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Pain management for improvement of HIV care and support in one Nigerian region: an educational intervention

      Implementation strategies for improvement of HIV care and treatment in resource-constrained settings depend first upon recognition that a symptom is a problem for the person living with HIV (PLWH). Pain occurs during all stages of HIV illness regardless of individual response to antiretroviral therapy. Health providers may fail to identify pain as a significant problem and overlook it when the patient offers this complaint. Perceived lack of means for pain management may play a role. Providers in Nigeria have not routinely identified this symptom as a significant problem. We describe initial activities to promote recognition of pain in one region of Nigeria. Following an introduction to the palliative approach to care, we conducted a one-week intensive iterative training to foster integration of pain management (PM) in HIV clinics. Eighteen mixed-discipline staff members (physicians, nurses, adherence counselors, community based treatment supporters, laboratory and quality improvement) made clinical home and hospital visits focused upon pain. Teams identified 64 barriers to introducing PM in four categories (patient, provider, cultural, and environmental); participated in group problem-solving; and identified low-cost mechanisms for introducing PM. Sensitization to pain as a problem; use of discipline-specific severity assessment methods; and describing availability of medications for PM were considered essential next-steps before introducing clinical skills. Implementation strategies included: 1) site selection for introducing PM based upon strength of working relationships; 2) development of an advocacy plan with needs assessment; 3) avoidance of work-overload for clinic staff; and 4) structured data review to evaluate impact. Staff learned that PM services must be based upon patient-described need and clarification of local cultural beliefs. Use of an integrated clinical team is fundamental to resolution of patient-level problems. The team plans to systematically introduce PM strategies although funding is limited.