Palliative care and antiretroviral treatment can be integrated

EDITOR—An estimated 80m AIDS related deaths will occur in Africa by 2025.1 As antiretroviral treatment expands in sub-Saharan Africa, the World Health Organization advocates its integration with palliative care because pain, other distressing symptoms, and complex psychosocial challenges persist throughout the HIV trajectory.2 Palliative care improves outcomes for patients with HIV3 and in Africa may complement antiretroviral treatment by increasing adherence through managing side effects, providing patient and family centred holistic care, and giving end of life care when necessary.4 However, reintegrating what have become two distinct disciplines is challenging.5

Hospice Africa Uganda was founded to provide affordable control of pain and symptoms, including oral morphine, and to develop a model of palliative care appropriate to Africa. It provides advocacy and training across Africa, education, and specialist palliative care in rural and urban settings alongside community volunteers and traditional healers; it also has links with clinics giving antiretroviral treatment.

We evaluated the success of integrated care by reviewing patients' files for new referrals to the hospice from March to August 2004. Of 311 referrals, 106 had HIV; 39 were accessing antiretroviral treatment at referral, and a further 12 had accessed treatment but defaulted. The primary reasons for referral of the 39 accessing treatment were severe pain (32), skin rash (4), diarrhoea (2), and nausea and vomiting (1).

Morphine had been accessed by 10 of the 106 patients with HIV before referral and was initiated by the hospice for a further 72 patients at their first visit. Chemoprophylaxis was initiated for 73 patients, 46 requiring treatment for opportunistic infections. Of the 67 patients not accessing antiretroviral treatment at referral, 45 were referred to a clinic for treatment.