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NANASI 12 March 2003

NANASI 12 March 2003
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IN THIS ISSUEOF NANASI:

  • More on VCT and training courses
  • Opportunistic infections: Pneumonia
  • A strategy to combat HIV and AIDS
  • AfriAfya: A Kenyan web site about AIDS
  • Sheet I for counselors: Irene - care in hospital or at home?

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MORE ON VCT AND TRAINING COURSES

Last month, the NANASI Counselors' sheet contained information about VCT and training courses for VCT counselors. Elizabeth Marum and her colleagues at CDC-KEMRI have written us that a one-week VCT course (for people who already hold a counseling certificate) is also offered in Kisumu. For details, contact AIDS Resource Center, Centers for Disease Control and Prevention (CDC)—KEMRI Collaboration, P. O. Box 1578 Kisumu 40100, Phone 035 42379, Email Manase Amollo on This e-mail address is being protected from spambots. You need JavaScript enabled to view it This e-mail address is being protected from spambots. You need JavaScript enabled to view it or Pamela Menya on This e-mail address is being protected from spambots. You need JavaScript enabled to view it This e-mail address is being protected from spambots. You need JavaScript enabled to view it

Dr. Marum also points out an important distinction between two types of HIV testing:

  1. Diagnostic counseling and HIV testing: The test is "ordered" by a health worker for a person (though the person may refuse), and the first "user" of the results is the health worker, for diagnostic and treatment decisions
  2. Voluntary counseling and testing (VCT): The test is requested by the client, not a health worker, and the first "user" of the test results is the client, for making personal decisions about sexual behavior, marriage, planning a baby, financial plans, etc.

OPPORTUNISTIC INFECTIONS: PNEUMONIA

If a person comes to clinic with recent onset of fever, cough and dyspnea, probably he/she has pneumonia. A person with pneumonia usually has tachycardia and tachypnea as well. If you don't know the HIV sero-status of the person, then order a rapid HIV test right away. This information will be valuable in the treatment of the person.

The diagnosis of pneumonia can be confirmed by physical examination: crepitations upon auscultation of the chest and/or dullness to percussion. X-ray examination will show lung infiltrates and consolidation.

The most common causes of pneumonia among people living with AIDS in Kenya are: Streptococcus pneumoniae, Pneumocystitis carinii, mycobacterium tuberculosis.

Other organisms also cause pneumonia, but less frequently than these. One always should examine the sputum for AFB. In resource-poor settings, we recommend the following treatments:

  • For tuberculosis, follow the Ministry of Health treatment guidelines. If the person is HIV sero-positive, then also give cotrimoxzole 2 tablets (960 mg.) bid.
  • For pneymocystis give cotrimoxazole 4 tablets tid. X 21 days (small adults and adolescents may take 3 tablets tid.)
  • For moderately-ill ambulatory patients with bacterial pneumonias including streptococcal pneumonia, give all three of the following medicines:
    Cotrimoxazole 2 tablets (960 mg.) bid x 14 days
    Amoxicillin 1000 mg. tid x 14 days
    Doxycycline 100 mg. bid. X 14 days
  • Severely-ill patients with dyspnea and high fever due to pneumonia should be admitted to hospital. Give supportive care such as intravenous fluids, analgesics, oxygen, anti-pyretics and anti-emetics if indicated. Give all three of the following medicines:
    Cotrimoxazole 4 tablets (1920 mg.) tid. X 21 days (Give fewer tablets for smaller patients)
    Penicillin crystalline, IV, 2,000,000 U. q6hrs x 10 days
    Doxycycline 100 mg. bid. X 21 days

Note: Gentamicin is not indicated in the initial treatment of pneumonia. It can be added after three days if there is poor response to the above regimen.

Prevention: After the above treatments are completed, HIV positive patients can help prevent subsequent episodes of pneumonia by taking:

Cotrimoxazole 2 tablets (960 mg.) each day indefinitely
Pneumovax (pneumo-23 vaccine) ½ ml. IM, every 5 years, gives protection against streptococcal pneumonia. To be effective, this vaccine must be taken before the CD4 count falls below 200. This vaccine costs more than Ksh2,000 per dose in Kenya.

HIV sero-positive people who have had a bout of pneumonia or TB should be offered the option of taking antiretroviral treatment.

COUNSELING SHEET "I": IRENE - CARE IN HOSPITAL OR AT HOME?

Irene, age 29, has been sick on and off for several years. Both she and her family know she has AIDS. Last week she was admitted to the hospital. Her fever is gone now, but she still coughs and has occasional headaches. Irene's prognosis is not good. The family and Irene are wondering whether to take her home. They have asked you to help them decide, plan and prepare.

Should Irene stay in hospital or should the family take her home?

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Home care is probably best if:

  • Irene herself wants to be at home
  • She understands and accepts her condition
  • The family knows how to keep her comfortable
  • The costs of hospital care are financially burdensome to the family

Hospital care may be needed for Irene sometime in the future

  • If she becomes acutely ill and needs close attention by nurses and doctors. Here are some examples: if she has a very high fever or constant diarrhea; if she becomes delirious or very confused; if she has not eaten for more than three days; if she is vomiting often
  • If she needs intravenous fluids or oxygen
  • If several serious problems occur at the same time
  • If she has extremely severe headache

Note: To prevent infections, Irene should receive cotrimoxazole, 2 tablets 2 times daily, whether she is in hospital or at home.

If Irene is at home, when does she need to see the nurse or doctor again?

  • For routine checkups -- to monitor weight, treat infections early and get regular supplies of medicines such as cotrimoxazole
  • When a new, unfamiliar problem occurs that the family cannot handle in the usual ways
  • If she has pain that becomes more severe, and the regular medicine is not strong enough to relieve it

Care for the family is an essential part of care for the sick person.

What is the best person to take care of Irene at home?

Irene and the family should decide who will be the "chief caregiver". They can choose, for example,

  • A family member who can be at home most of the time
  • A neighbor who can come every day while the family members are away from the house
  • A retired nurse or health worker who can be paid to come and stay with Irene every day

The chief caregiver will be able to do these things:

  • Understand Irene and her illnesses
  • Make sure she gets her daily medicine (such as cotrimoxazole)
  • Learn how to make her comfortable and content
  • Talk often with Irene, the family and the nurse about her health and her needs

Irene's family should arrange for the chief caregiver to have some time off every day and every week. Taking care of Irene will be a tiring job.

What do the family members need to know before they take Irene home?

The family needs some simple facts and skills that will give them confidence and ease in caring for Irene. You can teach some skills while Irene is still in hospital. Then encourage them to visit or call you later if they have questions about

  • What foods Irene should eat (Actually, she can eat anything she wants to eat. For people living with HIV and AIDS, no particular foods are required or forbidden. The family should prepare foods Irene likes, then give her small amounts often - and plenty of liquids to drink).
  • How to use pillows or boards to raise Irene's head, if she is coughing or has trouble breathing
  • How to prevent bedsores (Make the bed soft and move her every two hours - from one side, to the back, then to the other side)
  • How to keep Irene and the bed clean if she has diarrhea
  • How to avoid getting infected with HIV
  • What to do if she has sores in her mouth, trouble swallowing, rash, shingles, high fever or pain
  • How to make Irene feel she is still a part of the family

Later, the time will come to help Irene and the family prepare for her death.

  • The family can lessen their worries by planning together for the future - care of the children, how to pay for the funeral, where Irene wants to be buried
  • You can explain what might happen as Irene nears death - such as difficulty breathing, and going in and out of consciousness
  • After Irene's death, listen to family members and let them grieve

A STRATEGY TO COMBAT HIV AND AIDS

To combat HIV and AIDS, hospitals, churches, businesses and communities require a strategy. We propose a three-part strategy, which is feasible for Kenyan organizations in 2003.

I PREVENT HIV INFECTION

A Information and education.
Use individual and group trainers, videos, posers etc. to encourage sexual abstinence outside marriage, fidelity in marriage and condoms for discordant couples.

B Voluntary counseling and testing (VCT).
Establish VCT testing points with the intention of changing risky sexual behaviors of healthy persons. Trained counselor-testers help sero-negative persons avoid risky behaviors; they help sero-positive persons avoid spreading infection.

C Prevent mother-to-child transmission (PMTCT).
In ante-natal programs, nurse-counselors advise pregnant women to take nevirapine for prevention of HIV transmission to newborns. At post-natal visits, MCH nurses encourage contraception for HIV sero-positive women.

D Treat sexually-transmitted infections (STIs) aggressively.
Train and equip clinic staff for the syndromic diagnosis and treatment of common STIs.

II MAINTAIN THE HEALTH AND PRODUCTIVITY OF HIV-INFECTED PERSONS

A Monitor HIV-positive people and treat opportunistic infections early.
Enroll HIV-positive people in follow-up programs and record the clinical progress of their condition. Offer counseling, appropriate treatment and prophylaxis for opportunistic infections.

B Sponsor support groups or clubs.
Encourage the formation of mutual support groups among patients and families of HIV positive people.

C Offer antiretroviral (ARV) treatment to people living with HIV or AIDS.
Train and equip doctors and clinical officers to manage the care of people living with AIDS with low-cost, approved ARV regimens. Train nurses to monitor and advise people on ART.

III PROVIDE PALLIATIVE CARE FOR THE TERMINALLY ILL

A Train community-based and home caregivers.
Arrange for nurses to train, equip and supervise family members and lay caregivers in the techniques of washing, feeding, comforting and relieving pain of terminally ill people with AIDS.

B Provide advice and support for PLWHA and family members.
Arrange financial advice, legal advice, and planning for childcare, transportation and burial arrangement.

C Provide spiritual and emotional support for sick people and their families.
Contact and prepare priests, pastors and counselors to minister to the spiritual and emotional needs of those close to death, and also to their families before and after their death.

AfriAfya - Kenyan web site about AIDS

AfriAfya, the African Network for Health Knowledge Management and Communication, has recently set up a web site about AIDS and AIDS care, just for Kenya.
www.afriafya.org

You'll find pages for health workers and counselors. For example:

  • Myths and rumors
  • Cultural practices - helpful or harmful in the AIDS epidemic
  • Starting youth peer groups
  • The over-60 generation and AIDS
  • The epidemic in Kenya (and what has happened in Uganda)

Pages for the general public can easily be used in health education talks - or you can make them into brochures, flyers, handouts, role plays or posters:

  • What can I do to convince my partner to use a condom?
  • Should I go for an HIV test?
  • I suspect my husband

Many pages are in both English and Kiswahili.

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Contact Information

Health Action International (HAI) Africa Office
4th Floor, Top Plaza off Kindaruma Road Suite 4-2
P.O Box Nairobi - Kenya
Tel: +254 20 2692973 ext 108, Cell phone: + 254 0733 398654.
E-mail:info@haiafrica.org, Web:http:// www.haiafrica.org