NANASI 40: July 2005
In this issue of NANASI:
- Case Study: Herpes Zoster
- Q & A: Undetectable Viral Load
- Q & A: Condoms for whom
- Kaposi Sarcoma
- Announcement: Change of address
Case Study: Herpes Zoster
A 58-year-old man comes to the clinic with a one-week history of vesicular rash and pain radiating around the left trunk at about the T-7 level.
He has no other health problems. He has lost no weight. His appetite is good. Although his wife of 30 years lives in their home village, the man works as a police officer in the city.
The man is particularly worried about AIDS. Today he wants pain relief.
- How would you manage this patient?
- What tests would you request?
- 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 edition of NANASI
(Adapted from Nanasi HIV/AIDS Case Study book)
Q & A: Undetectable Viral Load
QUESTIONS from a doctor in Western Province:
1. When people take ARV's (antiretroviral medicines) their viral load may be quite low, even ‘undetectable'. Do they convert to sero-negative status?
ANSWER from a doctor in Nairobi Province:
Viral load is the amount of HIV in a sample of blood. Treatment with ARV's can reduce the amount of virus in the blood to a point that is undetectable. An undetectable viral load does not mean that the HIV infection is gone or that the person has become HIV negative; it simply means that the test is not sensitive enough to detect the small amount of HIV in the blood. Therefore the viral load will be undetectable but the person remains HIV positive and can still infect others.
2. Do they still need to practice safe sex with an undetectable viral load on ARVs?
ANSWER: Yes. ARV's are not a cure for HIV infection, and the viruses will remain in the blood thereby putting others at risk of infection. Furthermore, if this person has unprotected sex, he or she can be re-infected (infected again) with a different strain of HIV. ARV's do not prevent a re-infection. If a person is re-infected with a different strain of HIV, their immune system gets weaker. Therefore, all people should protect themselves and their partner by:
Abstaining from sexual intercourse
Being faithful to one partner with whom one has protected sex
Using a Condom whenever having sex.
Q & A: Condoms for whom?
QUESTION from an educator in a faith-based program: I work mainly with the youth in issues dealing with their sexuality. Rev. Gideon Byamugisha's statement [reported in The East African and in NANASI No. 36] got me thinking.
How do I encourage the youth to use condoms, tell them it is moral and not cause them to sin? How do I do that and remain true to God's word?
We are encouraging people to know their HIV status. In fact we are in the process of starting a VCT centre. But I will find it hard to tell the unwed youth I work with, "If you use condoms, you are very moral because you are planning your sex lives."
ANSWER from a colleague in another faith-based program:
I agree with you that we must not encourage people to "Do whatever you like, as long as you use a condom." Personally, I feel very comfortable teaching the idea that different people have different needs and find different solutions at the various stages of their lives.
I talk about ABSTINENCE for young people. Those who have never had sexual relations can be encouraged to delay their sexual debut. Those who have already had sexual relations, whether desired or forced, can be encouraged not to continue now, but to abstain until later. Abstinence is also appropriate for married couples at certain times -- when they are separated (for travels, study, or work), during an illness of one person, for a while after childbirth, etc.
FAITHFULNESS is definitely the best way for married couples. I try not to get stuck on any particular definition of "marriage". As we all know, many couples are not officially married in church, by civil registration, or even by traditional rites. Many such couples live together, have children, attend church, etc, and for them we can advocate for sexual faithfulness. For individuals who already have more than one sexual partner, our message must be "Choose one partner and stick to that one. Be faithful to that one. And both of you should go for HIV testing -- soon."
So where does that leave CONDOMS? They are important for people who are already in a different situation.
First are married or faithful couples, where one or both partners know they are HIV-infected. The Catholic Church is willing to consider condoms for this situation.
Other people are in a difficult situation and can't get out of it, such as married women who can't force their husbands to be faithful, but might persuade them to use condoms (with the wife and with other women) and to get tested.
Others such as sex workers sometimes can't just abruptly break off all relationships and income; they need empowerment, and support. Meanwhile they need condoms.
So peoples' needs differ in different stages and situations. Our messages need to differ also.
VERY SICK PATIENTS
Kaposi Sarcoma (KS) is the most common tumor arising in people living with HIV and is considered an AIDS-defining illness.
1) Cutaneous (skin): The skin lesions appear most often on the legs, face (especially the nose) and in the genitals. The colors associated with these lesions include many hues of pink, red, purple, and brown. KS lesions are typically papular, ranging from several millimeters to centimeters in diameter. Less commonly, KS lesions may be plaque-like, especially on the thighs and soles of the feet. Lymphedema can occur due to blockage of the lymphatic channels.
2) Extracutaneous involvement: Extracutaneous spread of KS is common. KS in the oral cavity is particularly common. It appears in the palate, followed by gingival and tongue involvement. Occasionally KS affects the gastrointestinal system, even without skin manifestations.
This can cause weight loss, abdominal pain, nausea, vomiting, and bleeding in some patients, although it may be asymptomatic in others. It can also affect the pulmonary (lung) system and present with shortness of breath, fever, cough, hemoptysis (coughing up blood), or chest pain. Many patients with pulmonary KS generally have KS in the oral cavity.
The major treatment goals for KS are palliation of symptoms; shrinkage of tumor to alleviate edema, organ compromise, and psychological stress; prevention of disease progression; and perhaps cure. Management options include:
a) Antiretroviral therapy: Most, if not all, KS patients should be advised to take ARV's which are associated with a regression in the size and number of existing KS lesions. This is particularly important in resource poor settings, where the other options discussed below are generally not available.
The other management options are either not available in resource poor setting or are expensive. In case such services are available, patients should always be referred to the centers offering the services.
b) Local therapy: Although KS is a systematic multifocal disease; local therapies may be most useful for localized bulky KS lesions. Some of the local treatments used are: alitretinoin gel, intralesional chemotherapy, radiation therapy, laser therapy, and cryotherapy, all of which can be quite effective at controlling local tumor growth.
c) Cytotoxic chemotherapy; Although many older chemotherapeutic agents have been found to very active against KS, both as single agents and combination, current systemic treatment of KS revolves around the newer liposomal anthracyclines, as well as paclitaxel. Older agents that have been used include: doxorubicin, bleomycin, vinblastine, vincristine and etoposide. The liposomal formulation of the anthracyclines provides the theoretical advantage of longer plasma half-life, higher tumor concentration of drug, and less toxicity in non-target organs: in other words, a better benefit-to-risk ratio compared with conventional chemotherapy.
Answer to the case study:
This man may have shingles as an opportunistic infection of HIV or he might have shingles for no known reason; many people of his age get shingles.
Offer this man an HIV rapid test and if it is negative, prescribe acyclovir and analgesics.
If the HIV rapid test is positive, then you must decide if the man is now a candidate for antiretroviral therapy. Usually infection with Varicella Zoster alone is a rather early manifestation of HIV and treatment with ARV's may be delayed, but as per the clinical guidelines, a CD4 count below 200 / mm3 would be a clear indication to start ARVs.
To shorten the acute stage of shingles, prescribe acyclovir 800 mg five times a day for seven days.
For pain, give paracetamol with codeine or dihydrocodeine. Calamine lotion or liniment may also be prescribed as topical aids. Many rural Africans use the sap of the frangipani tree as a lotion for relief of pain.
Announcement: Change of address
From July 2005 onwards, the new address for NANASI will be:
1) Postal address: PO Box 64559 - 00620 Mobil Plaza, Nairobi, Kenya
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