1. 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

2. 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

3. How do we do it? Resources World Bank Objectives GFATM Swedish Govt Japanese Govt PCU WB procurement and financial management rules

4. PCU Organigrama

5. 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

6. HIV – a recent epidemic in Moldova Sexual IDU

7. 2000 - 2003 • First AIDS patients start to die. • No ARVs are available. • Palliative care based on perspectives developed for terminal care in cancer.

8. 2000 – 2003.Sequvential Model of care Aggressive Intention Palliative intention Progression of disease, intensifying symptoms Asymptomatic disease Death

9. 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.

10. 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.

11. Nervous system Pain Headache: toxoplasmosis, cerebral lymphoma, criptococical meningitis. Perripheral Neuropatia: CMV infection.

12. Musculoscheletal Pain Artrites: reactive artritis, HIV-asociated artritis, aseptic arthritis, artropatia (ex. artropatia psoriatica), Miopatia: ZDV Miopatia Miozites: polimiozites

13. Diarrhoea Bacterial – Shigella, Campylobacter, Salmonella, E. coli, Mycobacterium avium intracellularis Protozoan – Cryptosporidium, microsporidiosis, isosporiasis, cyclosporiasis Viral – CMV Fungal – Candida, Coccidioodes, Hystoplasma

14. Nausea and Vomiting Toxines, gastric dismotility, liver metatszes, high intracerebral presure, fear. Rational antiaemetic therapy reqiures knowledge of the likely mechanism of vomiting

15. 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

16. 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.

17. Conclusion Palliative care in PLWA is different from CR. The model of care needs to be adapted to these differences.

18. 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.

19. Concurrent Model of Care(adapted from B. Gazzard) Aggressive Intention Palliative intention Progression of disease, intensifying symptoms Asymptomatic disease Death

20. 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.