Persons With AIDS Research Articles

Survival after cancer in Italian persons with AIDS, 1986-2005: a population-based estimation.

Cancer survival in persons with AIDS (PWA) after introduction of antiretroviral therapies remains poorly characterized. The aim is to provide population-based estimates of cancer survival, overall and for the most important cancer types in PWA, and a comparison with persons without AIDS (non-PWA) affected by the same cancer. PWA with cancer at AIDS diagnosis or thereafter were individually matched with non-PWA by type of cancer, sex, age, year of diagnosis, area of living, and, for lymphomas, histological subtype. Five-year observed survival and hazard ratios (HRs) of death in PWA versus non-PWA with 95% confidence intervals (CIs) were estimated. We included 2262 Italian PWA and 4602 non-PWA with cancer diagnosed during 1986-2005. Between 1986 and 1995, and 1996 and 2005, 5-year survival for all cancers in PWA improved from 12% to 41% and the corresponding HR versus non-PWA decreased from 5.1 (95% CI: 4.3 to 6.1) to 2.9 (95% CI: 2.6 to 3.3). During 1996-2005, HRs were 2.0 (95% CI: 1.4 to 2.9) for Kaposi sarcoma, 3.4 (95% CI: 2.9 to 4.1) for non-Hodgkin lymphoma, and 2.4 (95% CI: 1.4 to 4.0) for cervical cancer. HRs were 2.5 (95% CI: 2.1 to 3.1) for all non-AIDS-defining cancers, 5.9 (95% CI: 3.1 to 11.2) for Hodgkin lymphoma, and 7.3 (95% CI: 2.8 to 19.2) for nonmelanoma skin cancer. A ≤3-fold survival difference was found for cancers of the stomach, liver, anus, lung, brain, and the most aggressive lymphoma subtypes. The persisting, although narrowing, gap in cancer survival between PWA and non-PWA indicates the necessity of enhancing therapeutic approaches, so that PWA can be provided the same chances of survival observed in the general population, and improving cancer prevention and screening.

HIV-associated lung cancer

HIV-associated lung cancer

Excess Mortality Among Injection Drug Users With AIDS, New York City (1999–2004)

We calculated proportions and trends in contributing causes of death among persons with AIDS (PWA) and a history of injection drug use (IDU) in New York City and compared the proportions with those among PWA with a transmission risk of high-risk heterosexual sex (HRH) and men who have sex with men (MSM). We included all 10,575 injection drug user, HRH, and MSM residents aged 13+ years with AIDS reported by September 30, , who died from 1999 through 2004. Accidental drug overdose was the most frequent contributing cause of death among IDUs (20.5%). Overdose prevention initiatives may greatly and immediately reduce deaths among PWA.

Pulmonary Infections and Risk of Lung Cancer Among Persons With AIDS

Lung cancer risk is significantly increased among persons with AIDS (PWA), and increased smoking may not explain all of the elevated risk, suggesting a role for additional cofactors. We investigated whether AIDS-defining pulmonary infections (recurrent pneumonia, Pneumocystis jirovecii pneumonia, and pulmonary tuberculosis) affected the risk of subsequent lung cancer over 10 years after AIDS onset among 322,675 PWA, whose records were linked with cancer registries in 11 US regions. We assessed lung cancer hazard ratios (HRs) using Cox regression and indirectly adjusted HRs for confounding by smoking. Individuals with recurrent pneumonia (n = 5317) were at significantly higher lung cancer risk than those without [HR = 1.63, 95% confidence interval (CI) = 1.08 to 2.46, adjusted for age, race, sex, HIV acquisition mode, CD4 count, and AIDS diagnosis year]. This association was especially strong among young PWA (<50 years HR = 1.99 vs. ≥50 years HR = 1.10) and was significantly elevated during 5-10 years after recurrent pneumonia diagnosis (HR = 2.41; 95% CI = 1.07 to 5.47). Although attenuated, HRs for recurrent pneumonia remained nonsignificantly elevated after indirect adjustment for smoking. Lung cancer risk was unrelated to tuberculosis [(n = 13,878) HR = 1.12, 95% CI = 0.82 to 1.53] or Pneumocystis jirovecii pneumonia [(n = 69,771) HR = 0.97, 95% CI = 0.80 to 1.18]. The increased lung cancer risk associated with recurrent pneumonia supports the hypothesis that chronic pulmonary inflammation arising from infections contributes to lung carcinogenesis.

Nonlinear Burkitt lymphoma risk patterns with age and CD4 lymphocyte count among persons with AIDS in the United States

Background Trimodal age-specific incidence rates for Burkitt lym- phoma (BL) were observed in the U.S. general popula- tion, particularly among men. Because BL is AIDS- related, it is not known whether trimodal incidence peaks occur independently of immunosuppression. We therefore investigated age-specific BL incidence in per- sons with AIDS (PWA). Methods and adult/geriatric years, whereas the incidence rates for other NHLs increased from childhood to adult- hood. Compared to PWA aged 32-39 years, the adjusted incidence rate ratio (IRR) for BL was signifi- cantly elevated among PWA aged 0-19 years (2.3, 95% CI 1.2-4.4). The adjusted IRR for BL among PWA aged 20-31 years was significantly decreased (0.6, 95% CI 0.4-0.8), but the adjusted IRRs for BL among PWA aged 40-51 years, 52-59 years, and aged 60 years or older were not significantly different (1.0, 95% CI 0.8- 1.3), (0.8, 95% CI 0.4-1.4), and (1.4, 95% CI 0.7-2.7), respectively. The risk for BL among PWA with <50 CD4 lymphocytes/µL was 0.3 (95% CI=0.2-0.6) of those with ≥250 CD4 lymphocytes/µL, whereas the incidence for other NHLs rose with decreasing CD4 lymphocyte counts.

The Processes by Which Persons with HIV-Related Peripheral Neuropathy Manage Their Symptoms: A Qualitative Study

A variety of peripheral neuropathies occur throughout the course of HIV infection, with the most common peripheral nerve disorder of late HIV infection being distal symmetrical peripheral neuropathy (DSPN). Current management strategies often fail to achieve satisfactory pain relief. This study was designed to explore the everyday life experiences related to DSPN in persons with AIDS (PWAs) and the behaviors they initiate to alleviate the symptoms. A qualitative study using a grounded theory approach was used to better understand the impact DSPN has on PWAs. Many interventions were attempted and were ineffective; the effective ones were highly individualized. Emerging themes in the delimiting debilitation continuum included isolating the symptom cluster, inventing and testing interventions, and assimilating the annoyance. Results indicated a need for better DSPN assessment by nurses and teaching strategy development to manage the symptoms, and development of strategies to combat functional DSPN disabilities.

Social Stigma, HIV/AIDS Knowledge, and Sexual Risk: A Cross-Cultural Analysis1

The main aim of this study is to evaluate relationships linking social stigma, HIV/AIDS knowledge, and sexual risk among African American (AA) and South African (SA) college students. One major barrier to HIV prevention efforts is the social stigma associated with HIV/AIDS. Based on the Burkholder et al. (1999) findings, persons who engage in greater stigmatization of persons with AIDS (PWA) and gay people are associated with greater sexual behavior risk for HIV/AIDS. The present study attempted to replicate the Burkholder et al. study using African American and South African college students, but the findings were inconsistent with the aforementioned study. AA respondents had higher social stigma of PWA and gays and higher condom self-efficacy. While SA respondents were less likely to stigmatize PWA and gay persons and had high-perceived risk of being infected, they reported engaging in high-risk sexual behavior. The authors discuss the differences that may account for the dissimilar findings.

Hodgkin lymphoma and immunodeficiency in persons with HIV/AIDS

AbstractIn persons with HIV/AIDS (PWHAs), Hodgkin lymphoma (HL) risk is increased. However, HL incidence in PWHAs has unexpectedly increased since highly active antiretroviral therapy (HAART) was introduced. We linked nationwide HIV/AIDS and cancer registry data from 1980 through 2002. Immunity was assessed by CD4 T-lymphocyte counts at AIDS onset. Annual HL incidence rates were calculated for 4 through 27 months after AIDS onset. During 477 368 person years (py's) of follow-up in 317 428 persons with AIDS (PWAs), 173 HL cases occurred (36.2 per 105 py's). Incidence was significantly higher in 1996 to 2002 than earlier. Incidence in PWAs with 150 to 199 CD4 cells/μL was 53.7 per 105 py's, whereas in PWAs with fewer than 50 CD4 cells/μL, it was 20.7 per 105 py's (Ptrend = .002). For each HL subtype, incidence decreased with declining CD4 counts, but nodular sclerosing decreased more precipitously than mixed cellularity, thereby increasing the proportion of mixed cellularity HL seen in PWAs. We conclude that HL incidence is lower with severe immunosuppression than with moderate immunosuppression, and HAART-related improvements in CD4 counts likely explain the increasing HL incidence in PWHAS observed since 1996. With more severe immunosuppression, nodular sclerosing HL becomes infrequent, explaining the higher proportion of mixed cellularity HL found in PWAs. Pathogenesis implications are discussed.

Detection of rearranged immunoglobulin DNA in plasma

17518 Background: Tumor DNA is increasingly recognized as a marker in plasma or serum. B cells are characterized by immunoglobulin heavy chain rearrangements (IgH-R)and B cell malignancies by clonal IgH-R. We hypothesized that detection of clonal IgH-R DNA (a DNA spike) might reflect the presence of malignancy. Methods: We used a PCR and capillary electrophoresis. DNA from plasma of 6 healthy donors, 5 patients treated with rituximab, 5 persons with AIDS (PWA) but not lymphoma, 5 patients with AIDS-related lymphoma (ARL) and 5 patients with Hodgkin’s lymphoma (HL) was studied. In some cases matched peripheral blood mononuclear cells (PBMC) and followup specimens were available. Results: In plasma from healthy donors there was a normal (bell-shaped) distribution of IgH-R. In patients treated with rituximab (including a patient with an autoimmune disorder but no malignancy), IgH-R in plasma decreased by at least 100-fold. In PWA, there was a normal distribution of IgH-R. In pretreatment plasma from 2 of 5 patients with ARL, a DNA spike was detected superimposed on the background of IgH-R. The DNA spike was not detected in PBMC. In both ARL patients the spikes disappeared with therapy. However, in 1 it reappeared, and shortly thereafter the patient relapsed. Clinical relapse was associated with an increase in spike amplitude. The spike disappeared again with salvage chemotherapy. Identity of the pretreatment and relapse spikes was confirmed by sequencing. In 1 of 5 patients with HL a pretreatment DNA spike was detected in plasma. It decreased in serial specimens during the first month of combination chemotherapy. Conclusions: A normal distribution of rearranged Ig DNA is readily detected in plasma from healthy donors and patients. This normally distributed rearranged Ig DNA consistently disappears with rituximab therapy. A DNA spike can be detected in the plasma of some patients with B lineage lymphoma even when that spike is not evident in PBMC consistent with the possibility that this DNA is not derived from circulating tumor cells. The reappearance of a DNA spike may presage relapse. Further investigation will be required to determine the sensitivity and specificity of detection of such Ig DNA spikes and to confirm a tumor origin. No significant financial relationships to disclose.

In the Midst of a Hurricane: A Case Study of a Couple Living With AIDS

That is the big thing I have learned from this illness. The time is now, if you have people that you love and care about, you take that time. You have to live each day like you have a lifetime, and each day like you have just a short period of time. It's now, it's today. --Rosalie There are an estimated 1 million people living with HIV infection in the United States (Kalichman, 2000). As a result of new drug technologies, the life expectancy of these individuals has increased steadily (Kalichman, 2000; Trainor & Ezer, 2000). The transition from living with the HIV virus to dealing with AIDS, and the resultant physical and mental deterioration, brings numerous changes in the patient's lifestyle. Partners, friends, spouses, and other family members often become the primary caregiver for the person with AIDS, sometimes providing in-home care for 10 years or more (Kalichman, 2000; Richards, Acree, & Folkman, 1999). Research on nonprofessional caregivers has generally focused on parents or gay partners (Williams & Stafford, 1991). Heterosexual couples, however, represent a group with distinctive needs that are not always addressed in services oriented to gay couples. In a national survey of HIV-related mental health needs for persons with AIDS (PWAs), Lamping and Sachdev (1993) found several differences in the identified top concerns described by heterosexual and gay PWAs. Examples of top concerns reported by heterosexual PWAs, but not gay PWAs, include concerns about confidentiality; feelings of anger toward the health care system; and feelings of loneliness, isolation, and discrimination. Furthermore, compared with gay PWAs, heterosexual PWAs noted higher levels of distress associated with feeling rejected by others, problems accessing help, and telling others about their disease. Very little has been written specifically about heterosexual couples in which the partner is the primary caregiver for the PWA. The majority of case studies in the literature focus on the experiences of the PWA only (e.g., Gordon & Shontz, 1990), a limitation we sought to overcome in this study by interviewing not only a man with AIDS but also his wife, who was his full-time caregiver. This case study provides an illustration of this unique relationship and the special counseling needs that it creates. Depending on the stage of their illness, PWAs experience varying levels of stress. One of the most prevalent of these stressors is coping with changes in their social support system (Somlai & Heckman, 2000). There is evidence that many PWAs, because of their illness, are rejected by at least one family member, are abandoned by friends due to fear or discrimination, and/or lose their lovers (Crystal & Jackson, 1989). Some of the people in the PWAs' support system might also have AIDS and may die before the PWA, further reducing their available support (Bloom, 1997). PWAs and their caregivers often lose valuable social support due to the social stigma surrounding HIV transmission (Kalichman, 2000; Tross & Hirsch, 1988). Friends and family may become fearful of associating with individuals who have a disease perceived to be related to at-risk behavior. In fact, gay patients in gay communities, although marginalized, are usually more informed and have greater social support than heterosexual individuals living in communities in which AIDS is not as prevalent (Turner, Pearlin, & Mullan, 1998). An additional source of stress for PWAs is the cycle of sickness and health experienced with this illness (Kalichman, 2000). The cycle is often marked by periods of uncertainty, renewed hope, and readjustments (Trainor & Ezer, 2000). As time goes on, progressive loss of physical functioning creates an experience of multiple losses and an increasing need to ask for external help (Bloom, 1997; Holt, Houg, & Romano, 1999). The HIV replication process and adaptive qualities of the virus may require concurrent use of numerous medications to manage symptoms. …

Survival After Cancer Diagnosis in Persons With AIDS

The survival of persons with AIDS (PWA) has recently improved because of better antiretroviral therapies. Similarly, the prognosis of cancer has also improved. To determine if survival in PWA with cancer has also improved, we compared cancer survival in adults with and without AIDS using data from New York City from 1980 through 2000. Analyses were made for AIDS-related cancers (Kaposi sarcoma, non-Hodgkin lymphoma [NHL], and cervical cancer) and for 8 non-AIDS-related cancers (lung, larynx, colorectum, anus, Hodgkin lymphoma, breast, prostate, and testis). Death hazard ratios compared survival in PWA with cancer with that in cancer patients without AIDS, adjusted for age, sex, race, and calendar-time of cancer occurrence. The 24-month survival rate of PWA with cancer (9015 AIDS cancers and 929 non-AIDS-related cancers of 8 types) improved significantly for most cancer types. By 1996 through 2000, the 24-month survival rate in PWA was 58% for Kaposi sarcoma, 41% for peripheral NHL, 29% for central nervous system NHL, and 64% for cervical cancer. For non-AIDS-related cancers, survival of PWA was lowest for lung cancer (10%) but was >50% for most other cancer types. In 1996 through 2000, significant differences in survival between cancer patients with and without AIDS still remained for Hodgkin lymphoma and lung, larynx, and prostate cancers. We conclude that recent improvements in AIDS and cancer care have greatly narrowed the gap in survival between cancer patients with and without AIDS. Clinicians should be encouraged by the improving prognosis and be diligent about detecting and treating cancer in PWA.

AIDS Home- and Community-Based Waivers: Effects on Use of Services, Expenditures, and Survival

State Medicaid home- and community-based waiver programs for persons with AIDS (PWAs) were implemented with the expectation that PWAs would use these services in lieu of more expensive hospital-based care. If so, Medicaid spending per PWA should decline, and program costs fall. We analyze Florida Medicaid claims data for PWAs from December 1995 through December 1997 to determine how participation in the waiver program affects the use of inpatient services, the receipt of antiretroviral combination therapies (available to Medicaid recipients throughout the study period), monthly expenditures, and survival of PWAs. We find that waiver participants are more likely to receive combination therapies but less likely to use hospital-based care than nonparticipants; white men and sicker patients are more likely to join the waiver program than other eligible PWAs; monthly expenditures for waiver participants are 52% lower than for nonparticipants; and waiver participation does not affect survival.

AIDS Home‐ and Community‐Based Waivers: Effects on Use of Services, Expenditures, and Survival

State Medicaid home‐ and community‐based waiver programs for persons with AIDS (PWAs) were implemented with the expectation that PWAs would use these services in lieu of more expensive hospital‐based care. If so, Medicaid spending per PWA should decline, and program costs fall. We analyze Florida Medicaid claims data for PWAs from December 1995 through December 1997 to determine how participation in the waiver program affects the use of inpatient services, the receipt of antiretroviral combination therapies (available to Medicaid recipients throughout the study period), monthly expenditures, and survival of PWAs. We find that waiver participants are more likely to receive combination therapies but less likely to use hospital‐based care than nonparticipants; white men and sicker patients are more likely to join the waiver program than other eligible PWAs; monthly expenditures for waiver participants are 52% lower than for nonparticipants; and waiver participation does not affect survival.

Incidence of AIDS-defining cancers after AIDS diagnosis among people with AIDS in Italy, 1986-1998.

A record linkage was carried out between the Italian National Registry of AIDS and 19 cancer registries. The aim was to evaluate the 1986 through 1998 trends in incidence rate (IR) of AIDS-defining cancers (ADCs) among persons with AIDS (PWA) in Italy overall and according to various characteristics. A steady decrease in IRs was found for Kaposi sarcoma (KS) in men between 1986-1992 (2.5 per 100 person-years [py]) and 1997-1998 (1.0 per 100 py). Conversely, the first decrease in IRs of KS in women (from 0.9 to 0.6 per 100 py) and of non-Hodgkin lymphoma in both genders (from 1.7 to 0.7 per 100 py) was seen between 1993-1996 and 1997-1998, thus pointing to a favorable impact of highly active antiretroviral therapies. The decline was consistent across different age and HIV transmission groups, but it was more marked in PWA with a CD4 count >50 cells/microL than in PWA with more severe immune suppression. As a proportion of AIDS cases, invasive cervical cancer increased from 1.5% in 1993-1996 to 2.4% in 1997-1998, but IRs after AIDS could not be evaluated. On account of the marked decline of KS in men in 1997-1998, the overall burden of ADCs in Italy became similar in both genders.

Return migration in the context of parental assistance in the AIDS epidemic: the Thai experience

Most persons with AIDS (PWAs) eventually require demanding caregiving. This can prompt changes in living arrangements during the course of the illness. Few studies have attempted to examine the potential links between AIDS and migration from this perspective. The present study uses both direct and indirect approaches to examine the extent of return migration of adults with AIDS in Thailand and explores how this is linked to residence with and care by older aged parents. Methodological challenges and various approaches to the study of this phenomenon are discussed. Despite differences in the nature of information available from our samples and in basic sample characteristics, the findings show a consistent pattern suggestive of extensive return migration among PWAs. The fact that most return migrants die within a few months of their return indicates that they are seeking parental caregiving during the final stages of the illness. The vast majority of PWAs who returned home after becoming ill did so because of their illness, particularly due to a need for care.

Assessing effectiveness of home care for persons with AIDS: Analysis of methodological problems

The aim of this paper is to assess the methodological problems of an unsuccessful randomized controlled trial (RCT) conducted to evaluate the effectiveness, in terms of survival and quality of life, of the early offer of home care (HC) to persons with AIDS (PWA). The study carried out was an intention-to-treat RCT. Persons in the treatment group (TG) received the offer of HC at the moment of AIDS diagnosis; those in the control group (CG) received it six months from diagnosis. Many problems have hindered the progress of the study: particularly, the low compliance to the offer and the failure to enroll the required sample size have made the results unreliable. Analogous problems have been reported within other trials evaluating HC in different fields. The present study thoroughly evaluates the specific ethical and methodological problems encountered in designing and conducting a RCT on HC for PWA. We conclude that, before designing and conducting a RCT in this field, it is advisable to examine some main issues carefully, such as the acceptability of the offer of treatment, the expected compliance and the required size of the study population. If one or more of these elements prove to be problematic, the results of the trial risk being seriously compromised, and alternative approaches should be considered.

Patterns of Referral and Intervention for Persons with AIDS

Objective: This study identified reasons practitioners receive occupational therapy (OT) referrals for persons with AIDS (PWAs). Frequency of OT interventions and perceived priorities of PWAs at each Centers for Disease Control and Prevention (CDC) stage of the disease's progression were examined.Method: Surveys were sent to practitioners (N = 47) listed with AOTA having current or past work experience with PWAs. Twenty of the returned questionnaires were usable for analysis. Frequencies, ANOVAs, and weighted rank order statistics were used to bring meaning to the data.Results: Significantly more referrals for OT services were received for PWAs in Stages 3 and 4 of the disease than Stages 1 and 2 (F = 43.99, df = 3, p <.001). Referrals for early stages of the disease focused on role status, and play/leisure activities. In the latter stages, referrals for cognitive/perceptual skills, adaptive equipment, and caregiver training were more frequent. Frequency of interventions used by practitioners tended to mirror referral patterns, as did the perceived priorities of the PWA.Conclusion: Reasons for referral and the interventions used with PWAs throughout the stages of the AIDS/HIV disease were similar to the perceived priorities of PWAs receiving services from OT practitioners, and reflected the typical symptoms experienced by PWAs at each CDC stage.

Patterns of Referral and Intervention for Persons with AIDS

Objective: This study identified reasons practitioners receive occupational therapy (OT) referrals for persons with AIDS (PWAs). Frequency of OT interventions and perceived priorities of PWAs at each Centers for Disease Control and Prevention (CDC) stage of the disease's progression were examined.Method: Surveys were sent to practitioners (N = 47) listed with AOTA having current or past work experience with PWAs. Twenty of the returned questionnaires were usable for analysis. Frequencies, ANOVAs, and weighted rank order statistics were used to bring meaning to the data.Results: Significantly more referrals for OT services were received for PWAs in Stages 3 and 4 of the disease than Stages 1 and 2 (F = 43.99, df = 3, p <.001). Referrals for early stages of the disease focused on role status, and play/leisure activities. In the latter stages, referrals for cognitive/perceptual skills, adaptive equipment, and caregiver training were more frequent. Frequency of interventions used by practitioners tended to mirror referral patterns, as did the perceived priorities of the PWA.Conclusion: Reasons for referral and the interventions used with PWAs throughout the stages of the AIDS/HIV disease were similar to the perceived priorities of PWAs receiving services from OT practitioners, and reflected the typical symptoms experienced by PWAs at each CDC stage.

Changes in survival among people with AIDS in Lazio, Italy from 1993 to 1998. Lazio AIDS Surveillance Collaborative Group.

To investigate temporal changes in survival of persons with AIDS (PWA) diagnosed in Lazio, Italy. Longitudinal study of 2862 PWA registered at the AIDS Surveillance System in the period 1 January 1993 to 30 June 1997 and followed for vital status up to 31 May 1998. Hazard ratios (HR) of death were calculated by year of diagnosis and by year of follow-up, adjusting for gender, age, modality of exposure, CD4 cell count at diagnosis, and AIDS-defining illness, using the Cox proportional regression model. In the period 1 January 1993 to 31 May 1998, 1914 PWA died. The multivariate model showed a decrease of the risk of death for patients diagnosed from 1995 onward compared with patients diagnosed in 1993 [1995: HR 0.82; 95% confidence intervals (CI) 0.73-0.93; 1996: HR 0.44; 95% CI 0.38-0.51; first semester of 1997: HR 0.47; 95% CI 0.37-0.59]. The model with the year of follow-up modeled as time-dependent variable showed a statistically significant decline in the risk of death starting from the first quarter of 1997 (HR 0.62; 95% CI 0.48-0.80) and reached the minimum in the first two quarters of 1998 (first quarter: HR 0.13; 95% CI 0.08-0.21; second quarter: HR 0.14, 95% CI 0.08-0.25). There was a small difference in the magnitude of the risk estimates among genders, with a slower improvement in survival among females [first semester of 1997 for males HR was 0.51 (95% CI 0.39-0.66) whereas for females HR was 0.80 (95% CI 0.51-1.27)]. Survival of PWA in a population-based study improved significantly in the era when highly active antiretroviral therapy became available, but such improvement is not homogeneous among genders.

A Holistic Model for Counselling Persons with AIDS in Hong Kong

This is a paper aimed at drafting a holistic model for the care and counselling of persons with AIDS (PWAs) in Hong Kong. Holistic means that human beings can be at peace and enjoy the fullness of life in their physio-psycho-social-spiritual entity. Recognising the needs of PWAs in different phases of their illness, the writer offers “techniques” and “skills” to help them.