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Title: Palliative care-related problems in the first three months following HIV diagnosis in East Africa : a longitudinal study
Author: Simms, Victoria
Awarding Body: King's College London (University of London)
Current Institution: King's College London (University of London)
Date of Award: 2012
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Background: HIV policy states that palliative care is required from diagnosis onward, but evidence of the prevalence, severity and duration of patient-centred problems at HIV diagnosis is very limited, particularly in Africa. This thesis aims to determine palliative carerelated problems reported by outpatients over three months from diagnosis, taking a patient-centred approach. Methods: A prospective observational cohort was conducted in Kenya and Uganda. Twelve HIV facilities each consecutively recruited 100 adults and those diagnosed within 14 days previously were selected. Outcomes were the seven patient-response items of the APCA African POS, a validated instrument completed at four monthly intervals. Cross-sectional analysis used ordinal logistic regression (cross-sectional multivariate), proportion of net change (longitudinal univariate) and population averaged fixed-effects conditional logistic regression (longitudinal multivariate). Results: Among 438 participants (aged 18-59, 67% women), problems are highly prevalent at diagnosis (47% received no help and advice, 11% severe worry, 6% severe pain). Problems decrease over time on average but many persist after three months (e.g. 28% unable to share feelings). Physical problems decrease most rapidly, psychosocial more slowly. Poverty is a risk factor for pain, symptoms and difficulty finding life worthwhile(OR=0.8-0.9). Five outcomes are exacerbated by limited physical function(OR=1.6-3.1) but none are associated with CD4 count. Uniquely, difficulty sharing feelings is more common over time for those with full physical function (OR=0.7) and the highest relative wealth(OR=1.2). Psychosocial and spiritual problems are more severe in Uganda (OR=2.7-3.3). Patients taking antiretroviral therapy have fewer symptoms, more peace, and more help/advice(OR=0.6=0.7). Conclusion: This thesis presents the highest quality evidence of patient-reported problems at HIV diagnosis. Physical, psychological, social and spiritual problems are common and severe, requiring holistic assessment and management. The findings are relevant to service development in the context of scaled-up testing services for access to antiretroviral therapy. Staff need palliative care training, with support from specialist centres for intractable problems. This research contributes longitudinal analysis techniques appropriate for resource-limited settings, helping overcome research barriers.
Supervisor: Not available Sponsor: Not available
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral
EThOS ID:  DOI: Not available