HIV Care
Integration: making it happen Olivia Dix, Kimberly Green, and Carla Horne discuss five key steps HIV clinicians and programme managers can take to integrate palliative care into HIV services
Although there have been significant gains in care and treatment of people living with HIV (PLHIV), in the post- ART era they still have problems with pain and opportu- nistic infections as well as depression and other mental health problems. As well as affecting the quality of life for patients and their families, these physical and psycho- logical problems can affect adherence to treatment. Increasingly therefore, healthcare workers, PLHIV,
and development partners are working to ensure that greater focus is placed on the ‘care’ in HIV care and treatment services. They are training HIV healthcare workers in palliative care, ensuring better screening and management of patient pain and other symptoms, iden- tifying mental health morbidity and social problems, and providing the basic medicines and tools needed by clinics to deliver the care.1–4
This care component
needs to be fully integrated into treatment so that the patient and their families receive seamless services. They should be able to access different but connected health and psychosocial services from a single point of access. When integration is implemented well ‘people get the care they need, when they need it, in ways that are user-friendly and that achieve the desired results and provide value for money.’ Integration takes time and resources, but its measurable benefits at a health system and patient level have been identified in a number of studies.5–7
In the context of a busy clinic environment it can be difficult for healthcare workers to ensure that their patients’ physical and psychosocial symptoms are as well managed as they would like. To help enable HIV care and treatment programme managers and clinicians to integrate palliative care into adult and paediatric HIV services, FHI360 in partnership with the Palliative Care Initiative of the Diana, Princess of Wales Memorial Fund has produced We Care! a tool kit for integrating pallia- tive care into HIV services (the toolkit can be down- loaded from
www.fhi360.org/en/Topics/Topics_Pallia- tive_Care.htm,
www.theworkcontinues.org, and www.
apca.org.uk. This practical guide for HIV care and treatment implementers outlines the key steps towards full integra- tion of palliative care, provides a number of standard forms and tools that can be used and lists a wealth
Olivia Dix, Head of the Palliative Care Initiative, the Diana, Princess of Wales Memorial Fund, UK; Kimberly Green, Deputy Country Director, FHI360; and Carla Horne, Region- al Senior Technical Officer, Palliative Care FHI360.
26 Africa Health
of useful resources. Although there are challenges, a phased approach to integration and good external refer- ral networks make the integration possible. Palliative care should be part of the core business of a health service, and for this to happen it is essential that the necessary systems build on what is already there so, for example, questions on care and support needs are part of the assessment forms already used. The authors of the guide emphasise that there is no right or wrong model of integration. Each service or programme needs to adapt the processes described in the toolkit according to what makes the most sense in their operating environment. Integration can range from a robust referral system between a clinic to a local pal- liative care service, to complete integration of palliative care in HIV services through training HIV clinicians, enhancing screening practices for palliative care needs, and ensuring basic medicines are available.2,6
Table 1
provides a summary of the five types of HIV palliative care integration. Whatever the level of integration, there are three es- sential components of palliative care that an outpatient or in-patient HIV treatment service needs to include: • A complete holistic assessment of the needs of the patient and his/her family including: screening for pain and other physical symptoms; mental health and social support needs; emotional and spiritual needs; and a discussion on self-care skills and longer-term care needs with the patient and family.
• The provision of care and treatment based on the assessment.
• Making appropriate referrals to other services. The strengthening and expanding of existing net-
works is very important since PLHIV and their families require a continuum of prevention and care, with their needs addressed over time by different providers includ- ing HIV outpatient clinics, inpatient wards community and home-based care, day care, and hospices. In order to achieve this there are five key processes
(see Figure 1). The formation of the integration team (step 1) is key as it will have overall responsibility for the integration of palliative care into the other work in a way that is not burdensome for the staff. Experience has shown that it is best to pull together a multi-disciplinary team including management and administration, whose buy-in is cru- cial to sustainability of services. Assessment is the first task. There are several short assessment tools described in the toolkit that can be used to assess the palliative care needs of the patient and their family, but it is also
July 2012
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