an outpatient facility that introduced palliative care training to clinicians and stocked essential palliative care drugs, to outcomes of a cohort of patients at a similar HIV care facility with no palliative care, in Tanzania. Inclusion criteria were clinically significant pain or symptoms. Patients were followed from baseline fortnightly until week 10 using validated self-report outcome measures. For the primary pain outcome, the required sample size of 120 patients was recruited. Odds of reporting pain reduced significantly more at intervention site (OR=0.60, 95% CI 0.50-0.72) than at control (OR=0.85, 95% CI 0.80-0.90), p=0.001. For secondary outcomes, longitudinal analysis revealed significant difference in slope between intervention and control, respectively: Medical Outcomes Study-HIV (MOS-HIV) physical score 1.46 vs. 0.54, p=0.002; MOS-HIV mental health 1.13 vs. 0.26, p=0.006; and POS total score 0.84 vs. 0.18, p=0.001. Neither baseline CD4 nor antiretroviral therapy (ART) use was associated with outcome scores. These data are the first to report outcomes evaluating integrated HIV outpatient palliative care in the presence of ART. The data offer substantive evidence to underpin the existing WHO clinical guidance that states an essential role for palliative care alongside HIV treatment, regardless of prognosis.

Comparisons of HIV-Affected and Non-HIV-Affected Families Over Time

This study compares HIV-affected families and their non-HIV-affected neighbors' behavioral health outcomes and family conflict. To compare two groups from the same neighborhoods at four points over 18 months, mothers with HIV (MLH) (N=167) and their school-age children (age 6 to 20) were recruited from clinical care settings in Los Angeles, CA and neighborhood control mothers (NCM) without HIV (N=204) were recruited from modal neighborhoods. In addition, children living at home who were 12 years and older were recruited. We assessed parenting behaviors, family conflict, mental health, sexual behavior, substance use, and HIV-related health behaviors over time. MLH perceived greater economic insecurity at baseline, less employment, and involvement in romantic relationships. MLH reported more emotional distress and substance use than NCM. MLH, however, reported lowered HIV transmission risk. The random regressions indicated that MLH exhibited higher levels and became significantly less depressed and less anxious over time than their non-HIV-affected neighbors. MLH also reported less initial family violence and conflict reasoning than NCM; violence decreased and conflict increased over time for MLH relative to NCM. Children of MLH decreased their marijuana use but hard drug users of MLH increased their risk, over time, compared to children of NCM. Moreover, children of MLH reported more internalizing behaviors than children of NCM. Even when compared to other families living in the same economically disadvantaged communities, MLH and their children continue to face challenges surrounding family conflict, and key behavioral health outcomes, especially with respect to substance use and mental health outcomes. These families, however, show much resilience and MLH report lowered levels of HIV transmission risk, their children report no greater levels of HIV transmission risk and levels of family violence were lower than reported by families in the same neighborhoods.