HIV Care
• PLHIV with pain, fatigue and other symptoms are much less likely to be adherent to ART. The greater the number and the more severe the symptoms that PLHIV report, the lower their ART adherence levels are.24–28
poorer levels of adherence.25,29
• report better quality of life.41 Evidence also indicates that when ART clinics
Specifically, being in pain is associated with Some symptoms
(such as fatigue and difficulty concentrating) result in lower adherence, while poor adherence can also lead to an increase in prevalence and severity of symptoms.26
• Depression, anxiety and lack of social support are linked with disease progression and death, loss to follow-up, and reduced adherence to ART. ART ad- herence was reported as nearly twice as high among PLHIV participants who were not depressed and had good social support compared with those who were depressed and had lower levels of social support.30 Depression, stress and trauma in PLHIV have also been found to influence the immune system and to be associated with increased risk of death.31
PLHIV
with mental health disorders are also prone to miss- ing appointments and dropping out of care once they are enrolled.32–34
The power of integration ‘Lack of integration can result in late referrals, unnec- essary delays for treatment, transfer to an inappropri- ate setting of care, unnecessary suffering, and cost.’35 The intent of integration is to enable PLHIV to access different but connected health and psychosocial care services from one point of access, rather than via many fragmented services and providers. By doing this, HIV healthcare workers are better able to improve patient outcomes with efficiency for both the client and the healthcare system. The World Health Organization (WHO) strongly urges health managers and clinicians to adopt integra- tive approaches to service delivery, particularly at the primary and secondary service delivery levels, in order to maximise holistic patient-centred-care and cost-effi- ciency.36
These include:
• services that are better coordinated and less frag- mented;
• cost savings and efficiencies due to improved coor- dination and synergies;
• higher use of services, better coverage and therefore increased client access to services at each point of contact;
• increased quality of care and, as a result, better patient outcomes. Where ART clinics integrate community HIV care
(such as home-based care) in their services, PHIV are more likely to: • be adherent to ART;40–42 • stay in care; in a review of annual LTFU, the LTFU rates were found to be 3% for integrative services versus 24% for stand-alone ART clinics;14
• experience higher CD4 counts and lower viral load;41,42
• have greater ART durability;41 • experience better social support;43
20 Africa Health
integrate symptom management and other elements of palliative care as part of routine clinical services, PLHIV: • experience fewer and less distressing physical symp- toms;44
• are more adherent to ART;45–48 • have better immune function and reduced mortal- ity;44,46,48
• are less depressed and have fewer psychological problems;49,50
• report better overall quality of life.46 At the health systems level, palliative care integration into hospital services can to lead to significant cost sav- ings. Morrison and colleagues reported annual savings of US$1.3million in a 400-bed hospital and US$2.5mil- lion in typical university medical centres.51
Savings
are the result of identifying physical and psychosocial problems earlier and reducing the need for hospitalisa- tion. Where HIV clinics routinely ask patients about symptoms, they may also be better able to identify those at risk of viral rebound and use this information to make decisions regarding treatment durability.52
Better ART
adherence and retention in care also mean that PLHIV stay on more affordable regimens for longer and experi- ence less viral resistance.
HIV clinic and other healthcare workers involved with integrating HIV care (e.g. palliative care), report greater satisfaction in clinical care and better relation- ships and communication with patients.17
One doctor
The benefits of integration have been described at a health system and patient level.37–39
reported, ‘I think patients feel much more comfortable with me. They answer with ease whenever I ask them questions. They are also not hesitant to ask me ques- tions. In general, it is quite good atmosphere in the clinic and my consultation room now.’49 While the overall results of integration are many and predominately positive, there are, of course, challenges. The decision to integrate services means factoring in time to train, mentor and guide healthcare workers in new skills (e.g. management of pain). If patients perceive improvements in the quality of their care, there may also be increased demand for services, which can have an impact on staffing and projections for medicines needed. However, these challenges can be overcome by starting small and planning ahead.
Looking forward: opportunities for increasing access to HIV care Integrative health approaches are now more critical than ever. The United Nations HIV/AIDS Investment Framework calls for greater efficiencies, better prioritisa- tion and increased government financial contribution to basic programme activities, including HIV care and support.9 Integration of HIV care including palliative care into HIV services offers numerous opportunities ranging from improved adherence, better retention, improved wellbeing and quality of life, and cost-efficiencies. As Theo Smart outlines in the following article, it also contributes to advancing HIV prevention. Olivia Dix, in her article on palliative care and HIV services integra- tion, provides a number of strategies for implementers to
July 2012
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