Palliative care for HIV in the era of antiretroviral therapy availability: perspectives of nurses in Lesotho

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BACKGROUND

Nurses play a major role all over the world in the palliative care team.

AIM

The aim of this study was to investigate the knowledge and attitude of nurses toward palliative care in a tertiary level hospital in Nigeria.

SUBJECTS AND METHODS

SETTING

This cross-sectional questionnaire-based study was carried out among nurses at a tertiary health care facility in Ado-Ekiti, South-West Nigeria. A cross-sectional questionnaire-based study was carried out. The questionnaire sought information about the sociodemographic profile of respondents, their knowledge of definition and philosophy of palliative care among other things. Descriptive statistics was used to obtain the general characteristics of the study participants, while Chi-square was used to determine the association between categorical variables. A two-sided P < 0.05 was considered as significant.

RESULTS

A total of 100 questionnaires were returned with a female preponderance among the respondents with F: M ratio of 9:1. Regarding the definition of palliative care, 71.8% (48/66) of the respondents understood palliative care to be about pain medicine, 55% (33/60) thought it to be geriatric medicine, while 90.2% (83/92) felt palliative care is about the active care of the dying. Exactly 80.5% (66/82) respondents agreed that palliative care recognizes dying as a normal process while 84.1% (74/88) respondents were of the opinion that all dying patients would require palliative care. The use of morphine would improve the quality of life of patients according to 68.9% (42/61) of respondents.

CONCLUSION

There are gaps in the knowledge of healthcare workers in the area of palliative care and this call for a review of the current nursing curriculum and practice guidelines in Nigeria.

An Educational Intervention to Reduce Pain and Improve Pain Management for Malawian People Living With HIV/AIDS and Their Family Carers: A Randomized Controlled Trial

CONTEXT

Advances being made in improving access to HIV drugs in resource-poor countries mean HIV patients are living longer, and, therefore, experiencing pain over a longer period of time. There is a need to provide effective interventions for alleviating and managing pain.

OBJECTIVES

To assess whether a pain educational intervention compared with usual care reduces pain severity and improves pain management in patients with HIV/AIDS and their family carers.

METHODS

This was a randomized, parallel group, superiority trial conducted at HIV and palliative care clinics of two public hospitals in Malawi. A total of 182 adults with HIV/AIDS (Stage III or IV) and their family carers participated; carer participants were those individuals most involved in the patient's unpaid care. The educational intervention comprised a 30 minute face-to-face meeting, a leaflet, and a follow-up telephone call at two weeks. The content of the educational intervention covered definition, causes, and characteristics of pain in HIV/AIDS; beliefs and myths about pain and pain medication; assessment of pain; and pharmacological and nonpharmacological management. The primary outcome was average pain severity measured by the Brief Pain Inventory-Pain Severity subscale. Assessments were recorded at baseline before randomization and at eight weeks after randomization.

RESULTS

Of the 182 patient/carer dyads randomly allocated, 157 patient/carer dyads completed the trial. Patients in the intervention group experienced a greater decrease in pain severity (mean difference = 21.09 points, 95% confidence interval = 16.56-25.63; P < 0.001).

CONCLUSION

A short pain education intervention is effective in reducing pain and improving pain management for Malawian people living with HIV/AIDS and their family carers.

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.

Ambiguous diagnosis, futile treatments and temporary recovery: meanings of medical treatment among HIV/AIDS family caregivers providing care without ARVs

The capacity of countries with high HIV and AIDS prevalence to provide antiretroviral treatment and care for all people who need support remains a public health challenge. In Lesotho, there are improvements in this area but the high proportion of people who need ART yet they do not receive treatment suggests that many HIV-infected people continue to depend on medicines that treat opportunistic infections. The objective of the article is to explore caregivers' experiences with diagnostic procedures and outcomes, prescriptions and treatment outcomes when ARVs were unavailable. A phenomenological design using in-depth face-to-face interviews was used to obtain the experiences of 21 family caregivers about caregiving, including access to and use of medical treatments. Caregivers' experiences indicate that most of the consulted health professionals provided vague and inconsistent diagnoses while the medication they prescribed failed to treat most of the symptoms. Unavailability of medicines that control pain and symptoms effectively continues to be a prominent feature of HIV and AIDS home-based caregiving in Lesotho. It is recommended that health professionals should facilitate disclosure of HIV diagnosis to family caregivers to assist them to understand unstable treatment outcomes; and policy makers should strengthen home-based care by developing policies that integrate palliative care into HIV and AIDS care.

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.

End of life care in sub-Saharan Africa: a systematic review of the qualitative literature

Background

End of life (EoL) care in sub-Saharan Africa still lacks the sound evidence-base needed for the development of effective, appropriate service provision. It is essential to make evidence from all types of research available alongside clinical and health service data, to ensure that EoL care is ethical and culturally appropriate. This article aims to synthesize qualitative research on EoL care in sub-Saharan Africa to inform policy, practice and further research. It seeks to identify areas of existing research; describe findings specifically relevant to the African context; and, identify areas lacking evidence.

Methods

Relevant literature was identified through eight electronic databases: AMED, British Nursing Index & Archive, CINAHL, EMBASE, IBSS, MEDLINE, PsycINFO, and the Social Sciences Citation Index; and hand searches. Inclusion criteria were: published qualitative or mixed-method studies in sub-Saharan Africa, about EoL care. Study quality was assessed using a standard grading scale. Relevant data including findings and practice recommendations were extracted and compared in tabular format.

Results

Of the 407 articles initially identified, 51 were included in the qualitative synthesis. Nineteen came from South Africa and the majority (38) focused on HIV/AIDS. Nine dealt with multiple or unspecified conditions and four were about cancer. Study respondents included health professionals, informal carers, patients, community members and bereaved relatives. Informal carers were typically women, the elderly and children, providing total care in the home, and lacking support from professionals or the extended family. Twenty studies focused on home-based care, describing how programmes function in practice and what is needed to make them effective. Patients and carers were reported to prefer institutional care but this needs to be understood in context. Studies focusing on culture discussed good and bad death, culture-specific approaches to symptoms and illness, and the bereavement process.

Conclusions

The data support or complement the findings from quantitative research. The review prompts a reconsideration of the assumption that in Africa the extended family care for the sick, and that people prefer home-based care. The review identifies areas relevant for a research agenda on socio-cultural issues at the EoL in sub-Saharan Africa.

Palliative Care Program For Human Immunodeficiency Virus-Infected Patients: Rebuilding of an Academic Urban Program

Background: Palliative care is extremely important for human immunodeficiency virus (HIV)-infected clientele. The impact of HIV infection is significant in the city of New Orleans. As of September 2009, a cumulative total of 29 548 HIV/acquired immunodeficiency syndrome (AIDS) cases and 12 267 HIV-related deaths were reported in Louisiana. Methods: Retrospective review of charts of patients enrolled in our palliative care program. Results: As of September 2009, there were around 1800 active patients in our HIV outpatient clinic. A total of 5 (22%) patients had multidrug-resistant AIDS infection. Three (13%) referred patients had AIDS dementia. Progressive multifocal leukoencephalopathy (PML) and advanced HIV nephropathy were also reasons for referral (13% and 4% of referred patients, respectively). Around 9% of patients had advanced liver cancer with metastases. In all, 22% of patients had rapidly deteriorating functional status. The rest of the patients (26%) complained of cancer-related nausea and vomiting and progressive and nonresponsive weight loss. In terms of psychosocial assessment, the majority of referred patients had problems in areas such as social functioning, mood swings, unstable moods, problems with controlling temper, outbursts of anger, violence, and disturbing or unreal thoughts and beliefs. Conclusions: Palliative care is extremely important in the care of patients with HIV/AIDS. More research is needed to elaborate on best palliative care practices in the care of HIV-infected patients. Interesting to note is that there is significant proportion of patients with mental issues (substance abuse, psychiatric problems, depression, and despair) for which better resources are needed. Integration of services among clinical, mental, and palliative care providers might be needed to better serve this population.