Page 34 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 26 Guideline

A defining characteristic of palliative care is the notion of KwaZulu-Natal (KZN), Mpumalanga (MP), the Free State
total pain, the recognition that pain cannot be alleviated (FS) and the Eastern Cape (EC), with rates of 18.1%, 17.3%,
completely unless all contributing factors that inform 17.0% and 15.3%, respectively. Notwithstanding these
5
the patient’s life experience are addressed. Palliative care numbers, new HIV infections have fallen by 44% since 2012
is team work. The team comprises a range of medical, and HIV testing has been on the rise.
nursing, paramedical and psychosocially trained health and
community workers. The leader is usually a senior palliative The evolution of the South African epidemic has meant that
care-trained clinician. The South African National Policy many who are infected yet undiagnosed and ART naïve, or
Framework on Palliative Care envisages that these teams who have defaulted on ART in the past, now present to
will be accessed by patients – including those who are human hospitals and clinics with symptomatic disease, namely, the
immunodeficiency virus (HIV)-positive – at the community, HIV-sick. It is estimated that as many as 40% – 60% of the
district and regional levels in free-standing clinics and at beds in the public hospitals in KZN, Gauteng, MP and FS are
6,7
all district, secondary and tertiary-level hospitals across occupied by PLWHIV.
the country. These proposals are currently aspirational,
however, as significant barriers to implementation still exist: Few, if any, state hospitals offer a formal palliative care
approval and financing, recruitment and staffing, education service and despite access to ART since 2005, mortality from
and training, et cetera. HIV-related diseases remains high. Of the 14 431 patients
who died in Soweto’s Chris Hani Baragwanath Hospital
The individual matters. The process of palliative care is just, from 2006 to 2009, 64% of the men and 82% of the women
non-judgmental and given to all irrespective of colour, creed or were HIV infected. More than 90% of those dying between
class. ’The relief of suffering is considered one of the primary the ages of 30–40 years were HIV infected. 8
ends of medicine by patients and the general public’.
3
Causes of death of hospitalised HIV-sick
Yet patients and their families do not necessarily agree with in South Africa
health workers on the means to this end. A small but well-analysed autopsy group from the Charlotte
‘In the care of the dying, patients and their friends and families Maxeke Johannesburg Academic Hospital (CMJAH) is
9
do not divide suffering into its physical and nonphysical reported in Table 1. The dominant regional pathogen of the
sources the way doctors, who are primarily concerned with the HIV-infected patients is Mycobacterium tuberculosis. All who
physical, do.’ 3 died of TB had disseminated infection at the time of their
death. The first 90 days following the start of ART, namely,
Palliative care recognises this divide and addresses it by ‘early-ART’, is a key risk period for death from TB. The
taking all causes of suffering into account when aligning the recovering immune system has been implicated in these
goals of the patient with that of the caregiver and healthcare deaths, namely, the immune reconstitution inflammatory
system. A consultative, multi-disciplinary approach forms syndrome (IRIS) as the likely cause or complicating event in
the basis of this model of care. these deaths. 10

The HIV epidemic in South Africa Figure 2 summarises the admission diagnoses of 741 patients
in 2018, palliative care: Defining evaluated during a 6-month period on the Infectious Diseases
the need consultation service of the Helen Joseph Hospital, a public
hospital in Johannesburg, of which 93% of the consulted
HIV morbidity and mortality patients were HIV-infected. The individual bars demonstrate
the wide variety of conditions that affect the acutely sick.
The Joint United Nations Programme on HIV and AIDS
(UNAIDS) reported in 2016 that 7.1 million South Africans Although TB is the most frequent diagnosis, it is one of many
life-threatening conditions in this group of patients. Note
were HIV-positive. It was estimated that 56% were on
4
antiretroviral therapy (ART) yet viral control could only be that virtually all these conditions are treatable and the
11
confirmed in 45%. Although 95% of pregnant women had majority can be cured.
accessed ART, mother-to-child transmission of HIV in 2016
still resulted in 12 000 newborn infections. The 2017/2018 SA Models of HIV-palliative care:
Human Sciences Research Council’s (HSRC) report, released Addressing the need
in July 2018, estimated that 7.9 million South Africans are Models of palliative care vary. Three models that are
now living with HIV, an increase of 1.6 million over the past frequently encountered by the HIV clinicians in South Africa
5 years; 70.6% are taking ART; and 87.5% of PLWHIV aged (SA) are briefly discussed in this section.
15–64 years on ART have suppressed viral loads. The number
of new cases among women aged 15–24 years has remained
high since 2012 and is three times that of their male peers, No formal palliative care provided
while the overall prevalence of HIV among South Africans In this model (Figure 3), little or no palliative care is accessed
was 14%. Prevalence rates were higher in the provinces of prior to death. The HIV infection is not well controlled or is

http://www.sajhivmed.org.za 27 Open Access