Page 38 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 9 of 26 Guideline

on ART, the database is large, the index has wide BOX 2: The pain assessment chart: Key objectives. 36
applicability and its predictive value is superior to Objectives in the assessment of severe pain
individual and composite indices currently in use. 31,32 Most 1. Characterise the multiple dimensions of the pain:
of the indices used in this system, with the exception of • Intensity
baseline hepatitis C virus (HCV) serology, are routinely • Temporal features: onset, course, daily fluctuation and breakthrough pain
• Location and radiation
performed in the public sector in SA. Local HCV prevalence • Quality
is low (viz. 3% – 5%) and the absence of this index in the • Provocative or relieving factors
calculation of the score is unlikely to influence the result 2. Formulate an understanding of the nature of the pain:
(see Appendix 6 for more details). • Cause
• Probable pathophysiology
Choosing an assessment tool for South African patients • The pain syndrome: neuropathy, cancer pain, post-herpetic neuralgia, et cetera.
3. Characterise the effect of the pain on quality-of-life domains:
According to Merlin et al., ‘[a]ny attempt at prognostication
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that does not address whether the patient has had an • Effect on physical function and well-being
• Effect on mood, coping and related aspects of psychological well-being
adequate trial of ART would be ill-informed and inaccurate’. • Effect on role functioning and social/familial relationships
• Effect on sleep, mood, vitality and sexual function
In the United States, an estimated life expectancy of ≤ 6 4. Clarify the extent of concurrent disease and review the planned treatment
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months is a sufficient reason to access hospice support, and prognosis.
although no similar timeline has been formally adopted in 5. Clarify the nature and quality of previous laboratory tests and previous
treatments.
SA. While the VACS index has definite merit, it was not 6. Review the HIV and ART history:
intended to answer the question of eligibility to specialised • Approximate duration of HIV infection and manner of confirmation
hospice benefits, namely, home care and hospice admission. • Counselling and disclosure
The SPICT tool has wide applicability but fails to take in the • Most recent CD4 count and viral load, plus all available lab results, including
reversal of clinical disease on ART. This committee FBC, U&E, LFTs and HBV/HCV status
recommends the use of the SPICT tool where ART is unlikely • ART exposure, adherence and viral failure/drug resistance
to improve outcome, for example, end-stage cancer and • Prior opportunistic infections, for example, TB, PJP, CCM and malignancies
• Current symptoms in addition to pain.
irreversible end-organ failure, or where current or future ART 7. Elucidate medical comorbidities.
is judged by the medical and palliative care team to be futile. 8. Elucidate psychiatric comorbidities:
With regard to patients in SA’s private sector, provision of • Substance-use history
palliative care and hospice benefits is addressed in and • Depression and anxiety disorders
supported by the South African Medical Schemes Act 131 of • Personality disorders
1998. 34,35 At this time, it is recommended that Medical Schemes 9. Identify additional needs that require palliative care interventions:
utilise the SPICT tool when considering the reward of hospice • Additional symptoms
benefits and/or the ≤ 6 month estimated survival time as • Vulnerable/at-risk populations: children, specific sexual identity groups, for
example, sex workers, injection drug users, migrants and refugees
practised in the United States. However, the patient must be • Distress related to psychological or spiritual concerns
on ART or switch to active ART if treatment failure has been • Caregiver burden and concrete needs
confirmed and where ART remains a therapeutic option. • Problems in communication, care coordination and goal setting
Every HIV-infected person should be given the opportunity Source: Turck DC, Wilson HD, Cahana A. Treatment of chronic non-cancer pain. Lancet.
to access ART and enjoy its benefits. Where a patient refuses 2011;377:2226–2235. https://doi.org/10.1016/S0140-6736(11)60402-9
to take ART, yet requires hospice admission, addressing the ART, antiretroviral therapy; FBC, full blood count; U&E, urea and electrolytes; LFT, liver
function test; HBV, hepatitis B virus; HCV, hepatitis c virus; TB, tuberculosis; PJP, Pneumocystis
patient’s immediate need is of primary importance and the jirovecii pneumonia; CCM, Cryptococcal meningitis.
question of starting ART can be postponed.
South Africans is likely to accompany an identifiable clinical
Managing the HIV-sick: cause and the most valuable contribution the HIV and
Symptom control palliative care physician can make to pain management is to
identify the cause and treat it. The severity of the pain must
Pain control (see Box 2, Table 2 following, and be documented: ask the patient to describe the pain and to
Table 3-A6 in Appendix 6). rate it on a scale of 0 = ‘no pain’ to 10 = ‘the worst pain I have
ever experienced’. Can the pain be fitted into a recognisable
Of all treatment modalities reviewed, the best evidence for pain pattern, for example, peripheral neuropathy, post-herpetic
reduction averages roughly 30% in about half of treated patients, neuralgia and meningeal irritation, or is it associated with a
and these pain reductions do not always occur with concurrent specific site or organ, for example, perianal ulcers and
improvement in function. These results suggest that none of the
most commonly prescribed treatment regimens are, by bedsores, pulmonary or pleural disease, a tumour such as
themselves, sufficient to eliminate pain and have a major effect Kaposi’s sarcoma or a collection of enlarged lymph nodes?
on physical and emotional function in most patients with chronic While the clinical examination will provide some answers, a
pain. (Turck et al. , p. 2232) pain assessment chart will ensure that no aspect of the pain is
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omitted (see Box 3).
Chronic pain, that is, pain lasting ≥ 3 months, is common in
the HIV-infected population and is often the reason for The control of pain is a priority and must be addressed as
a palliative care consultation. Pain in HIV-infected soon as the patient arrives at a clinic or the admission ward.
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http://www.sajhivmed.org.za 31 Open Access