This page contains a Flash digital edition of a book.
HIV Care


Where’s the care in the post-ART era? Enhancing adherence, retention, and quality of life in people living with HIV through integrated approaches. Kimberly Green, Olivia Dix, Faith Mwangi-Powell, Carla Horne, and Emmanuel Luyirika discuss


Three decades into the HIV epidemic, a number of critical advances have been made in care and treatment. Combination antiretroviral therapy (ART) now reaches nearly half of those eligible, resulting in dramatic reductions of illness and death.1


People with HIV are


living longer than ever before, and are able to establish families, work, and lead normal lives. Even with these tremendous gains, people living with HIV (PLHIV) continue to need HIV care. This includes management of opportunistic infections, medication side effects, ageing and co-morbidities, and the physical symptoms that are associated with these events.2–4


They


also face depression, anxiety, and other psychosocial, socio-economic, or spiritual problems that can affect their quality of life and overall physical wellbeing, as well as their ability to adhere to treatment and to stay in care.4–8


HIV care and support involves, ‘a comprehensive set of services, including psychosocial, physical, socio- economic, nutritional, and legal care and support. These services are crucial to the well-being and survival of PLHIV and their care-givers as well as orphans and vul- nerable children. Care and support services are needed from the point of diagnosis throughout the course of HIV-related illness regardless of ability to access ART.’9 Palliative care is an essential component of HIV care that focuses on holistic assessment and care of patients and their families and addresses symptoms, pain, and emotional, social, and spiritual concerns.10 This article presents the critical HIV care challenges and the needs of PLHIV in the post-ART era; how they affect critical clinical and health system outcomes and why an integrated approach with a greater emphasis on care is essential moving forward.


Critical challenges in the post-ART era Despite efforts to promote earlier presentation into HIV clinical care and treatment, data from Africa and else- where indicate persistent late diagnosis and enrolment resulting in higher levels of morbidity and mortality.11 a global meta-analysis, Lawn and colleagues reported


high mortality rates in the first year of ART in sub-Saha- ran Africa (8–26%) compared with other regions of the world).12


Once on ART, retention in care is critical for optimal outcomes. Studies report a wide range of loss-to- follow-up in sub-Saharan Africa from 14% in a large multi-site cohort in South Africa to 24% in a multi- country study.13,14


Critically, retention tends to be worse


between the point of diagnosis and initial enrolment in care, with loss-to-follow-up (LTFU) in some cases as high as 86%.15 New challenges for HIV care are on the horizon. As PLHIV age, their risk of dementia, bone deterioration, non-AIDS related cancers, and organ-related diseases increases. Overall, PLHIV are significantly more likely to develop these diseases than people in the general population and to develop them earlier in life.3 Studies also suggest that at any given time 50% or more of patients presenting in an HIV clinic will require palliative care.16,17


The type and intensity of palliative


care needs differs between those who are first diag- nosed, those who are pre-ART, and PLHIV who are on ART or living with AIDS.18


In Tanzania, 41.1% of an


HIV clinic population, predominantly on ART reported moderate to severe pain, while in South Africa, 51.2% of a cohort on ART reported being in pain in the past 7 days.16,19


A cross-sectional study in ART patients in South


Africa diagnosed neuropathy, a debilitating and often extremely painful condition, in 30% of the cohort.20 Depression, anxiety and other mental health con- cerns are also prevalent in Africans living with HIV. A large study in the Free State of South Africa reported that 30.6% of those interviewed met the cut-off for clinical anxiety and 25.4% for depression.21


In a review of 23 In


Kimberly Green, Deputy Country Director, FHI360; Olivia Dix, Head of the Palliative Care Initiative, The Diana, Princess of Wales Memorial Fund, UK; Faith Mwangi-Powell, Executive Director, African Palliative Care Association, Kampala, Uganda; Carla Horne, Regional Senior Technical Officer, Palliative Care FHI360; and Emmanuel Luyirika, Deputy Clinical Director, Mengo Hospital, Kampala, Uganda.


July 2012


studies measuring depression in PLHIV across Africa, pooled estimated point prevalence was 31.2%.8 Despite the prevalence and severity of symptoms and mental health problems, they tend to be underdiag- nosed and treated. In one study, two-thirds of patients reported that symptoms were missed by clinicians while in another study, mental health disorders were not treated in more than 40% of patients requiring care.22,23


The interaction between HIV care needs and ART adherence, retention in care, quality of life, and mortality The previously described care needs not only have an im- pact on the quality of life of PLHIV but also on their ability to be adherent to ART, to stay in care, and to stay alive.


Africa Health 19


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68  |  Page 69  |  Page 70  |  Page 71  |  Page 72  |  Page 73  |  Page 74  |  Page 75  |  Page 76