HIV infection: the spectrum of symptoms and disease in male and female patients attending a London hospice

Is HIV Painful? An Epidemiologic Study of the Prevalence and Risk Factors for Pain in HIV-infected Patients

OBJECTIVES

To evaluate the prevalence, impact, and risk factors for pain among a cohort of human immunodeficiency virus (HIV)-infected adults treated with combination antiretroviral therapy if indicated according to current guidelines.

METHODS

This was a cross-sectional epidemiological observational study. All patients attending 1 HIV-outpatient center in the United Kingdom in a 10-month period were eligible. Patients completed a validated questionnaire enquiring about demographics, HIV factors, and symptoms of pain.

RESULTS

Of 1050 eligible participants, 859 (82%) completed a questionnaire. The 1-month period prevalence of pain lasting >1 day was 62.8% among whom 63% reported current pain. The prevalence of pain at most anatomic sites was broadly similar to that observed in population studies using the same questionnaires except that we found considerably higher rates of foot/ankle pain. The median duration of pain was 3 years (range, 0 to 51 y) and the median pain score was 5.0 on an 11-point visual analogue score. Over 40% of people in pain had consulted their primary care physician and >20% were taking analgesics daily. Independent risk factors for current pain were older age (P=0.001), time since diagnosis of HIV infection (P=0.001), and receipt of a protease inhibitor-based regimen (P=0.04).

DISCUSSION

Pain, and notably foot/ankle pain, is common among adults living with prevalent HIV and is associated with substantial morbidity and health care utilization.

Pain treatment in patients infected with human immunodeficiency virus in later stages: pharmacological aspects

Pain is a common and debilitating symptom of human immunodeficiency virus (HIV) disease, although it is often underestimated and undertreated, especially in HIV-infected intravenous drug users. It is more likely to occur in the later stages of the HIV disease, where it assumes particular significance, especially in terminally ill patients. However, its successful management is possible, though the goal of effective therapy is hampered by the side effects of highly active antiretroviral therapy and drug-drug interactions. In order to appraise these issues, a search in MEDLINE database was conducted. Book reviews and a search on relevant Web sites were also included. Treatment of HIV is itself very complex and becomes even more difficult when palliative therapy is added. Protease inhibitors, mainly ritonavir, and nonnucleoside reverse transcriptase inhibitors have higher interaction potential, due to their inducer or inhibitory actions on cytochrome P450, posing a risk when coadministered with palliative treatments; so, better outcomes can be achieved with knowledge of pharmacological aspects.

Presenting symptoms and signs in children referred for palliative care in Malawi

A study of 95 children referred for palliative care was carried out at Queen Elizabeth Central Hospital in southern Malawi, to determine the prevalence of different symptoms and signs. Seventy-seven percent of the children had HIV, 17% had cancer and 6% had a variety of other diagnoses. The commonest symptoms spontaneously presented by patients and carers were pain (27%) cough (22%) and diarrhoea (18%). Pain was significantly more common among children with cancer than those with HIV/AIDS. Cough, diarrhoea and mouth sores were significantly more common in those with HIV/AIDS. Many symptoms were not volunteered initially, but were revealed on direct questioning. This uncovered that 84% had a history of weight loss, 56% had fever and 51% had mouth sores. The commonest physical signs were wasting (76%), lymphadenopathy (40%) and oral candida (40%). Forty-seven percent of children with HIV had either lost their mother or had a mother who was sick. The wide range of physical symptoms and frequency of sickness or death in the children's mothers demonstrates the need for palliative care to be holistic, addressing the manifold physical, emotional and social problems associated with chronic and terminal illness.

The experience of physical symptoms among women living with HIV

As the number of women living with HIV and AIDS increases, so does survival time for individuals living with this chronic condition. Symptom existence, intensity, and bothersomeness greatly affect quality of life in women living with HIV and AIDS. Symptoms experienced by women living with HIV include symptoms related to HIV infection itself, those related to opportunistic infections, and those related to medications and treatments. Symptoms experienced by women include those common to both genders and those specific to females. The presence and intensity of symptoms varies with progression of the disease and with deteriorating status of HIV disease indicators. While research is limited on this topic, some research on the general symptom experience of women and on symptoms specific to or common among women has been done. Extended life expectancy among women with HIV increases the importance of nursing care focused on symptom assessment and symptom management. This article reviews research on symptoms commonly experienced by women living with HIV and presents implications for the care of women experiencing distressing symptoms.

Community outreach to patients with AIDS at the end of life in the inner city: reflections from the trenches

Indigenous community health outreach workers (CHWs), who serve as a bridge between underserved, difficult-to-reach minority populations and health professionals, can play a critical role in bringing palliative care to patients dying of AIDS and other illnesses in the inner city. Although the contribution of CHWs in the delivery of "curative" and preventive services has been well established, little attention has been given to CHWs in palliative care. Integrating the medical literature with experiences of a team providing HIV palliative care in the Bronx, a descriptive typology of critical stages and components in the work of CHWs in end-of-life care in the inner city is presented. A longitudinal case narrative, told from the perspective of the CHW, is used to demonstrate the richness and complexity of the CHW's role. The article concludes with a description of the experience of the CHW, straddling two worlds--the world of the inner city patient and the world of the health care providers--and explores the special characteristics of the individuals who can fill this vital role in palliative care.

Access and equity in HIV/AIDS palliative care: a review of the evidence and responses

The high prevalence of pain and other symptoms throughout the HIV disease trajectory, the need for management of side effects related to antiretroviral therapy, the continuing incidence of cancers and new emerging co-morbidities as a result of extended life expectancy under new therapeutic regimes, and the ongoing need for terminal care all prove the curative versus palliative dichotomy to be inappropriate. Although there is evidence for both need and effectiveness of palliative care in HIV patient care, access is often poor and care less than optimal. This review aimed to identify evidence of barriers and inequalities in HIV palliative care in order to inform policy and service development. Biomedical databases were searched using a specific strategy, and evidence extracted into the barrier and inequity categories of patient, clinician, service and disease factors. A model of the barriers and inequalities is presented from the evidence. Recommendations are made from the evidence for promoting access and outcomes through integrated palliative care from diagnosis to end-of-life, alongside antiretroviral therapy when initiated. Service responses that have attempted to increase access to palliative care are presented.

The influence of symptoms on quality of life among HIV-infected women

Symptoms serve as intervention foci for patients and health care providers. Research has established a relationship between symptoms and quality of life for persons living with HIV/AIDS. This article reports symptom prevalence and intensity data that include gynecological and cognitive symptoms self-reported by HIV-infected women (N = 118). Using a cross-sectional, descriptive design, data were obtained using the Center for Epidemiological Studies-Depression Scale (CES-D), Medical Outcomes Study Short Form-36 (MOS SF-36), and the revised Sign and Symptom Check-List for Persons Living with HIV/AIDS (SSC-HIV). Prevalent symptoms were depression (83%), muscle aches (84%), weakness (80%), and painful joints (71%). Symptoms with the highest mean intensity, however, were headaches, rash, insomnia, vaginal itching, and shortness of breath at rest. Symptoms also significantly predicted role functioning. This study contributes to our understanding the nature of symptoms and the influence of symptoms on role and physical functioning among HIV-infected women.

Palliative care for AIDS: challenges and opportunities in the era of highly active anti-retroviral therapy

In contrast to the first decade of the AIDS epidemic, the past decade has seen an increasing separation between AIDS care and palliative care services. While this may be due in part to the perception that AIDS is no longer a uniformly fatal illness, AIDS in fact remains an important cause of morbidity and mortality for young adult populations in the United States, particularly among certain racial-ethnic minorities. Death rates have remained steady since the dramatic decreases noted in the mid-1990s, and causes of death now increasingly include co-morbidities such as hepatitis B, C, end-organ failure, and various malignancies. Moreover, as AIDS has been transformed into a more manageable, chronic disease in the era of 'highly active antiretroviral therapy' (HAART), the opportunities for palliative care interventions have only increased. Patients with AIDS continue to experience a high burden of pain and other chronic symptoms, over a longer period of time, with a disease course marked by more cumulative exacerbations and remissions than when AIDS was a stereotypic, rapidly fatal illness. Advance care planning and discussions of goals of care are more complex and involve more uncertainty than was the case when prognosis was clear-cut and treatment options were more limited. For all of these reasons, it is important for the distance which has developed between HIV and palliative care providers to be bridged. Contrary to popular perceptions, palliative medicine continues to have much to offer in the HAART era for the care of patients and families with HIV/AIDS, for whom treatment outcomes will only benefit from greater integration of disease-specific and palliative interventions. The challenge for care providers is now to implement successful strategies for integrating AIDS and palliative care services in all relevant clinical environments.

Palliative care for AIDS at a large urban teaching hospital: program description and preliminary outcomes

BACKGROUND

Despite major advances in therapy, acquired immune deficiency syndrome (AIDS) remains an important cause of morbidity and mortality in young adult populations. As AIDS has been converted into a chronic disease, it has resulted for some patients in a more protracted course of symptomatic illness. Comprehensive care for late-stage human immunodeficiency virus (HIV) disease now involves an increasingly complex mixture of disease-specific and palliative therapies, requiring coordination and collaboration between AIDS and palliative care services. We describe the experience of developing a palliative care consultation service for patients with AIDS at a large urban teaching hospital, funded by the Health Resources and Services Administration as one of six national demonstration projects for the integration of HIV and palliative care.

SETTING

An 1100-bed medical center in the Bronx, New York. The multidisciplinary consultation team included a physician, nurse practitioner, social worker, chaplain, outreach worker, psychiatrist, and ethicist. Patients were referred from inpatient AIDS services and outpatient care sites.

METHODS

Patients underwent standardized assessment with clinical case review, Memorial Symptom Assessment Scale (MSAS), Mini-Mental Status Examination (MMSE), Karnofsky score, and Rapid Disability Rating Scale (RDRS). Interventions and follow-up outcomes were recorded and categorized. All deaths were analyzed and predictors of mortality were determined by bivariate and logistic regression analysis.

RESULTS

Program referrals have been steady, with 132 patients followed by the consultation service from July 2000 through October 2001; 73% were referred from inpatient services (representing 12% of all AIDS inpatients admitted to the hospital during the study period); 57% of patients were male, 36% African American, 55% Hispanic; 44% had a history of injection drug use. Median baseline values included: CD4+ T-lymphocyte count = 35/mm3, HIV viral load = 53,813 copies per milliliter, Karnofsky = 40, MMSE = 0 (with a median score of 24 for those able to complete the examination); number of severe symptoms reported by MSAS = 4; 71% had one or more serious impairments in activities of daily living (ADL) by RDRS. In addition to AIDS, 20% of patients had malignancies and 13% had end-stage liver disease. Presenting problems and priority issues identified at consultation included: care decisions/goals of care (68%), pain (40%), psychosocial issues (31%), depression (23%), anxiety (19%), nausea/vomiting (14%), insomnia (13%), and patient/family/team conflict (13%); these problems were fully or partially resolved in 68-91% of cases. 63 patients died (median days enrolled = 35); leading causes of death included AIDS (38%), sepsis (19%), cancer (19%), and liver failure/cirrhosis (17%). Death was predicted only by baseline functional status (Karnofsky, MMSE, ADL impairment), and not by CD4+ count, viral load, or any AIDS-specific variables.

CONCLUSION

Results suggest an important and ongoing need for palliative care services for patients with advanced HIV/AIDS, whose needs are likely to increase as AIDS evolves into more of a chronic disease. Patients were readily referred from predominantly inpatient settings, with very advanced disease; problems included a mix of medical and psychosocial issues, and were readily resolved by the consultation team in most cases. Death was predicted only by baseline functional status, not by traditional HIV disease markers. Mortality reflected both AIDS-related and non-AIDS-specific causes. Further studies are needed to identify more specific prognostic variables and to continue to improve palliative care treatment outcomes in late-stage patients with AIDS.

The clinical profile of end-stage AIDS in the era of highly active antiretroviral therapy

The purpose of this study was to describe the clinical profile of end-stage acquired immune deficiency syndrome (AIDS) since the advent of highly active antiretroviral therapy (HAART). A cross-sectional examination of human immunodeficiency virus (HIV)-infected patients who attended a public HIV outpatient clinic and died between 1996 and 2001 was conducted (n = 669). All clinical and demographic data were collected from the Centers for Disease Control (CDC) Adult Spectrum of Disease database. The prevalence of first-time acquisition of AIDS-defining conditions 12 months before death were evaluated. The prevalence of renal disease, hepatic disease and substance use were also evaluated. The majority of the patients were 35 years old or older, male, African American and HAART-experienced. The six AIDS-defining conditions with the highest percentages of first-time acquisition in the last 12 months of life were HIV dementia (91.8%), progressive multifocal leukoencephalopathy (PML) (91.7%), wasting (90.9%), Mycobacterium avium complex infection (MAC) (80.0%), lymphoma (78.6%), and cytomegalovirus infection (CMV) (78.1%). Forty-four percent of the patients were diagnosed with at least one of these six conditions 12 months before death. More than one third of the patients had renal or hepatic failure, injecting drug use (IDU) as the HIV risk factor, and history of substance use. AIDS-defining conditions continue to have an impact on mortality, especially the neurologic conditions and wasting. However, other conditions, such as renal and hepatic disease, are becoming important causes of mortality because the HIV-infected population now includes more drug users, and HIV-infected patients are surviving for longer periods. These results should help clinicians better time the discussion of end-stage options and improve the patient's quality of life.

HIV as a chronic disease: implications for long-term care at an AIDS-dedicated skilled nursing facility

OBJECTIVE

To describe the characteristics and outcomes of the first 3 years of admissions to a dedicated skilled nursing facility for people with acquired immunodeficiency syndrome (AIDS).

METHODS

Systematic chart review of consecutive admissions to a 30-bed, AIDS-designated long-term care facility in New Haven, Connecticut, from October 1995 through December 1998.

RESULTS

The facility has remained filled to 90% or more of its bed capacity since opening. Of 180 patients (representing 222 admissions), 69% were male; mean age was 41 years; 57% were injection drug users; 71% were admitted directly from a hospital. Leading reasons for admission were (1) the need for 24-hour nursing/medical supervision, (2) completion of acute medical treatment, and (3) terminal care. On admission, the median Karnofsky score was 40, and median CD4+ cell count was 24/mm3; 48% were diagnosed with serious neurologic disease, 44% with psychiatric illness; patients were receiving a median of 11 medications on admission. Of 202 completed admissions, 44% of patients died, 48% were discharged to the community, 8% were discharged to a hospital. Median length of stay was 59 days (range 1 to 1,353). Early (< or = 6 months) mortality was predicted by lower admission CD4+ count, impairments in activities of daily living, and the absence of a psychiatric history; long-term stay (> 6 months) was predicted by total number of admission medications, neurologic disease, and dementia. Comparison of admissions from 1995 to 1996 to those in 1997 to 1998 indicated significantly decreased mortality rates and increased prevalence of psychiatric illness between the two periods (P < .01).

CONCLUSIONS

A dedicated skilled nursing facility for people with AIDS can fill an important service need for patients with advanced disease, acute convalescence, long-term care, and terminal care. The need for long-term care may continue to grow for patients who do not respond fully to current antiretroviral therapies and/or have significant neuropsychiatric comorbidities. This level of care may be increasingly important not only in reducing lengths of stay in the hospital, but also as a bridge to community-based residential options in the emerging chronic disease phase of the AIDS epidemic.

The level of need for palliative care: a systematic review of the literature

Palliative care services have developed rapidly over the past 30 years, with little evaluation as to how needs have been met by these new services. As part of a systematic review of palliative care, evidence of the needs of patients and carers has been evaluated from the current literature. Of the total of 673 articles related to the 10 areas within the main review, 64 provided evidence on the need for palliative care services over the period from 1978 to 1997. A further nine articles were added in November 1998 after the end of the study of update the review with more recent research. Need can be assessed in one of two ways: either by adopting an epidemiological approach or by examining health service usage. In the former, evidence is provided on disease-specific mortality, and related to the duration of symptoms prior to the patient's death. As an example of this, it is suggested that services may need to provide pain control for 2800 patients per million (p/M) population dying from cancer each year and 3400 p/M with noncancer terminal illness. Using health service usage as an indicator of need, 700-1800 p/M with cancer and 350-1400 p/M with noncancer terminal illness would require a support team or specialist palliative home care nurse, with 400-700 cancer p/M and 200-700 noncancer p/M requiring inpatient terminal care. Studies indicate that at present usage, palliative care is being provided by 40-50 hospice beds/M. Despite this provision, there remains evidence that in certain areas of care such as pain control, there still remains a high degree of unmet need.

Palliative care and AIDS: 2 – Gastrointestinal symptoms

With the use of more intensive antiretroviral therapies (highly-active antiretroviral therapy, HAART) particularly in first world countries, reductions in the mortality and morbidity of HIV infection are being seen. However, though the prevalence of symptoms may change, symptom control does continue to be a problem for many people with HIV, particularly as their disease progresses. This is the second of 2 CME articles about palliative care and HIV infection. The first gave a background to palliative care, and covered symptom control of pain1. This article gives suggestions for the treatment of common gastrointestinal symptoms in HIV infection; nausea and vomiting, cachexia and anorexia and chronic diarrhoea.

The use of specialist palliative care services by patients with human immunodeficiency virus-related illness in the Yorkshire Deanery of the northern and Yorkshire region

To examine the use of palliative care services by patients affected by human immunodeficiency virus (HIV) in hospices which do not specialize in the care of HIV patients, a tape-recorded, semistructured interview was carried out in 12 hospices in the UK. The interview explored concerns about such provision, as well as actual issues encountered. The study revealed that all 12 hospices accepted referrals for people affected by HIV and had clear working practices on infection control. between 1990 and 1996, 48 individuals affected by HIV had contact with the hospices. The number of referrals was not related to the size of the hospice. Thirty-nine individuals had a total of 655 days of inpatient care (range 1-35 days); mean length of stay 12.7 days. Twenty-four (62%) died during their first admission. Referrals came from disparate sources and this affected the amount and type of specialist HIV support available to the hospice. The paucity of referrals raised concerns in most of the units as to how to maintain skills. Issues about maintaining confidentiality of diagnosis in a multiprofessional team, and after death were highlighted. All units expressed concerns about the impact on fundraising of HIV-related admissions. Overall it was felt that the hospice units were failing to meet the palliative care needs of the majority of people affected by HIV or acquired immunodeficiency syndrome (AIDS) in the region. Possible reasons for this are given.