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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 2: Overview of Clinical IssuesAs with the findings related to pain, symptoms in AIDS may result from the specific effects ofopportunistic infections (e.g., sweats, fever, in disseminated MAC infection, dyspnea inpneumocystis carinii pneumonia), from the apparent effects of the progression of HIV infectionitself 26 picas (e.g., weight loss, fatigue), from medications (e.g., antiretroviral-induced nausea andvomiting), or from the non-specific manifestations of late-stage illness (e.g., depression, fatigue,malaise). As with studies of the prevalence of pain, much of the observational knowledge regardingsymptom prevalence in AIDS was generated in the pre- or early HAART era, and thespecific effects of certain opportunistic infections may have diminished as these entities havebecome less common. 3, 7, 41 Nevertheless, the challenges of symptom management have also grownwith several factors:1. The prolongation of the chronic disease phase in some patients, with the resulting moreprotracted late-stage course described above, requiring more sustained attention to complexsymptom management in chronically ill patients;2. The recognition of the wide cumulative range of drug toxicities and symptomatic sequelaewhich occur in patients on long-term antiretroviral therapy;3. The assessment of the contribution of drug toxicities vs. the underlying effects of diseaseprogression, raising important clinical issues regarding the competing effectiveness andtoxicity of different therapeutic options (e.g., balancing short-term quality of life vs. longtermprolongation of life in a patient contemplating a potentially toxic antiretroviral regimen,deciding whether disease-specific therapy may also in fact have a palliative impact onsymptoms in a given situation, etc.);4. The emergence of co-existing co-morbid conditions that have complicated the managementof patients with AIDS, including chronic viral hepatitis (especially but not limited to hepatitisC), and chronic co-morbid psychiatric illness and substance abuse in patients withAIDS. 42-44As with the management of pain, clinicians caring for patients with AIDS need to be familiarwith the science and practice of palliative medicine, which has emerged as a fast-growing specialtyreceiving increased attention in the United States and elsewhere. Indeed, the UnitedStates is a relative newcomer to the field, with much of the scientific and professional contributionto palliative medicine having emanated first from the United Kingdom and Canada. 29 Theliterature of palliative medicine has documented impressive advances in recent years in theelucidation of pathophysiology and treatment of many of the common symptom syndromes listedabove, such as nausea and vomiting, dyspnea, fatigue, and weight loss. 29, 45 Some of this work hasincluded palliative care in the context of AIDS. 46 Much recent work has also been done in thepsychopharmacologic treatment of depression and anxiety and other psychiatric illness, includingthe treatment of such conditions at the end of life, 47 and many treatment options exist forthese conditions as well. These options will be discussed in more detail in Chapter 5, ConstitutionalSymptoms, and Chapter 10, Psychiatric Problems, respectively.Although some complicated syndromes in symptom management, as in pain management, wouldbenefit from the input of a palliative care specialist, in many cases primary HIV care providerscan identify and treat a wide range of AIDS-related symptoms using standard palliative medicinestrategies that will both enhance patients’ quality of life and also maximize the likelihoodof adherence to disease-specific therapy in cases in which this is still an option. Basic familiaritywith both realms of care should be part of the clinical repertoire of all AIDS care providers. As is16U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau