The integration of palliative care services into routine HIV care

INTRODUCTION: With the advent of highly active antiretroviral therapy (HAART), the number of MN-infected patients continues to increase. This increase in life expectancy has brought increasing morbidity: complications of aging, polypharmacy, co-morbid chronic diseases and increased symptom burdens. HAART side effects also continue to be a problem. Although drugs like stavudine (d4T) are no longer recommended first-line therapy, they are still widely used and cause significant peripheral neuropathy. Palliative care is a discipline within medicine dedicated to providing supportive care to patients with serious and chronic illnesses. Integrating palliative care services into routine HIV care could help treat burdensome symptoms of MN-infected patients, whether from HAART, co-morbid conditions or end of life issues.;MANUSCRIPT 1: The Need for Integration of Palliative Care Services for HIV-infected Patients..;OBJECTIVE: The purpose of this review is to analyze the available evidence regarding the use of palliative care approaches to the MN-infected patient in both developed and resource-limited settings.;DESIGN: Major themes about palliative care and HIV were distilled from the available literature and a theory about the value of palliative care as an adjunct or supportive treatment in the formal management of HIV infection will be described.;DISCUSSION: HIV-infected patients are rapidly aging, suffering from high symptom burden related to their infection and its treatment, and many of these symptoms are untreated or undertreated. There is robust evidence for successful palliative care management of symptoms, improvement of patient and family satisfaction and reduction of cost for other chronic illnesses. Incorporating palliative care services into routine HIV care has the potential to not only improve patients' quality of life, but also impact clinical outcomes as well.;MANUSCRIPT 2: Effects of a Reduced Dose of Stavudine on the Incidence and Severity of Peripheral Neuropathy in HIV-Infected Adults in South Africa. .;BACKGROUND: Although recent WHO guidelines recommend withdrawing stavudine (d4T) from first-line ART therapy, it remains commonly used in resource-constrained settings. In 2006, WHO recommended decreasing the dose of d4T from 40mg to 30mg to mitigate toxicities. We compared the incidence and severity of peripheral neuropathy (PN) by d4T dose in a retrospective cohort study.;METHODS: Patients' charts from an ART-naive population at a rural clinic in KZN, South Africa were retrospectively reviewed for signs and symptoms of incident PN and were graded for severity using the DAIDs scale. Patients enrolled prior to the WHO guideline change were enrolled if they were on d4T 40mg for at least 6 months. After the guideline change all patients were initiated on d4T 30mg.;RESULTS: A total of 475 patients were analyzed; 235 in the 40mg cohort (152.7 person-years [py]) and 240 in the 30mg cohort (244.7py). Incidence of peripheral neuropathy was 90.4/100 py (95% CI:75.9-106.8) in the 40mg cohort versus 40.5/100py (95% CI:32.9-49.3) in the 30mg group (incidence rate ratio [ERR]=0.45, p <0.0001). There was no difference in proportion of severe peripheral neuropathy cases (grade 3/4) between the cohorts; 8.3% in the 40mg group and 8.9% in the 30mg group (p=1.0). In a multivariate analysis risk of peripheral neuropathy was associated with increasing age (HR=1.65 95% CI:1.24-2.19), higher dose (HR=2.1, 95% CI:1.61-2.74) and concurrent tuberculosis therapy (HR= 1.41 95% CI:1.06-1.87).;CONCLUSION: Incidence of peripheral neuropathy in the 40mg cohort was extremely high and though lower in the 30mg cohort, the rate was nonetheless unacceptably high.;OVERALL CONCLUSION: HIV-infected patients both in developed and resource-limited settings have increasing symptoms due to various drug toxicities, aging, and increasing co-morbidities that have profound effects on patients' quality of life and have been shown to impact adherence and retention. There is a robust evidence base for successful palliative care management of symptoms, improvement of patient and family satisfaction and reduction of cost for other chronic and severely symptomatic conditions. In addition to providing safer treatment to all patients, adjunctive palliative care involvement should be a part of standard HIV care from diagnosis to death.