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

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 23: Medical Care in Advanced AIDSmoting communication and demonstrating caring than preparing unwanted or discomfiting meals.Explicit reassurance to the caregiver that the patient will not starve to death, and that suffering is notincreased, is critical both for patient comfort and the reduction of caregiver anxiety.26 picasAIDS-Associated MalignanciesSeveral cancers are now AIDS-defining illnesses including Kaposi’s sarcoma (KS), non-Hodgkinslymphoma, and invasive cervical carcinoma in women. The diagnosis and staging of these malignanciesare identical to diagnosis and staging in the HIV-negative patient. The prognosis, however,is worse.• Kaposi’s SarcomaDermatological KS often responds well to treatment, whereas visceral KS, including the lung and GItract, is not curable. Although some patients may obtain short-term control with HAART and systemicchemotherapy such as a doxorubicin-containing regimen, in general palliation is the primary goal.Absent regulatory and financial barriers, addressed in Chapter 18: Legal and Financial Issues, allpatients with incurable KS should be referred to hospice.• Non-Hodgkins Lymphoma (NHL)The incidence of NHL is estimated at up to 2% per year in HIV-infected patients and 20% over threeyears in AIDS patients. In the HIV-positive patient, NHL is always high grade B cell histology, isalways disseminated (Stage III or IV), and presents as either systemic, CNS or body cavity disease.Diagnosis of CNS lymphoma should prompt hospice referral as average survival is only 2 to 4 months.Radiation does not prolong survival and provides minimal palliation. Systemic lymphoma has beentreated with modified regimens with an average survival of eight months. At the end of therapy,however, and certainly at relapse, patients should be referred to hospice or otherwise be allowed tobenefit from intensive palliative care. 35Progressive Multifocal Leukoencephalopathy (PML)Progressive multifocal leukoencephalopathy (PML) is thought to be caused by reactivation of the JCvirus, a human papovavirus. The sudden deterioration of intellectual and physical function of PMLheralds a median survival of 2 to 4 months. Recent trials have demonstrated no improvement withnovel interventions. 36, 37 While clinical investigation should continue, and some clinicians recentlyhave opted to use empiric cidofovir even though this is of unproven efficacy, active PML marks theneed for intensified palliative care.Anecdotally, a number of patients described as presenting with PML have experienced greatly improvedscans and significantly improved longevity following the initiation of HAART. However, patientswith PML who do not experience immune reconstitution with antiretroviral therapy have verylimited life expectancy.Advanced Liver DiseaseAdvanced liver disease due to viral hepatitis is becoming a leading cause of death in patients infectedwith HIV. While treatment guidelines for the management of HIV-infected patients co-infected withhepatitis B and/or C continue to advance, not even the emerging new treatments will be effective inpreventing mortality for patients with advanced cirrhosis and liver failure.XXIIIU.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 485