NANASI 7: October 2002
In this issue of NANASI:
- Spotlight on Maua: Four steps to church mobilisation
- Opportunistic infections: Prevention with cotrimoxazole
- Where to refer your patients: In Mombasa and Nairobi
- Accidental needle sticks: How common are they ?
- "Sheet E" For Counselors: Edward - considering anti-retroviral medicines
SPOTLIGHT ON MAUA METHODIST HOSPITAL
A FOUR-STEP APPROACH TO CHURCH MOBILISATION
Step 1. Start at the top
Church leaders knew exactly where AIDS problem s were most pressing and which churches would be able to establish an active health committee and start a pilot project !
Step 2. Allow time for initiative to grow
The church health committee must organise itself independently from the health provider. Insist on proven performance. The committee you want to work with must have successfully organised events and projects before you can even think of a partnership. Keep waiting and prodding...
Step 3. Take time to build a pilot program - slowly and together
a) Clarify expectations
Question 1: Who has the problem?
Question 2: What do we each have to offer?
Question 3: Are we ready to accept and be seen with people with HIV and AIDS?
Question 4: Who pays the bill?
b) Use sustainable local resources
c) Establish a network -- bring together all available local and national resources
Step 4. Convince through success
This is what we want to prove: Care is prevention and it is cost effective !
- Only patients receiving palliative care are enrolled in the program.
- All enrolled patients should join the insurance scheme and pay the premium.
- Patients pay reduced fees for all services. The difference is claimed from the insurance.
- Patients who are unable to pay full premium or fees are assisted by the community and (where needed) by donors
If we can successfully care for a large proportion (70%) of people with AIDS in one community (Machungulu), we will see the effect of "community counselling" resulting in behaviour change. Other communities will come running!
OPPORTUNISTIC INFECTIONS :
PREVENTION WITH COTRIMOXAZOLE
Cotrimoxazole (trimethoprim-sulfamethoxazole or TMP-SMZ) is the most important drug used to prevent opportunistic infections in people living with HIV and AIDS. If patients are symptomatic, they can minimize their infection problems and stay healthier longer by taking cotrimoxazole each day. Indeed, the patients with the most severe AIDS (WHO stages III & IV) seem to benefit most from cotrimoxazole prophylaxis. This drug is inexpensive, easy to take and has minimum side effects.
Cotrimoxazole can prevent or delay the manifestations of the following conditions:
- pneumocystis pneumonia
- acute, unexplained fevers
- non-typhoid salmonellosis
- bacterial dermatoses
- non-specific enteritis and diarrhea
- isospora diarrhea
- cerebral toxoplasmosis
- herpes zoster
- pneumococcal pneumonia and septicemia
- co-infections in patients taking anti-tuberculosis therapy
Some authorities hold that keeping opportunistic infections in check actually slows the progression of AIDS and its destruction of the immune system.
Resistance: Eventually resistance will probably develop, yet up to now, few organisms have developed significant resistance to cotrimoxazole. In Kenya, some resistance has been found in Streptococcus pneumoniae and in isolates of nontyphoid salmonella; however cotrimoxazole still retains its usefulness against these organisms.
Adverse reactions to cotrimoxazole are unusual. Skin rash may occur, and the drug may have to be stopped if the rash is severe. Serious and life-threatening drug reactions rarely occur. (Fever, sore throat, pallor, jaundice or purpura may signal a rare hematologic reaction.)
People living with HIV and AIDS should begin daily preventive treatment with cotrimoxazole when signs of AIDS begin to appear (weight loss, pneumonia, chronic diarrhea, oral thrush and an absolute lymphocyte count <1,000). Pregnant women who are infected with HIV and symptomatic should take cotrimoxazole throughout pregnancy. All sero-positive HIV patients who take anti-tuberculosis therapy should also take cotrimoxazole prophylaxis. Most patients should continue to take cotrimoxazole for life. If a patient has received anti-retroviral therapy (ART) for several months and shows good indications of the return of protective immunity, cotrimoxazole may be stopped.
Dose: Adult and adolescent patients should begin prophylaxis with cotrimoxazole (400/80 mg) one tablet bid. After 2-3 months, if the patient is stable, reduce dose to cotrimoxazole (400/80 mg) one tablet daily.
Newborn infants born to HIV-infected mothers should receive cotrimoxazole prophylaxis, beginning at 4-6 weeks of age. Because of the immature immune system, prophylaxis should continue for the first year of life (or until the infant is found not to be infected with HIV).
Age 1-6 months: give 100/20 mg cotrimoxazole daily (½ tsp. suspension)
Age 6-12 months: give 200/40 mg cotrimoxazole daily (1 tsp. suspension)
Later, if the child begins to show signs of AIDS, cotrimoxazole prophylaxis can be restarted:
10 Kg child: give 200/40 mg daily (1 tsp. suspension or 1 pediatric tab.)
15 Kg child: give 300/60 mg daily (1½ tsp. suspension or 1½ ped. tabs.)
>20 Kg child: give 400/80 mg daily (2 ped. tabs or 1 adult tab.)
MEDS supplies generic cotrimoxazole in three formulations:
- tablets (400/80mg)
- 518 Ksh for 1000 tablets
- pediatric tablets-flavored (200/40mg)
- 48 Ksh for 100 tablets
- suspension (200/40mg/ 5 ml)
- 17 Ksh for 100 ml
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