Page 37 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 8 of 26 Guideline

suppression, namely, previous TB, recurrent bacterial and discontinuation of active care. In every circumstance, the
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other infections and unexplained weight loss. Despite patient must be treated with dignity and respect and every
adherence to therapy, INRs remain at an increased risk of attempt made to correct the underlying life-threatening
disease and death notwithstanding years of documented process and to offer where possible, life.
viral suppression. No dependable treatment currently
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reconstitutes the blood compartment with CD4 cells in this Mortality indicators: Assessment tools
group of patients. Attempts to address this situation by
changing background ART in those who are virologically Karnofsky score
suppressed have not been successful and this is mainly Although scores of ≤ 50% are often used as a qualifier for
discouraged. Where the patient’s usual medication may hospice admission, scores of < 60% are significant and
be incriminated, for example, AZT or trimethoprim- should trigger consultation with the palliative care team. 28
sulfamethoxazole, alternative drugs should be tried. However, given the potential for ART to reverse underlying
disease in the HIV-infected – the Lazarus effect – the
Prevention, such as commencing ART as soon as possible after absolute score must be viewed with caution. The usefulness
the start of HIV infection when CD4 cells are likely to be of the Karnofsky score as a measure of impending mortality
abundant and the thymus is functional, is the therapeutic in this group of patients has not been established (see
safeguard against immune non-response to ART. Appendix 3 for more details).
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In addition to this group are those HIV-infected with The Support and Palliative Care Tools
identifiable causes of immune suppression, for example, The Support and Palliative Care Tools (SPICT ) are used in
TM
steroid use, alcohol abuse, herbs such as the ‘African potato’, the United Kingdom and have been applied to patients with
chemotherapy, infections such as TB and Mycobacterium avium HIV and cancer. The tool is not specific to HIV and does not
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complex (MAC), malignancies and rheumatological conditions consider the role of ART and the curative potential of the
such as systemic lupus erythematosus (SLE), rheumatoid treatment in several life-threatening infections, for example,
arthritis and drugs that are used to control these conditions. sulfonamides in cerebral toxoplasmosis and Pneumocystis
jiroveci pneumonia (PJP), TB drugs in disseminated TB,
Management of the comorbid condition or removal of the antifungals in cryptococcal meningitis (CM), et cetera.
offending toxin, for example, alcohol or steroids, may
improve the immune response of these patients. The • General indicators:
likelihood of cannabinoid use influencing the human immune ß Increasing physical and/or mental regression or
system either negatively or positively is currently unknown. dependency 2
If these agents are indicated for the palliation of symptoms, it ß A low BMI (viz. < 18 kg/m and/or 5% – 10% loss of
seems reasonable to continue to monitor CD4 response as per body weight)
the usual intervals recommended in current ART guidelines. ß Ongoing and troublesome symptoms
ß Plea for supportive and palliative care or the wish to
Morbidity and mortality risk from HIV infection: die.
General indicators
Assessment: Two or more ‘general’ indicators = unmet
While all should be able to access the costlier components of supportive and palliative care needs = qualify for palliative
a palliative care service, for example, admission to hospice care benefits.
and home nursing, it is acknowledged that the capacity of
palliative care services in SA is limited. Who are in greatest • Clinical indicators:
need? No randomised, controlled palliative care trial ß Worsening frailty and cognitive/neurological,
addresses this question directly. Nevertheless, several cardiovascular and/or respiratory status
observational studies have identified associations that ß Worsening of cancer
provide some answers (see Appendix 2); these indicators ß Onset of life-threatening end-organ failure.
change and their significance may diminish or reverse with
time on ART. The following baseline characteristics in a large Assessment: One or more ‘clinical’ indicators = unmet
South African observational study influenced mortality in supportive and palliative care needs = qualify for palliative
the first year after starting ART: WHO stage, body mass index care benefits (see Appendix 5 for more details).
(BMI), haemoglobin level, CD4 cell count, HIV plasma VL
and symptoms. Yet, once on long-term ART, only CD4 cell The Veterans Aging Cohort Study index
count, BMI, haemoglobin level and a suppressed VL retained This scoring system (Veterans Aging Cohort Study – VACS
survival significance. Another observational study that index) was developed in North America and Europe,
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included data from South, Central and West Africa found focuses on the HIV-infected and uses seven clinical or
that age, gender and baseline CD4 cell count continued to laboratory indices that assist with the long-term (viz. 6 years)
predict death at 6, 12, 24 months and beyond while taking prediction of survival (death) following the start of ART.
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ART. These factors indicate the need of palliative care but Although the data reflect the experience of high-income
are not to be used to define ‘therapeutic futility’, that is, the countries and examine the risk of death in patients already

http://www.sajhivmed.org.za 30 Open Access