People living with HIV disease may need a referral for palliative care input at any point though the disease trajectory, from the point of diagnosis into the advanced stages. However, not all patients will need to be seen by specialist palliative care. Modern, holistic health care services should be able to provide very basic palliative care by paying attention to the “total care” needs of the patent and their family, offering support when needed and applying basic knowledge of pain and symptom control.

More complex cases may require the specialist skills of a multiprofessional palliative care team. There are many appropriate reasons for referring to palliative care, and referrals should not be restricted to the terminal stages of the disease when the end-of-life seems imminent.

Some examples of when co-management between HIV and palliative care teams can improve the quality of overall care include:

• advising on and delivering expert pain and symptom control where distressing symptoms have persisted.
• managing the emotional and physical challenges experienced by patients and families facing advanced disease when the patient’s health may deteriorate. Support may be needed to make treatment decisions and to come to terms with an uncertain prognosis.
• assisting in the adjustment to living with new and emerging co-morbidities such as cancers.
• assessing and managing complex health and social care needs for patient and families who are preparing for a discharge for the patient to be cared for at home.

In order to achieve best patient care and quality of life, and to ensure appropriate referrals are considered, HIV and palliative care teams should establish guidelines for referral criteria and patient co-management. These efforts can be very rewarding in understanding and respecting each other’s specialties, and in establishing successful ways of harmonising active treatments and palliative care.

It should be remembered that the introduction of the palliative care team might raise some anxieties for patients and families due to its origins in terminal care. Patients may choose to refuse to see palliative care staff if they believe them to be solely responsible for end-of-life care, or may see their involvement as a sign that active treatment is to be withdrawn without discussion. Such misunderstandings can be avoided through ongoing integrated care systems where palliation is routinely introduced and withdrawn as appropriate. Some palliative care clinicians introduce themselves to patients as members of the “symptom control team” to allay such fears. It is important that HIV clinicians have a broad understanding of what palliative care offers to those living with HIV disease so that they may introduce the potential for referral to the patient without causing undue anxiety.