Copy of ] International Center for AIDS Care and Treatment Programs

Palliative Care in Tanzania: A new focus for ICAP in 2007 ICAP Annual Meeting October 1-5, 2007 Nairobi, Kenya Background on Tanzania • • • • Population of 37 m. 26 Regions 7% HIV prevalence Scale up nationally with 80,000 on Rx – 150,000 on HIV care – 400,000 in need • ~2 million estimated HIV+ • Regionalization What do we know about HIV and Pain? • Pain recognized as symptom amongst both HIV and cancer clients – 80% of people with HIV experience pain • 35,000 new cancer patients are diagnosed in Tanzania annually 12% with KS • Known association with HIV and cancers, especially KS Types of Cancer in HIV patients Data from Ocean Road Cancer Institute, 2005 PEPFAR Definition of Palliative Care • Palliative care is a comprehensive approach to providing services which supports quality of life for HIV-positive adults and children. PEPFAR Definition of Palliative Care, cont’d • PEPFAR programs take a broader view, incorporating clinical, psychological, spiritual, social and preventive care services. • • • • • complements and enhances antiretroviral treatment (ART), address symptoms and minimize suffering From point of diagnosis to end of life Family centered approach Palliative care is provided with respect for patient autonomy and choice, support for care givers, and appreciation and respect for cultural values, beliefs and customs. Advent of palliative care in Tanzania • Tanzania’s Ministry of Health and Social Welfare recognized need for addressing chronic illnesses (cancer, diabetes, arthritis, etc.) in 1999 – ‘Home based care’ began as national endeavour in 1999 • Programs provide good supportive care to patients at home but not palliative care in the real sense – Limited clinical care elements, morphine restricted Advent of palliative care, cont’d • Recent recognition to expand pain management and symptom control as part of HIV/AIDS programs – opioids and analgesics – Still concerns about addiction – Morphine is controlled substance • Tanzania AIDS Commission and MOH developed joint strategy 2003-2006 • Growing interest amongst the USG to include pain management as part of care package for HIV – In 2007 ICAP Tanzania with others asked to assist Needs in palliative care • Only four providers in Tanzania carrying out holistic PC, including morphine dispensing • Although Ocean Road Cancer Institute practicing some form of palliative care for 30 years • Was a place of ‘last resort’ as patients referred with advanced disease – Palliative modalities sole option – Counseling, support, chemo, radiation Needs, cont’d • National policy on palliative care • Technical skills in managing HIV patients with KS and with general pain issues • Increase access to drugs for OIs, pain management • Decentralizing availability of pain management as whole • Expand type of provider able to prescribe • Decentralizing oncology services What is Available • Ocean Road Cancer Institute is the only tertiary hospital providing specialized Cancer treatment in Tanzania – Rolling out district programs with Princess Di – HIV oncology services (radiation and chemo) • Palliative care unit established in 1996 • ORCI only provider able to certify other facilities to manage morphine Involvement of District in Palliative Care • Recent pilot in one district in Dar es Salaam successfully integrated palliative care into the District team responsibility • In 2006, a total of 1835 clients received palliative care services at the facility and at home – 935 clients with HIV – 351 KS patients were attended at ORCI; 60% were HIV positive and were further managed at CTC clinic for possible ART – In Kinondoni district, 48 family care givers and 26 home-based care workers in the primary health care settings were trained in palliative care service provision and 720 clients received care. HIV/AIDS Services at Ocean Road • With ICAP, HIV/AIDS care and treatment clinic commenced services in June 2005 – Cumulative 665 on HIV care (june 07) – Cumulative 373 on RX – 40% with both HIV and cancer • Initially the CTC was meant to serve only HIV-infected cancer patients attending cancer treatment. It currently also serves non-cancer clients Next steps • ICAP Tanzania awarded funds to expand palliative care to zonal referral hospitals, and ultimately districts – Currently finalising a SOW and for support this year • USG and ICAP identified the need to palliative care expansion and has requested us to build capacity of Ocean Road to manage a national expansion program – has capacity to certify centers for morphine use, and potentially community groups – Work will involve training teams in holistic palliative care at facility level – Development of operational guidelines on use of oral morphine – Link with home based care programs to include palliative care/pain management Overall goal • Ocean Road Cancer Institute and Columbia University-ICAP will collaboratively decentralize pain management and symptom control services and management of HIV-related Kaposi’s sarcoma to zonal consultant hospitals and will continue to lead National efforts in scaling up palliative care services to the district level. Objectives • Objective 1 – Build human resource capacity to provide effective management of HIV-related Kaposi’s sarcoma and Palliative Care services for HIV/AIDS patients at BMC, MRH, MNH and KCMC • Objective 2 – Support initiation of basic palliative care services and management of KS to HIV/AIDS patients at BMC, MRH, MNH and KCMC Cont’d • Objective 3 – Support development of National guidelines on management of HIV-related Kaposi’s sarcoma and use of opioids in palliative care services (to work with the NACP, MOH and key ART actors) • Objective 4 – With ORCI lead the development of National Palliative Care services roll out plan with Tanzania Ministry of Health and Social Welfare Questions • Experiences from other ICAP countries in expanding facility and home based palliative care? • Relationship between pain and adherence to care/RX? • Best ways to integrate pain management into our programs? Answers…… • ICAP ANNUAL MEETING 2008 Acknowledgements • Ministry of Health, National AIDS Control Program Tanzania • Ocean Road Cancer Institute • USG PEPFAR team • Centers for Disease Control • ICAP Tanzania team members