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HIV Care


not meeting the needs of PLHIV for HIV care and sup- port services.12


These services are generally available


in pockets within countries, provided by a centre of excellence or hospice here, and an HIV-implementer/ non-governmental institution there. Consequently, large numbers of people who test positive are not making it into pre-ART care services, access to ART is inequitable, and programmes continue to fail to have a major impact on the incidence of new HIV infections. The cases listed in this paper are just a few of the examples of HIV care and support services that improve prevention through uptake and retention in care. There are many best practices/models in resource-limited settings that have been shown to work well. To achieve PHDP, these models will need to be replicated, and integrated into existing ART clinical services and other programs to achieve greater scale of service delivery. Otherwise, there is a risk that ART for prevention will become just another good idea that failed to pan out due to poorly supported implementation.


References 1. Cohen M et al. Antiretroviral treatment to prevent the sexual transmission of


HIV-1: results from the HPTN 052 multinational randomized controlled ART. Sixth International AIDS Society Conference on HIV Pathogenesis, Treatment and Prevention, Rome, abstract MOAX0102, 2011.


2. GNP+, UNAIDS. 2011. Positive Health, Dignity and Prevention: A Policy Frame- work. Amsterdam, GNP+, 2011.


3. Lugada E, Levin J, Abang B, et al. Comparison of home and clinic-based HIV testing among household members of persons taking antiretroviral therapy in Uganda: results from a randomized trial. J Acquir Immune Defic Syndr 2010; 55: 245–52.


4. Doherty T. Quality of in-home rapid HIV-testing by community lay counsellors in a rural district of South Africa. 5th South African AIDS Conference, Durban, 2011.


5. Wachira J et al. What is the impact of home-based HIV counselling and testing on the clinical status of newly enrolled adults in a large HIV care program in Western Kenya? Advance online edition CID December 8, doi: 10.1093/cid/ cir789, 2011.


6. Mermin J, Were W, Ekwaru JP Mortality in HIV-infected Ugandan adults receiv- ing antiretroviral treatment and survival of their HIV-uninfected children: a prospective cohort study. Lancet 2008; 371: 752–9).


7. Apondi R, Bunnell R, Awor A, et al. Home-Based Antiretroviral Care is Associ- ated with Positive Social Outcomes in a Prospective Cohort in Uganda. J Acquir Immune Defic Syndr 2007; 44: 71–6.


8.


Behforouz HL, Farmer PE, Mukherjee JS. From directly observed therapy to accompagnateurs: enhancing AIDS treatment outcomes in Haiti and in Boston. Clin Infect Dis 2004; 38 Suppl 5: S429–36.


9. Demeester Rm, Omes C, Karasi JC, et al. Adherence to first-line antiretroviral regimens in Rwanda. J Acquir Immune Defic Syndr 2005; 40: 113–14. doi: 10.1097/01.qai.0000176590.68430.59.


10. O’Laughlin KN, Wyatt MA, Kaaya S, et al. How treatment partners help: social analysis of an African Adherence Support Intervention. AIDS Behav 2012l;16: 1308–15.


11. FHI 360. USAID SHARPER Semi-annual progress report. Accra, Ghana, April 30, 2012.


12. GNP+. In press.


Care and support during the pre-ART stage:


what is the role of palliative care? Michelle Meiring reflects on ways palliative care can support pre-ART service delivery


The HIV epidemic has played a significant role in the development of palliative care in Africa. In the early days of the epidemic in South Africa, before the wide scale rollout of antiretroviral treatment (ART), palliative and home-based care programmes were being estab- lished at an unprecedented rate, largely to address the needs of the dying patient and his/her family. In addition to developing the essential skills required to provide good end-of-life care, palliative and home-based care programmes were extending themselves to provide care and support to large numbers of orphans left behind af- ter their patients had died. These programmes certainly did well riding the waves of the epidemic (new infec- tions, deaths, and orphans) predicted by the Actuarial Society of South Africa (ASSA) in 2003 when South Africa was in its AIDS-denialist phase.1 Then along came ARVs and it was imperative that


palliative care services started to provide care and support to HIV patients on ART. Such care included


Dr Michelle Meiring, National Clinical Director, The Bigshoes Foundation, and Honarary Lecturer, Division of Palliative Medicine, School of Public Health and Family Medicine, University of Cape Town, South Africa.


24 Africa Health


assisting with issues around adherence and the manage- ment of distressing symptoms either caused by oppor- tunistic infections, immune-reconstitution illnesses, or anti-retrovirals themselves. The rapid rollout of ART in South Africa has led to improved survival rates as well as creating one of the largest populations of patients on chronic medications for a life-long communicable illness in the world. The ASSA 2008 model clearly demonstrates a much larger population of patients on ART than was predicted in 2003 (see Figure 1) also accounting for much higher numbers of people living with the virus in South Africa. Green and Harding’s articles in this issue bear testimony to the difference palliative care can make to the quality of life of these patients, clearly demonstrating superior outcomes in patients receiving integrated palliative care as well as HIV care versus patients receiving standard HIV care alone.2 Now that significant in-roads have been made into supporting patients on treatment, what is the role of pal- liative care in extending itself into the pre-ART phase? Particularly given that the World Health Organization definition says that palliative care should begin at the time of diagnosis.


July 2012


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