Nurse-led palliative care can be successfully integrated into routine HIV services in Kenya

Integrating nurse-led palliative care into routine HIV services has positive effects for the psychological wellbeing of patients taking antiretroviral therapy (ART), investigators report in The Lancet HIV. The study was conducted in Kenya between 2011 and 2012 and involved 120 ART-treated individuals reporting pain or symptoms. They were randomised to receive a palliative care intervention or standard of care. The intervention did not have any benefits in terms of reported pain – the primary study outcome – but it did significantly improve patients’ psychological quality of life and psychiatric morbidity.

Authors of an editorial call for HIV care and palliative care to be integrated, and the ending of the “the false dichotomy that has long divided disease-modifying HIV care and palliative care.”

Improvements in treatment and care mean that many HIV-positive patients now have a near-normal life expectancy. But even effective ART can be associated with pain, symptoms,and a high risk of psychological disorders such as anxiety and depression. These problems can have serious negative effect on quality of life and also can have a negative impact on HIV treatment outcomes.

Glossary

palliative care

Palliative care improves quality of life by taking a holistic approach, addressing pain, physical symptoms, psychological, social and spiritual needs. It can be provided at any stage, not only at the end of life.

morbidity

Illness.

standard of care

Treatment that experts agree is appropriate, accepted, and widely used for a given disease or condition. In a clinical trial, one group may receive the experimental intervention and another group may receive the standard of care.

low income countries

The World Bank classifies countries according to their income: low, lower-middle, upper-middle and high. While the majority of the approximately 30 countries that are ranked as low income are in sub-Saharan Africa, many African countries including Kenya, Nigeria, South Africa and Zambia are in the middle-income brackets. 

depression

A mental health problem causing long-lasting low mood that interferes with everyday life.

Research conducted in richer countries has demonstrated that integrating palliative care into routine HIV services can have positive benefits for both the physical and mental health of ART-treated individuals. But little is known about the feasibility or impact of integrated palliative care in middle- and low-income countries.

Palliative care is available in Kenya and training for medical staff – including nurses –  is being expanded. An international team of investigators designed a study to assess the potential benefits of nurse-led palliative care delivered alongside routine HIV care for patients at a private clinic in Kenya.

To be eligible for recruitment, patients were required to be on established ART and to have moderate-to-severe pain or other symptoms. The 120 individuals recruited to the study were randomised to receive a palliative care intervention or usual HIV care. The study lasted four months.

The primary outcome was pain, measured using the African Palliative Outcome Scale (APOS). The investigators also assessed physical and psychological quality of life, psychological morbidity, ability to share feeling with family and friends, and inner wellbeing (a feeling of peace).

Most (81%) of the patients were women and the median age was 39 years. Patients had been taking ART for an average of 2.5 years and median CD4 count was 358 cells/mm3.

Improvements for pain, mental and physical quality of life, psychiatric morbidity and symptoms, worry, feeling at peace, and obtaining help and advice from family and friends to plan for the future, were recorded in both the intervention and standard of care groups.

The intervention did not significantly improve pain scores relative to the control group. However, it was associated with a significant improvement in mental health quality of life (p = 0.01). Integrated palliative care was also associated with improved psychiatric morbidity (p = 0.04), ability to share feelings (p = 0.005), and obtaining help and advice from family to plan for the future (p = 0.002).

Even though the study failed to show that integrated palliative care had a significant advantage over standard of care in terms of pain, the authors were still enthusiastic about their findings. They comment: “this trial provides the first evidence that a nurse-led palliative care intervention has a positive effect on patient-reported outcomes in people with HIV taking ART.”

The authors of the editorial were equally enthusiastic about the study’s findings, which they say show “the feasibility of palliative care integration and its effect on psychological wellbeing for patients taking ART.” They also suggest that integrating palliative care into general HIV services could help achieve wider goals for HIV outcomes in resource limited settings.

Lowther K et al. Nurse-led palliative care for HIV-positive patients taking antiretroviral therapy in Kenya: a randomised controlled trial. The Lancet HIV. 

Herce ME et al. Integrating HIV and palliative care: ending the false dichotomy. The Lancet HIV. http://dx.doi.org/10.1016/S2352-3018(15)00115-0