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NANASI 14: May 2003

NANASI 14: May 2003

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IN THIS ISSUE: INFANTS AND CHILDREN WITH AIDS

  • Cotrimoxazole for infants and children
  • ARV treatment for infants & children
  • WHO -- AIDS Staging for Infants and Children
  • COUNSELING SHEET J - Why keep it secret?

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DOSAGE OF COTRIMOXAZOLE FOR INFANTS AND CHILDREN WHO ARE HIV SERO-POSITIVE.
 
UNAIDS recommends for infants and children a daily dose of trimethoprim 150 mg./m2 plus sulfamethoxazole 750 mg./m2.  Because this regimen in some clinics may be difficult to compose, an approximate equivalent is suggested below.

Age 1-6 months:  give 100/20 mg. daily  (1/2 tsp. suspension daily)
Age 6-12 months: give 200/40 mg. daily  (1 tsp. suspension daily)

5-10 Kg. child:  give 200/40 mg.  daily  (1 tsp suspension or ½ adult tab. daily)
15 Kg. child:  give 300/60 mg daily (11/2 tsp suspension or ¾ adult tab. daily)
>20 Kg. child:  give 400/80 mg daily. (1 adult tab. daily)

Note:  MEDS sells generic cotrimoxazole :

Adult tablets (400/80 mg.): KSh 465 for 1000 tablets
Flavored pediatric tablets (200/40 mg.): KSH 82 for 100 tablets
Suspension (200/40 mg. / 5 ml. tsp.) : KSH 15 for 100 ml. suspension


ANTI-RETROVIRAL (ARV) TREATMENT FOR INFANTS AND CHILDREN IN RESOURCE-POOR SETTINGS

Because the cost of ARV drugs has come down, more infants and children should be considered for ARV treatment.  The program below is taken from World Health Organization (WHO) recommendations (April 2002). Dr. Kenneth Colina, pediatric consultant at Kijabe Hospital, has adapted these recommendations to resource-poor settings in Kenya. Remember: whether a child receives ARV treatment or not, all those infected with HIV should receive cotrimoxazole prophylaxis.

When to start ARV treatment:


For children less than 18 month of age:
For children less than 18 month of age:

    *
      Where CD4 testing is available:
      An infant born to a HIV sero-positive mother:
      Treat if PCR test is positive OR
      Treat if WHO pediatric stage III* and CD4 <20% total lymphocytes
    *
      Where CD4 testing is not available:
      An infant born to HIV sero-positive mother.
      Treat only if PCR test is positive

For children more than 18 months of age:

    *
      Where CD4 testing is available:
      If HIV rapid test is sero-positive:
      Treat if CD4 <15% of total lymphocytes OR
      Treat if WHO pediatric stage III* (regardless of CD4).
    *
      Where CD4 testing is not available:
      If HIV rapid test is sero-positive:
      Treat if WHO pediatric stage III*

                 
PCR tests are available in Kenya: 

Nyumbani Diagnostics Laboratory (on Dagoretti Road, Karen, tel. 02-883731/882371)offers PCR-RNA testing for KSh. 3,500 per test.

Diagnostic Pathogens Laboratory (Ngong Road/Ring Road Kilimani, tel. 02-577785)
offers PCR-DNA testing for KSh. 2,000 per test.


COUNSELLlNG SHEET "J" Why keep it secret?

JANE, A CLINICAL OFFICER

Jane is seeing a young man in the outpatient clinic. She notices from his clinic card that he tested HIV+last year. Today the patient says he has diarrhea, so Jane writes a prescription and says, "Everything will be fine in a couple of days. Come back if you have any other problems."

WAIT! IS JANE AFRAID TO SAY THE WORD "AIDS"?

How can Jane be more honest and helpful?

The patient knows he is HIV +. Jane knows he is HIV +. She expects this man to have more episodes of diarrhea and other opportunistic infections. Jane can prescribe co-trimoxazole to prevent diarrhea and pneumonia.

   1.
      And why not talk about AIDS right now?   
      
      Here's what Jane can say:
      
      You remember that you tested positive for HIV last year. The HIV viruses have been multiplying in your body, and now your resistance to infections is breaking down. I'm giving you medicine for a few days for this diarrhea.  I'm also giving you cotrimoxazole to prevent diarrhea and other problems that people with HIV often get.  Cotrimoxazole is not expensive at all (only a few shillings a day). You should take it every day, probably for the rest of your life.
   2.
      I'd like to weigh you and check you regularly to see how you are getting along. So I'll give you a return date two months from today.
   3.
      Before that time, you are welcome to come any time. If any other health problem is troubling you, come back to see us, even before your return date.  Watch especially for coughing or diarrhea that lasts two days or more.  We need to catch any new problems early!
   4.
      Now let's think about your wife --- could you ask her to come to see me soon? We'll suggest she have an HIV-test. If she's HIV-negative, we'll talk about her risk of getting HIV infection from you, and we'll talk about condoms and other ways to keep her from getting infected. If your wife is already HIV-positive, we can start monitoring her health and her weight now.
   5.
      You've probably heard about Anti-Retroviral medicines (ARVs). You don't really need to start taking them now, but you might later on. We'll keep your records each month, so when the time comes that ARV medicines might help, we can decide the best ones for you. We do have ARV medicines here at our clinic, and the prices are much lower than they used to be.

WE CAN DO IT - WE CAN BREAK THE SILENCE! 

LET'S TELL PEOPLE THE GOOD NEWS ABOUT HIV AND AIDS NOWADAYS!

DR. SHAH

For several months, Dr. Shah has been treating a man for cough and oral thrush. Now the man has been admitted to hospital with pneumonia.

Dr. Shah tells him, "I'd like to do some tests -- an X-ray and a hemoglobin test."

STOP!

Why is Dr. Shah avoiding the HIV test? What is he afraid of?

Why doesn't he tell the patient that they need HIV test results? Why is he keeping silent?

HOW CAN DR. SHAH BREAK THIS SILENCE?

It is very likely that this patient already is thinking of AIDS and wonders why Dr. Shah never mentions it. And Dr. Shah needs the HIV test results - now -- in order to give proper treatment.

Note -- This is not a situation for VCT

VCT (Voluntary Counseling and Testing) means testing a healthy person who, on his own, wants to know his HIV status, in order to make decisions about his own life and actions.

This is a situation where Diagnostic Testing is needed.

In this case it is the doctor who needs the HIV-test information, in order to care for his patient properly. Without that information, he cannot give adequate treatment.


What should Dr. Shah say ?

"We are going to test you for HIV today. Once I know that test result, I will have a much better idea how best to treat you.  Do you have any questions to ask me ?

"When we have the test results, I'll ask one of our nurses to talk with you. She will be able to answer your questions and spend some time talking with you about what a positive or a negative test result means."
       

HOW CAN WE BREAK THROUGH OUR OWN SILENCES?

LET'S TEST AND TELL --- SO WE CAN GIVE OUR PATIENTS PROPER CARE


Treatment with ARVs at Kijabe:

Dr. Colina and his team at Kijabe have developed a dosage scheme based upon the weight of the child.  Because pediatric ARV drug formulations (syrups and suspensions) are expensive in Kenya and none of them yet are available as generics, Dr. Colina uses adult sized generic tablets and capsules for his pediatric patients.  He has found that parents are willing and able to break tablets and open capsules in order to have the nearly correct dose of a drug.  Sometimes the children are able to swallow the entire adult tablet; sometimes the tablet must be crushed and put into water for the child to swallow it.  Parents understand that by these measures they are saving much money.  A clear explanation to the parents is important for their cooperation.

Dr. Colina's system works at Kijabe Mission Hospital.  Although this system may not be the ideal as prescribed in official texts and guidelines, it deserves to be considered for use in resource-poor settings.

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