Uganda was the first country in Africa to have made palliative care for people with HIV and cancer a priority in its National Health Plan (2000-2005) [54] and one of the 49 medical services designated as ‘essential clinical care’ [55], and serves as an example to other countries in this regard. In Kenya, although there has been some progress in palliative care provision, more remains to be done, particularly towards improving access to medication for moderate to severe pain and developing a plan of action for palliative care integrated with HIV care [56]. Second, continued advocacy to ensure

the availability of pain-relieving drugs, including opioids, is essential [23]. Morphine and codeine Inhibitors,research,lifescience,medical should ‘be available within the context of functioning health systems at all times in adequate amounts, in the appropriate dosage forms, with assured quality, and at a price the individual and the community can afford’ [57]. Third, the fact that pain, whether physical or psychosocial Inhibitors,research,lifescience,medical in nature, was not always reported to healthcare staff, means routine Inhibitors,research,lifescience,medical assessment embedded in clinical practice is required as standard. Proactive questioning to ascertain patient needs may be facilitated by communication skills

training for staff as well as use of the APCA African Palliative Outcome Scale in clinical practice [58]. Fourth, community initiatives to continue to reduce stigma and discrimination against those with HIV infection and their family members are required. There

is evidence that such initiatives should involve debate and dialogue Inhibitors,research,lifescience,medical to challenge obstacles to changing health-damaging attitudes and behaviours [34,59]. Research recommendations The model presented in Figure 1 Inhibitors,research,lifescience,medical should be subjected to further testing in other African HIV populations and using quantitative methods. The effectiveness of palliative care interventions for HIV patients in sub-Saharan Africa should be determined. A systematic Proteasome inhibitor review of the effect of palliative care on HIV patient outcomes these found that home palliative care and inpatient hospice care significantly improved outcomes in the domains of pain and symptom control, anxiety, insight and spiritual wellbeing [50]. However, only five papers from Africa were identified, and none of these reported a quantitative evaluation of the outcomes of palliative care. Evaluation and outcome data are essential in developing country settings where best use must be made of available resources [24,60]. Lastly, there is some evidence that psychological support in the form of peer support groups may be effective in reducing mental disorder in African HIV populations [19], but further research is required to establish good practice in the provision of psychosocial and spiritual support to patients with HIV in sub-Saharan Africa.