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"Let Me Live the Way I Want to Live, Until I Can't"

Peter A. Selwyn, MD, MPH; Marshall Forstein, MD

JAMA. 2003;290:806-814.

Recent advances in human immunodeficiency virus (HIV) therapy have significantly reduced HIV-related mortality in the developed world, but mortality rates have plateaued, and AIDS remains a leading cause of serious illness and death for young adults. The chronic nature of the HIV disease course and the increasing burden of cumulative HIV-related morbidity and treatment-related toxic effects pose new challenges to the care of patients over time. Uncertainties about prognosis and the promise and limitations of rapidly evolving therapies have made decision making about advance care planning and end-of-life issues more complex and elusive than when the disease course was more uniform, rapid, and predictable. The emerging biomedical paradigm of highly active antiretroviral therapy (HAART) as the cornerstone of treatment has helped to transform HIV into a manageable chronic disease, yet at the same time has resulted in a more narrow focus and a de facto separation between disease-specific "curative" and symptom-specific "palliative" care for patients with HIV/AIDS. As patients survive longer in the latter stages of progressive HIV disease, they may in fact have increasing need for comprehensive symptom management as well as wide-ranging need for psychosocial, family, and care planning support. In the HAART era, the false dichotomy of curative vs palliative care for patients with HIV/AIDS must be supplanted by a more integrated model to provide comprehensive care for patients with advanced HIV disease and their families.

Author Affiliations: Department of Family Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY (Dr Selwyn) and Department of Psychiatry, Cambridge Hospital, Harvard Medical School, Boston, Mass (Dr Forstein).

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