HIV Care Meets Telehealth: a Review of Successes, Disparities, and Unresolved Challenges.

PURPOSE OF REVIEW: This review summarizes the current state of telehealth utilization in HIV care delivery by highlighting successes, gaps, and unresolved challenges related to access, disparities, care providers in and standardization of policies and protocol. RECENT FINDINGS: Telehealth adoption in HIV care delivery in the USA has been successful. Despite this success, racial minority groups, older adults, and individuals with low telehealth literacy report low preference, dissatisfaction, and experience poorer health outcomes than other groups. Lack of broadband access, compatible devices, standardization, and government regulations of telehealth in HIV care contribute to poor patient-provider experience and utilization. Telehealth remains a valuable tool in HIV care. However, disparities exist in access and health outcomes. Telehealth literacy, broadband access, protecting patients' data, policies, and standardized protocols are critical in sustaining telehealth for HIV care. Further research is needed on preferences and how specific telehealth platforms influence HIV treatment outcomes.

Low Rates of Lung Cancer Screening Referrals in Patients With Human Immunodeficiency Virus: A Correlational Study.

People living with HIV (PLWH) have an increased risk of lung cancer compared to the general population. In 2013, the United States Preventive Services Task Force (USPSTF) released their lung cancer screening (LCS) guidelines. However, the impact of these guidelines has not been well established in PLWH. The objective of this retrospective descriptive study is to evaluate the frequency of lung cancer screening referrals and factors associated with LCS referrals using the 2013 USPSTF screening guidelines in at-risk PLWH. We collected demographic and clinical information on PLWH from electronic medical records from July 2016 to July 2018. Descriptive statistics, chi-square tests, t-tests, Wilcoxon rank sum tests, and Fisher's exact tests were used for analysis. Only 14% of patients who met 2013 USPSTF screening guidelines were referred for screening. Patients who received a referral were more likely to have received tobacco cessation counseling. Patients who received and completed a referral were more likely to have hepatitis C infection. Quality improvement strategies are needed to improve rates of LCS in PLWH.

Structural vulnerability among patients with HIV and SARS-CoV-2 Co-infection: descriptive case series from the U.S. Midwest.

HIV and COVID-19 disproportionately impact marginalized populations, especially racial and ethnic minorities. This descriptive case series from an HIV clinic in the U.S. Midwest explores the sociodemographic and clinical characteristics of 37 individuals with HIV and SARS-CoV-2 co-infection. All 37 had suppressed viral loads prior to diagnosis with COVID-19, and all 37 survived. Relative to our overall HIV clinic population, over twice as many Hispanic patients, three times as many undocumented patients, and four times as many refugee patients contracted COVID-19, highlighting the structural vulnerability of these sub-populations.

Preexposure Prophylaxis for HIV Prevention in a Rural Southern Clinic.

OBJECTIVES: Little is known about implementing preexposure prophylaxis (PrEP) for human immunodeficiency virus (HIV) in the rural US South, where most HIV infections occur. To investigate how to better reach the at-risk population in rural eastern North Carolina (ENC), the characteristics and clinical courses of those receiving PrEP from our clinic were reviewed and analyzed. METHODS: A retrospective study was used to describe the characteristics and outcomes of PrEP participants in rural ENC. RESULTS: Thirty-five patients were included whose median age was 37 years (range 22-69). The majority of patients tolerated PrEP well and continued the medication, with only 6 (17%) discontinuations; the reasons for discontinuing included partner mistrust, intolerance to medication, and pregnancy. Patients who initiated PrEP in ENC were more likely to be insured (89%), White (66%), and male (69%). Average travel time to the clinic was 34 minutes (range 2-123 minutes) and the average travel distance was 23 mi (range 1-93 mi). CONCLUSIONS: The study results were noteworthy given that in North Carolina, young Black men have the highest estimated rates of HIV infection. The reasons behind this discrepancy are likely multifactorial, and this study highlights the need for future programs and research to make PrEP more widely accessible to the at-risk population in this rural ENC community.

Cost-effectiveness of HIV screening in emergency departments: a systematic review.

In 2016 worldwide, 1.8 million people were newly infected with HIV. About 36.7 million had HIV but 14 million were unaware, did not seek treatment and were likely to infect others. Undiagnosed HIV infection is a major contributor to transmission. Therefore, screening is critical to prevention. Although CDC recommends routine screening in the emergency department (ED), implementation is not universal or sustained. Cost-effectiveness of ED-based screening could enhance implementation. We address the question: Is HIV screening in the ED cost-effective? Using the Joanna Briggs Institute guidelines, we conducted a systematic review of economic evaluations of ED-based HIV screening. We found 311 studies with 12 duplicates. We excluded 276 studies that did not conduct economic evaluations and another three for lack of quantitative data, leaving 20 articles for the full review. We reviewed cost-effectiveness ratios (CER), incremental cost-effectiveness ratios (ICER), and average costs per diagnosis, quality-adjusted life years, averted transmissions and per patient linked to care. CER and ICER were below CDC thresholds indicating that HIV screening in the ED is cost-effective. Therefore, ED-based HIV screening should be widely implemented, supported and sustained as a cost-effective tool for combating HIV/AIDS.

Cultural Competence and Humility in Infectious Diseases Clinical Practice and Research.

Infectious diseases as a specialty is tilted toward social justice, and practitioners are frequently on the front lines of the battle against health inequity in practices that are diverse and sometimes cross international borders. Whether caring for patients living with the human immunodeficiency virus, tuberculosis, or Ebola, infectious diseases practitioners often interact with those at the margins of societies (eg, racial/ethnic/sexual/gender minorities), who disproportionately bear the brunt of these conditions. Therefore, cultural barriers between providers and patients are often salient in the infectious diseases context. In this article, we discuss cultural competence broadly, to include not only the knowledge and the skills needed at both the organizational and the individual levels to provide culturally appropriate care, but also to include "cultural humility"-a lifelong process of learning, self-reflection, and self-critique. To enhance the quality and the impact of our practices, we must prioritize cultural competence and humility and be mindful of the role of culture in the patient-provider-system interactions, in our larger healthcare systems, and in our research agendas and workforce development.

Characteristics of Out-of-Care Patients Who Required a Referral for Re-engagement Services by Public Health Bridge Counselors Following a Brief Clinic-Based Retention Intervention.

The NC-LINK Project initiated both clinic-based retention services and state public health bridge counselor-based (SBCs) re-engagement services to retain and re-engage people living with HIV infection (PLWH) in care. The goal of this project is to compare efforts between clinic-based retention and SBC re-engagement services to determine whether patients are more or less likely to remain in HIV care services. Clinic appointment data were used to identify patients who were last seen more than 6-9 months prior. Patients either received clinic-based retention services only or were subsequently referred to the SBC re-engagement intervention if the retention services were unsuccessful. The frequency of re-engagement in care (180 days) and HIV suppression (VLS, within 1 year) was examined for patients in these two groups. The SBC group was less likely to have VLS at the visit prior to referral (adjusted OR 2.04, 95% CI 1.53, 2.72). Patients who were referred to the SBC were less likely to re-engage in care within 180 days as compared to those who received clinic-based retention services only (adjusted OR 0.29, 95% CI 0.21, 0.41).

Past Care Predicts Future Care in Out-of-Care People Living with HIV: Results of a Clinic-Based Retention-in-Care Intervention in North Carolina.

Poor retention in care is associated with higher viral load (VL) results and decreased rates of viral load suppression (VS) in people living with HIV (PLWH). Therefore, improving retention in HIV care is a priority of national significance. The NC-LINK Retention Project utilized a systematic approach to identify, locate, and attempt to return to care patients who did not attend a clinic appointment for 6-9 months. Clinical and surveillance data were used to evaluate associations between patient characteristics and VL outcomes. Between January 1, 2013 and December 31, 2014, 1118 patients at participating clinics were identified as out-of-care and referred to retention staff. Of these, 712 (64%) were located in North Carolina. Patients with recent prior medical care (aPR 1.43, 95% CI 1.25, 1.66) and recent VS (aPR 1.28, 95% CI 1.16, 1.41) were more likely to be located. Of located patients, 58% re-engaged in care within 90 days of retention referral. Patients who achieved VS within 180 days were more likely to be 40-49 years (aPR 1.19 95% CI 1.01-1.40; compared with 18-29 age group), had insurance at their last visit (aPR 1.19 95% CI 1.01-1.77), had a care visit in the prior year (aPR 1.37 95% CI 1.05-1.77), and had VS at the prior care visit (aPR 2.54 95% CI 1.98-3.25). Clinic-based retention efforts may be effective at helping PLWH decrease out-of-care periods, but prior patterns of care usage persist.

Treatment-Naïve HIV-Infected Patients Have Fewer Gut-Homing ß7 Memory CD4 T Cells than Healthy Controls.

OBJECTIVES: The integrin α4ß7 is the gut-homing receptor for lymphocytes. It also is an important co-receptor for human immunodeficiency virus (HIV) via glycoprotein (gp)120 binding. Depletion of gut cluster of differentiation (CD)4 T cells is linked to chronic inflammation in patients with HIV; however, measuring CD4 cells in the gut is invasive and not routine. As such, establishing a peripheral marker for CD4 depletion of the gut is needed. We hypothesized that α4ß7 CD4 T cells are depleted in the peripheral blood of treatment-naïve patients with HIV compared with healthy controls. METHODS: The study groups were treatment-naïve patients with HIV and uninfected controls. Subjects were included if they were 18 years or older with no history of opportunistic infections, active tuberculosis, or cancer. We collected peripheral blood and examined on whole blood using flow cytometry for the following cell surface markers: CD4, CD45RO, chemokine receptor type 5, C-X-C chemokine receptor type 4 (CXCR4), and the integrin ß7. We collected demographic information, including age, sex, and ethnicity, as well as viral load (VL) and CD4 count. Two-sample t tests and Fisher exact tests were used to compare the differences between the two groups. Spearman correlation coefficients were calculated between CD4 count and log10- VL and percentage of CD4+/CD45RO+/ß7+ and log10- VL in patients. RESULTS: Twenty-two subjects were enrolled in the study (12 patients with HIV and 10 controls). There were no differences in age or sex between the two groups. There were more Hispanics and fewer Asians in the group comprising patients with HIV compared with the control group (7 vs 2 and 0 vs 4, P = 0.05, respectively). Patients infected with HIV had significantly lower frequencies of CD4+/CD45RO+/ß7+ cells (median 12%, range 5-18 compared with uninfected controls: median 20%, range 11-26, P = 0.0007). There was a statistically significant difference in the percentage of CD4+/CD45RO+/C-X-C chemokine receptor type 4+ cells between patients (72%, range 60%-91%) compared with controls (79%, range 72%-94%, P = 0.04). The percentage of CD4+/CD45RO+/chemokine receptor type 5+ did not differ between the group of patients with HIV and the control groups (22%, range 11%-57% vs 27%, range 14%-31%; P = 0.8, respectively). There was no correlation between percentage of CD4+/CD45RO+/ß+ cells and log10- VL as measured by the Spearman correlation coefficient (r = 0.05, P = 0.88) in patients infected with HIV. CONCLUSIONS: Memory CD4 ß7+ cells are reduced significantly in the peripheral blood of untreated patients infected with HIV, which could be used as a noninvasive indicator of intestinal CD4 T cell loss and recovery. Further studies are needed to examine whether depletion of these CD4+/CD45RO+/ß7+ cells in the peripheral blood parallels depletion in the gut of treatment-naïve patients with HIV and whether levels return to control levels after treatment.

Perceptions of the COVID-19 Vaccination Within a Convenience Sample of Sudanese Americans.

INTRODUCTION: Sudanese American and other immigrant and refugee communities are at greater risk for exposure to COVID-19. This survey sought to better characterize COVID-19 vaccination practices, motivators, and drivers for hesitancy among Sudanese Americans. METHODS: We developed an online, cross-sectional survey in English and Arabic distributed by Sudanese American community leaders in April 2022 with data stored anonymously in REDCap. Inclusion criteria were self-reporting being born within Sudan and living in the US within the last 2 years. Descriptive analysis tested survey responses for possible associations between the primary outcome, self-reported vaccination status, and questions regarding vaccination history, perspectives on vaccination, and demographic characteristics using Fishers Exact and Chi Squared Tests. RESULTS: Of 111 survey responses received, 107 met inclusion criteria. 93% of respondents reported COVID-19 vaccine uptake with the primary motivation to protect oneself from disease. The most cited reason for vaccine hesitancy was belief it had not been studied enough. The group that reported vaccination had higher levels of education (.032) and were more likely to perceive that COVID-19 vaccinations were able to reduce spread (.001), decrease severe outcomes (.004), and benefits outweighing their risks (.004). DISCUSSION AND CONCLUSIONS: This survey population of Sudanese Americans demonstrated high levels of vaccine uptake (93%), far greater than either the corresponding US (78%) or Sudanese population (15%). It is likely that high levels of educational attainment moderated vaccine uptake, though our survey may not have had the power to fully evaluate vaccine hesitancy.

Using an Adaptive Listening Tour and Survey to Promote Faculty Reflection on Diversity, Equity, and Inclusion (DEI) in the Pre-clinical Undergraduate Medical Curriculum.

Descriptive studies regarding how to integrate diversity, equity, and inclusion (DEI) into medical education are lacking. We utilized the AAMC's Key Steps for Assessing Institutional Culture and Climate framework to evaluate our current curriculum via listening tours (n = 34 participants) and a survey of the 10 pre-clinical block directors, to better understand the opportunities and challenges of improving DEI in the pre-clinical curriculum. Opportunities included diversifying cases and standardized patients, enhancing information on systemic racism and social determinants of health, and increasing racial humility and population genetics/epigenetics training. Faculty had issues with "correct ways" to incorporate DEI and time constraints. Supplementary Information: The online version contains supplementary material available at 10.1007/s40670-023-01924-7.

Acceptability, Feasibility, and Appropriateness of Implementation of Long-acting Injectable Antiretrovirals: A National Survey of Ryan White Clinics in the United States.

Background: The approval of long-acting injectable cabotegravir/rilpivirine (LAI CAB/RPV) heightened the urgency of ensuring effective implementation. Our study assesses readiness and barriers to implement LAI CAB/RPV across Ryan White-funded clinics in the United States. Methods: We conducted a cross-sectional survey between December 2020 and January 2021 using validated 4-item measures: acceptability of intervention measure (AIM), intervention appropriateness measure (IAM), and feasibility of intervention measure (FIM). Associations between measures and clinic characteristics were evaluated via Spearman rank correlations. A 5-point Likert scale ranked potential barriers of implementation responses. Open-ended questions were analyzed through a thematic approach. Results: Of 270 clinics, 44 (16%) completed the survey: 38% federally qualified health centers, 36% academic, 20% community-based organizations, 14% hospital outpatient, and 9% nonprofit. Means (SD; range) were as follows: AIM, 17.6 (2.4; 12-20); IAM, 17.6 (2.4; 13-20); and FIM, 16.8 (2.9; 7-20). Twenty percent were not at all ready to implement LAI CAB/RPV, and 52% were slightly or somewhat ready. There was a significant association between AIM and the proportion of Medicaid patients (AIM, rho = 0.312, P = .050). Community-based organizations scored the highest readiness measures (mean [SD]: AIM, 19.50 [1.41]; IAM, 19.25 [1.49]; FIM, 19.13 [1.36]) as compared with other clinics. Implementation barriers were cost and patients' nonadherence to visits. Conclusions: There is variability of readiness yet high levels of perceived acceptability and appropriateness of implementing LAI CAB/RPV among Ryan White clinics, necessitating tailored interventions for successful implementation. A special focus on addressing the barriers of adherence and the cost of implementation is needed.

Effectiveness and Safety of Bictegravir/Emtricitabine/Tenofovir Alafenamide in Patients With HIV-1 Infection and Ongoing Substance Use Disorder: The BASE Study.

Background: People with human immunodeficiency virus (HIV) and substance use disorder (PWH/SUD) are at higher risk of nonadherence to antiretroviral therapy. Bictegravir/emtricitabine/tenofovir alafenamide (B/F/TAF) exhibits high rates of efficacy with a favorable adverse event profile. The BASE study (NCT03998176) is a phase 4, single-arm study evaluating the effectiveness and safety of B/F/TAF among PWH/SUD. Methods: Viremic (HIV RNA >1000 copies/mL) PWH/SUD initiated B/F/TAF once daily for 48 weeks (W). The primary endpoint was proportion of participants with HIV RNA <50 copies/mL at W24. Secondary endpoints were proportion of participants with HIV-1 RNA <50 copies/mL at W48, safety, B/F/TAF adherence (dried blood spot [DBS] concentrations of emtricitabine triphosphate and tenofovir diphosphate [TFV-DP]), substance use (NIDA-ASSIST), and quality of life (SF-12). Results: Forty-three participants were enrolled; 95% reported methamphetamine use. Median age was 38 (range, 21-62) years; 21% were female, 81% White, 14% Black, and 16% Hispanic. Thirty-two (74%) and 21 (49%) participants had HIV RNA <50 copies/mL (intention-to-treat) at W24 and W48, respectively. Seven participants (16%) experienced confirmed virologic failure through W48; 1 developed emergent drug resistance (M184V). Fifteen participants (35%) experienced grade ≥3 adverse events. Five participants (12%) reported suicidal ideation; none resulted in discontinuation. Median DBS concentrations were representative of 5-6 doses/week (TFV-DP, 1603 fmol/punches). NIDA-ASSIST scores declined from baseline to W48 with methamphetamine use decreasing most (-7.9 points; -29%), and SF-12 physical/mental scores increased 1.2 and 7.6 points, respectively. Conclusions: B/F/TAF among a high-risk population of PWH/SUD resulted in an initial 72% viral suppression rate at W24 before dropping to 49% at W48 as retention declined. One participant developed emergent drug resistance (M184V).

Fluorescence-guided photoimmunotherapy using targeted nanotechnology and ML7710 to manage peritoneal carcinomatosis.

Fluorescence-guided intervention can bolster standard therapies by detecting and treating microscopic tumors before lethal recurrence. Tremendous progress in photoimmunotherapy and nanotechnology has been made to treat metastasis. However, many are lost in translation due to heterogeneous treatment effects. Here, we integrate three technological advances in targeted photo-activable multi-agent liposome (TPMAL), fluorescence-guided intervention, and laser endoscopy (ML7710) to improve photoimmunotherapy. TPMAL consists of a nanoliposome chemotherapy labeled with fluorophores for tracking and photosensitizer immunoconjugates for photoimmunotherapy. ML7710 is connected to Modulight Cloud to capture and analyze multispectral emission from TPMAL for fluorescence-guided drug delivery (FGDD) and fluorescence-guided light dosimetry (FGLD) in peritoneal carcinomatosis mouse models. FGDD revealed that TPMAL enhances drug delivery to metastases by 14-fold. ML7710 captured interpatient variability in TPMAL uptake and prompted FGLD in >50% of animals. By combining TPMAL, ML7710, and fluorescence-guided intervention, variation in treatment response was substantially reduced and tumor control improved without side effects.

Factors associated with viral suppression among cisgender women living with human immunodeficiency virus in the United States: An integrative review.

INTRODUCTION: Women account for 23% of new human immunodeficiency virus diagnoses in the United States, yet remain understudied. Adherence to antiretroviral therapy and consequent viral suppression are keys to preventing human immunodeficiency virus transmission, reducing risk of drug resistance, and improving health outcomes. OBJECTIVES: This review identified and synthesized peer-reviewed studies in the United States describing factors associated with viral suppression among cisgender women living with human immunodeficiency virus. METHODS: We searched five databases: Cumulative Index to Nursing and Allied Health (CINAHL), PubMed, Embase, Scopus, and PsycINFO, and reported the findings using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Eligible studies included: (1) peer-reviewed English-language articles published since 2010; (2) includes only cisgender women; (3) participants were at least 18 years of age; (4) reported metrics on viral loads; and (5) conducted in the United States. RESULTS: Fourteen studies in total were reviewed. Eight studies had adult women living with human immunodeficiency virus, four recruited only pregnant women, and two included only racial minority women. The most commonly reported factors negatively associated with viral suppression were substance use (n = 4), followed by availability of health insurance, financial constraint, complexity of human immunodeficiency virus treatment regimen (n = 3), and intimate partner violence (n = 2). Other factors were depression, race, and age. In addition, all four studies that included only pregnant women reported early human immunodeficiency virus care engagement as a significant predictor of low viral loads pre- and post-partum. CONCLUSION: Substance use, financial constraint, lack of health insurance, human immunodeficiency virus treatment regimen type, intimate partner violence, and late human immunodeficiency virus care pre-post pregnancy were the most common factors negatively associated with viral suppression. There is a paucity of data on viral suppression factors related to transgender and rural populations. More human immunodeficiency virus research is needed to explore factors associated with human immunodeficiency virus treatment outcomes in transgender women and cisgender women in rural U.S. regions.

The Value of a Longitudinal Human Immunodeficiency Virus Track for Medical Students: 10-Year Program Evaluation.

We surveyed graduates of a longitudinal medical school human immunodeficiency virus curriculum to evaluate its impact. Respondents felt comfortable caring for people with human immunodeficiency virus (PWH) and found value from the curriculum regardless of ultimate career path. Programs like this contribute to the development of culturally sensitive clinicians comfortable caring for PWH.

Antiretroviral Refill Histories as a Predictor of Future Human Immunodeficiency Virus Viremia.

BACKGROUND: The use of adherence measures as markers for virologic failure (VF) has been studied. Yet, there is currently no single adherence metric recommended for VF. Antiretroviral prescription refill histories, for people living with human immunodeficiency virus (HIV), are readily accessible and can be easily quantified to an estimated adherence level. METHODS: Participants from a Midwestern US HIV clinic were retrospectively evaluated from 2018 to 2020. Refill histories (RH) and last HIV RNA for each participant were abstracted for each study year. RH were quantified as a percentage of days covered (PDC) and VF was defined as HIV RNA >200 copies/mL. PDC values were matched with subsequent year HIV RNA (matched pair). Sample t test were used to compare mean PDC level by viral suppression status and generalized estimating equations models were used to determine the predictability of PDC level for VF. An optimal PDC threshold for VF was determined using receiver operating characteristic curve analysis and Youden index. RESULTS: A total of 1056 participants contributed to 1923 matched pairs (PDC/HIV RNA); mean age was 48.3 years, 24% women, and 30.6% Black. PDC levels differed significantly based on dichotomized HIV RNA (2018-2019: >200: 40% [95% confidence interval {CI}, 33%-46%] vs ≤200: 85% [95% CI, 84%-87%], P < .0001; 2019-2020: >200: 45% [95% CI, 38%-51%] vs ≤200: 87% [95% CI, 86%-89%], P < .0001). Based on the Youden index value of 0.66 (sensitivity 0.77, specificity 0.89), the optimal PDC threshold predictive of VF was 52%. CONCLUSIONS: Lower antiretroviral therapy (ART) adherence levels were predictive of future VF when PDC ≤52%.

Association between a name change from palliative to supportive care and the timing of patient referrals at a comprehensive cancer center.

PURPOSE: Palliative care consultation services are now available in the majority of cancer centers, yet most referrals to palliative care occur late. We previously found that the term "palliative care" was perceived by oncology professionals as a barrier to early patient referral. We aimed to determine whether a service name change to supportive care was associated with earlier referrals. PATIENTS AND METHODS: Records of 4,701 consecutive patients with a first palliative care consultation before (January 2006 to August 2007) and after (January 2008 to August 2009) the name change were analyzed, including demographics and dates of first registration to hospital, advanced cancer diagnosis, palliative care consultation, and death. One-sample proportions tests, median tests, χ(2) tests, and log-rank tests were used to identify group differences. RESULTS: The median age was 59 years, 50% were male, and 90% had solid tumors. After the name change, we found: (a) a 41% greater number of palliative care consultations (1,950 versus 2,751 patients; p < .001), mainly as a result of a rise in inpatient referrals (733 versus 1,451 patients; p < .001), and (b) in the outpatient setting, a shorter duration from hospital registration to palliative care consultation (median, 9.2 months versus 13.2 months; hazard ratio [HR], 0.85; p < .001) and from advanced cancer diagnosis to palliative care consultation (5.2 months versus 6.9 months; HR, 0.82; p < .001), and a longer overall survival duration from palliative care consultation (median 6.2 months versus 4.7 months; HR, 1.21; p < .001). CONCLUSION: The name change to supportive care was associated with more inpatient referrals and earlier referrals in the outpatient setting. The outpatient setting facilitates earlier access to supportive/palliative care and should be established in more centers.

Integration of palliative care into COVID-19 pandemic planning.

The COVID-19 pandemic is expected to surpass the healthcare system's capacity to provide intensive care to all patients who deteriorate as a result of the disease. This poses a unique challenge to healthcare teams of rationing care during pandemic when resources are scarce. Healthcare providers will need to acquire new skills in care decision making and effective symptom control for patients who do not receive life-saving measures. In this review, we describe some of the important palliative care considerations that need to be incorporated into COVID-19 pandemic planning. The main aspects to be considered include decision algorithms for rationing care, training on effective symptoms management, alternative delivery methods of palliative care services such as telemedicine and finally death and bereavement support for surviving family members who are likely to be isolated from their loved one at the moment of death.