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7–6 | Clinical Manual for Management of the HIV-Infected Adult/2006 References ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Alexander C. Palliative and End-of-Life Care. In: Anderson JR, ed. A Guide to the Clinical Care of Women with HIV. Rockville, MD: Health Services and Resources Administration; 2005. Available online at hab.hrsa.gov/publications/womencare05/. Accessed May 20, 2006. American Academy of HIV Medicine. Pain Management. The HIV Medicine Self-Directed Study Guide (2003 ed.). Los Angeles: AAHIVM; 2003. Association of Nurses in AIDS Care. Pain. In: Kirton C, ed. Core Curriculum for HIV/AIDS Nursing, 2nd ed. Thousand Oaks, CA: Sage Publications; 2003:143-155. Breitbart W. Suicide Risk and Pain in Cancer and AIDS. In: Chapman CR, Foley KM, eds. Current and Emerging Issues in Cancer Pain: Research and Practice. New York: Raven Press; 1993:49-66. Hahn K, Arendt G, Braun JS, et al. A placebocontrolled trial of gabapentin for painful HIVassociated sensory neuropathies. J Neurol. 2004 Oct;251(10):1260-6. O’Neill WM, Sherrard JS: Pain in human immunodeficiency virus disease: a review. Pain. 1993 Jul;54(1):3-14. Singer EJ, Zorilla C, Fahy-Chandon B, et al. Painful symptoms reported by ambulatory HIV-infected men in a longitudinal study. Pain. 1993 Jul;54(1):15-9. Slaughter A, Pasero C, Manworren R. Unacceptable pain levels. Am J Nurs. 2002 May;102(5):75, 77. Swica Y, Breitbart W. Treating pain in patients with AIDS and a history of substance use. West J Med. 2002 Jan;176(1):33-9. U.S. Department of Health and Human Services. Management of Cancer Pain. Rockville, MD: Department of Health and Human Services; 1994. U.S. Department of Health and Human Services. Guidelines for the Use of Antiretroviral Agents in HIV- 1-Infected Adults and Adolescents. October 10, 2006. Available online at aidsinfo.nih.gov/Guidelines/ GuidelineDetail.aspx?GuidelineID=7. Accessed July 7, 2007. ♦ ♦ Weinreb NJ, Kinzbrunner BM, Clark M. Pain Management. In: Kinzbrunner BM, Weinreb NJ, Policzer JS, eds. 20 Common Problems: End-of-life Care. New York: McGraw Hill Medical Publishing Division; 2002:91-145. World Health Organization. Cancer Pain Relief and Palliative Care, Report of a WHO Expert Committee. Geneva: World Health Organization; 1990.
Palliative Care and HIV Background Palliative care is not curative care, but is supportive, symptom-oriented care. It is usually needed throughout the course of disease progression to relieve patients’ suffering and promote quality of life. Palliative care is important for patients with any medical condition. It may be used in conjunction with disease-specific care or as the sole approach to care. Palliative care includes the following: ♦ ♦ ♦ ♦ Management of symptoms (eg, fatigue, pain) Treatment of adverse effects (eg, nausea, vomiting) Psychosocial support (eg, depression, advance care planning) End-of-life care Following is the widely used definition of palliative care according to the World Health Organization: Palliative medicine is the study and management of patients with active, progressive, far advanced disease for whom the prognosis is limited and the focus of care is the quality of life. [It is] the active total care of patients whose disease is not responsive to curative treatment. Control of pain, of other symptoms, and of psychological, social, and spiritual problems, is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families. Palliative care in AIDS patients comprises a continuum of treatment consisting of therapy directed at AIDSrelated illnesses (eg, infection or malignancy) and treatments focused on providing comfort and symptom control throughout the life span. This care may involve multidimensional and multidisciplinary services, including HIV medicine, nursing, pharmacy, social work, complementary/alternative medicine, and physical therapy. Palliative Care in the Era of Antiretroviral Therapy With advances in HIV-specific therapy and care, HIV infection is no longer a rapidly fatal illness. Instead, those patients who are able to tolerate antiretroviral therapy (ART) often experience a manageable, chronic illness. The death rate from AIDS, however, continues to be Section 7—Pain and Palliative Care | 7–7 significant: approximately 15,000-16,000 per year in the United States. In many parts of the world, patients are not able to obtain specific treatments for HIV or for opportunistic illnesses, and supportive or palliative care may be the primary mode of care available to patients with advanced AIDS. Regardless of access to diseasespecific treatment, people living with HIV continue to experience symptoms from HIV disease and its comorbid conditions, and those taking ART may experience adverse effects. Integrating palliative care with disease-specific care is important in the treatment of patients with HIV to promote quality of life and to relieve suffering. S: Subjective The patient with advanced HIV disease complains of 1 or more of the following: ♦ ♦ ♦ ♦ ♦ ♦ Agitation Anorexia Chronic pain Constipation Cough Decubitus ulcers or pressure sores O: Objective ♦ ♦ ♦ ♦ ♦ ♦ ♦ ♦ Delirium Dementia Depression Diarrhea Dry skin Dyspnea Fatigue Fever Conduct a complete symptom-directed physical examination. A: Assessment and P: Plan Treatment ♦ ♦ ♦ ♦ ♦ ♦ ♦ Increased secretions ("death rattle") Nausea Pruritus Sweats Vomiting Weakness Weight loss Table 1 lists common symptoms of AIDS and their possible causes. Also included are disease-specific treatments and palliative interventions. Depending on the situation, either or both of these treatments may be appropriate. Consider the patient’s disease stage and symptom burden, the risks and benefits of therapies, and the patient’s wishes. Practitioners should note that some of the palliative treatments may have substantial long-term adverse effects and should be used to alleviate symptoms only in late-stage or dying patients.
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Preface—About this Manual | Clini
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Previous Editions Atlanta Contribut
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Initial Physical Examination Backgr
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Genitals/Rectum • Inspect the gen
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Initial and Interim Laboratory and
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Section 1—Testing and Assessment
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Patient Education ♦ ♦ ♦ ♦ D
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Section 2—Health Maintenance and
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References ♦ ♦ ♦ ♦ ♦ ♦
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Occupational Postexposure Prophylax
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P: Plan Laboratory Testing Provide
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For hepatitis C, no recommended pro
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as hepatitis C or another sexually
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for treatment is appropriate, and b
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contact with the patient. Patients
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tablet daily of trimethoprim-sulfam
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Opportunistic Infection Prophylaxis
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Discontinuing Primary Prophylaxis P
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Latent Tuberculosis Background Late
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INH may cause liver toxicity and it
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Patient Education ♦ ♦ ♦ ♦
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Reducing Maternal-Infant HIV Transm
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Some states require written informe
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contraindicated during pregnancy be
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Section 3—Antiretroviral Therapy
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Nelfinavir (Viracept) Adequate drug
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Section 4—Complications of Antire
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♦ ♦ ♦ Toronto General Hospita
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Adverse Reactions to HIV Medication
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egimen, symptoms of fatigue could i
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Recreational Drugs and Antiretrovir
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Section 4—Complications of Antire
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LSD, Mescaline, Psilocin, and Methy
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Immune Reconstitution Syndrome Back
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A: Assessment In the appropriate cl
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Eye Problems Background The immunos
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Fever Background Although fever may
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Headache Background Headache may ha
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Lymphadenopathy Background Lymphade
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Treatment Treatment will depend on
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Neurologic Symptoms Background The
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Pulmonary Symptoms Background Short
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Treatment Once the diagnosis is mad
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Candidiasis, Oral and Esophageal Ba
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Maintenance therapy Use caution whe
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Cervical Dysplasia Background Cervi
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Patient Education ♦ ♦ ♦ ♦ P
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Cryptosporidiosis Background Crypto
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Gonorrhea and Chlamydia Background
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Treatment of Gonorrhea Treatment op
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Hepatitis B Infection Background He
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Hepatitis C Infection Background He
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pregnancy. Ribavirin is teratogenic
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Herpes Simplex, Mucocutaneous Backg
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References ♦ ♦ ♦ ♦ ♦ Cent
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Kaposi Sarcoma Background Kaposi sa
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Treatment Treatment of KS is not co
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Molluscum Contagiosum Background Mo
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Mycobacterium avium Complex Backgro
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Table 1. Interactions between Rifab
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Mycobacterium tuberculosis: Treatme
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P: Plan Diagnostic Evaluation Durin
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Table 1. Regimens for Treatment of
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Rifabutin may be substituted for ri
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Page 338 and 339: Toxoplasmosis Background Toxoplasma
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Page 346 and 347: Oral Health Background Examination
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