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NANASI 52: February 2007

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In this issue of NANASI:
•    Case Study: Follow up of an HIV- exposed infant
•    Q & A: Garlic and ARVs
•    HIV and Malaria
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Case Study: Follow Up of HIV-Exposed Infant
Grace is an 18 year-old woman who was diagnosed with HIV during her first pregnancy. She enrolled in the PMTCT program and took nevirapine at the onset of labor. Her baby, Sam, received nevirapine at birth. Grace and Sam return for their first post-partum check at 6 weeks, and are doing well. Sam is breast feeding without difficulty and has gained weight as expected. Grace wants to know if Sam has HIV.
What do you tell her?
What tests should be used?
What other interventions are recommended?
When should Grace bring Sam back to clinic for his next appointment?
Discuss the case as a group, and then refer to the comments on the last page of this newsletter.
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Question from the nutritionist at a HIV clinic in Nairobi
Garlic and ARVs - is it true that garlic reduces the effectiveness of the ARVs?
Answer from AfriAfya - Knowledge Management Unit
Garlic has been used for several centuries to treat high blood pressure (hypertension), elevated cholesterol, fungal infections, stomach ulcers and some cancers. Today, it is available in tablet form and is often used by people who have suffered a heart attack or have a high chance (risk) of suffering from a heart attack.
The most recent use of garlic has been in HIV infection. The way in which garlic helps in the presence of HIV is unclear, though it is thought to be an immune booster.
A medicine is effective only when it reaches a specific optimal level or concentration in the blood. When garlic was tested for interactions with various ARVs, it was found to have an effect on a particular one, saquinavir (a protease inhibitor). The use of garlic with saquinavir reduced the levels of saquinavir in the body by up to 50%. At those lower levels, saquinavir would not be able to work effectively in suppressing HIV. Furthermore, when medicines are in the body at lower-than-recommended concentrations, the virus more easily becomes resistant to them. Drug-resistant HIV is a worldwide threat to the efforts against HIV.
Saquinavir is not routinely used in Kenya for the treatment of HIV. It is not available in the current government ART program and it is not one of the WHO- or Ministry of Health- recommended ARVs for routine use.
When taking ARVs, it is important to be careful about combining these medicines with other "herbal" and "natural" foods or medications as they might have negative effects on each other. It is important to realize that even something as common as garlic can have a negative effect on medicines.
Be informed about various medicines, herbs, vitamins and other treatment methods before you start recommending them or mixing them together. Always encourage clients to inform healthcare workers about any kind of herbal medication they are taking, as some of these have the potential to interact with ARVs.
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Malaria and HIV
In Africa, an estimated 40 million people are living with HIV, with an annual mortality of over 3 million.  Over 500 million clinical plasmodium falciparum (the parasite causing malaria) infections occur every year with more than a million malaria-associated deaths. There is now growing evidence that dual infection with HIV and malaria fuels the spread of both diseases in sub-saharan Africa.
What is the impact of HIV on malaria parasitaemia and clinical severity in adults and children?
HIV disease impairs the acquired immunity to malaria which is seen in older children and adults in endemic areas. Studies have provided evidence of increased frequency (with rates 1- to 2- fold higher) of both parasitaemia and clinical malaria in HIV-positive adults, with increasing risk and higher density parasitaemia associated with more advanced immunosuppression. Adults with HIV also have a higher risk of severe clinical malaria, particularly in areas of unstable transmission.
The situation is somewhat more complicated in children. In recent studies in Uganda, rates of parasitaemia among HIV+ children above the age of 5 were 1.7 fold higher than in those without HIV, and they had greater parasite density as well. However, in infants, studies failed to demonstrate an increase in frequency or density of parasitaemia in those living with HIV.
What is the impact of malaria on HIV?
Like other major opportunistic infections including TB, malarial episodes can transiently increase the HIV viral load in a person, and thus could theoretically have an impact on HIV disease progression and HIV transmission. People with an asymptomatic malaria infection experience an increase in HIV viral load if they have a fever and high parasite density (eg. > 2000), and they return to their viral load baseline about 8-9 weeks following effective antimalarial treatment. During the episode of increased viral load, however, an increased risk of transmission and progression of HIV could result.
Placental malaria is associated with increased expression of placental macrophages, which means that there may be an increased risk of mother to child transmission (MTCT) of HIV. However, whether malaria during pregnancy enhances the risk of MTCT remains elusive and more studies are required on this issue.
What is the effect of HIV on malaria treatment outcomes?
Some recent studies have shown that HIV infected adults may have poorer response to anti-malarial therapy, though the data are not clear on the reasons for this. More studies are being conducted on this topic.
There are currently no data on how HIV may affect response to treatment of clinical malaria in pregnancy. However, older studies in Malawi compared different chloroquine prophylaxis or intermittent preventive treatment (IPT) regimens. In these studies, HIV+ women had higher rates of persistent and breakthrough parasitaemia, and peripheral and placental parasitaemia at delivery, indicating a poorer response to both prophylaxis and treatment.
What is the impact of cotrimoxazole prophylaxis on the incidence of malaria?
Cotrimoxazole prophylaxis has been recommended for all people living with HIV in sub-Saharan Africa. A number of studies have demonstrated that daily cotrimoxazole prophylaxis also leads to a reduction in malaria incidence in HIV+ people.
The question of what to use in pregnant women is more complicated. Cotrimoxazole has been shown to be beneficial in HIV+ pregnant women, and studies have demonstrated that cotrimoxazole prophylaxis significantly improves birth outcomes . However, concurrent administration of IPT with sulfadoxine-pyrimethamine (SP, an antimalarial commonly used in IPT) and cotrimoxazole has been associated with a substantially increased incidence of severe adverse reactions in HIV+ people, and therefore is not recommended. WHO recommends daily cotrimoxazole as an alternative to IPT with SP for immunocompromised, HIV+ women.
What are the implications for individual patients and programs?
People living with HIV should be targeted for malaria prevention interventions, such as insecticide-treated nets for those living in endemic areas, and chemoprophylaxis for non-immune individuals traveling to malarial zones. Given the high efficacy of cotrimoxazole to prevent malaria infection, cotrimoxazole-treated patients who present with fever are much less likely to have malaria and warrant a more detailed diagnostic evaluation. For those on cotrimoxazole prophylaxis who do develop malaria, treatment needs to be with non sulfa-based / anti-folate drugs. Similarly, and as outlined above, pregnant women on cotrimoxazole should not receive sulfa-based IPT for placental malaria.
In terms of program implications, an important target group for malarial prevention in control programs should be people living with HIV and, conversely, HIV prevention and treatment programs should offer the opportunity to deliver malarial prevention interventions.
(Adapted from NAM-aidsmap)
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ANSWER TO THE CASE STUDY FROM PAGE 1
Sam is an HIV-exposed infant: an infant born to an HIV+ mother. Infants exposed to HIV need close follow up because if infected they are at risk for rapidly progressing disease. Follow up is therefore vital for ALL HIV-exposed infants in order to:
•    Identify those who are infected early
•    Monitor growth and development
•    Offer PMTCT and infant feeding options
•    Preserve immune function by offering ARVs
•    Provide prophylaxis against opportunistic infections
You tell Grace that Sam has not reached the age where he can be tested for HIV using the antibody test. However if a PCR machine is available within the hospital, then a test can be done 6 weeks after birth.
Other interventions will include weighing Sam, measuring his length and head circumference and plotting them on the growth chart, checking his development, completing the physical examination, prescribing cotrimoxazole, and providing counseling about infant feeding (exclusive breastfeeding). Sam should also undergo routine immunizations. You should then schedule to see Sam in one month.

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