NANASI 42: February 2006
In this issue of NANASI:
- Case Study: Pregnancy and TB
- Q&A: Effect of Tobacco on HIV Infection
- AIDS Epidemic Update: ‘Prevention the New Treatment'
Case Study: Pregnancy and TB
A 23-year-old nulliparous woman, in her first trimester of pregnancy, came to the antenatal clinic for routine care. In the PMTCT program, she volunteered for HIV testing and was found to be HIV positive. She was sent to your clinic for care and advice.
Upon examination, you discover crackles in the upper lobe of the left lung. She admits that she has had a persistent cough for the past 2 months and has lost 3 kilograms. You obtain a sputum sample which is positive for Acid Fast Bacilli (AFB, the test for tuberculosis). A complete blood count shows 5400 white blood cells, with 64% neutrophils and 33% lymphocytes. Her hemoglobin is 9.5 g/dl.
- How would you manage this person?
- What tests would you request?
- What medicines would you prescribe?
- What advice would you offer?
- Adapted from Nanasi case study book
Discuss the case as a group and then refer to the back page of this issue for comments.
What is the effect of tobacco on HIV infection?
Question from a health care worker in a dispensary: What is the effect of tobacco on HIV infection?
Answer from AfriAfya Knowledge Management Unit
There are two types of tobacco. Smoked tobacco is found in cigarettes, cigars and pipes. Smokeless tobacco is sniffed through the nose (dry snuff) or chewed in the mouth (wet snuff).
Smoking tobacco disables the protective cells in the breathing system. HIV infection also disables and destroys the protective cells. When living with HIV, therefore, one should avoid smoking because of the higher risk of lung infections -- the most common killer in people living with HIV.
Smokeless tobacco has higher levels of nicotine than smoking cigarettes and so is very addictive. It is difficult to stop the habit.
Smokeless tobacco causes various irritations in the mouth. White thickened patches may appear on the gum, cheeks and sometimes on the tongue; these are known as leukoplakia. These patches are not painful but they are sensitive to touch and spicy foods. These patches can also become cancerous. When one is HIV positive, the patches are usually fuzzy and often form ridges on the sides of the tongue (hairy leukoplakia). They are often mistaken for oral thrush. They too can become cancerous.
It is important to remember that taking alcohol when chewing tobacco worsens the risk of mouth irritation. Alcohol makes it easier for the harmful chemicals in tobacco to penetrate the lining of the mouth, thus increasing the harm caused by tobacco.
Although it is difficult to stop sniffing or chewing tobacco because of its highly addictive properties, it is strongly recommended to do so because all these patches improve, or even disappear, after a year or so when one successfully quits.
Chewing tobacco also causes cancer of the mouth, the throat, the voice-box and the oesophagus (between the throat and the stomach). With HIV infection specifically, one is at an increased risk of developing a cancer known as Kaposi's sarcoma. This shows up as black patches in the mouth and can only be treated using strong anti-cancer drugs (chemotherapy) which have severe side effects. Chewing tobacco also increases the risk of developing this form of mouth cancer. Finally, it also damages the teeth and gums and increases the risk of developing high blood pressure and heart disease.
HIV positive or not... if you have never smoked, chewed or sniffed tobacco, DON'T START!
AIDS Epidemic Update: ‘Prevention the New Treatment' (Compiled by Dr. Aziz Abdallah)
Over 40 million people are living with HIV worldwide, according to figures released by UNAIDS, which estimates that there were 5 million new infections in 2005. Increases were seen in every region of the world with the exception of the Caribbean.
However, UNAIDS highlights evidence that prevention efforts are working in certain parts of the world. Increased condom use, delay in first sexual experience and fewer sexual partners have led to a fall in overall HIV prevalence in parts of Kenya, Zimbabwe and the Caribbean. Although this shows the success of the ABC prevention model (abstain, be faithful, use a condom) it remains a shameful fact that increased mortality due to unavailability of treatment has also led to a drop in HIV prevalence.
Similarly, sustained efforts in diverse settings have helped bring decreases in HIV incidence in men who have sex with men in many western countries, among young people in Uganda, among sex workers and their clients in Thailand and Cambodia and among injecting drug users in Brazil and Spain.
In an effort to dramatically increase access to HIV treatment and prevention, Lesotho will launch the world's first drive to have every person in the country learn their HIV status. There will be extensive community mobilization and education followed by door-to-door visits. The campaign hopes to reach all households by end of 2007.
Despite some success, HIV prevention remains patchy worldwide and only 10% of HIV-positive individuals know they are infected with the virus. But what does this mean for us?
HIV prevention works, but needs intensifying. As we scale up treatment services, prevention efforts should be accelerated simultaneously. In sub-Saharan Africa, it is estimated that a comprehensive prevention and treatment package would avert 55% of the new infections that otherwise could be expected to occur until 2020.
What role can we play as healthcare workers?
- HIV prevention should become a routine part of primary health care
- Promote greater access to voluntary HIV counseling and testing while promoting principles of confidentiality and consent
- Provide HIV-related information and education to enable individuals to protect themselves from infection
- Advocate for the ABC - abstain, be faithful, and use a condom - model of prevention. Reducing the number of sexual partners has been key to controlling the HIV epidemics in Uganda and Thailand. In Uganda, HIV prevalence has fallen from 15% to 5% in the space of a decade and ‘'each component of the ABC approach probably had an important role''
- Create referral linkages between testing centers and the HIV clinics
- HIV testing must be offered at all centers, as should education about HIV, access to condoms, and other prevention tools
- Public information campaigns about sexually transmitted infections and the spread of HIV should be strengthened
- Involvement of people living with HIV: there is evidence that at least a third of HIV-positive people have unprotected anal or vaginal sex. The aim of condom use for people living with HIV is to avoid acquiring new sexually transmitted infections and super infection with other HIV strains, to delay disease progression and avoid passing HIV to others
- Prevention efforts must target people of all ages especially the youth
- Prevention of mother to child transmission: all HIV positive pregnant mothers should be offered the service to reduce risk of transmission
- Post exposure prophylaxis should be offered to healthcare workers for occupational exposures
- Confront and mitigate HIV-related stigma and discrimination
- Advocate for universal access to ART.
These strategies do not stand alone, but work in combination.
Answer to the case study:
Begin anti-TB treatment today according to the national protocol. Isoniazid, rifampicin, pyrazinamide and ethambutol are all safe in pregnancy. Streptomycin should not be used as it can cause permanent deafness in the baby.
Meanwhile the mother should be sent for CD4 screening (if available) and ALT. The mother would also benefit from multivitamins and cotrimoxazole prophylaxis (after the first trimester).
Patients with HIV-related TB can receive ART and anti-TB treatment at the same time, but careful evaluation is necessary in judging when to start ART. Although pregnancy and tuberculosis treatment may complicate management of HIV, pregnant women in need of ART should still begin treatment as soon as possible. While the primary purpose is to improve and protect the health of the mother, the treatment is expected substantially to reduce mother to child transmission of HIV.
The optimum time to initiate ART treatment depends on CD4 cell count, tolerance of TB treatment, and other clinical factors. The following table gives a guide on when ART can be initiated in patients with TB.
CD4 count < 100/mm3
Start anti-TB treatment
CD4 count 100 - 200/mm3
Start anti-TB treatment
CD4 count 200 - 350/mm3
Start anti-TB treatment
CD4 count not available
Start anti-TB treatment
Depending on the above, we would start ART when appropriate. If the mother does not require ART at this time, she should be sent to the PMTCT program where she will receive a single dose nevirapine to be taken at the onset of labour. She will also receive nevirapine syrup to be given to the baby within 72 hours to reduce the risk of HIV transmission.
Regarding ART and TB medicines in the pregnant woman, there are concerns about an interaction with nevirapine-based ART during the rifampicin-containing phase of tuberculosis treatment. Thus, if a pregnant woman has tuberculosis and ART is initiated, consider instead the following:
Efavirenz (EFV) based regimens: EFV should normally be avoided both in pregnancy and also in women of childbearing potential unless adequate contraception is available and used. If EFV must be used in pregnancy, it should only be taken in the second or third trimesters. Adequate contraception must be made available postpartum, and the woman must be counseled about the importance of avoiding pregnancy if she would continue EFV therapy.
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