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NANASI 50: November 2006

In this issue of NANASI:
=====================
-        Case Study: Mother positive - Baby positive
-        Are there blood groups that give immunity to HIV?
-        World Health Organization 2006 Guidelines: Recommendations on the use of
co-trimoxazole prophylaxis among infants and children
-        Medicine Prices: for essential medicines found in this issue
=====================
________________________________________
Case Study: Mother positive - Baby positive

A healthy 24-year-old woman was tested during her first pregnancy and found to
be HIV positive. A second test to confirm was also positive. She did not take
nevirapine when she went into labour and her newborn baby was not given
nevirapine within three days after birth.

Today the woman brings her two-month-old baby to clinic to learn if he too is
living with HIV. The baby appears healthy and weighs 3.5 kilograms.
How would you assess and treat the mother and baby?
What tests would you require?
What medicines would you prescribe?
What advice would you offer?

Discuss the case as a group, and then refer to the comments on another page of
this newsletter.
________________________________________
Are there blood groups that give immunity to HIV?
Question from a community member attending a health facility in a low income
area

Answer from the Knowledge Management Unit, AfriAfya

No. There is no blood group that is immune to HIV infection. HIV infection
affects all persons and their blood group does not matter.

There are 4 main blood groups: O, A, B and AB. Most people have blood group O,
while AB is the most uncommon blood type.

The blood groups are also divided into Rhesus positive and Rhesus negative. This
is a protein in the blood that affects which blood type can be given to whom.
Rhesus positive blood contains that protein while Rhesus negative blood does
not contain that protein. If you give Rhesus positive blood to a person with
Rhesus negative blood there will be a severe reaction that can result in
death.

Most people are Rhesus positive (85 %). The use of the term "positive" and
"negative" in blood grouping has nothing to do with HIV infection.

A person's blood group can be described as O [Rhesus] positive or O negative, A
positive or A negative, etc.  When these two ways of classifying the blood
groups are combined, O positive is the most common type and AB negative is the
rarest.

It then means that for many medical conditions, most of the people affected are
blood group O positive, simply because it is the most common blood type
overall. It is the same reason why most people living with HIV have the blood
group O positive. Again, it is not because of the blood group specifically, but
simply because they are the majority of the world's population. There are very
few people with the blood group AB negative and so very few of those with that
blood group will test positive for HIV, again not because of their blood type
but because they are few in the world in general.

Each and every person is at risk of contracting HIV if they do not abstain or
practice safer sex. It does not matter which blood group they have.
________________________________________
World Health Organization 2006 Guidelines: Recommendations on the use of co-trimoxazole prophylaxis among infants and children

What is co-trimoxazole and why is it recommended?

Co-trimoxazole is a combination antibiotic which is widely available,
inexpensive and quite safe. It is used to treat many different types of
infections. In people living with HIV and AIDS it is recommended for the
prevention of Pneumocystis Carinii Pneumonia (PCP) because PCP is common,
deadly and preventable. It can also prevent other infections like
Toxoplasmosis, bacterial pneumonias, some forms of diarrhea and malaria.

Which infants and children should receive co-trimoxazole prophylaxis?

a) Children and infants who have been exposed to HIV: Co-trimoxazole prophylaxis
is recommended for all HIV-exposed infants starting at 4-6 weeks of age (or at
first encounter with the health care system) and continued until HIV infection
can be excluded. Co-trimoxazole prophylaxis is also recommended for HIV-exposed
breastfeeding children of any age and should be continued until HIV infection
can be excluded by HIV antibody testing (beyond 18 months of age) or virologic
testing (before 18 months of age) at least 6 weeks after the child has been
completely weaned from breast milk.

b) Infants and children documented to be living with HIV: All children younger
than 1 year of age living with HIV should receive co-trimoxazole prophylaxis
regardless of symptoms or CD4 or CD4 percentage. After 1 year of age,
co-trimoxazole prophylaxis is recommended for symptomatic children (WHO stages
2, 3, or 4 of HIV disease) or children with CD4 <25%. All children who begin
co-trimoxazole prophylaxis (irrespective of whether co-trimoxazole was
initiated in the first year of life or after that) should continue until the
age of 5 years when they can be reassessed. Adult clinical staging and CD4
count thresholds for co-trimoxazole initiation or discontinuation apply to
children older than 5 years.

c) Secondary co-trimoxazole prophylaxis in infants and children: Children with a
history of treated PCP should be administered secondary co-trimoxazole
prophylaxis with the same regimen recommended above.

When can the co-trimoxazole prophylaxis be discontinued?

a) HIV-exposed infants and children confirmed to be HIV negative: Co-trimoxazole
prophylaxis can be discontinued when HIV infection has been definitely excluded
by:
- a confirmed negative HIV virological test 6 weeks after complete cessation of
breastfeeding in infant less than 18 months of age
or
- a confirmed negative HIV antibody test in a child more than 18 months of age
and 6 weeks after complete weaning.

b) Children living with HIV in the context of ART-related immune recovery: Given
that children with HIV have a high risk of bacterial infections, the general
recommendation is that, among children confirmed to be living with HIV in
resource-limited settings, co-trimoxazole should be continued irrespective of
immune recovery in response to ART. However, children older than 5 years who
are stable on ART and with a CD4 and clinical evidence of immune recovery can
be reassessed and consideration can be given to discontinuing the prophylaxis
in accordance with the recommendations for adults and adolescents.
Co-trimoxazole prophylaxis should be recommended if the CD4 percentage falls
below the age-related initiation threshold or if new or recurrent WHO clinical
stages 2, 3 or 4 conditions occur.

c) Discontinuation for co-trimoxazole adverse reactions: Prophylaxis should be
stopped if the child has a severe adverse drug reaction. Although reactions are
uncommon, these may include extensive exfoliative rash, Steven-Johnson syndrome,
or severe anemia or pancytopenia.

Everyone starting co-trimoxazole prophylaxis and their guardians and caregivers
should be provided with verbal or written information on potential side effects
and what to do if these happen.  For children who cannot tolerate
co-trimoxazole, its therapeutic alternatives (such as dapsone) must be
considered.

The guidelines quoted in this article are available to be downloaded in full
from the WHO web site, on
http://www.who.int/hiv/pub/guidelines/ctxguidelines2006.pdf.

________________________________________
Answer to the case study from page 1

Any baby born to an HIV positive mother will be sero-positive for the first 9-12
months of life. Some babies still are sero-positive for as long as 15-18 months
after birth. For this reason, it is useless to test this baby at age two months
because he most certainly is sero-positive.

The usual HIV rapid tests detect only HIV antibodies. If the mother is HIV
positive, her antibodies pass to the baby through the placenta and thus the
baby will test sero-positive until the mother's antibodies in the baby fade
away some months later. For this reason, do not test the baby with an HIV rapid
test until the baby is 18 months of age. By that time if the baby truly does
have HIV, then his own antibodies will give a positive test result to a rapid
test.

It is important to identify infants living with HIV and refer them for HIV care
as soon as possible. Where available, a PCR test can be done after 6 weeks of
age. If the infant is breastfed, the test should be done at least 12 weeks
after the child is completely weaned. It must be noted that this test, however,
is expensive and often not available in resource-limited settings like ours.

25 - 40% of babies of HIV positive mothers are born with HIV. The percentage of
HIV negative babies increases when appropriate and comprehensive
prevention-of-mother-to-child-transmission programs are functioning and
supported.

Finally, co-trimoxazole prophylaxis is recommended for all HIV-exposed infants
starting at 4-6 weeks of age (or at first encounter with the health care
system) and continued until HIV infection can be excluded. Co-trimoxazole
prophylaxis is also recommended for HIV-exposed breastfeeding children of any
age and should be continued until HIV infection can be excluded by HIV antibody
testing (beyond 18 months of age) or virologic testing (before 18 months of age)
at least 6 weeks after the child has been completely weaned from breast milk.

Medicine prices for the essential medicines found in this issue*
Medicine    Strength and Formulation    Pack Size    Price (Ksh)
Co-trimoxazole    suspension 240mg / mL    50 and 100 mL    13 and 19
    tablet 400 / 80 mg    1000    502
    paediatric tabs 200 / 40 mg    100    50
Prices from MEDS (August 2006)
NANASI is produced by AfriAfya, HAI Africa, and staff from Columbia University's
International Center for AIDS Care and Treatment Programs.  NANASI is funded by
Liverpool VCT.
NANASI, PO Box 64559 - 00620 Mobil Plaza, Kenya
This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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In this issue of NANASI:
=====================
-        Case Study: Mother positive - Baby positive
-        Are there blood groups that give immunity to HIV?
-        World Health Organization 2006 Guidelines: Recommendations on the use of
co-trimoxazole prophylaxis among infants and children
-        Medicine Prices: for essential medicines found in this issue
=====================


Case Study: Mother positive - Baby positive


A healthy 24-year-old woman was tested during her first pregnancy and found to
be HIV positive. A second test to confirm was also positive. She did not take
nevirapine when she went into labour and her newborn baby was not given
nevirapine within three days after birth.

Today the woman brings her two-month-old baby to clinic to learn if he too is
living with HIV. The baby appears healthy and weighs 3.5 kilograms.

How would you assess and treat the mother and baby?
What tests would you require?
What medicines would you prescribe?
What advice would you offer?


Discuss the case as a group, and then refer to the comments on another page of
this newsletter.


Are there blood groups that give immunity to HIV?

Question from a community member attending a health facility in a low income
area


Answer from the Knowledge Management Unit, AfriAfya

No. There is no blood group that is immune to HIV infection. HIV infection
affects all persons and their blood group does not matter.

There are 4 main blood groups: O, A, B and AB. Most people have blood group O,
while AB is the most uncommon blood type.

The blood groups are also divided into Rhesus positive and Rhesus negative. This
is a protein in the blood that affects which blood type can be given to whom.
Rhesus positive blood contains that protein while Rhesus negative blood does
not contain that protein. If you give Rhesus positive blood to a person with
Rhesus negative blood there will be a severe reaction that can result in
death.

Most people are Rhesus positive (85 %). The use of the term "positive" and
"negative" in blood grouping has nothing to do with HIV infection.

A person's blood group can be described as O [Rhesus] positive or O negative, A
positive or A negative, etc.  When these two ways of classifying the blood
groups are combined, O positive is the most common type and AB negative is the
rarest.

It then means that for many medical conditions, most of the people affected are
blood group O positive, simply because it is the most common blood type
overall. It is the same reason why most people living with HIV have the blood
group O positive. Again, it is not because of the blood group specifically, but
simply because they are the majority of the world's population. There are very
few people with the blood group AB negative and so very few of those with that
blood group will test positive for HIV, again not because of their blood type
but because they are few in the world in general.

Each and every person is at risk of contracting HIV if they do not abstain or
practice safer sex. It does not matter which blood group they have.


World Health Organization 2006 Guidelines: Recommendations on the use of co-trimoxazole prophylaxis among infants and children


What is co-trimoxazole and why is it recommended?

Co-trimoxazole is a combination antibiotic which is widely available,
inexpensive and quite safe. It is used to treat many different types of
infections. In people living with HIV and AIDS it is recommended for the
prevention of Pneumocystis Carinii Pneumonia (PCP) because PCP is common,
deadly and preventable. It can also prevent other infections like
Toxoplasmosis, bacterial pneumonias, some forms of diarrhea and malaria.

Which infants and children should receive co-trimoxazole prophylaxis?

a) Children and infants who have been exposed to HIV: Co-trimoxazole prophylaxis
is recommended for all HIV-exposed infants starting at 4-6 weeks of age (or at
first encounter with the health care system) and continued until HIV infection
can be excluded. Co-trimoxazole prophylaxis is also recommended for HIV-exposed
breastfeeding children of any age and should be continued until HIV infection
can be excluded by HIV antibody testing (beyond 18 months of age) or virologic
testing (before 18 months of age) at least 6 weeks after the child has been
completely weaned from breast milk.

b) Infants and children documented to be living with HIV: All children younger
than 1 year of age living with HIV should receive co-trimoxazole prophylaxis
regardless of symptoms or CD4 or CD4 percentage. After 1 year of age,
co-trimoxazole prophylaxis is recommended for symptomatic children (WHO stages
2, 3, or 4 of HIV disease) or children with CD4 <25%. All children who begin
co-trimoxazole prophylaxis (irrespective of whether co-trimoxazole was
initiated in the first year of life or after that) should continue until the
age of 5 years when they can be reassessed. Adult clinical staging and CD4
count thresholds for co-trimoxazole initiation or discontinuation apply to
children older than 5 years.

c) Secondary co-trimoxazole prophylaxis in infants and children: Children with a
history of treated PCP should be administered secondary co-trimoxazole
prophylaxis with the same regimen recommended above.

When can the co-trimoxazole prophylaxis be discontinued?

a) HIV-exposed infants and children confirmed to be HIV negative: Co-trimoxazole
prophylaxis can be discontinued when HIV infection has been definitely excluded
by:
- a confirmed negative HIV virological test 6 weeks after complete cessation of
breastfeeding in infant less than 18 months of age
or
- a confirmed negative HIV antibody test in a child more than 18 months of age
and 6 weeks after complete weaning.

b) Children living with HIV in the context of ART-related immune recovery: Given
that children with HIV have a high risk of bacterial infections, the general
recommendation is that, among children confirmed to be living with HIV in
resource-limited settings, co-trimoxazole should be continued irrespective of
immune recovery in response to ART. However, children older than 5 years who
are stable on ART and with a CD4 and clinical evidence of immune recovery can
be reassessed and consideration can be given to discontinuing the prophylaxis
in accordance with the recommendations for adults and adolescents.
Co-trimoxazole prophylaxis should be recommended if the CD4 percentage falls
below the age-related initiation threshold or if new or recurrent WHO clinical
stages 2, 3 or 4 conditions occur.

c) Discontinuation for co-trimoxazole adverse reactions: Prophylaxis should be
stopped if the child has a severe adverse drug reaction. Although reactions are
uncommon, these may include extensive exfoliative rash, Steven-Johnson syndrome,
or severe anemia or pancytopenia.

Everyone starting co-trimoxazole prophylaxis and their guardians and caregivers
should be provided with verbal or written information on potential side effects
and what to do if these happen.  For children who cannot tolerate
co-trimoxazole, its therapeutic alternatives (such as dapsone) must be
considered.

The guidelines quoted in this article are available to be downloaded in full
from the WHO web site, on
http://www.who.int/hiv/pub/guidelines/ctxguidelines2006.pdf.


Answer to the case study from page 1


Any baby born to an HIV positive mother will be sero-positive for the first 9-12
months of life. Some babies still are sero-positive for as long as 15-18 months
after birth. For this reason, it is useless to test this baby at age two months
because he most certainly is sero-positive.

The usual HIV rapid tests detect only HIV antibodies. If the mother is HIV
positive, her antibodies pass to the baby through the placenta and thus the
baby will test sero-positive until the mother's antibodies in the baby fade
away some months later. For this reason, do not test the baby with an HIV rapid
test until the baby is 18 months of age. By that time if the baby truly does
have HIV, then his own antibodies will give a positive test result to a rapid
test.

It is important to identify infants living with HIV and refer them for HIV care
as soon as possible. Where available, a PCR test can be done after 6 weeks of
age. If the infant is breastfed, the test should be done at least 12 weeks
after the child is completely weaned. It must be noted that this test, however,
is expensive and often not available in resource-limited settings like ours.

25 - 40% of babies of HIV positive mothers are born with HIV. The percentage of
HIV negative babies increases when appropriate and comprehensive
prevention-of-mother-to-child-transmission programs are functioning and
supported.

Finally, co-trimoxazole prophylaxis is recommended for all HIV-exposed infants
starting at 4-6 weeks of age (or at first encounter with the health care
system) and continued until HIV infection can be excluded. Co-trimoxazole
prophylaxis is also recommended for HIV-exposed breastfeeding children of any
age and should be continued until HIV infection can be excluded by HIV antibody
testing (beyond 18 months of age) or virologic testing (before 18 months of age)
at least 6 weeks after the child has been completely weaned from breast milk.

Medicine prices for the essential medicines found in this issue*

Medicine

Strength and Formulation

Pack Size

Price (Ksh)

Co-trimoxazole

suspension 240mg / mL

50 and 100 mL

13 and 19

tablet 400 / 80 mg

1000

502

paediatric tabs 200 / 40 mg

100

50

Prices from MEDS (August 2006)

NANASI is produced by AfriAfya, HAI Africa, and staff from Columbia University's
International Center for AIDS Care and Treatment Programs.  NANASI is funded by
Liverpool VCT.
NANASI, PO Box 64559 - 00620 Mobil Plaza, Kenya
This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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