NANASI 38: May 2005
In this issue of NANASI:
- Q & A: Why do patients ‘default'
- Q & A: HIV infection in malaria endemic areas
- Q& A: New patients who never show up at HIV clinic
- Case Study: Husband positive - wife positive
- Management of Chronic Diarrhea
Q & A: Why do patients "default"* ?
KEMRI recently did a study tracing women who were "defaulters" in an HIV clinic. They found the women were at highest risk of defaulting if they:
- Were under age 24
- Had fewer than 8 years education
- Were married.
These were lessons learned in the study:
- Couple counseling helps patients stick to the right procedures.
- Frequent home visits are necessary to patients who are very ill, because they tend to move quite often and may be lost to follow-up.
- Simple written materials can help patients and families understand what to do.
- Clinic staff should encourage patients to participate in support groups, and should show genuine interest in what the groups are doing.
Study reported at annual meeting of University of Nairobi STD/AIDS Collaborative Group, January 2005
* Note from NANASI editors: We don't really like the word "default". It seems to put the fault and the blame on the patient. Actually, the problems may be in the family or in the community. In fact, the clinic staff may be the real ones at "fault" if they did not take the time or make the effort to understand the patient, the home situation, and the difficulties that might occur.
What other words can we use? "Non-compliance" also suggests that we know exactly what the patient should or should not do, and that the patient's duty is to comply with what we say is best. What about "adherence"? That means sticking to something or to some procedure. It seems a bit less judgmental. In any case, all three words are abstract and difficult. We should not use them at all when talking with patients, with families, or with community workers!
Q & A: Why is HIV infection more prevalent in malaria endemic areas?
Question from a medical doctor in a primary health care facility in Nairobi
Answer from AfriAfya Knowledge Management Unit
There is strong proof of the relationship between HIV infection and malaria today. The January 15th issue of Lancet confirms this. It reports that the viral load of HIV nearly doubles when there is also malaria infection in the same patient. Treatment of malaria brings a drop of the viral load. This means that a patient infected with both malaria and HIV is more likely to infect others with HIV because the viral load is high at the time.
Studies done in Kenya and Zimbabwe also indicate that this is more so in pregnant women.
As it is, pregnant women are at an increased risk of malaria infection. Low birth weight babies, pre-term delivery and other complications of malaria in pregnancy are higher when the mother is HIV positive. Death of the mother or the baby is also more common when both malaria and HIV infections are present. Due to the higher viral load during malarial infection, mother-to-child transmission is more likely.
A UNICEF report of February 2003 shows three relationships between malaria and HIV:
HIV infection increases the risk of contracting malaria and increases the severity of the disease. 25 % - 30 % of adults with malaria are HIV positive and this is an important consideration for the health care worker. Prophylaxis with Cotrimoxazole reduces the incidence of malaria amongst those infected with HIV by up to 80 % in studies done in Uganda.
Malaria infection worsens HIV infection by increasing the viral load and the chances of transmitting the disease through body fluids. There is reduced immunity and therefore an increased chance of opportunistic infections.
Malaria infection causes anemia that is often severe enough to require blood transfusion. Frequent blood transfusion or the use of unscreened blood in resource-poor settings increases the risk of HIV infection.
The recommendation is aggressive prevention of malaria infection in HIV infected patients through the use of insecticide-treated mosquito nets, prophylaxis, etc. Early treatment of malaria in HIV positive patients is very important. Finally, it is important for health care workers to be on the look out for HIV infection when treating cases of severe malaria among adults.
Q & A: New patients who never show up at HIV clinic
QUESTION from a nurse in a maternal and child health unit: We now test about 90-95% of new women in our ante-natal clinics every month. Of course, we tell any HIV+ woman about our hospital's HIV clinic. But very few of them ever show up there.
What can we do to make sure these mothers get the HIV clinical follow-up they need, so they can stay healthy and active?
ANSWER from nurses in another ante-natal clinic (ANC):
We have had the same problem. We are inviting a staff member from the HIV clinic to come each day we hold ante-natal clinic, to give a talk on what the clinic offers to HIV+ people. This will make the women feel they are being followed without being stigmatized.
Also, the HIV+ mothers in ANC will already be familiar with the person from the HIV clinic. They will not feel shy, and they will be able to trace that person for clinic follow-up.
ANSWER from a pediatrician:
We had the same referral problem with HIV+ children when they were discharged from the children's ward. We told the parents where the HIV clinic is located, and we gave them a special clinic card with a return date for the child's first clinic visit. Even so, most of them never went to the HIV clinic.
Finally, I decided to walk with the parent and child to the clinic room and introduce the new child patient to the clinic staff. When I don't have time to do this myself, I ask one of our ward support staff to accompany the parent and child and introduce them. Or I call an HIV clinic counselor or a volunteer to come fetch them and introduce them to the clinic room and the staff.
Case study: Husband positive - wife positive
A husband and wife together come to the clinic because both had been tested at a Voluntary Counseling and Testing center (VCT) and both are sero-positive. They have no adverse clinical signs or symptoms. They have been happily married for eight years and both work in factory jobs.
The couple has two children; the boy is in primary school and the girl is aged 2 years.
The children appear to be in good health.
How would you manage this couple?
What advice would you offer them?
Discuss the case as a group, and then refer to the comments on another page of this NANASI.
VERY SICK PATIENTS
Chronic diarrhea is defined as "three or more liquid stools a day, continuously or off and on, for more than one month." While acute diarrhea can occur in any patient, chronic diarrhea usually is an indicator of advanced HIV infection and occurs in over 50% of patients at some point during their illnesses.
Specific pathogens may be isolated in up to 75% to 80% of patients with chronic diarrhea.
The differential diagnosis includes the following pathogens:
Bacterial infection: Campylobacter, Shigella, and Salmonella species
Protozoal infection: Cryptosporidium species, Giardia Lamblia, Isospora Belli,
Entomoeba histolytica, Microsporidium species
Toxin Induced: Escherichia Coli and Clostridium difficile
Mycobacterial infection: Mycobacterium tuberculosis
Viral Infection: cytomegalovirus, Herpes Simplex Virus
The evaluation of the patient includes questions about duration; frequency; severity; consistency of the stool; and presence of concomitant symptoms, such as fever, abdominal pain, tenesmus, and weight loss. It is also important to take a history of previous antibiotic use because frequent hospitalization and exposure to antibiotics puts HIV patients at high risk of infection with a toxin-producing strain of Clostridium difficile.
Whenever possible, the cause of the diarrhea should be established and specific treatment provided. Failing this, management is symptomatic.
There are five steps in the management of a patient with chronic diarrhea.
1) Treat dehydration. Oral rehydration is best, and extra potassium can be given in the form of bananas, tomatoes, and papayas, or by potassium tablets. If the patient cannot tolerate oral fluids, intravenous solutions containing potassium can be used. They are:
Lactated Ringers Solution (Hartmann's Solution) or normal saline to which 1 vial of 15 % potassium chloride (40 mmol.) per liter has been added. (Intravenous dextrose solutions are not warranted in the rehydration of a diarrhea patient because they replace none of the salts which have been lost in the diarrheal stool.)
2) Nutritional support. This is very important to avoid wasting. Try giving regular small meals as tolerated by the patient. A high energy and protein intake reduces the degree of muscle wasting.
3) Learn if the stool contains blood (RBCs and/or WBCs) or if it is watery without blood cells. A microscopic examination of the stool will help to make this determination.
Microscopy also will show if the patient is infected with trophozoites of amoeba or giardia.
4) Give appropriate antibiotics.
For bloody stools (containing RBCs / WBCs) give:
Cotrimoxazole tablets 960 mg BID for 5-7 days (if patient was not on prophylaxis before)
Ciprofloxacin 500 mg BID for 7 days
Norfloxacin tablets 400 mg BID for 7 days
Ofloxacin 400 mg BID for 7 days
Metronidazole tablets 400 mg TID for 7 days
It is clinically impossible to distinguish the different agents without stool culture. Therefore, if treatments above are not effective, try erythromycin (500 mg BID for 5 days) if symptoms of bloody diarrhea persist (for Campylobacter).
The quinolones (ciprofloxacin, norfloxacin, ofloxacin and others) are the preferred agents in cases of bloody diarrhea, so use them whenever possible.
For watery stool (without RBCs nor WBCs) give:
Cotrimoxazole tablets 960 mg TID for 10-14 days
And / or
Albendazole tablets 400 mg BID for 14-21 days.
Adjunct treatment for unremitting chronic diarrhea may be started after the above treatments have been underway for 3-5 days and visible blood has cleared. These medicines only give symptomatic relief. Commonly used adjunct treatments are:
- loperamide tablets 2 mg. Give 1 tablet after each stool. Max 6 tablets / day.
- codeine phosphate tablets 30 mg. Give 1 tablet every 4-6 hrs as needed.
- dihydrocodeine tablets 30 mg. Give 1 tablet every 4-6 hrs as needed.
5) Prevent future attacks of diarrhea by maintaining the patient's intake of cotrimoxazole. Give one cotrimoxazole tablet 960 mg daily for life. If chronic diarrhea does not respond to the above treatments, transfer the patient to a larger hospital center where more advanced diagnostic and treatment possibilities are available.
These medicines to treat chronic diarrhea are available from MEDS in Nairobi:
cotrimoxazole tablets 480 mg.
metronidazole tablets 400 mg.
norfloxacin tablets 400 mg.
potassium chloride 15% IV solution (40 mmol./ 10 mL vial)
potassium slow release tablets 600 mg.
Oral Rehydration Solution packets 500 mL.
dihydrocodeine tablets (DF-118) 30 mg.
loperamide tablets (Imodium) 2 mg.
Comments on the case study: Husband positive - wife positive
It is important to register and follow patients as soon as they test positive for HIV, regardless of whether they are symptomatic or not. This asymptomatic couple should undergo evaluation. As for all patients who come to the clinic, they should have a complete medical history, physical examination and laboratory evaluation (whenever possible). The purpose is to determine:
- Staging of HIV infection
- Presence of co-infections
- Concomitant medications, including traditional therapies
The evaluation of the couple should include a social assessment, substance abuse, other illnesses, adherence counseling and other factors that might impact on adherence. The WHO staging of the HIV infection should be done at this point. All patients should then be started on cotrimoxaxazole (septrin) 960 mg daily and 1 multivitamin tablet daily.
After this, give them appointments for review every 2 - 3 months. Although the children, might possibly but not likely be infected, I would not call them for testing unless symptoms appear. Below is a summary of the importance of cotrimoxazole and multivitamins.
There is now evidence showing important benefits of cotrimoxazole for ALL HIV patients, regardless of the stage of their disease or their CD4 count. The benefits are as follows:
Prophylaxis against Toxoplasmosis
Prophylaxis against PCP pneumonia
Prophylaxis against common bacterial infections
Slow decline of the CD4 cells
Slow rise of viral load
Decrease in death rate by 46% (in patients with CD4 count <200)
Decrease rate of malaria by 72%
Fewer hospital admissions
ALL HIV patients should be offered cotrimoxazole prophylaxis for life at a dose of 960 mg daily.
Multivitamins may act as potent antioxidants and reduce HIV replication, slowing disease progression.
Multivitamin supplementation can delay HIV disease progression, improve mortality, and help delay initiation of antiretroviral therapy.
Therefore ALL HIV patients should be offered multivitamin supplements for life.
-- Something for small dispensaries --
Nazareth Hospital announces a special program designed to assist small dispensaries and health centers to care for persons infected with HIV. This program will send to your health facility an experienced AIDS nurse who will instruct staff on how to:
Counsel and test patients
Monitor and record patient progress
Prevent and treat common opportunistic infections
Evaluate the need for referral to centers for ARV treatment
REMEMBER: most people infected with HIV do not need ARV medicines yet, but they do need regular care and monitoring. Moreover, most small facilities should not and cannot properly provide ARV treatment; larger facilities with advanced laboratories and more experienced personnel are required.
However, small facilities are extremely important in the fight against AIDS and Nazareth Hospital can help dispensary personnel develop these basic skills. We are limited to helping only dispensaries which are less than 1 hour's matatu ride from Nazareth Hospital.
For assistance and information in developing an HIV program for your dispensary, contact Miss Nkatha Njeru, tel. 0733-853456 OR 020-342185 OR 020-6752911 OR 066-50700 Ext. 68.
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