NANASI 4 July 2002
IN THIS ISSUE OF NANASI:
* Antiretroviral therapy: What lab tests are required? New WHO guidelines
* Spotlight on Mugunda: Positives and negatives working together
* Q and A: How can we be registered as a VCT Center?
* Opportunistic infections: Candida albicans
* Detachable sheet B for counselors: Benson, the counselor who has never been tested
WHAT LABORATORY TESTS ARE REQUIRED FOR STARTING AND MONITORING ANTIRETROVIRAL THERAPY (ART)?
The World Health Organization (WHO), in its April 2002 document, "Scaling up antiretroviral therapy in resource-limited settings - Executive Summary", lists four levels of laboratory tests that may be employed, depending on available resources. In symptomatic HIV infection, a number of tests are good to have, but are not absolutely essential. One should not delay the start of ART simply because all the desirable laboratory tests have not been done. Only Level 1 tests are absolutely necessary, if the person cannot pay for others.
Level 1 Absolute minimum laboratory tests
* HIV rapid test or ELISA test
* Hemoglobin (Hb) or hematocrit (Hct)
Level 2 Basic tests
* white blood cell count (WBC) and differential
* SGOT or SGPT
* Serum creatinine or BUN
* Blood sugar
* Pregnancy test
Level 3 Desirable supplemental tests
* serum lipids
* CD4 count
Level 4 Optional tests
* viral load
"When laboratory monitoring is limited, close monitoring becomes even more crucial!"
SPOTLIGHT ON MUGUNDA: POSITIVES AND NEGATIVES WORKING TOGETHER
The Mugunda Fighters of IDS meet once a month in the Catholic church of Mugunda (a rural area halfway between Nyeri and yahururu in Central Province).
The June meeting had about 50 members present to discuss all kinds of topics:
* getting all members enrolled in the National Hospital Insurance Fund (NHIF)
* certificates for four members who had just completed a counseling course
* which members during the next month would go to talk about HIV and AIDS at local schools, churches and the police camp
* good nutrition for people living with HIV and AIDS.
When visitors arrived, the meeting stopped briefly, and the officers explained the purposes of the group:
* to be in the frontlines, fighting the stigma of HIV and AIDS
* to take training in order to be better volunteers
* to extend services where and when needed
* to campaign for a world free of HIV and AIDS
One of the requirements for membership is to be tested for HIV. "Now," said the spokesman, "will all the sero-negative members stand up?" About half the people stood. "Now all the sero-positive members." The other half stood.
"Our membership help each other and our wider community," someone explained. "The sero-positive members help the others understand what it is like to be living with HVI and they are very effective educators in schools and churches. The sero-negative members help with the education and offer friendship and support to their colleagues."
Two nurses hold a mobile general clinic in Mugunda twice a week. A health center (an hour's drive away) follows Mugunda PLWA each month.
Q&A: CAN WE BECOME A REGISTERED VCT CENTER?
Question - From Plateau Hospital (near Eldoret): We have seen lists in the newspaper of Voluntary Counseling and Testing Centers (VCTs) all around Kenya. Can our hospital be registered as a VCT center?
They will send a team to visit your hospital and see if you meet the basic requirements:
* two people have been trained to do VCT counseling and testing
* you understand and follow the national guidelines for VCT
* you have a small room and a locked cupboard for records
* your counselors can keep the simple VCT records
If you need more training in counseling, contact Mary Mutiga at CHAK 020 4441920. Once you are a registered center, you will be able to receive free tests for your VCT clients. Good luck!
SHEET B FOR COUNSELORS: BENSON - A COUNSELOR HO HAS NEVER BEEN TESTED
You have recently been trained in HIV counseling and you yourself were counseled and tested during the training. Back at your hospital, you are having a teatime chat with Benson, a nurse who often talks with people coming to the hospital for an HIV test. You are surprised to learn that Benson has never been tested for HIV himself. He says, "I'm just not ready yet."
What would you say to Benson?
We posed this question to a number of experienced counselors. Here were some of their suggestions:
* Knowing one way or the other will give you peace of mind
* Most Kenyans (86%) are HIV negative. Wouldn't it be nice to know whether you are negative or positive?
* Remember, you don't have to tell any of us your results. You can just say, "Yes, I have been tested."
* As a counselor, I feel I have to practice what I preach.
* Even if you are HIV positive, it is not as bad as it used to be. Nowadays we can do so many things for a person who is HIV positive. We can actually prevent diarrhea, tuberculosis and other infections. We can advise on nutrition and how to stay healthy. When infections happen, we can treat them early. We can monitor the person's weight and lymphocyte count, to know when the time comes for him to start antiretroviral therapy (ART).
* I'm glad I had a test. It wasn't easy, because I had inside fears and "what ifs". But I thought it was important for me to know and feel what my clients experience.
* You could go to a VCT center somewhere in town. You don't have to give your name, and you can see how other counselors treat their clients.
* I'm a counselor, and I can't counsel people about something I haven't done myself.
* Just knowing whether you are positive or negative makes it easier to plan the future for yourself and your family.
* If you find out you are HIV negative, you'll feel you are sort of starting your life over
* If you find out you are HIV+, you can start having regular medical checkups. If you start getting infections, you can start treatment early. Maybe you can start using the antiretroviral medicines now that the price has come down.
* Some people are afraid of going for HIV testing. They are afraid of finding out they are HIV+. They are afraid of their own reactions to the news. They fear what will happen to them. They are afraid of what people around them will say and do. Those are perfectly normal fears that everyone feels.
* If you are HIV negative, you can plan how to stay negative the rest of your life. If you are HIV positive you can plan how to stay healthy and how to avoid infecting anyone else.
* Do you plan to tell your results to anyone? What do you think their reaction will be?
* Think it over, Benson. I won't bother you about this, but we can meet in about a week and discuss again.
One counselor shared her own experience:
I myself was fearing to take the HIV test. Then one day I was in a workshop with about 35 people, and the leader said to us: "In Kenya, 2.6 million people are infected with HIV. How many of us here are in that group?"
No one raised a hand, except the leader herself. We were quite surprised. "So," she said, "I am the only one."
She paused then went on, "In Kenya 26 million people are HIV negative. How many of us are in that group?" A few people raised a hand. I did not raise mine, because I did not know where I belonged. I had not been tested.
The leader then said, "It is good to know if one is positive or negative. Then you know how to plan your life."
That statement challenged me. The next week, I went for a test.
OPPORTUNISTIC INFECTIONS: Candida albicans
Candida albicans (monilia) is a fungus (yeast) that often is found on the skin and mucosal surfaces; it cannot be completely eradicated from the body. When the body's immune system is deficient, this fungus overgrows and can cause symptoms. If the body's immune system is restored (as with good antiretroviral therapy), the candida problem diminishes over time. The most common manifestations of opportunistic Candida overgrowth are:
Oral candidiasis: presents as white or red plaques on the inside of the mouth (thrush), on the tongue and sometimes as cracks on the outside corners of the mouth (chelilitis). Mild cases which do not cause pain require no treatment. People who complain of mouth pain, sore throat and difficulty swallowing require episodic treatment for these symptoms. Even though oral thrush may foretell a poor, long-term prognosis, patients should not be given maintenance therapy.
Genital candidiasis: may present as white vaginal discharge, vulval itching and redness of the vulva. Because this disorder is so common in healthy women (and in women with diabetes), it should not be regarded necessarily as an opportunistic infection secondary to HIV. Cases which are asymptomatic require no treatment. Men can also be troubled with Candida infection of the genitalia which can present with redness and itching.
Esophageal candidiasis: usually occurs in people who already have visible oral candidiasis. The person usually complains of retro-sternal pain or "heartburn". There is difficulty swallowing and the food seems to get "hung up" when passing through the esophagus. This condition is serious and always requires treatment.
Treatments for opportunistic Candida infections, available from MEDS
Gentian violet solution (0.25%) is an effective, inexpensive treatment. Some people may find the purple color objectionable. Give as an oral swish and swallow 1mlbid for 14 days. For genital infections, apply to genitalia once daily for 7 days. (MEDS price: 47Ksh for 25mg. crystals)
Clotrimazole oral paint 1% Give orally 4 drops five times daily for 14 days. (MEDS price: 22Ksh for 15ml. vial)
Clotrimazile pessaries 200mg Insert vaginally 1 pessary daily for three days. (MEDS price: 16Ksh for 3 pessaries)
Ketoconazole tablets 200mg Give 1 tablet bid for 14 days. (MEDS price: 891Ksh for 100 tablets)
Fluconazole tablets 50mg Give 100mg bid for 10-14 days. Reserve this treatment for advanced esophageal infections or where ketoconazole is contraindicated due to active liver disease. (MEDS price: 50 tablets for Ksh2280 or Ksh46 per tablet).
WHAT IS PALLIATIVE CARE?
* A shift in attitude from "curing diseases" to "caring for the patient and the family"
* Special knowledge: A solid base of theory, psychiatry, pharmacology, pharmacology, pastoral care
* Particular skills: wound care, prescribing and pain control, pressure sores, keeping the mouth moist and free of fungus
* For a person near the end of life, there is always something that can be done.
With thanks to Dr. David Allbrook, Palliative Care Specialist, Maua Hospital
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