8 th European Forum – Gastein 2005 To cure - occasionally To relieve – often To comfort – always (Hippocrates, 400 AC) PALLIATIVE CARE FOR PLWA IN MOLDOVA.

8th European Forum – Gastein 2005

To cure - occasionally

To relieve – often

To comfort – always

(Hippocrates, 400 AC)

PALLIATIVE CARE FOR PLWA IN MOLDOVA

Victor Volovei

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What do we do?

We find (good) solutions, fill the gaps, and build a federation of resourcesto support the country`s TB and AIDS programmes

Inputs Conversion Outputs Process

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How do we do it?

PCU

WB procurement and

financial management rules

Resources

Objectives

World Bank

GFATM

Swedish Govt

Japanese Govt

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PCU Organigrama

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Complexity. Critical Success Factors.Who brings what?

PCU: Managerial

Incentives&Rewards

Motivation

Customer Orientation Interoperability

Team spirit

WB: StructuralOrganisational Design

Programme Concept Workforce Management

Policies and Procedures Quality Management

GOM:InfrastructuralFacility LocationCapacityVertical IntegrationTrained service providers

Standards

GFATM: Financial

Ownership

Rapid Access to Funding Flexible Procedures

IDA

GFATM

NGOs GOM

Reduced Morbidity

And Mortality from

TB/AIDS/STIs

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HIV – a recent epidemic in Moldova

Dynamic of HIV in Moldova 1987 - 2004

1992 1994 1996 1998 2000 2002 2004

0

100

200

300

400

500

Sexual

IDU

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2000 - 2003

• First AIDS patients start to die.

• No ARVs are available.

• Palliative care based on perspectives developed for terminal care in cancer.

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2000 – 2003.Sequvential Model of care

Aggressive Intention Palliative intention

Progression of disease, intensifying symptoms

Asymptomatic disease

Death

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How are AIDS patients different from cancer patients

• Relatively young• Benefit from treatment of complications

even in cases of severe immunodeficiency.

• Knowledge of causes of symptoms more important than in cancer.

• Prognosis more difficult: dramatic improvements after treatment of OI or initiation of HAART.

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Digestive PainOdinophagia: candida, CMV, or herpetic oesophagitis. Abdominal pain: CMV, tumors (lymphoma, Kaposi sarcoma), side effects of pharmaceuticals (DDZ - pancreatitis ; antidiarrhoeal - obstipation). Anorectal: abcesses, CMV or Herpetic proctitis, anal cancer.

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Nervous system Pain

Headache: toxoplasmosis, cerebral lymphoma, criptococical meningitis.

Perripheral Neuropatia: CMV infection.

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Musculoscheletal Pain

Artrites: reactive artritis, HIV-asociated artritis, aseptic arthritis, artropatia (ex. artropatia psoriatica),

Miopatia: ZDV Miopatia

Miozites: polimiozites

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Diarrhoea

Bacterial – Shigella, Campylobacter, Salmonella, E. coli, Mycobacterium avium intracellularis

Protozoan – Cryptosporidium, microsporidiosis, isosporiasis, cyclosporiasis

Viral – CMV

Fungal – Candida, Coccidioodes, Hystoplasma

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Nausea and Vomiting

Toxines, gastric dismotility, liver metatszes, high intracerebral presure, fear.

Rational antiaemetic therapy reqiures knowledge of the likely mechanism of vomiting

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Principles of Pain Management

Same as in CR, according to WHO guidelines, BUT: pain in AIDS has usually a treatable origin!

Specific tests and treatment remain important during palliative care

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Moldova 2003 – introduction of HAART

• No point in the progression of the disease when patients become incurable

• Palliative care provided in parallel with curative care

• Role of palliative care increasing with progression of disease.

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Conclusion

Palliative care in PLWA is different from CR.

The model of care needs to be adapted to these differences.

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Treating PLWA in Moldova after 2003

• Palliative care combined with periodic curative treatment.

• No clear border between aggressive and palliative care. Aggressive treatment continues till death.

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Concurrent Model of Care(adapted from B. Gazzard)

Aggressive Intention

Palliative intention

Progression of disease, intensifying symptoms

Asymptomatic

disease Death

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Health System Decisions in Moldova

• No investment in “classical type” hospices for PLWA.

• Strengthening of clinical capacity to provide HAART

• Integration of palliative services into the treatment of PLWA.