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NANASI 41: November 2005

NANASI 41: November 2005

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In this issue of NANASI:

  • Case Study: TB/HIV and ART
  • Q & A: Condom pore size and size of HIV
  • Q & A: Use of Nevirapine in PMTCT
  • Reader survey: Please answer and return!
  • New Address

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CASE STUDY: TB/HIV and ART

A 36-year old male presents with wasting, cough and night sweats. His sputum is AFB* positive. His chest x-ray has bilateral infiltrates. His HIV test is positive. His CD4 count is 40 cells/mm3. He is started on 4-drug treatment for TB. He gives a history of oropharyngeal candidiasis and shingles two years ago. He weighs 52 kgs.

1) When would you start his ART?
2) What tests would you request?
3) What are your options for ART?
4) What dosages will you use?
5) What advice would you offer?

Discuss the case as a group, then refer to the comments on page 4 of this issue

*AFB is Acid Fast Bacilli ("sputum for AFB" is a test for the tuberculosis bacilli)


Q & A: Condom pore size and size of HIV

QUESTION from a community nurse at a dispensary in Mazeras, Kwale District: How does the size of the condom pore compare to the size of the HIV?

ANSWER from KMU, AfriAfya:

The condom pore is approximately 50 times that of the virus, HIV. It is important, however, to note that movement of the virus is determined by many factors, not just size alone. This has been proven through laboratory studies as well as "real-life studies" of sexually active couples. It is known that consistent and proper use of a condom reduces the risk of HIV infection by at least 85 % in real life. No other method apart from abstinence comes close to this. It is therefore important that the condom be viewed as the best alternative to abstinence.

To explain further, let us look at the basis of promoting the use of a condom. The theory behind it is that latex condoms cover the penis and provide an effective barrier to exposure to secretions such as semen and vaginal fluids, blocking the pathway for sexual transmission of HIV infection.  This is because the virus does not exist on its own but is infective when contained in a body fluid e.g. blood, semen or vaginal fluid. It will therefore not move out of the fluid and across the condom pore to infect the other partner. Studies between discordant couples (where one partner is HIV positive while the other partner is uninfected) indicate that use of a condom gives a high degree of protection to the uninfected partner.

On the other hand, one must recognize that the condom is manufactured and although batch testing is performed for quality assurance, there could be some degree of imperfection, depending on the batch. The condom is then handled and used by human beings, again offering opportunities for error and possible imperfection. All these combine to possibly result in tears, breakages, slipping off, etc. This is why proper condom use will still not give 100 % effectiveness.

In conclusion, 85 % protection is 85 times better than unprotected sex, during which the risk of infection is 100 %.


Q & A: Nevirapine for Prevention of Mother to Child Transmission

Question from nurse working in an HIV clinic in Kibera: Is Nevirapine treatment for HIV+ pregnant women? Why doesn't the baby get infected?

Answer from AfriAfya:

Nevirapine is an anti-retroviral medicine that prevents multiplication of HIV within the body. Due to the problem of resistance, nevirapine, like all other ARVs, is not used alone in the treatment of HIV. Thus when nevirapine is used alone for PMTCT, it is not used as a form of treatment but rather to protect the baby from infection by the mother. This is included as one of WHO's recommendations for PMTCT in resource-limited settings.

Transmission of HIV between a mother and her child occurs during pregnancy (rarely), during birth (majority of cases) and during breastfeeding (number of cases unknown). When labor begins, there is the beginning of separation of the child from the mother, a process which is completed with the birth of the child. During this time of separation, there is an increased chance of HIV crossing from the mother to the baby through blood, through the "breaking of the waters", and as the baby is born. By giving the mother nevirapine when labor begins, it acts to halt the multiplication of viruses and to keep their levels in the mother's body low while she gives birth. When the level of virus is low in the mother's blood and in the "waters" then the baby has less chance of being infected with HIV. Once the baby is born, he/she is given a single dose of nevirapine, again to prevent multiplication of any viruses that may have crossed into the baby's blood during pregnancy or at birth. The effect of nevirapine is not prolonged and it must be stressed again that it cannot be used alone as treatment of HIV.


Comments on the case study: TB/HIV and ART

This patient is in WHO stage 3 of HIV infection (owing to the TB disease and oropharyngeal candidiasis). He should have been on cotrimoxazole prophylaxis at least from the onset of his opportunistic infections (2 years ago).

The immediate step to take is to treat his TB, following the National Standard Treatment Guidelines. He should also be put on cotrimoxazole prophylaxis at the dose of 960mg daily.

The optimum time to initiate ART treatment depends on the CD4 cell count, the person's tolerance of their TB medicines, and other clinical factors. The following table gives a guide on when ART can be initiated on patients with TB.

CD4 Count

Treatment recommendation

< 100/mm3

Start anti-TB treatment
Start ART as soon as possible (once TB treatment is tolerated)

100 - 200/mm3

Start anti-TB treatment
Start ART after intensive phase

200 - 350/mm3

Start anti-TB treatment
Start ART after completion of TB treatment

if CD4 count not available

Start anti-TB treatment
Consider clinical status: start ART as appropriate

This patient should be started on ART as soon as TB treatment is tolerated, which in most cases takes about  two weeks.

Before initiation of ART, baseline tests should be done (Hb, ALT, CD4 count) and the patient counseled about the medicines.

Potential interactions between anti-tuberculosis medicines and some ARVs complicate the choice of ARV regimen. As per the national protocol, a regimen consisting of d4T/3TC + EFV should be given to this patient while he is receiving rifampicin-based anti-tuberculosis treatment:

Stavudine 30 mg BID
Lamivudine 150 mg BID
Efavirenz 600 mg Nocte

Nevirapine containing ARV regimens can be used with rifampicin-free anti-tuberculosis treatment.

The patient should be counseled on the side effects, and should report back as soon as possible in case he experiences any of them.  He should also be counseled on the importance of adherence to medication (specifically including his cotrimoxazole, anti- TB medicines and ARVs).

Health care workers should always be alert for drug interactions and paradoxical reactions after the start of ART. Clinical monitoring of the patient, and where indicated, laboratory monitoring, is recommended.

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