You are here

NANASI 47: August 2006

NANASI 47: August 2006

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

In this issue of NANASI:

  • Case Study: Mother negative - baby positive
  • Q & A: Treatment interruption
  • Q & A: Cotrimoxazole prophylaxis
  • Very Sick Person: Immune Reconstitution Syndrome (IRIS)
  • Please send your questions!
  • New email address

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

Case Study: Mother Negative - Baby Positive

This young mother had received PMTCT counseling and testing during the first trimester of her pregnancy. She was HIV negative.

She gave birth to a healthy baby girl. Eight months later, the baby lost weight, developed pneumonia and a generalized pustular rash. A clinical officer requested an HIV rapid test and the result was positive.

The mother brings the baby to you for help and an explanation.

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 another page of this newsletter.


Q&A: Interrupting ART and Kenya policy on cotramoxazole prophylaxis

QUESTION: (From a medical officer in Bomet): A person I have been helping care for has been on stavudine, lamivudine and nevirapine for 3 years. He is doing well clinically and the CD4 count is 800 cells/mm3. Is it safe at this point to stop his ARVs temporarily for some period?

ANSWER: (From Dr. Aziz Abdallah of Columbia University's International Center for AIDS Care and Treatment Programs)

People with a good response to ART often have CD4+ cell counts that are high, suggesting the possibility that treatment could be discontinued until the CD4+ cell count is again reduced to a level at which it has been decided that ART be resumed. There have been multiple small uncontrolled trials on this, but recently we have the benefit of a definitive study addressing this tactic, called the "SMART" trial. It included over 5000 people from 33 countries who had a good virologic response to ARVs plus a CD4 + cell count increase over 350 /mm3.

These people were randomly chosen to either have continuous treatment or discontinuation of ART until the CD4 + cell count decreased to less than 250 /mm3. The trial was ended prematurely as a result of excessive adverse outcomes among the people whose treatment was being interrupted. There was increased rate in disease progression, death and serious adverse drug reactions among the group whose treatment was interrupted. The conclusion of this study is that CD4 + cell-guided treatment interruption is associated with excessive adverse events including complications, adverse drug reactions, and death.

The conclusions from multiple studies of this strategy suggest that CD4 + cell-guided treatment interruption has been inadequately  studied to allow for firm conclusions, and the results of the "SMART" trial are concerning enough that structured treatment interruption cannot be currently recommended.  It must be studied further to better define specific guidelines. Indeed, the guidelines for antiretroviral therapy in Kenya do not recommend treatment interruption for routine management of people living with AIDS.

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

QUESTION: (From a VCT counselor in Nairobi) Two years ago I was told that cotrimoxazole prophylaxis should be offered to all people who test HIV positive. Now I meet more and more HIV positive people who do not receive cotrimoxazole if they have a CD4 count of even 300 or 500. Have the policies changed?

ANSWER: (From Dr. Aziz Abdallah of Columbia University's International Center for AIDS Care and Treatment Programs)

Prevention of opportunistic infections is an important aspect in managing HIV. It is current policy in Kenya that all HIV positive people be given cotrimoxazole prophylaxis unless contraindicated. This recommendation is also in line with the revised WHO guidelines on the use of cotrimoxazole prophylaxis in HIV positive people in Africa, and is supported by currently available evidence. In cases where giving cotrimoxazole to all HIV positive people would overwhelm clinical services, cotrimoxazole administration can be prioritized for those with symptomatic infection and/or CD4 < 350 cell/mm3.

There is no clear evidence to support a decision and timing on when to discontinue cotrimoxazole prophylaxis for people on ART in resource limited settings. In view of the broad benefit derived from this simple intervention even in people with relatively good immune status, and the complexity of having entry- and exit- criteria based on CD4 levels in this setting, it is recommended that everyone on ART continue taking cotrimoxazole unless contraindicated. Cotrimoxazole effectively protects against the following infections in people living with HIV: Toxoplasmosis; PCP; common bacterial infections including bacterial pneumonia and sepsis; diarrhea including that caused by isospora belli; and malaria.


VERY SICK PERSON
Immune Reconstitution Syndrome (IRIS)

Immune reconstitution syndrome is the development of symptoms of opportunistic infections (OIs) after a person has started taking ARVs for HIV treatment. It affects around 10% of people living with AIDS, and as many as a quarter of those starting treatment with a CD4 cell below 50 cells/mm3.  Severe cases can sometimes be fatal. It is caused by the recovering immune system becoming able to recognize and attack disease-causing organisms that were lying dormant in the body, causing the development of inflammation.

IRIS usually develops 1 - 3 months after initiation of effective ART and should not be confused with treatment failure.

The risk factors for IRIS include:

1) Initiation of concurrent ART while treating an opportunistic infection such as TB, CMV or cryptococcal meningitis
2) Low CD4 cell count at ART initiation, especially less than 50/mm3
3) For TB patients, an extra-pulmonary site of disease

Clinical presentation of IRIS varies, and depends on the causative organisms and the organ system that is affected. In Kenya IRIS commonly involves TB, and most often extrapulmonary TB. In such patients there will be persistent or increasing fever despite effective anti-TB treatment, worsening pulmonary inflammation where the lungs are involved, and increasing lymphadenopathy. Other conditions associated with IRIS include PCP, cryptococcal meningitis, CMV retinitis, and hepatitis B.

The following criteria can help in diagnosing IRIS:

1) New or worsening symptoms of an infection or inflammation after starting ART (within 1 - 3 months)
2) Symptoms not explained by a new infection or the expected course of an infection that was diagnosed previously
3) If available, a significant drop in viral load (at least 1 log 10)

Management

- For people who are not yet on ART, always treat the OI first
- In people already on treatment for an OI it is necessary to determine whether this is a progression of disease (e.g. ARV failure) or IRIS. Treatment of the disease should be continued, and ART should not be stopped. Sometimes therapy with anti-inflammatory agents or steroids can reduce the severity.
- As much as possible ART should be continued at the same time. Occasionally ART has to be temporarily withheld if a person is unable to adequately adhere to all treatment, if drug interactions occur, or the inflammatory reaction is very severe.

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

Answer to the case study:

It is biologically impossible for an HIV negative mother to give birth to an HIV positive baby. Laboratory error is the most likely explanation of this situation. Retest both the mother and the baby to confirm the results. It is possible for the mother to have been tested some months prior to giving birth, and to have been in the ‘window period'. Later, after the baby is born, then both of them would be sero-positive.

It is possible that the baby was infected via an unsterile needle injection or through blood transfusion. Try and trace the medical history of the baby, including where she was treated, and what treatments she received. If the baby is indeed is HIV positive, begin cotrimoxazole prophylaxis immediately and evaluate her in a few weeks for ART.

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

Please send NANASI your questions!

Do you have any questions related to the management of HIV and AIDS? Please send them to the NANASI team at P.O. Box 64559, 00620 Mobil Plaza, Nairobi, Kenya, or email them to This e-mail address is being protected from spambots. You need JavaScript enabled to view it

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

New email address

NANASI has a new email address: 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