With the introduction of new classes of anti-retroviral therapy such as protease inhibitors (PI's), and better control of opportunistic infections, the perception of HIV may be changing from that of inexorably fatal disease to that of chronic illness.
The ability to measure the amount of circulating virus (viral load, HIV RNA) has dramatically changed both the management of disease and the ability to predict survival.
Previously published data using the CD4+ cell count alone as a prognostic marker will not be as helpful in determining appropriateness for hospice care.
With the announcement that viral load could be suppressed to undetectable levels for at least a year in 90% of treated patients by a combination of AZT, 3TC and indinavir, a PI, a new air of hopefulness exists in AIDS treatment.
Although authorities now discuss the possibility of eradicating HIV from patients, it is far from certain that new drugs will result in complete reconstitution of the immune system, or in recovery of other organ systems already seriously damaged by HIV.
Therefore, at this time these Guidelines must reflect past literature until newer studies are available.
HIV mortality is influenced by new and changing therapies, practitioners' skill and experience in management, and individual patient tolerance for treatment. Other factors contribute to the difficulty of prognosis in this disease. It occurs predominately in the young, who are both constitutionally better able to withstand a heavy burden of disease, and less likely to forego intensive therapies, than the more elderly populations typical of other end-stage illnesses. Because of improved prophylactic regimens, most deaths from AIDS are now caused by opportunistic infections, persistent wasting, or neoplasm.
It is important to discuss a patient's clinical course with a physician who is experienced in caring for persons with HIV disease or with one who is experienced in Palliative Medicine. As in any end-stage disease, optimum therapy should have been exhausted or refused by the patient. The course over the previous month may reflect the patient's prognosis.
Concerning protease inhibitors, unless patients taking these medications fit the CD4+ and viral load criteria listed below, they may have a prognosis considerably longer than six months. Thus these drugs may be considered life-prolonging, not palliative, in the hospice setting. Additionally, patients already enrolled in hospice who decide to start these medications may lengthen their prognosis considerably.
The following factors are correlated with early mortality and therefore may be helpful when evaluating a patient for palliative care.
I. CD4+ count
. Patients whose CD4+ count is below 25 cells/mcL, measured during a period when patient is relatively free of acute illness, may have a prognosis less than six months, but should be followed clinically and observed for disease progression and decline in recent functional status.
. Patients with CD4+ count above 50 cells/mcL who are followed by an experienced AIDS practitioner probably have a prognosis longer than six months unless there is a non-HIV-related co-existing life-threatening disease. In one study of CD4+ counts and mortality, median survival of the entire population of patients with CD4+ < 50 was 11.9 months.
II. Viral load
. Patients with a persistent HIV RNA (viral load) of >100,000 copies/ml may have a prognosis less than six months.
. Patients with lower viral loads may have a prognosis of less than six months if.
. They have elected to forego antiretroviral and prophylactic medication.
. Their functional status is declining.
. They are experiencing complications listed in IV below.
III. Life-threatening complications with median survival
The following HIV-related opportunistic diseases all are associated with prognosis less than six months. Note that prognosis may be longer for certain conditions if patient elects treatment:
. CNS lymphoma: 2.5 months
. Cryptosporidiosis: 5 months
. Wasting (loss of 33 % lean body mass): < 6 months
. MAC bacteremia, untreated: < 6 months
. Visceral Kaposi's sarcoma unresponsive to therapy: 6 month mortality 50 %.
. Renal failure, refuses or fails dialysis: < 6 months
. Advanced AIDS dementia complex: 6 months
. Toxoplasmosis: 6 months
IV. The following factors have been shown to decrease survival significantly and should be documented if present
. Chronic persistent diarrhea for one year, regardless of etiology.
. Persistent serum albumin < 2.5 gm/dl.
. Concomitant substance abuse.
. Age greater than 50.
. Decisions to forego antiretroviral, chemotherapeutic and prophylactic drug therapy related specifically to HIV disease.
. Congestive heart failure, symptomatic at rest.
Adapted from U.S. Department of Health and Human Services. Assistant Secretary for Planning and Evaluation. Important questions for hospice in the next century. Internet. Accessed on April 29, 2010.