Page 49 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 20 of 26 Guideline

• Dying in a South African public hospital
ß Impending death is often accompanied by feelings of terror, loneliness, pain and abandonment. These feelings are likely to add to the
suffering of patients in busy hospitals characterised by shortages of beds, staff and medicines. Family often absent at the time of
death. The ‘end-of-life’ discussion occurs rarely, if at all, and the family often feels left-out and aggrieved, and regret occurs as seldom
the gathering together of loose ends takes place during the contented arrival of life’s end.
• Bereavement counselling
ß Usually not given to the patient or family before or after death. Questions of the bereaved are often left unaddressed and anger and
disappointment are seldom addressed. Litigation is an option for the disgruntled family.

Appendix 2: Indicators of increased mortality of HIV-infected patients
Demographic indicators of an increased risk of death:
• Age ≥ 45–50 years old. Risk increases with age and includes risk from comorbid disease. Male gender is frequently associated with
increased risk but confounded by late entry into care, poor retention in care, lower baseline CD4 cell counts and older age at entry than
female gender.

Clinical indicators of an increased risk of death:
• Unintended weight loss of > 10% of normal body weight, and/or BMI ≤ 18 kg/m .
2
• AIDS-defining clinical conditions yet the risk is not the same for all events. Tuberculosis, cryptococcal meningitis (CM) and malignancy in
Africa carry a higher risk than other AIDS-defining conditions.
• AIDS and non-AIDS-defining cancers in the HIV-infected people.
• Comorbid disease and end-organ failure: renal, liver, cardiac and respiratory.
• Confirmed ARV-resistance, particularly high-level resistance to all major classes of ARV.
• Hospital re-admission rates and Grip Strength. Thirty-day hospital re-admission rates in HIV-positive adults are associated with other
markers of poor outcome, namely low CD4 counts, AIDS-defining illnesses, non-AIDS-defining infections and unreliable utilisation of
medication.

Laboratory indicators of an increased risk of death:
• CD4 count: CD4 ≤ 200c/mm or lower. The lower the level (e.g. < 50 c/mm ), the greater the risk.
3
2
• Anaemia: particularly if severe (viz. Hb < 8 g/dL).
• HIV viral load: high levels (viz. > 100 000 copies/mL) prior to ART and detectable levels while on ART. The higher the level, the greater the
risk, for example, malignancy.

Combination indicators of an increased risk of death:
• The Veterans Aging Cohort Study (VACS) Index. This scoring system developed in the USA incorporates seven clinical or laboratory indices
that, taken together, predict death in HIV-infected persons. Several observational reports indicate that this index has superior predictive
value to both single and composite indices currently in use. The role of Hepatitis C virus positivity in the VACS scoring system is numerically
small and unlikely to negatively influence its utility in Southern Africa where the prevalence of HCV is low, that is, 3% – 5%.

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