In this issue of NANASI:
- Case Study: Refusal to tell husband
- Vertical HIV Transmission Risk With Prolonged Rupture of Membranes
- Male Circumcision and the Risk of HIV Infection
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Case Study: Refusal to tell husband
This 37-year-old woman works as a nurse in a nearby hospital. During a hospital-wide VCT campaign, she was found to be HIV positive. For years, she has worked on the medical wards and numerous times she has been in contact with blood and fluids of people living with HIV. Nevertheless, today she is surprised to learn that she is HIV positive, because she feels quite healthy and continues to work full time.
The woman is advised to bring in her husband for VCT, but she is reluctant to do so until she is absolutely certain that her own result is not a false-positive one.
- How would you manage this situation?
- What tests would you request?
- What advice would you offer?
Discuss the case as a group, and then refer to the comments on the back page of this newsletter.
Question from a Medical Officer at an HIV clinic in Nairobi
Vertical HIV Transmission Risk with Prolonged Rupture of Membranes
A woman diagnosed as HIV-positive in the antenatal clinic had a CD4+ cell count of 190 cells/mcL. We commenced stavudine + lamivudine + nevirapine 2 weeks after diagnosis. After 3 days she presented with prolonged premature rupture of membranes (PPROM, i.e. when the waters break). There were no signs of chorioamnionitis or labor developing. Is there evidence that PPROM increases risk of HIV transmission to the baby?
Answer from Dr. Aziz Abdallah
You bring up an extremely important issue related to perinatal transmission of HIV and probably other viruses as well. Several studies have documented an association between perinatal transmission and with prolonged rupture of membranes (PROM), especially when it is associated with long labor. Studies on the timing of infection that were carried out before the advent of antiretroviral therapy (ART) suggest that about 80% of infants are infected near delivery. This is thought to occur either through maternal-fetal transfusion during labor or through direct contact with infectious virus in genital secretions, direct contact with blood, or because of manipulations that cause the skin to break. These data suggest that obstetrical factors may have an important influence on transmission.
One large sub-study of the Women and Infants Transmission Study (WITS) assessed the relationship between length of time from rupture of membranes (ROM) to delivery and perinatal transmission of HIV. Among the 525 women assessed, it was found that if membranes were ruptured for more than 4 hours before delivery, 25% of infants became infected; when ROM occurred less than 4 hours before delivery, only 14% became infected. Women who had ruptured membranes for more than 4 hours had a two-fold increase in risk of transmission of HIV to their infants, regardless of the mode of delivery.
Male Circumcision and the Risk of HIV Infection
Male circumcision as a tool for HIV prevention has received considerable attention in recent years. Several studies, and more recently, two clinical trials, have found that circumcision reduces the risk of HIV transmission to men by up to 50%.
How may circumcision help reduce the risk of HIV infection?
Five possible mechanisms have been proposed. First, the foreskin contains a high density of langerhans cells (the prime target for sexual HIV transmission) compared with cervical, vaginal, or rectal mucosa. Second, the foreskin increases the risk of ulcerative STIs, which facilitate the transmission of HIV. Third, the susceptibility of the foreskin epithelial cells to disruption during intercourse may facilitate HIV transmission. Fourth, the environment under the foreskin (moisture and temperature) may favor micro-organism survival and replication. Fifth, a circumcised penis develops a layer of keratin that minimizes the risk of transmission.
Is a call for mass prophylactic circumcision in Kenya and sub-Saharan Africa to prevent the spread of HIV infection justified?
While the benefit of circumcision has been proven, such a call could be premature, risky, and could result in a false sense of security.
A significant portion of persons in southern and eastern Africa believe that male circumcision prevents the transmission of STIs and HIV, and enhances sexual performance. The publicity surrounding the potential protective effect of transmission against HIV transmission has contributed to an increased number of persons seeking circumcision in eastern Africa. Feeling protected and anxious to try' their new shape, newly circumcised men may embark on risky sexual behavior and thus increased risk of HIV infection. It is therefore important to counsel all clients that circumcision does not totally prevent either partner from HIV infection.
What are some of the concerns with mass circumcision?
To meet the high demand for circumcision, unskilled health care workers (sometimes traditional healers) perform this operation under unsanitary conditions, placing their patients' at risk for sepsis, bleeding, tetanus, hepatitis B, HIV infection, partial penile amputation, and death. Individuals should be encouraged to seek circumcision services from recognized government / private institutions with trained personnel. Resources and training are needed to make male circumcision safe and widely available, something the Ministries of Health are addressing.
What is the way forward with circumcision?
The devastating impact of AIDS in Kenya and sub-Saharan Africa requires urgent, effective and scientifically sound interventions. The evidence that circumcision lowers the risk of HIV infection is good and should be encouraged, but this operation can be used only in conjunction with other effective interventions, such as abstinence, being faithful, condom use, etc. Therefore a useful strategy will be to integrate circumcision with all other things to prevent new HIV infections such as:
- Prevention, diagnosis, and treatment of all STIs in the community
- Promoting ABC
- Empowerment of local persons to become more active in the fight against HIV and AIDS
- Educating the population (especially women)
- Alleviating poverty
The focus with circumcision should be infants first, then adolescents, and adult men. UNAIDS (the UN Joint Program on HIV and AIDS) is planning to release guidelines on how to carry out safe circumcision on a mass scale (which will be summarized in an upcoming Nanasi).
ANSWER TO THE CASE STUDY FROM PAGE 1
This nurse deserves to have a confirmatory test to know if she truly HIV positive. A repeat Elisa test or, if available, an HIV-PCR test would be appropriate, even though it is expensive.
If her HIV-PCR test shows that the woman is indeed is positive, one must encourage her to bring her husband in for VCT. The woman should also be encouraged to register at the clinic where medical examination, staging of HIV infection, and baseline tests that include CD4, Hb and liver function tests can be done. The woman will also benefit from cotrimoxazole prophylaxis that protects against some of the common opportunistic infections.
The woman should continue her nursing work and can choose whether to be open about her status at work or not
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