**5. Palliative care for people living with HIV**

Palliative care is critically important for people living with HIV to address multiple problems related to the diseases, its medication, and complications like pain, drug adverse effects, emotional distress, and physical symptoms [5]. These groups of patients experience a high degree of emotional problems like anxiety, depression, and mental health problems compared to general population [10]. Moreover, it is important for people living with HIV because of the following dimensions [8, 9]:


### **6. Ranges of treatment needed for people living with HIV**

Palliative care needs for people living with HIV are multifaceted, depending on many factors such as the stage of the disease, the health infrastructure or system of each country, and the socio-economic status of patients. People living with HIV need palliative care for symptom and other related problem managements. Globally about 5.7% of adults living with HIV are needing palliative care at the end of life. The government should integrate palliative care policy in the national health delivery to improve the HIV care delivery system [11]. The service delivery should be patient centred which should be individualised, flexible, and collaborative. Communication should be open that will facilitate for shared decision-making during treatment planning [12, 13]. Therefore, people living with HIV need palliative care for symptom management, psychological support, family support, spiritual support, etc.

#### **7. Symptom management**

The treatment of people living with HIV requires the balance between acute and control of symptoms. Many people living with the disease suffer from different symptoms including pain. The common symptoms that require treatment are pain, nausea, vomiting, diarrhoea, weight loss, sleep disturbance, depression, mouth sore, sadness, fever, cough, skin problem, and respiratory problems [14, 15].

The central focus of palliative care is symptom management. For symptom management, opioids are essential for pain management. It is vitally important to consider the WHO pain management ladder. However, the plan for pain management

**129**

*Palliative Care in HIV/AIDS*

*DOI: http://dx.doi.org/10.5772/intechopen.85847*

and side effects of the drug management [8].

ing methods for pain symptoms [8, 16].

identify and avoid aggravating factors.

care for patients with mouth sore [16, 17].

poorly controlled infections [16, 17].

as rice soup, porridge, ORS, bananas, and other soups [16].

depends on the individual preference. Managing symptoms enables people living with HIV to function fully. The need for palliative care for people living with HIV arises from the disease and its associated complications like varieties of symptoms

*Pain* is the most common symptom patients are suffering from and for which they should be treated if they complain of it. It can be managed both medically and psychologically. Spiritual and emotional support and counselling should always include the medical management of pain of people living with HIV. Deep breathing techniques, relaxation, and distracting attention of patients will also help as reliev-

*Nausea and vomiting* are another common distressing symptom the patients need to get advice on foods and feeding habits. The patients need to drink water, tea, ginger, etc. to get rid of the symptoms. The person with these problems should

*Diarrhoea* is also a common problem which needs management. It may be a side effect of antiretroviral regimens; other causes include Cytomegalovirus colitis, cryptosporidiosis, microsporidiosis, giardiasis, Kaposi sarcoma, and other infective agents. Oral rehydrating solutions should be given to prevent dehydration. Use oral rehydration solution if there is a large volume of diarrhoea. *Encourage the patient to drink plenty of fluids to replace lost water.* If it is not possible to get oral rehydrating solutions, local remedies could be considered. To prevent and control diarrhoeal symptoms, it is advisable to avoid eating raw foods. In general, for diarrhoeal disease management, it is recommended to increase frequency of food intake, such

*Mouth sore* is perhaps more than any other symptoms that could affect communication as well as comfort of people living with HIV. A sore mouth is very common in palliative care and may be severe in people living with HIV. It causes painful swallowing which may be caused by Cytomegalovirus ulcers of the mouth or oesophagus, virus, or fungal infection*.* In most cases it can be prevented by keeping the mouth clean and moist and treating any infections promptly. Nystatin oral drops after food and at night hold dose in the mouth to allow it to act topically. For fluconazole 50 mg daily for 5 days, use higher doses (200 mg daily for 2 weeks) if patient has difficulty swallowing and you suspect oesophageal candidiasis. Rinsing the mouth with diluted salt water after eating and at bedtime is the recommended

*Fever* in people living with HIV infection usually suggests an infectious complication. It may be a side effect of antiretroviral regimens; if suspected, assess and treat cause with paracetamol or acetylsalicylic acid, and encourage the patient to drink water, diluted tea, or fruit juice frequently. Fever, cough, weight loss, and night sweats in an HIV-infected person may indicate a heightened suspicion of tuberculosis (TB). At all stages of HIV, TB must be diagnosed, treated, and controlled. If fever is persisting, palliative care team must agree to do all that could minimise suffering [16]. *Weight loss* is also another challenge in the management of HIV conditions despite the use of antiretroviral therapy. Resting energy expenditure is high, and, therefore, food intake should be increased to prevent detectable risk of death. There are different related factors with weight loss in people living with HIV. These include mouth sore, disease of the upper gastrointestinal tract, anorexia, side effects of drugs, food insecurity, malabsorption due to diarrhoeal disease, and

*Sleep disturbance* like insomnias, which is a subjective complaint of inadequate nocturnal sleep, is manifested as difficulty of initiating or maintaining sleep, earlymorning awakening, non-restful sleep, or a combination of all of these. In many cases insomnia is a symptom of another mental or physical disorder which includes pain,

#### *Palliative Care in HIV/AIDS DOI: http://dx.doi.org/10.5772/intechopen.85847*

*Palliative Care*

**5. Palliative care for people living with HIV**

the daily life of the patient.

progress to advance illness.

complications.

**7. Symptom management**

Palliative care is critically important for people living with HIV to address multiple problems related to the diseases, its medication, and complications like pain, drug adverse effects, emotional distress, and physical symptoms [5]. These groups of patients experience a high degree of emotional problems like anxiety, depression, and mental health problems compared to general population [10]. Moreover, it is important for people living with HIV because of the following dimensions [8, 9]:

• **Complex disease process:** People living with HIV are suffering from ranges of several complications and opportunistic infections and related treatment side effects.

• **Complex treatments:** People living with HIV need lifetime treatment for viral suppression and treatment for comorbidities which will also create stress on

• **Stigmatisation and discrimination:** In many parts of the world, people living

• **The burden on healthcare workers:** The healthcare workers face stress related to lack of resources, symptom management, and management of related

Palliative care needs for people living with HIV are multifaceted, depending on many factors such as the stage of the disease, the health infrastructure or system of each country, and the socio-economic status of patients. People living with HIV need palliative care for symptom and other related problem managements. Globally about 5.7% of adults living with HIV are needing palliative care at the end of life. The government should integrate palliative care policy in the national health delivery to improve the HIV care delivery system [11]. The service delivery should be patient centred which should be individualised, flexible, and collaborative. Communication should be open that will facilitate for shared decision-making during treatment planning [12, 13]. Therefore, people living with HIV need palliative care for symptom management, psychological support, family support, spiritual support, etc.

The treatment of people living with HIV requires the balance between acute and control of symptoms. Many people living with the disease suffer from different symptoms including pain. The common symptoms that require treatment are pain, nausea, vomiting, diarrhoea, weight loss, sleep disturbance, depression, mouth sore, sadness, fever, cough, skin problem, and respiratory problems [14, 15].

The central focus of palliative care is symptom management. For symptom management, opioids are essential for pain management. It is vitally important to consider the WHO pain management ladder. However, the plan for pain management

• **Complex family issues:** The disease has a great impact on the productivity of the family. The financial burden will increase as parents got infected and

with HIV are still suffering from stigmatisation and discrimination.

**6. Ranges of treatment needed for people living with HIV**

**128**

depends on the individual preference. Managing symptoms enables people living with HIV to function fully. The need for palliative care for people living with HIV arises from the disease and its associated complications like varieties of symptoms and side effects of the drug management [8].

*Pain* is the most common symptom patients are suffering from and for which they should be treated if they complain of it. It can be managed both medically and psychologically. Spiritual and emotional support and counselling should always include the medical management of pain of people living with HIV. Deep breathing techniques, relaxation, and distracting attention of patients will also help as relieving methods for pain symptoms [8, 16].

*Nausea and vomiting* are another common distressing symptom the patients need to get advice on foods and feeding habits. The patients need to drink water, tea, ginger, etc. to get rid of the symptoms. The person with these problems should identify and avoid aggravating factors.

*Diarrhoea* is also a common problem which needs management. It may be a side effect of antiretroviral regimens; other causes include Cytomegalovirus colitis, cryptosporidiosis, microsporidiosis, giardiasis, Kaposi sarcoma, and other infective agents. Oral rehydrating solutions should be given to prevent dehydration. Use oral rehydration solution if there is a large volume of diarrhoea. *Encourage the patient to drink plenty of fluids to replace lost water.* If it is not possible to get oral rehydrating solutions, local remedies could be considered. To prevent and control diarrhoeal symptoms, it is advisable to avoid eating raw foods. In general, for diarrhoeal disease management, it is recommended to increase frequency of food intake, such as rice soup, porridge, ORS, bananas, and other soups [16].

*Mouth sore* is perhaps more than any other symptoms that could affect communication as well as comfort of people living with HIV. A sore mouth is very common in palliative care and may be severe in people living with HIV. It causes painful swallowing which may be caused by Cytomegalovirus ulcers of the mouth or oesophagus, virus, or fungal infection*.* In most cases it can be prevented by keeping the mouth clean and moist and treating any infections promptly. Nystatin oral drops after food and at night hold dose in the mouth to allow it to act topically. For fluconazole 50 mg daily for 5 days, use higher doses (200 mg daily for 2 weeks) if patient has difficulty swallowing and you suspect oesophageal candidiasis. Rinsing the mouth with diluted salt water after eating and at bedtime is the recommended care for patients with mouth sore [16, 17].

*Fever* in people living with HIV infection usually suggests an infectious complication. It may be a side effect of antiretroviral regimens; if suspected, assess and treat cause with paracetamol or acetylsalicylic acid, and encourage the patient to drink water, diluted tea, or fruit juice frequently. Fever, cough, weight loss, and night sweats in an HIV-infected person may indicate a heightened suspicion of tuberculosis (TB). At all stages of HIV, TB must be diagnosed, treated, and controlled. If fever is persisting, palliative care team must agree to do all that could minimise suffering [16].

*Weight loss* is also another challenge in the management of HIV conditions despite the use of antiretroviral therapy. Resting energy expenditure is high, and, therefore, food intake should be increased to prevent detectable risk of death. There are different related factors with weight loss in people living with HIV. These include mouth sore, disease of the upper gastrointestinal tract, anorexia, side effects of drugs, food insecurity, malabsorption due to diarrhoeal disease, and poorly controlled infections [16, 17].

*Sleep disturbance* like insomnias, which is a subjective complaint of inadequate nocturnal sleep, is manifested as difficulty of initiating or maintaining sleep, earlymorning awakening, non-restful sleep, or a combination of all of these. In many cases insomnia is a symptom of another mental or physical disorder which includes pain,

anxiety, depression, drug withdrawal, and side effects of certain ARV regimens, especially those with efavirenz [17]. A general care for sleep disturbance includes:


*Respiratory symptoms* are also common problems people living with HIV are suffering from. For instance, cough or difficulty breathing may be due to common opportunistic infections seen in people living with HIV. Difficulty in breathing is a frightening experience due to fear of death. Therefore, as a general care:

