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PRACTITIONER SECTION |
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| Year : 2001 | Volume
: 55
| Issue : 3 | Page : 159-164 |
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Malignancy in Aids : Institutional management or home care?
Indu Bansal1, Kaushal2, Aggarwal2
1 Department of Medicine, Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
2 Department of Radiotherapy; Pt. B.D. Sharma Post Graduate Institute of Medical Sciences, Rohtak, India
Correspondence Address:
Indu Bansal
House no. 15, Couples hostel, Medical Enclave, Rohtak-124001.
India
PMID: 11482170
How to cite this article:
Bansal I, K, A. Malignancy in Aids : Institutional management or home care?. Indian J Med Sci 2001;55:159-64 |
HIV infection/AIDS is undoubtedly the most talked of disease entity of our times, unabated spread and lack of cure has made this disease assume the magnitude of pandemic. [1] Latest reports from UNAIDS/WHO estimate that over 33.4 million people are now living with HIV infection-one in every 100 sexually active adults (15-49 years) and, by the end of the century, the number has crossed 40-50 million. [2]
In India, the first sero-positive person was reported from Chennai in 1986 and the fist case of AIDS from Mumbai in 1987. [3] Since then the epidemic is growing steadily and WHO/UNAIDS estimate that by the year 2000 AD India has around 3-5 million people suffering from HIV/ AIDS and this is the largest burden of HIV in single country. [3] According to latest reports of national AIDS Control Organisation (NACO), a cumulative total of 9504 AIDS cases have been reported up to 31st Oct., 1999. [3] AIDS is the humanities gravest challenge and AIDS and malignancy together constitute a deadly combination. Over 40% of all patients with HIV infection will develop malignant disease at sometime during their course of illness. [4] The development of cancer in the setting of HIV infection is a devastating event and highlights the role of impaired immunity in the generation of various neoplasms. [5] Improved strategies to suppress viral replication and prevent opportunistic infections generally have enabled patients with HIV to live longer and more productively. Unfortunately, AIDS associated neoplasia are increasing. Kaposi's sarcoma, primary central nervous system lymphoma, intermediate and high grade B-cell lymphoma, and invasive cervical carcinoma are the most commonly encountered malignancies in AIDS and now a days are considered as AIDS-defining conditions. Recent information suggests an indirect role for HIV in the pathogenesis of these tumours. [5]
The occurrence of a cancer in the setting of an immuno-deficiency state whether the two are casually related or not, may have a profound effect on both the natural history of the disease as well as therapeutic outcome. The HIV infected individual for example, is more likely to present with advanced, rapidly progressive disease that responds less well to therapy than one might expect in a non HIV infected individual. [6]
HIV infection poses unique obstacles to treatment of malignancy. [6] The terrible fact is that AIDS, is more than just a disease, a medical condition, a health problem. It is a threat to social and economic development, to people in the most productive phase of their lives, to family life, to mothers and their children, to entire cultures and populations. [7] The oncologist treating such a patient is often placed in the position of having to risk further immuno-compromise in order to administer adequate therapy for the treatment of an aggressive neoplasm. [6] Poor bone marrow reserve and the risk of intercurrent opportunistic infection may compromise the delivery of adequate dose intensity and the occurrence of excessive toxicity in response to chemotherapeutic agents. Radiotherapy may also impair the physician's ability to administer adequate therapy. [6] Clinical care of a person with AIDS can considerably improve his or her quality of life. The authors recommend that the care of patients having malignancy with AIDS should be mainly at home rather than in an oncology center. This will ensure the patient's and family's comfort as most of the specialised cancer centers in India are at a considerable distance away from patient's homes. Frequent visits to a cancer center will exhaust the patient and attendants emotionally, physically financially. This is especially true because irrespective of the pains taken by the family and the specialists, a cure is an unlikely possibility. We recommend that only one specialist from oncology and one primary health physician should be responsible for the care of a patient having malignancy with AIDS in India.
Primary health care physician living in the patients home town are the first doctors who come in contact with such patients and can manage many of their suffering in primary care setting. The primary care physicians are obligated to become competent in the diagnosis and management of HIV infected persons. Complicated opportunistic infections or malignancies associated with AIDS may require referral to subspecialists, but the magnitude of the problem alone dictates that HIV infection and AIDS be in the realm of competence of primary care physician. [7]
Primary care physicians need to know how to gain access to clinical trials, experimental therapies, and `compassionate use" protocols. There are parallel obligations to provide educational support in the form of publications and postgraduate courses to enable primary care physicians to gain and maintain competence in caring for HIV-infected patients. In addition, counseling should be given to professional colleagues in any health care discipline who may have unwarranted perceptions or fears about risks involved in providing care to HIV-infected persons. [7] In the United States, the estimated life time cost of treating a person with HIV from the time of infection until the death is $ 19,000. Add to it, the exorbitant cost of treating a malignant patient with AIDS. [9] These constitute enormous burden on already limited resources in Indian sub-continent. So the authors recommend that after specialist consultation and single or limited fractionated RT, chemotherapy may be administered in primary health care setting. It is advantageous both for the patient and his relatives as well as for medical resources. Moreover, the number of people exposed to HIV infection are also minimised. Therefore, the authors recommend that primary health care physicians should mainly be responsible for treating malignant patients with AIDS. Primary health care physicians can provide home care to these patients. [7] Home care includes 1) medical & nursing service available 24 hours a day, 2) activation of social resources for the support of the patient user, 3) constructive cooperation with relevant institutions, 4) relieving the patients's physical and mental suffering, 5) aroma therapy, oil massage, hair cuts, music therapy, and 6) support by volunteers. [8]
The AIDS patients having malignancy are best managed at home for a large part of their illness [9] . The family should be educated about common conditions likely to affect the patient, the immediate home management of these conditions, the likely side effects of the medications given and infection control measures. The common symptomatic remedies to be told to family members are as follows. [9]
1) Fever: paracetamol/aspirin, tepid sponging except in children 2) pain: paracetamoV aspirin 3) cough: codeine linctus or cough mixture 4) diarrhoea: ORS 5) vomiting metoclopromide/domperidone 6) management of wounds/ sores: applications of freshly prepared gentian violet or povidone iodine and keeping the part dry.
Primary health care physicians while giving specialised care to such patients should always take strict precautions to prevent HIV transmission. He should educate the family regarding the following specific points. The patient's secretions should be covered with absorbent material, like gauze, cotton, newspaper, cloth etc. and disinfectant fluid should be poured over it for 10-15 minutes. For disinfecting 5% dettol, savlon, cidex etc. may be used. Hands should always be washed with soap and water immediately after exposure to patient's secretions. Relatives having obvious cuts on the hand should avoid handling of body secretions. Plenty of household plastic bags/polythene bags/tissue paper should be kept ready at patient's bed side. Soiled linen and clothes should be soaked in bleach solution for ˝ hour and should be washed in usual way after that. Vomits, stool, urine should be flushed away after disinfection and the container should be cleaned with bleach solution. The area of blood contamination should be mopped with bleach solution. Blood should be soaked in tissue paper or blotting paper and/or cotton and then the paper or cotton should be burnt.
The primary health care physicians should collaborate with the oncologist to give preliminary specialised care for a particular neoplasm at PHC setting. Intravenous chemotherapy may be given for lymphoreticular malignancies at home (e.g. methotrexate, prednisolone, bleomycin, adriamycin, cyclophosphamide and vincristine). Intra-lesional injection of vinbiastine sulphate at a concentration of 0.2-0.4 mg/ml at bi-weekly intervals is quite effective for management of Kaposi's sarcoma, if there are only a few lesions. For wide spread Kaposi's sarcoma systemic therapy with interferon, doxorubicin and daunorbicin are quite effective. When the inevitable end comes, utmost care is needed even for the disposal of the dead body of a patient of malignancy with AIDS. The dead body should be disposed off at the earliest without any delay. The cremation of the dead body is the ideal method of disposal. If burial is insisted upon due to social and religious beliefs, the dead body should first be wrapped in a cloth sheet soaked in bleaching powder solution and then a locally available water proof sheet/plastic/polythene should be used to cover the entire body over the cloth. Unwrapping and direct handling of the body should not be allowed even for rituals.
The main advantage of our recommendation is that only one specialist and one primary health care physician are responsible for the care of the patient, who are completely aware of the patient's physical, psychological, financial and social background. The main advantage of the home care of such patients is patient's and family's comfort, lesser mental, physical. Social, emotional and financial agony. If all these facts are kept in mind then a lot of mental, physical, social, emotional and financial agony of these already distressed patients can be drastically reduced in home care setting and institutional care may be instituted as and when the need arises.
| ¤ Summary | |  |
In India, the first sero-positive person was reported from Chennai in 1986 and the first case of AIDS from Mumbai 1987 [3] . Since then the epidemic is growing steadily and WHO/UNAIDS estimate that by the year 2000 AD India has around 3-5 million people suffering from HIV/ AIDS and this is the largest burden of HIV in single country [3] . Over 40% of all patients with HIV infection will develop malignant disease at sometime during their course of illness [4] . AIDS and malignancy together constitute a deadly combination. The authors recommend that the care of patients having malignancy with AIDS should be mainly at home rather than in an oncology center. This will ensure the patient's and family's comfort as most of the specialized cancer centers In India are at a considerable distance away from patient's homes. Frequent visit to a cancer center will exhaust the patient and attendants emotionally, physically and financially. This is especially true because irrespective of the pains taken by the family and the specialists, a cure is an unlikely possibility. Only one specialist from oncology and one primary health physician, who are completely aware of the patient's physical, psychological, financial and social background, should be responsible for the care of a patient having malignancy with AIDS in India. The main advantages of the home care of such patients are: patient's and family's comfort; lesser mental, physical, social, emotional and financial agony; and minimum need for institutional care, which may be instituted as and when necessary.
| ¤ References | | |
| 1. | Bhasln SK, Pandit K, Kannan AT, Dubey KK. Impact of IEC intervention on knowledge regarding AIDS arnonst senior secondary school children of East Delhi. Ind J Corn Med 1999; 24:167-71.  |
| 2. | Josh! PL. Basic epidemiology and natural history of HIV/AIDS. JIACM 1999; 4: 1623. |
| 3. | Monthly reports on surveillance for HIV infection/AIDS cases in India. National AIDS Control Organisation. Ministry of Health and Family Wefare, Govt. of India (31st Oct. 1999). |
| 4. | Moran TA. Nursing challenges of caring for patients with HIV-related malignancies. Cancer Nurs 1996; 19: 384-91. |
| 5. | Aboulafia DM. Human immunodeficiency virus associated neoplasms: epidemiology, pathogenesis and review of current therapy. Cancer Pract 1994; 2: 297-306. [PUBMED] |
| 6. | Kaplan LD, Volberding PA. Neoplasms in Acquired Immunodeficiency Syndrome. In: Devita VT, Hellman S, Rosenberg SA, eds. Cancer. Principles and Practice of Oncology Philadelphia: JB Lippincott, 1985; 21: 6-20. |
| 7. | Human Immunodeficiency virus (HIV) infection : American College of Physicians and Infectious Diseases Society of America. Ann Intern mod 1994; 120; 310-319. |
| 8. | Arai F, Osako M, Shimoaraiso Y, Sakamoto T, Miyashita T, Yamanouch H. Home hospice care at a clinic. Qual Health Res 1999:9:182-97. |
| 9. | Sen Gupta D. Training module on HIV infection and AIDS for medical officers of PHC 1995. |
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