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NANASI 51: December 2006/January 2007 Bumper Issue

In this issue of NANASI:
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•    Case Study: Contraception
•    HIV prevention strategies with PLWH
•    Alcohol use among clients accessing VCT and ART services
•    WHO releases revised guidelines for diagnosis of smear negative and extrapulmonary TB in HIV-prevalent settings
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Case Study: Contraception
This 35-year old mother of six is HIV positive. She is not on ARVs and is taking cotrimoxazole 960 mg OD. She has been coughing for 3 weeks and because of fine crepitations in both lungs, X-ray and sputum examinations were requested. Three samples of sputum were negative for AFB (acid fast bacilli, the test used to detect TB). The X-ray was suggestive of pulmonary (lung) tuberculosis. This is the second time that she had been diagnosed with TB.
The woman was enrolled on the TB program and given rifampicin, pyrazinamide, isoniazid, ethambutol and streptomycin. She was advised not to get pregnant because a pregnancy at this time would be detrimental to her health. For that reason, she enrolled in a nearby family planning clinic and was prescribed oral contraceptives (levonorgestrel 0.15 mg and ethinyl estradiol 0.03 mg), which she takes faithfully.
Three months later she missed her monthly period. A pregnancy test was positive.
How would you assess and treat this woman?
What advice would you offer?
Discuss the case as a group and then refer to the comments on the back page of this newsletter.
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HIV PREVENTION
Preventing HIV transmission in people living with HIV
Strategies for the prevention of HIV transmission have mainly targeted HIV negative people at risk of becoming infected with HIV. There is growing concern about the infection and re-infection incidence of HIV and other sexually transmitted infections (STIs), as well as high-risk behaviors among individuals who are already living with HIV.  Thus it is important to focus on prevention efforts for PLWH.
There are four strategies that can be used to advance HIV prevention efforts:
1.    Prevent new infections by working with persons living with HIV (PLWH) and their partners
2.    Offer HIV testing as a routine part of medical care
3.    Implement new models for diagnosing HIV infections outside medical settings
4.    Further decrease perinatal HIV transmission.
In this section we will discuss the first strategy. Healthcare workers are in a unique position to incorporate HIV prevention into the medical care of persons living with HIV. The strength of this approach includes
•    linking the prevention of HIV transmission to the treatment of HIV and other STIs
•    offering repeated opportunities to intervene in high-risk behavior
•    developing a trusting relationship which might offer further understanding about an individual's tendencies toward high-risk behaviors
•    potentially knowing the sexual contacts of the HIV infected individual, and
•    serving as a source of information and support for the PLWH.
Prevention efforts for HIV positive individuals require familiarity with some of the issues that lead to high-risk behavior. These include, among others, substance abuse (marijuana, heroin, cocaine, Viagra®), fatigue of using barrier methods, attempts to enhance intimacy, poor understanding of how the virus is transmitted, gender inequalities, economic disparities, and misunderstanding about the effects of medicines for HIV.
It is important to obtain the sexual history and any history of drug use at every visit. This involves an understanding of the sexual activities of patients. Ask whom they have sex with, what sort of sexual activities they have, and whether they use any drugs. When discussing sexual and drug-related issues, avoid expressing any judgment in facial expressions, tone of voice or body language. Employ good listening skills by allowing the patient to speak without interruption, nodding, keeping eye contact, using body language to show that you are listening, and asking open-ended questions (such as "Anything else?" or "Tell me more") when the patient stops speaking. Be respectful about what the patient is telling you and reassure them about confidentiality.
The presence of STIs in either HIV positive or negative individuals increases the likelihood that the virus will be transmitted during a high-risk exposure. This underscores the importance of offering screening for STIs to PLWH. Annual screening is probably a reasonable frequency for many PLWH, but more frequent screening (e.g. at 3 - 6 month intervals) may be indicated for those who are involved in high risk behaviors. When counseling PLWH, they should be made aware that STIs such as syphilis, hepatitis B, and herpes can be more difficult to treat and cause a more severe infection in PLWH. This information might further discourage high-risk behavior.
Prevention messages to patients should always include advice encouraging them to protect themselves and their partners from HIV and/or STIs, and to disclose their HIV status to sexual partners.
If sexual histories and prevention messages are given at each clinic visit, the counseling session of the visit can last 3 to 5 minutes. Each counseling session need not address all high-risk behavior, but may focus on a gradual change to decrease risks. At follow up visits, the counselor can focus on the behaviors not addressed at previous visits. Keep in mind that changing sexual and drug use behavior is a gradual process and partial success can make a big impact on the epidemic.
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Alcohol use among clients accessing VCT and ART services
Voluntary counseling and testing (VCT) services play a vital role in HIV prevention and care. By determining and discussing an individual's HIV status, VCT can promote the adoption of HIV prevention behaviors and facilitate early initiation of antiretroviral therapy (ART). However, an important challenge facing VCT service providers is the use of alcohol among their clients.
Alcohol use has been associated with high-risk sexual behavior. It reduces inhibitions and self-control, which makes it easier for individuals to engage in risky behavior, such as multiple sex partners and unprotected sex.
A study among clients of rural public health clinics in Kenya found that more than half of them reported "hazardous" drinking behavior, suggesting that alcohol use is a serious problem (Shaffer et al. 2004).
Horizons, in partnership with Liverpool VCT & Care Inc. and The Steadman Group, conducted a study in December 2005 to explore the need for integrating alcohol counseling and referral into VCT services, and the preparedness of service providers to address alcohol use among clients accessing Kenyan health facilities. The study also included providers who counsel patients about ART because alcohol use can have a major impact on PLWH, and drinking alcohol is associated with poor adherence to ART (Samet et al. 2004).
Findings from the study indicated that alcohol is indeed an issue among VCT and ART clients, and that providers are not prepared to address it in a uniform and systematic way.
VCT counselors reported that it is not uncommon for alcohol users to seek HIV testing while intoxicated. This underlines the importance of always inquiring from your clients about factors such as alcohol and drugs which could impact on adherence.
The study methodology consisted of focus groups and in-depth interviews with VCT and ART providers, patients on ART, bar patrons, and others in Nairobi and Mombasa. Although not representative of the whole country, the study provides important insights into the issues surrounding alcohol use in the context of VCT and ART services in Kenya.
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WHO releases revised guidelines for diagnosis of smear negative and extrapulmonary TB in HIV-prevalent settings
When someone with a suspected case of TB is dangerously ill, in particular a person with HIV, flexibility may be needed when making the diagnosis, according to recommendations just released by the World Health Organization (WHO). The new guidelines revise previously used algorithms in an effort to speed up the diagnosis of smear-negative pulmonary and extrapulmonary TB in resource-limited settings wherever HIV is prevalent.
Problems diagnosing TB in people with HIV
In people living with HIV, TB can be exceedingly difficult to detect by the usual methods, such as smear microscopy and chest X-ray. Smear microscopy involves using a microscope to look for the actual Mycobacterium tuberculosis (M.tb) organism in a sample of sputum (or other biological specimen) that has been stained with a special dye. However, specimens from people with HIV and TB are frequently ‘smear negative.'
Likewise, chest X-rays, if available, may look normal or not like TB in a person with HIV and TB.  Furthermore, many PLWH develop extrapulmonary forms of the disease. Culturing the organism can usually provide a definitive diagnosis, but culturing takes weeks, and is not commonly available for many people in resource-limited settings.
"Rates of smear-negative pulmonary and extrapulmonary TB have been rising in countries with HIV epidemics," says the WHO document. "The mortality rate among PLWH TB patients is higher than that of HIV negative TB patients, particularly for those with smear-negative pulmonary and extrapulmonary TB."  The delays in diagnosis and the resulting delay in treatment contribute to this increased mortality.
Revised clinical definitions of TB
Given the strong association of HIV with TB, the new WHO recommendations lower the bar somewhat for the evidence required to diagnose TB in someone with HIV who has the symptoms of TB. For example, WHO typically recommends performing smear microscopy on three sputum samples for anyone one with a cough for two or three weeks, and if two of the specimens are positive, a diagnosis of pulmonary TB can be made. Now, however, WHO suggests acquiring only two sputum specimens for smear microscopy from someone who is HIV-positive (or when there is strong clinical evidence of his or her being HIV-positive). This should reduce the time (and repeated visits the patient has to make to the clinic) required to make a diagnosis. If one of the specimens is positive, a diagnosis of pulmonary TB can be made.
Smear-negative pulmonary TB
If both the specimens are smear negative, but a chest X-ray (if available) suggests TB, a diagnosis of smear-negative TB can be made if the clinician decides to treat with a full course of TB treatment and monitor closely for the response (that would a signal that the finding was correct). In addition, a diagnosis of smear-negative TB can be reached once a specimen sent for culture comes back positive for M.tb.
Antibiotics trial in the dangerously ill patient
However, smear microscopy and chest X-rays may not pick up TB in some patients who are too ill to wait the weeks or months that it might take to get a culture result back from the reference laboratory. There are several ‘danger signs' that indicate a need for emergency measures, including if the person is unable to walk unaided, has a respiratory rate over 30 per minute, a fever higher than 39 °C or a pulse rate of over 120 per minute.
In cases where someone is this dangerously ill but the diagnosis is unclear or cannot be reached rapidly enough, the new WHO recommendations suggest sending the person as quickly as possible to a higher-level facility. If that is not possible, then the person should be immediately put on a broad-spectrum parenteral antibiotic, and, depending upon the CD4 cell counts or clinical setting, treatment for Pneumocystis carinii pneumonia (PCP) should be considered as well. At this time, WHO says that there isn't enough clinical evidence to make any broad recommendations about which specific antibiotics would be best to use (this should be guided by the country's Standard Treatment Guidelines for community acquired bacterial infections), however, fluoroquinolones should NOT be administered because this class of antibiotics has activity against M.tb, and thus could delay TB diagnosis.
Then, for the next few days while the patient is on antibiotic therapy, all available lab tests (including an HIV test) should be conducted. If the patient is indeed HIV positive and there is no clinical improvement after three to five days on the antibiotics, chances are the person has smear negative TB, and he or she should be put on TB treatment. However, the guidelines point out that people should continue to be assessed for TB, even if there is a response to antibiotics (since there could be a co-infection, or some antibiotics may have mild, but not curative, anti-TB activity).
Extrapulmonary TB
Healthcare workers at all levels need to be on the lookout for extrapulmonary TB in people with HIV. In addition to a cough (which may or may not be present), a variety of symptoms, fevers with night sweats, weight loss, difficulty breathing, swollen lymph nodes, or swollen arms and legs, or a chronic headache or altered mental state could all be suggestive of TB in another part of the body.
Extrapulmonary TB can take such a wide variety of forms because in a person with advanced immunosuppression, the mycobacterium can infect tissues in almost any part of the body. The most common areas include the lymph nodes (especially in the neck or under the arms), the pleura (the membrane that lines the lungs and chest cavity — usually just one side is infected) and disseminated TB (spread to a number of sites in the body). M.tb can also infect the tissue around the heart, or the meninges (the membranes covering the brain and spinal cord) and other areas.
It is important to note that extrapulmonary TB is even more commonly associated with HIV status than smear negative pulmonary TB, so learning the patient's HIV status is all the more essential for a diagnosis. According to the WHO document, "about one-third of deaths in HIV positive Africans are due to disseminated TB but only about half of HIV positive patients who die from disseminated TB are diagnosed before death."
The revised definition of extrapulmonary TB requires obtaining a positive result, by smear microscopy or culture, on at least one biological specimen from the site of infection. Or, a diagnosis may be made if there is histological or strong clinical evidence consistent with extrapulmonary TB in a person with (or strongly suspected of having) HIV, and a decision to treat with a full course of anti-TB treatment.
Acquiring a good specimen from the site of infection may be difficult with the exception perhaps of TB lymphadenitis (needle aspiration of lymph nodes generally produces material with a high diagnostic yield by culture or smear microscopy). Therefore, clinicians often have to make a presumptive diagnosis and initiate TB treatment on the basis of strong clinical evidence alone (and then monitor for a response).
The accurate diagnosis of extrapulmonary TB can be complex and difficult, particularly in peripheral health facilities. Referral to the district level is advised whenever possible. Nevertheless, "simplified, standardized clinical management guidelines for most common and serious forms of extrapulmonary TB" are included in the WHO document (please see link below).

See online: http://www.who.int/entity/tb/publications/2006/tbhiv_recommendations.pdf

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