Page 48 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 19 of 26 Guideline

Appendix 1: Palliative care model: No care

Characteristics of this model include:
• Acute hospitalisation
ß Even when seriously ill, palliative care and support are generally not offered in public or private hospitals in South Africa.
ß Primary attention is directed to acute and curative care.
ß Care is seldom a team work; each caregiver works independently and very few have had formal training in palliative care.
ß The public health system’s masterplan is usually focused on early discharge and the emptying of beds in preparation for the next
intake of acutely ill patients.
ß Patients are seldom, if ever, asked about their end-of-life thoughts or wishes.
ß Families rarely participate in the provision of the patient’s care.
ß The day-to-day care provided in many of SA’s public hospitals is given by junior doctors, for example, community service doctors,
interns, medical officers, registrars, et cetera, particularly in district and rural hospitals. Supervision is not uniform and senior consultants
in public hospitals are seldom in the wards every day and less often in the evenings and at night.
• The HIV patient
ß Patient characteristics. Many patients are newly diagnosed or previously diagnosed and started on ART but had been lost to follow-up.
The presentation is diverse: comorbid conditions (e.g. diabetes, renal failure, hepatitis B, et cetera), AIDS-defining and non-AIDS-
defining diseases (e.g. community acquired pneumonia [CAP], pneumocystis pneumonia [PJP], et cetera), anaemia, low platelets,
gastroenteritis, ART-associated toxicity and treatment failure (viral resistance), et cetera. Occasionally the primary presentation is with
a condition not immediately associated with HIV, for example, trauma, malaria, skin rash, et cetera. Often patients are very ill and the
mortality rate is substantial.
ß Tuberculosis (TB) is frequent, needs to be excluded in all and is the major cause of death. Care requires attention to symptomatic
control (palliation), curative therapy and the prevention of transmission.
ß Poverty and limited social resources with adherence problems. Non-disclosure to family members is frequent, stigma dictates
behaviour and non-disclosure results in non-adherence which leads to treatment failure.Neurocognitive dysfunction is common and

may contribute to non-adherence (forgetfulness) and unreliable clinic attendance of some. The care of the HIV-infected needs to be
broad-based to ensure that social, psychological and practical needs are met.
ß The HIV-sick. Many patients present with more than one major diagnosis, for example, TB and bacterial pneumonia, PJP and renal
failure, Kaposis’s sarcoma (KS) and bacteraemia et cetera, and multiple concurrent diagnoses increase mortality. Antiretrovirals are
toxic and drug–drug interactions are frequent and occasionally life-threatening, for example, drug-induced liver injury (DILI), Stevens–
Johnson syndrome (SJS) and erythema multiforme (EM).
• Laboratory indices
ß Baseline HIV diagnostic tests (HIV antibody tests) are still not performed on all who are admitted to South African private and public
hospitals. HIV-directed care, for example, ARVs, cannot be given without this baseline information. Only ART can control HIV infection.
3
ß CD4 counts are often low in this group of patients, for example, < 200 cells/mm , and patients are vulnerable to a variety of opportunistic
diseases.
ß Viral load. The South African National ART guidelines discourage checking a patient’s viral load (VL) at the time of the baseline
assessment, but recommend that the VL is checked 6 months after starting ART and annually thereafter. Elevated VL means adverse
survival if on ART. Persistently high VL indicates increased risk of cancer in the HIV-infected people.
3
ß Markers of mortality: Anaemia (Hb < 8 g/dL), CD4 < 200 cells/mm , VL (especially > 100 000 copies/mL), end-organ failure (renal,
liver), a low BMI (< 18 kg/m ).
2
ß Delay in laboratory turn-around times. Histology results appear particularly resistant to short turn-around times yet the care of the
HIV-cancer patient depends on tissue confirmation. Patients without timely results do not get chemotherapy, do not start ART early
enough and do not survive.
• Radiology
ß Access to ultrasound, echocardiography, computed tomography (CT) and magnetic resonance imaging (MRI) scans, et cetera, in the
government sector and especially in rural and secondary level hospitals is poor and delays in obtaining these tests are widespread,
even in larger public hospitals.
ß Transfer to referral centres is difficult to expedite: transport is not always readily available and permission is needed, as is the
willingness of the referral hospital to accept the patient.

• Medical team
ß The care of the HIV-well is explained in guidelines. The care of the HIV-sick requires practical training and the acquisition of bedside
skill, as good palliative care will require a good knowledge of the care of the HIV-sick.
ß Junior doctors, for example, community service doctors, interns and registrars, carry a major responsibility in the day-to-day provision
of patient care in SA’s public hospitals. Additional training will be needed to equip junior staff on how to triage between the curative
and palliative disciplines of care and the combinations of both.

http://www.sajhivmed.org.za 41 Open Access