You are here

NANASI 48: September 2006

In this issue of NANASI:
============================
•    Case Study: Sickly child
•    Q & A: Side effects of antiretroviral medicines
•    Very Sick Person: Anemia and HIV
•    Medicine Prices: for essential medicines contained in this issue
•    NANASI newsletter now on the Internet
•    World Health Organization Publishes numerous new ART guidelines
=============================
________________________________________
Case Study: Sickly Child
A girl had been born to an HIV positive mother. At the time of delivery, both the mother and the child were asymptomatic. The mother received prophylactic nevirapine but the baby received none. At birth, the child weighed 2,400 grams. Today at 18 months of age she weighs 7 kilograms. She walks but does not talk. She has had several bouts of bacterial skin infection and once she had pneumonia which was treated with penicillin.
Today her mother brings in the child because she does not seem as active as other children. She notices that her weight is less than the weight of other girls of the same age.
How would you manage this situation?
What tests would you request?
What advice would you offer?
Discuss the case as a group, and then refer to the comments on the back page of this newsletter.
________________________________________
QUESTION: (From a nurse in Kibera Clinic)
What are the common side effects of ARVs and how can we manage them?
ANSWER: (From AfriAfya)
Every medicine can cause some undesirable effects or discomforts, known as side effects. HIV is treated with 3 medicines used together, and so there can be a number of side effects experienced by a person on this treatment. Fortunately, once the body gets used to the medicines, these side effects usually go away. However, if they continue, are severe, or progressively worsen, it is important for the person on ARVs to return to clinic / hospital and tell the health care team about all their side effects.
Here is a list of the more common ones and some direct advice you could give people in your clinic:
Itching of the skin
This can be reduced by bathing with soap and water. Use soap that does not have any perfume. Then keep the skin dry. If this does not help, the doctor will be able to prescribe medicine to take the itchiness away.
Vomiting and nausea (feeling like vomiting)
•    Take the medicine with a small meal
•    Eat small meals rather than large ones. Take these small meals more frequently (5 - 6 small meals per day)
•    Take sips of clean (boiled and cooled) water, weak tea or oral rehydration salts (ORS) until the vomiting stops
•    Avoid spicy and fried foods because they may make it worse
If you have stomach pain or fever, this is more serious. If there is blood in the vomit or the vomiting is going on for more than a day, then you need to go back to the clinic / hospital.
Burning or pain in the hands or feet
It is important to wear loose fitting socks and shoes and not to walk a lot. Soak the feet in warm water and massage them especially in the evening.  When in bed, sleep with the feet uncovered. If this feeling becomes worse or you are unable to walk because of the pain, then you should visit the clinic for more help.
Feeling hot and cold (fever and chills)
Try to rest in a quiet dark room with your eyes closed and use cold wet cloths on the forehead and face. Continue to drink cool water, as much as you can. If this continues or becomes worse, you will need to see the doctor.
Joint pains
Try to do a bit of light exercise.  If this does not help, you will need to visit the doctor.
Feeling tired (fatigue)
Try to wake up and go to sleep at the same time every day.  Try to get a little exercise. Try to make sure that there is something ready to eat at any time so that when you feel too tired to prepare food, you will not go hungry.
If you become so tired that you are unable to move or eat, you must go back to the clinic / hospital.
Which side effects are serious and need a repeat visit to the hospital?
There are some side effects which are more serious.  For people experiencing them, they should proceed straight to hospital as soon as possible to avoid further complications.  Here is more direct advice you could provide on these side effects.
Yellowing of the eyes or skin
This is also known as jaundice and it is a sign of a problem with the liver. Most medicines must pass through the liver to be broken down and thus often also have an effect on the functions of the liver. It is therefore important to see a doctor as soon as possible.
Dizziness and shortness of breath
This can occur with some medicines and can result in fainting or loss of consciousness. It is important to be checked as soon as possible.
Severe skin rash
A skin reaction sometimes occurs when using medicine for TB as well as other conditions. It is usually a mild reaction that clears within a week or so. In some cases, however, this rash may be severe, becoming widespread all over the body to include the lips, eyes, nostrils and genitals. The itching is very severe and the pimples, which are big and resemble boils, may burst open leaving wounds. This severe reaction (Stevens-Johnson Syndrome) requires urgent care including admission to hospital.
________________________________________
VERY SICK PERSON
HIV and Anemia
Anemia is usually characterized by a hemoglobin level of <14 g/dL in men and <12 g/dL in women. In people with HIV infection, anemia has been linked to decreased survival and to lower quality of life. Conversely, correction of anemia has been shown to improve survival and quality of life.
Anemia has many potential causes and, in HIV-positive people, several of these may occur at the same time. Common causes include:
•    Anemia of chronic disease: HIV and AIDS, other co-illnesses
•    Bone marrow suppression due to medications (eg. zidovudine, cotrimoxazole, ganciclovir, valganciclovir, dapsone, ribavirin)
•    Bone marrow infiltration by infection or malignancy (eg. Mycobacterium avium complex, tuberculosis, cytomegalovirus, lymphoma, myelodysplasia)
•    Nutritional deficiencies (eg. low vitamin B12 or folate)
•    Iron deficiency (eg. from blood loss)
•    Hypogonadism
Anemia of chronic disease, due to the effects of HIV itself, is very common in people with lower CD4 counts (<200 cells/µL) and higher HIV viral loads, as well as in those who are underweight, female gender, and older (age >50).
Medication-induced anemia, particularly from zidovudine (AZT) and trimethoprim-sulfamethoxazole (TMP-SMX), is also very common and may occur quickly after initiation of these medicines. Careful monitoring is crucial in these cases (eg. with hemoglobin check 2-4 weeks after initiation of AZT and regularly thereafter).
People who have gradual declines in hemoglobin may compensate and be asymptomatic even at very low hemoglobin levels. Others may complain of weakness, fatigue, shortness of breath, pallor, dizziness, syncope, nausea, anorexia, headache, palpitations, chest pain, sleep disturbance, anxiety, malaise, or confusion.
Diagnostic Evaluation Recheck hematocrit and hemoglobin to confirm anemia, and complete blood count with differential to determine whether other cytopenias are present. Consider the following as initial tests to determine the cause of anemia: mean corpuscular volume (MCV), peripheral blood smear, reticulocyte count, bilirubin (total and direct), iron studies (ferritin, iron, transferrin, total iron binding capacity), hemoccult testing for fecal blood, and a pregnancy test if indicated.
See figure below, for a possible diagnostic approach:
Figure 1: Simplified Diagnostic Approach to Anemia in HIV-positive Individuals

illustrationillustration

Adapted from: Volberding PA, Levine AM, Deiterich D, et al. Anemia in HIV infection: clinical impact and evidence-based management strategies (Figure 4. Simplified diagnostic approach to anemia in HIV-infected individuals). Reprinted with permission from the University of Chicago Press. Clin Infect Dis. 2004 May 15;38(10):1454-63.
Abbreviations: AZT = zidovudine; ddC = dideoxycytidine; DIC = disseminated intravascular coagulation; HB = hemoglobin; MCV = mean cell volume; RBCs = red blood cells; TTP = thrombotic thrombocytopenic purpura
Consider checking the testosterone level in individuals with anemia of uncertain cause, particularly if they have other signs or symptoms of hypogonadism.
Consider bone marrow biopsy if the diagnosis is unclear, if the anemia is chronic and/or severe, if evaluation does not determine the cause, or if the anemia is accompanied by pancytopenia. Bone marrow biopsy also may be performed to confirm a diagnosis.
Management: Treatment will depend on the etiology and on the severity of the anemia. People with severe anemia may require transfusion (unless hemolysis is suspected) and/or hospitalization for evaluation and treatment.
Consider treating anemia of chronic disease with ART, if it is otherwise indicated, but avoiding those ARVs associated with bone marrow toxicity. Often, mild anemia will resolve on its own after the start of ART as the immune system is reconstituted.
If medicine-induced anemia is suspected, stop the offending medicine, if possible. For example, if the person is taking AZT and other causes of anemia have been excluded, consider substituting another nucleoside/nucleotide analogue like d4T (stavudine) in place of AZT. If it is not possible to alter therapy, consider using erythropoietin (EPO) or red blood cell transfusion to increase the hematocrit level.
EPO may be used to stimulate red blood cell production. A typical dosage of recombinant human EPO is 40,000 units weekly by subcutaneous injection. Note that EPO replacement is ineffective if the erythropoietin level is >500 international units per liter (check serum EPO levels before treatment), or if iron levels are low. For patients in whom EPO is started, monitor the hemoglobin and hematocrit regularly (e.g., every week until stabilized, then every 4 weeks), adjusting the dose as required.  But note that EPO is not widely available, nor affordable, in resource poor settings.
Treat iron deficiency with ferrous sulfate 200 mg orally 3 times daily.
Treat nutritional deficiencies as indicated:
•    folate deficiency: folic acid 1-5 mg daily for 1-4 months
•    Vitamin B12 deficiency: hydroxycobalamin (Vit. B12) 1 mg intramuscular once daily for 7 days then once weekly for 4 weeks, then once monthly OR 1-2 mg orally once daily.
________________________________________
Answer to the case study:
This child's growth is retarded. At the age of 18 months, she should weigh more than 8 kilograms. The history of pneumonia and skin infections is worrisome and might indicate immunosuppression.
The child should have an HIV rapid test done. If it is positive, cotrimoxazole prophylaxis should be started and ARVs considered. If she is HIV negative, then other causes of her growth retardation should be investigated.
======================

MEDICINE PRICES
For essential medicines featured in each issue of NANASI, prices for those available from MEDS will be referenced as a quick resource for readers.

800x600 Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4 /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman","serif";}

* MEDS price list, 01 August 2006 version

800x600 Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4 /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman","serif";}

Medicine

Strength

Pack Size

Price (KSh)*

ORS

500mL

50 / pack

155

Ferrous Sulfate tablet

200mg

1000

88

Folic Acid tablet

5mg

1000

105

Vitamin B12 injection

1mg / mL

1 ampoule

15

Cotrimoxazole tablet

400 / 80 mg

1000

550

==========================

NANASI on the Internet

All editions of the NANASI Newsletter (right from the very first one from April 2002!) are now available on the Internet. To see them, go to: http://www.haiafrica.org and click on the "NANASI" link on the left side of the page.  You can use the search button to search specific topics.  IMPORTANT DISCLAIMER: As more and more is learned about HIV and its treatment, information and advice included in past issues may now be obsolete and should be treated as an archive and not a treatment guide.

============================

WHO Publishes New Treatment Guidelines

The World Health Organization (WHO) has recently published new guidelines for HIV and AIDS treatment. The guidelines are available on the internet (http://www.who.int/hiv/pub/guidelines/en/). In the next issue of NANASI, we will summarize some of the main points in the relevant recommendations. Below are the titles and the web sites where you can view the guidelines:

1) Antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/adult/en/index.html

2) Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/art/en/index.html

3) Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/pmtct/en/index.html

4) Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults in resource-limited settings
http://www.who.int/hiv/pub/guidelines/ctx/en/index.html

5) WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children
http://www.who.int/hiv/pub/guidelines/hivstaging/en/index.html

6) WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings
http://www.who.int/hiv/pub/meetingreports/clinicalmentoring/en/index.html

* MEDS price list, 01 August 2006 version
==========================
NANASI on the Internet
All editions of the NANASI Newsletter (right from the very first one from April 2002!) are now available on the Internet. To see them, go to: http://www.haiafrica.org and click on the "NANASI" link on the left side of the page.  You can use the search button to search specific topics.  IMPORTANT DISCLAIMER: As more and more is learned about HIV and its treatment, information and advice included in past issues may now be obsolete and should be treated as an archive and not a treatment guide.
============================
WHO Publishes New Treatment Guidelines
The World Health Organization (WHO) has recently published new guidelines for HIV and AIDS treatment. The guidelines are available on the internet (http://www.who.int/hiv/pub/guidelines/en/). In the next issue of NANASI, we will summarize some of the main points in the relevant recommendations. Below are the titles and the web sites where you can view the guidelines:
1) Antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/adult/en/index.html
2) Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/art/en/index.html
3) Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/pmtct/en/index.html
4) Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults in resource-limited settings
http://www.who.int/hiv/pub/guidelines/ctx/en/index.html
5) WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children
http://www.who.int/hiv/pub/guidelines/hivstaging/en/index.html
6) WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings
http://www.who.int/hiv/pub/meetingreports/clinicalmentoring/en/index.html

800x600 Normal 0 false false false EN-US X-NONE X-NONE MicrosoftInternetExplorer4 /* Style Definitions */ table.MsoNormalTable {mso-style-name:"Table Normal"; mso-tstyle-rowband-size:0; mso-tstyle-colband-size:0; mso-style-noshow:yes; mso-style-priority:99; mso-style-parent:""; mso-padding-alt:0in 5.4pt 0in 5.4pt; mso-para-margin:0in; mso-para-margin-bottom:.0001pt; mso-pagination:widow-orphan; font-size:10.0pt; font-family:"Times New Roman","serif";}

 

Medicine

Strength

Pack Size

Price (KSh)*

ORS

500mL

50 / pack

155

Ferrous Sulfate tablet

200mg

1000

88

Folic Acid tablet

5mg

1000

105

Vitamin B12 injection

1mg / mL

1 ampoule

15

Cotrimoxazole tablet

400 / 80 mg

1000

550

* MEDS price list, 01 August 2006 version

==========================

NANASI on the Internet

All editions of the NANASI Newsletter (right from the very first one from April 2002!) are now available on the Internet. To see them, go to: http://www.haiafrica.org and click on the "NANASI" link on the left side of the page.  You can use the search button to search specific topics.  IMPORTANT DISCLAIMER: As more and more is learned about HIV and its treatment, information and advice included in past issues may now be obsolete and should be treated as an archive and not a treatment guide.

============================

WHO Publishes New Treatment Guidelines

The World Health Organization (WHO) has recently published new guidelines for HIV and AIDS treatment. The guidelines are available on the internet (http://www.who.int/hiv/pub/guidelines/en/). In the next issue of NANASI, we will summarize some of the main points in the relevant recommendations. Below are the titles and the web sites where you can view the guidelines:

1) Antiretroviral therapy for HIV infection in adults and adolescents in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/adult/en/index.html

2) Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/art/en/index.html

3) Antiretroviral drugs for treating pregnant women and preventing HIV infection in infants in resource-limited settings: towards universal access
http://www.who.int/hiv/pub/guidelines/pmtct/en/index.html

4) Guidelines on co-trimoxazole prophylaxis for HIV-related infections among children, adolescents and adults in resource-limited settings
http://www.who.int/hiv/pub/guidelines/ctx/en/index.html

5) WHO case definitions of HIV for surveillance and revised clinical staging and immunological classification of HIV-related disease in adults and children
http://www.who.int/hiv/pub/guidelines/hivstaging/en/index.html

6) WHO recommendations for clinical mentoring to support scale-up of HIV care, antiretroviral therapy and prevention in resource-constrained settings
http://www.who.int/hiv/pub/meetingreports/clinicalmentoring/en/index.html

Very Popular


Warning: Creating default object from empty value in /home/haiafric/public_html/modules/mod_mostread/helper.php on line 79

Warning: Creating default object from empty value in /home/haiafric/public_html/modules/mod_mostread/helper.php on line 79

Warning: Creating default object from empty value in /home/haiafric/public_html/modules/mod_mostread/helper.php on line 79

Warning: Creating default object from empty value in /home/haiafric/public_html/modules/mod_mostread/helper.php on line 79

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