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8 th European Forum – Gastein 2005. To cure - occasionally To relieve – often To comfort – always (Hippocrates, 400 AC) PALLIATIVE CARE FOR PLWA IN MOLDOVA Victor Volovei. Inputs Conversion Outputs Process . What do we do?.

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8 th european forum gastein 2005

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

what do we do

Inputs Conversion Outputs

Process

What do we do?

We find (good) solutions, fill the gaps, and build a federation of resources

to support the country`s TB and AIDS programmes

how do we do it
How do we do it?

Resources

World Bank

Objectives

GFATM

Swedish Govt

Japanese Govt

PCU

WB procurement and

financial management rules

complexity critical success factors who brings what
Complexity. Critical Success Factors.Who brings what?

PCU:Managerial

Incentives&Rewards

Motivation

Customer Orientation Interoperability

Team spirit

WB: Structural

Organisational Design

Programme Concept Workforce Management

Policies and Procedures Quality Management

IDA

Reduced Morbidity

And Mortality from

TB/AIDS/STIs

GOM

NGOs

GOM:Infrastructural

Facility Location

Capacity

Vertical Integration

Trained service providers

Standards

GFATM

GFATM:Financial

Ownership

Rapid Access to Funding Flexible Procedures

2000 2003
2000 - 2003
  • First AIDS patients start to die.
  • No ARVs are available.
  • Palliative care based on perspectives developed for terminal care in cancer.
2000 2003 sequvential model of care
2000 – 2003.Sequvential Model of care

Aggressive Intention

Palliative intention

Progression of disease, intensifying symptoms

Asymptomatic disease

Death

how are aids patients different from cancer patients
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.
digestive pain
Digestive Pain

Odinophagia: candida, CMV, or herpetic oesophagitis.

Abdominal pain: CMV, tumors (lymphoma, Kaposi sarcoma), side effectsof pharmaceuticals (DDZ - pancreatitis ; antidiarrhoeal - obstipation).

Anorectal: abcesses, CMV or Herpetic proctitis, anal cancer.

nervous system pain
Nervous system Pain

Headache: toxoplasmosis, cerebral lymphoma, criptococical meningitis.

Perripheral Neuropatia: CMV infection.

musculoscheletal pain
Musculoscheletal Pain

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

Miopatia: ZDV Miopatia

Miozites: polimiozites

diarrhoea
Diarrhoea

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

Protozoan – Cryptosporidium, microsporidiosis, isosporiasis, cyclosporiasis

Viral – CMV

Fungal – Candida, Coccidioodes, Hystoplasma

nausea and vomiting
Nausea and Vomiting

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

Rational antiaemetic therapy reqiures knowledge of the likely mechanism of vomiting

principles of pain management
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

moldova 2003 introduction of haart
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.
conclusion
Conclusion

Palliative care in PLWA is different from CR.

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

treating plwa in moldova after 2003
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.
concurrent model of care adapted from b gazzard
Concurrent Model of Care(adapted from B. Gazzard)

Aggressive Intention

Palliative intention

Progression of disease, intensifying symptoms

Asymptomatic

disease

Death

health system decisions in moldova
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.