The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

Chapter 2.26 picasOverview of Clinical IssuesIIPeter A Selwyn, MD, MPH, and Mimi Rivard, ANP, MSNINTRODUCTION■ The past two decades have seen both the emergence of AIDS as a new, life-threatening infectiousdisease and its conversion from a rapidly fatal illness into a manageable chronic disease.This pattern has been most marked in industrialized countries where the promise of HIV-specifictherapies has been realized for many individuals living with HIV. However, even in the era of‘highly active antiretroviral therapy’ (HAART), AIDS remains an important cause of morbidityand mortality in many young adult populations, and attention to palliative and end of life issuesis an essential aspect of clinical care. In the early years of the AIDS epidemic, clinicians had tolearn about palliative care by necessity, in the absence of any hope of curative therapy. With theadvent of antiretroviral therapy and the ability to control HIV disease progression, it remainsimportant to incorporate relevant aspects of palliative care in the comprehensive managementof patients with AIDS. Rather than being ‘either-or,’ curative and palliative approaches to HIVcare need to be ‘both-and,’ and one paradigm need never fully substitute for the other. Thischapter will outline some of the important clinical issues in HIV palliative care, many of whichwill be addressed in greater detail in subsequent chapters.EPIDEMIOLOGY■ Starting in the early 1980’s, AIDS rapidly became the leading cause of death for young adultsin the United States. 1 With advances in AIDS care and HIV-specific therapy in the mid-1990’s,mortality rates began to decline, and with the introduction of the protease inhibitors in 1996,the rates declined even more dramatically. 2-7 However, the decline in death rates has sinceplateaued, and there remain approximately 15,000 deaths per year from HIV/AIDS. 4 While thenumber of deaths from AIDS dropped by 25% and 42% from the preceding years in 1996 and1997, respectively, these figures dropped to 17% and 8% for 1998 and 1999. 4,6 Moreover, the declinesin death rates have not been uniform across all populations affected by HIV/AIDS, anddecreasing mortality has not been as pronounced among African-Americans and Latinos as ithas been among whites. 4,8 In addition, the incidence of new HIV infections is not believed tohave decreased, and has remained stable at approximately 40,000 new cases per year. 8 As aresult of these trends, AIDS-related mortality continues to be an important phenomenon, andthe number of patients living with HIV (i.e., the prevalence of AIDS) has actually increased. 4,8(Figure 2-1.)A condensed version of this chapter was previously published in the online publication Innovationsin End-of-Life Care as Selwyn PA, Rivard M. Palliative care for AIDS: Challenges and opportunitiesin the era of highly active anti-retroviral therapy. Innovations in End-of-Life Care. 4(3),2002. www.edc.org/lastactsU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 5