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NANASI 37: April 2005

NANASI 37: April 2005

In this issue of NANASI:

  • The new editorial board for NANASI
  • Case Study: Cotrimoxazole lapsed
  • Q & A: Strategies to improve adherence to treatment
  • Peripheral neuropathy and HIV
  • Q & A: Running out of chase buffer
  • Q & A: Importance of multivitamins


New NANASI Editorial Board

Dr Richard Brown and Dr. Judith Brown, who founded and edited NANASI, will be leaving Kenya soon. They have handed over this great project to a new editorial board:

- Dr. Aziz O. Abdallah  Liverpool CT and Care Kenya
- Christa Cepuch  Health Action International (Africa)
- Dr. Robert Kimutai  HIV/AIDS Program, US Army Medical Research Unit (Kenya)
- Jane Meme   Nazareth Hospital (HFC)
- Dr. Annerose Kaiya  Afriafya
- Beth Muehleisen  Tenwek Hospital
- Elizabeth Amailuk  Health Action International (Africa)

We will be looking for your continued support to continue this great work and to help our brothers and sisters.


CASE STUDY: Cotrimoxazole lapsed

This 31-year-old man is HIV sero-positive.  He does not take ARV's, but he had been taking cotrimoxazole for 6 months. He has not been troubled with diarrhea, which first brought him to clinic six months ago. His weight is stable. Although he does not feel entirely well, he has been working at his job as a part-time carpenter.

For the past two months, he has not taken any cotrimoxazole. Today he comes to clinic saying that he wants to start ARV drugs. He says that he thinks he can earn enough money to pay for them.

  • How would you manage this patient? What advice would you offer him?

Discuss the case as a group, and then refer to the comments on another page of this NANASI

Q & A: Strategies to improve adherence

QUESTION from a nurse in a district hospital in Nyanza Province: How can we help our patients to adhere to antiretroviral therapy (ART)?

ANSWER from Liverpool VCT counseling department:

Adherence to ART is well recognized to be an essential component of individual and programmatic treatment success. Higher levels of adherence are associated with improved immunity. Compliance rates exceeding 95% are desirable in order to maximize the benefits of ART. This means taking the drugs at the right time, correct dose and observing any dietary restrictions.

The proper education of patients before the initiation of therapy is vital for the success of adherence strategies. Such education should cover basic information about HIV and its manifestations, the benefits and side effects of ARV medications, how the medications should be taken and the importance of not missing any doses.

General measures that can help to increase adherence

  • Do not rush into starting ARV's - wait until a patient has shown that they are able to keep a number of appointments at the clinic and adherence counseling sessions
  • Involve the patient in the plan of care
  • Provide simple written information - information on HIV in general, ARVs and adherence issues
  • Use Fixed Dose Combinations (FDCs) if possible (3 drugs in one pill)
  • Ensure a continuous, sustainable supply of drugs
  • Warn patients about common side effects
  • Encourage patients to identify a ‘'Treatment Buddy'' - ideally a house member (or members), who can accompany them to clinic appointments and help to support them with adhering to treatment on a day - to - day basis
  • Use group sessions
  • Ensure all health care workers give the same adherence messages - even brief reinforcement of these messages at every clinic visit is recommended.
  • Keep an organized appointments record - without this the providers will be unaware of patients missing appointments, and hence not picking drugs.
  • Perform a "Readiness assessment" with all patients
  • After the initiation of therapy it is essential to maintain support for adherence. This should involve adherence assessments whenever there is a visit to a health center, reinforcement of adherence principles to the patient by continuous treatment supporters, and the continuous involvement of relatives, friends and/or community support personnel.

In summary, adherence counseling should be an ongoing process during each clinic visit and should be part of all care programs.

Peripheral neuropathy and HIV

Peripheral nerve damage is one of the most common neurological complications of HIV/AIDS.

HIV associated sensory neuropathies include:

  • Distal sensory neuropathy (DSP) (the most common, which occurs in the advanced stages of HIV disease)
  • Antiretroviral drug toxic neuropathy (ATN) caused by stavudine, zalcitabine and didanosine (NRTI's).

These two forms of neuropathies are phenotypically identical, and form the commonest neurological disorder, affecting 30% of patients. Usually there are no visible signs of this condition, only symptoms: burning pain, tingling and numbness of the toes and feet.  

Later, the patient might suffer painful involvement of the ankles, calves and fingertips and eventually, diminished Deep Tendon Reflexes (DTR).The pain is typically bilateral, of gradual onset and usually most severe on the sole of the foot.

Symptoms are generally worse at night and can be aggravated by innocuous stimuli, such as bed sheets or wearing shoes. Abnormalities on examination include reduced or absent ankle reflexes and increased vibratory and pin thresholds.

DSP is associated with advanced HIV disease. Lower CD4 count and higher viral load are risk factors.

While the incidence of most neurological complications of HIV has fallen with the introduction of ART, neuropathies have become more common, coinciding with the use of antiretroviral drugs (i.e. stavudine and didanosine).

The only distinguishing characteristic of antiretroviral drug toxic neuropathy is the temporal association with the use of antiretroviral drugs especially the NRTI's.

Otherwise, the two conditions are virtually indistinguishable. The onset of antiretroviral drug toxic neuropathy ranges from one week to 6 months, depending on the NRTI and the patient's dose. Symptoms may continue to worsen after discontinuation of the offending agent, followed by improvement in most (two-thirds) but not all patients over a period of weeks to months.

What other things can cause peripheral neuropathy apart from HIV and antiretroviral drugs?

Neuropathies can also be caused by diabetes mellitus, hypothyroidism, alcohol, Vitamin B12 deficiency, metronidazole (use more than 2 weeks), dapsone and vincristine.

If the patient already is taking ARV drugs, these drugs may have to be reduced or changed depending upon the severity of DSP symptoms.  The patient should move his feet and walk around as much as possible. For relief of pain, one should give pain medications in a stepwise fashion in accordance with the WHO analgesic ladder until relief is obtained. 

The following drugs are recommended:

Paracetamol 500 mg  q4h.
Ibuprofen 200-400 mg. q6h.

Amitriptyline 25-150 mg. nocte.
Phenytoin 100-200 mg bid.
Carbamazepine (Tegretol)  200 mg.  bid.

LATER (for severe or refractory pain) ADD: 
Dihydrocodeine (DF 118)   15-30 mg. q4-6 h.
Morphine 5-10 mg. q3-4h.

Currently, the only therapies shown to be effective are lamotrigine and recombinant human nerve growth factor, of which the latter is not commercially available and there are no plans currently to develop this agent for clinical use. Lamotrigine is an anticonvulsant that has a therapeutic effect seen more in antiretroviral drug toxic neuropathy than distal sensory neuropathy.

Q & A: Running out of chase buffer

QUESTION from a diagnostic counselor in Eastern province: Often the chase buffer for my Determine test kits is used up before all the 100 tests have been used. How can I deal with this problem without throwing away unused tests?

ANSWER from a laboratory technician in a large Central Province hospital:

The Abbott Company, which manufactures Determine tests, provides just enough chase buffer for the 100 tests of each kit. On-the-ground experience in real-life situations proves that more chase buffer is often needed and that the Abbott Company should provide a larger quantity with each kit.

However, we have found a way to deal with this problem. Normal saline (Nacl 0.9% solution), one drop per test, will give an accurate test result. Negative results are sure and positive results are sharp. Have your laboratory prepare normal saline in small dropper vials for use in HIV testing.

While genuine chase buffer is always preferred, substitution with normal saline will give acceptable results. 


Q & A: Multivitamins for people living with HIV/AIDS

QUESTION from a nurse at a health center in Nairobi: Why are multivitamins important for people living with HIV?

ANSWER from Dr. Aziz: Multivitamins may act as potent antioxidants and reduce HIV replication, slowing disease progression, reducing mortality, and helping delay the start of antiretroviral therapy. It is therefore important to offer multivitamins for life to ALL your patients living with HIV/AIDS.


Comments on the case study: Cotrimoxazole lapsed

If this man cannot be relied on to take cotrimoxazole, which is cheap, how can he be expected to take ARVs, which are expensive?

I would explain to the man that ARV treatment is never ending; that he should not start them if there is any chance that he cannot continue them.

Prescribe cotrimoxazole for another two months. See if the man takes them faithfully and returns to clinic as scheduled. At that time, you might feel that he is ready to consider ARV's

(Adapted from Nanasi HIV/AIDS case study book)

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