NANASI 11 February 2003
IN THIS ISSUEOF NANASI:
- Opportunistic infections: Medicines for HIV and AIDS Clinics
- Following your patients: WHO activity levels
- Q&A: Testing babies for HIV
- Update: ARVs in church health facilities in Kenya
- Sheet H for counselors: Training for counselors - VCT
OPPORTUNISTIC INFECTIONS: Medicines for HIV and AIDS Clinics
The following medicines are recommended for outpatient clinics which treat adults and adolescents living with HIV or AIDS. Most of these medicines are available from MEDS (Note: ARV medicines are not included in this list).
Recommended medicines for a basic-level clinic
Amitriptyline 25 mg. tablets
Amoxicillin 250 mg. tablets
Clotrimazole skin cream
Clotrimazole oral drops
Cotrimoxazole 480 mg. tablets
Gential violet 1% solution
Loperamide 2 mg. tablets
Metronidazole 200mg. tablets
Norfloxacin 400 mg. tablets
Oral rehydration packets
Paracetamol 500 mg. tablets
Promethazine 25 mg. tablets
Recommended additional medicines for a second-level clinic
Acyclovir 200 mg. tablets
Cimetidine 400 mg. tablets
Chlorphenamine 4 mg. tablets
Doxycycline 100 mg. tablets
Erythromycin 250 mg. tablets
Cloxacillin 250 mg. tablets
Dihydrocodeine (DF-118) 30 mg. tablets
Ketoconazole 200 mg. tablets
Recommended equipment and supplies for all clinics
Weighing scale of good quality
Torch or other good light source
FOLLOWING YOUR PATIENTS
WHO Activity Level: The World Health Organization has devised a very simple score to follow the level of activity of a person living with HIV. This score, along with weight and other clinical parameters, can assist in following a person and knowing the progression of his/her illness. The Activity Level of each person should be assessed by simple questioning and recorded at each follow-up visit.
Activity level 1 - a completely asymptomatic person, doing usual activities
Activity level 2 - the person has some symptoms, but continues usual activities
Activity level 3 - the person rests in bed for a few hours each day
Activity level 4 - the person stays in bed most of the day
Q&A: TESTING BABIES FOR HIV
Question from the matron at a home for orphaned children:
We test all children who enter our home to know if they are infected with HIV. Sometimes babies test positive at first, then later show a negative result. How can this be?
Answer from Dr. T. Macharia of the Nazareth Hospital AIDS Service:
The HIV tests generally used to detect HIV infection do not test for the infection itself, but rather for antibodies which result from the infection. People who are infected usually generate detectible antibodies by 1-2 months after the infection occurs. HIV antibodies pass through the placenta from mother to fetus, but an HIV infection generally does not pass through the placenta to the fetus or to the baby. (If a baby gets an HIV infection, it usually happens during labor and delivery).
This if you test a newborn baby from an HIV sero-positive mother, the baby will always show a positive test result, because the baby possesses antibodies from the mother for at least the first 1-9 months of life. After this time, the mother's antibodies disappear from the baby's blood.
Most babies born to HIV positive mothers are not infected with HIV. However, those who are infected will develop their own antibodies to HIV during the first year of life. There is no easy means of knowing during the first year of life if a baby's positive HIV antibody test is from his mother's antibodies or his own antibodies resulting from his own infection. To avoid confusion, it is best to wait and test babies for HIV infection after the first year of life.
On the other hand, if it is important to know if a baby is really infected with HIV (in order to give early treatment), you can order an HIV-PCR test from a special laboratory. This test is expensive (Ksh 2-3000), but it will show positive in the first week of life if the baby himself is infected.
SHEET G: VOLUNTARY COUNSELING AND TESTING (VCT)
Church hospitals have been offering HIV testing for many years. In the 1980s, tests were done only for blood donors or for patients under doctor's orders. In those days, HIV tests were expensive, complicated and could be done only by specially-trained laboratory technicians. Nowadays HIV testing is much simpler. Only a finger-prick is required. Hospitals buy Determine tests for less than Ksh120 per test and Unigold tests for less than Ksh180.Results are available in about 15 minutes.
In many church hospitals in Kenya, doctors, clinical officers and nurses are doing HIV tests every day. They use simple, rapid tests to help diagnose and treat sick people right in the wards and outpatient clinic rooms. This is diagnostic testing to help the doctor and patient decide the next steps in treatment.
What is different about Voluntary Counseling and Testing (VCT)?
VCT is requested by healthy people who want to know their own HIV status. VCT Centers are now open in many Kenyan cities, offering walk-in services at low cost. The entire VCT process is done by one counselor with one client in less than an hour. VCT includes pre-test counseling - to help the person think about a positive or a negative HIV test result, and what it will mean to him personally. Then, right in the same room, the counselor shows the client the test strip and does the test. They wait 15 minutes, then together read the test results. Next is post-test counseling - an HIV negative person talks about ways to stay negative. An HIV positive person learns about ways to live positively - how to stay healthy, where to go for treatment, where to go for more counseling, how to meet other people living with HIV, etc. If your hospital or program wants to offer VCT services in the area you serve, here are two aspects to consider in advance:
- VCT clients should pay only 50-100 Ksh. These low client fees can cover materials (cotton, alcohol, gloves, etc) and the counselor's time. You will need to qualify for free HIV tests under NASCOP (Ministry of Health) *
- VCT must be accessible and quick. The VCT room must be easy to find. A counselor (or several) must be standing by during the hours VCT is offered. (Counseling and test require a total of 30-60 minutes per person). A VCT service must have counselors truly available to counsel and test all walk-in clients who ask for a test.
What kind of people make good VCT counselors?
Good counselors are likeable, trustworthy people who are able to listen, willing to let people make their own decisions, and able to keep information confidential. Good VCT counselors have been tested for HIV themselves, and they very much want to do VCT. Above all, counselors must be available, so when they are on VCT duty, they are not interrupted with other duties.
Nurses may not be the best VCT counselors. Nurses are often busy caring for sick people and counseling them and their families, so they are not free and completely available for VCT. Nurses' long training and their hands-on nursing skills are extremely valuable in outpatient clinics and hospital wards, but are not necessary in a VCT center.
Do VCT counselors need special training?
Yes. To qualify for free Determine and Unigold tests from the Ministry of Health, you must have two people with special VCT training. Here are some ideas for finding the right people:
- Hire a person who is already qualified as a VCT counselor
- Send a staff member, probably not a nurse, to a VCT course. For example, think of a counselor, social worker, chaplain, or health educator who really wants to do VCT counseling (full-time or during set times of the week).
- Identify people outside the hospital who are already active in AIDS-related work and now would like to do VCT counseling. Sponsor them for a VCT course, then hire or contract with them specifically for VCT. For example, in your area you might find:
o Community AIDS educators, community health workers
o Teachers, church members, retired nurses
o Members of small Christian communities who make home visits to people living with AIDS
o Members of AIDS action and education groups (ages 22 and up)
What VCT training is available?
Three organizations in Kenya currently offer officially recognized VCT courses:
National AIDS Control Council (NACC), Box 61307, Nairobi, Phone 2715144, 2250510
CDC, Box 30137, Nairobi, Phone 2717529
UPDATE: ARVS IN CHURCH HEALTH FACILITIES IN KENYA
The first two issues of NANASI (April and May 2002) contained information on AIDS-related activities in church hospitals around Kenya. Since that time, MEDS has continued to train doctors and COs in ARV treatment and has begun importing some generic medicines. The price of treatment has continued to fall, and more church hospitals have begun offering their patients antiretrovirals. We recently contacted church facilities all over Kenya and gathered this information:
- MEDS has trained 123 doctors and 32 COs to use ARVs
- 46 facilities have doctors or clinical officers trained to use ARVs
- 32 facilities have started treatment on some patients
- 16 facilities have started treatment on > 10 patients
- 8 facilities have started treatment on > 50 patients
- 4 facilities have started treatment on > 100 patients
- An estimated 2400 patients have been started on ARV treatment, an increase of > 400% over the past year
- In general, fewer than 5% of presenting AIDS patients receive ARVs
- In general, ARVs are started only after patients are symptomatic
- In general, few or no baseline laboratory tests are done
- Follow-up is done clinically when people return for ARVs
- Usually a three-drug HAART regimen is prescribed which includes:
o 2 nucleoside reverse transcriptase inhibitors
o 1 non-nucleoside reverse transcriptase inhibitor
- These medicines mostly are purchased as generics from MEDS
- Cost to the adult is usually Ksh3000-6000 per month.
Potentials and strengths for expanding ARV services:
- A medical infrastructure already is in place: personnel, buildings, laboratories, administrative expertise, procurement networks
- Facilities are well-integrated into the communities they serve
- Flexibility in procedures and practices, unencumbered by outsiders
- Church facilities have valuable experience in the delivery of ARV services
HERE'S AN IDEA: Good news door-to-door
To prepare for World AIDS Day last December, 10,000 volunteers in one part of South Africa went from door to door, telling people good news about HIV and AIDS. Think of all the good things you have to share with your community:
- Where to go for HIV testing and counseling, and how it can help
- Nevirapine is available to prevent mother-to-child HIV transmission
- Many opportunistic infections can now be prevented
- The prices on ARV medicines have come down
Share the good news about HIV and AIDS!
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