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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 19: Palliative Care in Resource-Poor Settings4. Patient access. Opioids should be available in locations that will be accessible to asmany patients as possible.5. Medical decisions. Decisions concerning the type of drug to be used, the amount of26 picasthe prescription and the duration of therapy are best made by medical professionalson the basis of individual patients’ needs, and not by regulation.6. Dependence. Physical dependence, which may develop when opioids are used to treatchronic pain, should not be confused with psychological dependence.Financing must be secured for essential drugs. In Latin America, the “South-South Cooperation”Initiative is using a strategy of partnership among neighboring countries to become morepowerful advocates for cheaper medications, particularly AIDS drugs. The Bamako Initiative isa revolving fund for financing essential drugs, with countries joining together to decrease pricesand maintain commitment to buy and distribute them. In India, the production of cheap immediate-releasemorphine has aided the distribution and affordability of this essential drug. 45 Thecooperation of the pharmaceutical industry is needed to spread this practice to other nations.Drug availability must include medications appropriate for pain relief and symptom control,regardless of the availability of other types of treatment. Access to palliative care services willalways be essential, whether or not people have had access to other therapies including ART. In1997, the UNAIDS HIV Drug Access Initiative (DAI) was developed to improve access to ART inresource-poor areas. Until 1999, DAI focused exclusively on ART, but it now is also promotingother means of treatment—including palliative care (see www.unaids.org/). 46MODEL INITIATIVES TO ADVANCE PALLIATIVE CAREIN RESOURCE-POOR SETTINGSPalliative Care in UgandaThe Ugandan Ministry of Health included palliative care as an integral part of all EssentialClinical Care in its National Health Sector Strategic Plan 2000/01–2004/05. 47 48 Table 19-2 detailsthe palliative care component of the Ministry of Health’s mandate for essential clinicalcare. Palliative care is in the core budget of the minimum healthcare package, with set goals forimplementation and verification. Uganda has an essential drug program, and the revision ofrestrictive drug laws now allows for trained palliative care nurses to prescribe and administeroral morphine in home-based settings.The program has developed a broad public education policy for AIDS that includes professionaleducation in palliative care at all healthcare levels. The government supports “Hospice Uganda”as a resource and training center for community- and home-based palliative care. 49 VariousNGOs, including The AIDS Support Organization (TASO), provide counseling, care and supportservices, further increasing the reach of palliative care in underserved areas. Uganda’s Partnershipfor Home-Based Care in Rural Areas and the Mildmay Center for Palliative HIV/AIDS Carein Kampala have been cited in UNAIDS’ Best Practice Collection. 27XIXThe Enhancing Care InitiativeThe Enhancing Care Initiative is a collaborative effort of the Harvard AIDS Institute withAIDS Care Teams in Brazil, Puerto Rico, Senegal, South Africa and Thailand. The focus of thisinitiative is to implement continuity of care programs in 10 care areas. These include preventionapproaches with HIV counseling and testing, basic medical care services, and community-basedU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 401