NANASI 10: January 2003
In this issue of NANASI:
- Rape: Preventing adverse consequences
- Opportunistic Infections: Clinic follow-up of HIV patients
- Q and A: nevirapine and efavirenz
- Sheet G for Counselors: Grace was raped last night
RAPE: PREVENTING ADVERSE CONSEQUENCES
A woman who has been raped often suffers shame, physical trauma, psychological trauma and medico-legal frustrations.
However, three potential consequences can be prevented - if you act quickly:
(1) HIV infection
(2) Unwanted pregnancy
(3) Other Sexually Transmitted Infections
HIV infection is the most important consequence to avoid and immediate action is required! As soon as a woman enters the clinic and states that she was raped, GIVE HER ONE TABLET OF NEVIRAPINE IMMEDIATELY. Do not wait for laboratory tests. Do not wait for counseling. Do not wait to examine her. Do not wait for her to register and pay her clinic fee. Just give her a 200 mg. tablet of nevirapine right away. If the woman was not to be exposed to HIV, the nevirapine will not harm her. If the woman was exposed to HIV, prompt nevirapine may save her life. Nevirapine tablets always should be kept in the casualty ward for immediate use.
The woman then should be counseled and tested for HIV with a rapid test (for example, Determine). If the test is positive, then probably the woman already was infected with HIV; after a confirmatory HIV test or physical examination is done, she should be counseled appropriately. If the initial rapid test is negative, then the woman may be given Anti-Retroviral therapy (ARV) for two months. At the end of three months, you may repeat the rapid HIV test; if it still is negative, you probably can assume that the woman was not infected by the rape. An alternative to the rapid test is an HIV - PCR test, which will indicate (in less than one week after the rape) if she has been infected. A PCR test costs about KSh 2,000, and must be done at a special laboratory.
Appropriate, low-cost Anti-Retroviral therapy for a woman who has been raped :
Stavudine 30 mg. bid
Lamivudine 150 mg. bid
Nevirapine 200 mg. daily for two weeks, then bid thereafter.
Zidovudine 300 mg. bid
Lamivudine 150 mg. bid
The police should search for the assailant, and if he is apprehended, he should be tested (forcefully if necessary) for HIV.
If the assailant is HIV-positive, the woman should continue ARV therapy for the full two months. If the assailant is HIV-negative, the woman can stop ARV therapy.
Unwanted pregnancy resulting from rape can also be avoided by prompt action. If oral drugs containing female hormones are given within 5 days of the rape, implantation within the uterus of a fertilized human egg (ovum) can be prevented and thus pregnancy averted. The most readily available hormone drugs are oral contraceptive pills. Here are pills that commonly are sold in Kenya. Some of them should be kept in the casualty ward for immediate use.
Microgynon-30 (available from MCH and Family Planning clinics)
Take 5 pills immediately, then take 5 pills 12 hours later
Femiplan (available from chemists for KSh 20 per pack)
Take 5 pills immediately, then take 5 pills 12 hours later
Postinor-2 (available from chemists for KSh 95 per pack) Take 2 pills immediately
Remember -- to be effective, the first dose should be taken within 5 days of the rape.
SEXUALLY TRANSMITTED INFECTIONS
Other Sexually Transmitted Infections can be prevented if appropriate antibiotics are given at the earliest time possible. Commonly transmitted infections in rape are: gonorrhea, syphilis, chlamydia and herpes. Unfortunately, there is no treatment for Herpes infection. The other infections you can treat preventively with:
ceftriaxone (Rocephin) 125 mg. IM - 1 stat. dose
ciprofloxacin (Cipro) tablet 500mg. po - 1 stat dose
cotrimoxazole tablets 480 mg. 10 tablets daily for 3 days.
THEN ALSO GIVE
doxycycline 100 mg.caps. 1 cap.bid for 14 days.
To prevent infections, this treatment should be given at the first visit to the clinic. Do not delay!
The editors of NANASI are grateful to these colleagues who wrote, read, or revised articles during 2002:
Doctors: Dr. Chakaya, Dr. Ken Colina, Dr. Bruce Dahlman, Dr. Jeremiah Laktabai, Dr. Thomas Macharia, Dr. Paul Manning, Dr. Evans Manuthu.
Nurses, clinical officers and counselors: Mary Chege, Stanley Gitari, Anthony Kibaru, Robert Lettington, Eunice Muaniki, Charity Mugambi, Francis Muthiri, Mary Mutiga, Mary Njeri, Dionysia Njeru, Jane Njeru, Nicholas Njeru, Fr F Romano, Nancy Wangombe, Jemima Waigi.
And special thanks to Action Aid (Dr. Chris Ouma and Ms. Susan Ngugi) for printing and mailing NANASI each month in 2002!
Opportunistic infections: CLINIC FOLLOW-UP OF HIV PATIENTS
Any person who is HIV-positive should have regular clinic follow-up visits, whether he is sick or not sick, and whether he receives Anti-Retroviral (ARV) therapy or not. Follow-up visits are scheduled for patients with other chronic diseases: diabetes, hypertension, cardiomyopathies, renal failure, liver failure, etc. It is unthinkable that someone infected with HIV should not be scheduled for regular follow-up visits as well. Telling an infected person to "return prn" is not acceptable care for HIV patients.
The purpose of follow-up visits is to give preventive therapy (eg., Cotrimoxazole) and to detect and treat opportunistic infections early. If a person lives healthily and avoids serious opportunistic infections for as long as possible, his HIV will progress very slowly, and he should be able to live a longer and healthier life. On the other hand, if the patient has many infectious episodes, his HIV condition will deteriorate fast.
Of course, the frequency of follow-up visits will vary from patient to patient. A person who has no symptoms (WHO activity level 1) probably requires a follow-up visit only every 2-4 months. On the other hand, an HIV patient under TB treatment should be seen at least every month, and even more frequently at the beginning of treatment. A patient with diarrhea probably should be seen weekly until the diarrhea subsides and then monthly from then on.
At every follow-up visit, certain signs and symptoms should be noted and recorded systematically. In this way, one will know when the patient begins to fail and what remedies to offer. Every clinic or hospital should establish a standardized follow-up protocol; one that is simple, direct and easy for nurses and clinical officers to follow. At Nazareth Hospital, the following items are recorded on the patient's own card at each follow-up visit:
- Date of visit
- WHO activity level (1,2,3 or 4)
- Oral lesions
- Lymph node enlargement
- Skin problems
- Gastro-intestinal symptoms
- Genital lesions
- Lymphocyte (or CD4) count (when applicable)
- Medicines currently taken
- Next review date
These items are printed on a card and given to the patient to keep and bring to the next follow-up visit. On the back of the card is space for more detailed notes if required.
Q and A: nevirapine and efavirenz
Question: A doctor in Eastern Province asks -- Generic nevirapine is now available from MEDS at low cost. Can I substitute nevirapine for patients who already have started taking efavirenz (Stocrin)?
Answer: Dr. Susan Girois, AIDS expert from Lyon, France, replies -- Yes, nevirapine is of the same class of drugs as efavirenz (non-nucleoside reverse transcriptase inhibitor), and it has the same action and resistance pattern as efavirenz. These drugs usually can be used interchangeably.
However, one must be aware of their different side effects. Nevirapine should be used with caution in patients with liver problems or in T.B. patients who take Rifater, which can be toxic to the liver. On the other hand, women who are pregnant or who are likely to become pregnant, in order to protect the foetus, should not take efavirenz. Instead, they should take nevirapine which is safe in pregnancy. Both these drugs may provoke a skin rash during the first weeks of treatment.
The starting dose of efavirenz is 600 mg. each night. (Note: if the patient currently is taking Rifater, one should give efavirenz 800 mg. each night)
The starting dose of nevirapine is 200 mg. daily for 14 days, then increase to 200 mg. bid thereafter.
If one already has begun efavirenz, one can change right away to full-dose nevirapine, 200 mg. bid.
SHEET G FOR COUNSELORS: Grace was raped last night
Grace is 16 years old. She was raped last evening as she walked home from a church meeting. Her parents brought her right away to the hospital casualty department. The clinical officer on duty examined her and did the paper work, then sent the family home until morning. At 8 a.m. he phoned a woman counselor and asked her to meet with Grace and her parents when they arrived. Here's how the counselor described the situation:
First, I asked the CO whether he had remembered to have Grace take a nevirapine tablet (to prevent HIV infection) and emergency contraceptive pills (to prevent a pregnancy). Fortunately, she had taken both the night before.
Then I went to the outpatient department and found that the family had arrived a few minutes before. Grace and her mother were sitting together and crying quietly. Her father was pacing up and down the corridor and seemed angry.
I asked Grace to come into a quiet room alone. I managed to make her feel at ease and asked her to narrate the story of what happened. Every now and then, I asked for details. Grace cried often, and showed deep bitterness. Gently I tried to ask questions that would help Grace express some of the questions and emotions I thought she might be feeling - suicidal thoughts, wanting to kill the rapist, guilt, fear that her parents would reject her, shame about what her younger sister would think of her.
Grace told me tearfully that she had had dreams of remaining a virgin until marriage, and now all her dreams had ended. I was really affected by Grace's anguish - she could have been my own daughter. But I had to remember that it was Grace and her feelings and her family that I was dealing with, not my own.
Then Grace and I took a short break.
When we came together again, Grace mentioned her fear of getting pregnant and having to have an abortion. I was able to reassure her that she had already taken medicine to prevent a pregnancy from happening.
I then mentioned AIDS and found that Grace had begun worrying about that, too. I reminded her that she had already taken a preventive pill (nevirapine) the night before, and I explained that we would test her later in the morning. She was relieved to know that if she tested HIV-negative, we could give her preventive medicines to take for a couple of months (even if the man who attacked her was not found and tested for HIV).
We then decided it was time to bring Grace's parents into our discussion. We went over some of the same concerns again with them. I discovered that Grace's father was accusing her mother of not watching Grace carefully and not being strict enough. As the father talked, he showed bitterness that all his dreams for his oldest child had been completely shattered. The mother was able to tell us how guilty she felt.
Gradually, all three realized they had similar feelings - guilt, shame, bitterness, fear, embarrassment, and anger. A key moment was when Grace's father tearfully embraced her and her mother. I could see then that the parents were probably ready to accept the situation and give Grace the love and care and support she would need.
All this took a long time - nearly three hours. In the process, I realized that my job as counselor was, first, to connect Grace with her parents and with others she needed. Second, I would try to mobilize support for all of them.
We have planned another counseling session after about two weeks. That should give Grace and her parents time to find some emotional stability and to clear thoughts of suicide. The family together will decide whether Grace will come see me alone, or whether she will bring her parents.
I am looking forward to our next session.
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