NANASI 36: March 2005
In this issue of NANASI:
- CASE STUDY: Genital ulcers
- Q & A: PMCT mothers who deliver elsewhere
- Question: What about unbooked deliveries?
- Q & A: A safe environment to break the news
- VERY SICK PATIENTS: Lactic acidosis
- COUNSELING SHEET "Z": Marlene plans to marry
CASE STUDY: Genital Ulcers
A 38-year-old, divorced woman has returned to clinic because of the recurrence of painful sores of the labia minora and painful intercourse. She had similar lesions last year, but this year there are more sores, and the pain is worse.
In addition, she has experienced a whitish vaginal discharge which aggravates the sores. The woman washes dishes and cleans in a restaurant. Recently she could not work because of her discomfort and tiredness.
On inspection, there are about one dozen lesions, which appear as discrete 2-8 mm. ulcers with a reddish base. There has been no weight loss or other general finding.
HOW WILL YOU MANAGE THIS SITUATION ?
- What questions will you ask the patient?
- Will you request any tests?
- What drugs will you prescribe?
- What advice will you give?
Discuss this case in a group, then read the comment (on another page of this NANASI).
"The physician who knows AIDS knows medicine"
Q & A: PMCT mothers who deliver elsewhere
Question from nurses in an active PMCT program: How do we deal with administering the preventive medicines to HIV+ mothers who do not deliver in hospital?
Answer from NANASI:
You are not the ones who needs to "administer" the medicine! Remember, the prevention pills should be taken when labor begins. Labor begins at home, so the woman needs to have the pills at home with her.
You can give the pills to the woman anytime after she has tested HIV+, and well in advance of her delivery date. That way, as soon as labor begins, she herself can start taking the pills. Wherever the woman delivers, she knows she has done her best to protect her baby.
Some nurses ask, "But what should I do if the woman loses her pills before her delivery time?" The answer is simple - Give her more pills! (These pills cost very little, and you may save her baby's life.)
Question: What about unbooked deliveries?
Pumwani Maternity had 22,000 deliveries last year, and 50% were "unbooked" (the women did not attend ante-natal care at Pumwani).
Kenyatta Hospital Maternity had 8,000 deliveries, and 60 % were "unbooked".
(Statistics from a recent University of Nairobi study)
- What do you do in your maternity department?
- Are you providing PMCT medicines to women in labor who are "unbooked"?
Q & A: A safe environment
Question from hospital-based counselors: An HIV+ person may need a "safe environment" to break the news to a relative or partner.
How can we provide it?
Suggestions from NANASI:
- In medical wards, have a quiet room available, away from public view.
- In VCT and outpatient areas, have an extra room with a "Do not disturb" sign to hang on the door.
- Help the HIV+ person plan in advance how to break the news. Suggest practice with an empty chair (by pretending that the partner or relative is sitting there).
- Ask how that person might react and what will happen next.
- Offer to be present or available, if the HIV+ person wants you to be.
- When the people are together, give them plenty of time for anger, crying, shock, despair, love, prayer, etc. Be available to answer their questions, and encourage them to come back again.
COUNSELING SHEET "Z": MARLENE PLANS TO MARRY
Marlene is 23 years old, HIV positive, and has been taking antiretroviral medicines for about a year. She looks and feels good, and her lab tests show excellent response to treatment.
Marlene tells you she is planning to get married. A friend has told her she should not marry, but Marlene cannot accept that. She is asking for your opinion.
FOR DISCUSSION AND THOUGHT
- What questions will you ask Marlene?
- What information does Marlene probably need?
SOME QUESTIONS TO ASK MARLENE
- Do you know, Marlene, whether your fiancé is HIV positive or HIV negative?
- Does your fiancé know you are HIV positive?
- Does he want to have children? Do you?
- You say that your recent laboratory test shows that you have no "detectable" HIV viruses in your blood. Do you know what that means?
- Does your fiancé know you are taking ARV medicines? Will he help you?
INFORMATION MARLENE AND HER FIANCE MAY NEED
Information about HIV viruses
Marlene still has HIV viruses in her body. Even when antiretroviral medicines are working well, many viruses remain, and they may reproduce more every day. As far as we know, Marlene will always have HIV viruses, she will always have to take ARVs, and she will always be able to pass viruses to other people.
Information about ARV medicines
Marlene has been taking ARVs very well during the past year. Ask her how she managed to do that, and who helped her. Will she lose that particular person's close support if she gets married?
A recent study at KEMRI found that these are the people least likely to take their ARVs correctly:
- Under age 24
- Less than 8 years of school
Will marriage turn Marlene into a poor ARV patient? That could happen, unless her husband encourages, supports and reminds her to take her medicines.
Information about marriage, and about infecting spouse and infants
Let's consider the different possibilities:
- If an HIV positive person marries an HIV-negative person: They can live in the same house without fear that the HIV-negative person will get infected. But if they have sexual relations, they will never be free from that fear. To put it another way, they can eat together, sleep in the same bed, enjoy each other, touch, hug and show affection. But if the man's penis enters the woman's vagina, there is a chance that HIV viruses will pass from the infected person to the other person. Condoms can reduce greatly the chance of HIV infection, but they are not 100% effective.
- If an HIV positive person marries an HIV positive person and they have sexual relations without a condom, they may be passing new and different types of HIV viruses to each other. The new combined HIV strains may make their illness worse.
- The couple must decide whether they want children and if so, when. If they do not want children at all (or not at a particular time), they need to use good and effective contraception. If an HIV positive woman becomes pregnant, she must get good antenatal care and follow the best PMCT procedures. Even if she follows all instructions about labor, delivery and feeding her babies, no one can guarantee that her children will be free of HIV.
So - should Marlene get married? She and her fiancé must know each other's status and also the facts about HIV. They need to think realistically about the future, and they need to talk with their family and friends. Only then will they be able to make a good decision.
VERY SICK PATIENTS
Lactic Acid is a by-product of the normal metabolism of almost every cell of our body. Usually lactic acid is produced and removed from the cell physiologically, and it causes us no harm. Yet, some HIV patients who take anti-retroviral drugs (ARVs) develop a very high lactic acid level, which is a result of the ARV's action upon certain enzymes within the cell. A high lactic acid level is called, "lactic acidosis" and it can cause the HIV-patient to become seriously ill and even die. For this reason, it is good for clinicians to be aware of the possibility of lactic acidosis if their ARV patients are not doing well. Some consultants estimate that lactic acidosis occurs in fewer than 1 in 200 patients taking ARVs.
The ARVs that can lead to lactic acidosis are Nucleoside Reverse Transcriptase Inhibitors (NRTIs). Three particular NRTIs are often associated with lactic acidosis, especially if two of these are used together.
stavudine (D4T), the most common offending NRTI
didanosine (DDI), a particularly common offender when used with stavudine
zidovudine (AZT, ZDV), a less common offending NRTI
- Lactic acidosis occurs more frequently in women than in men.
- Lactic acidosis occurs more often in women who are pregnant.
- Lactic acidosis often occurs in persons who are overweight or obese.
- It arises gradually in patients who have taken NRTIs for a month or longer.
The most common symptoms of lactic acidosis are:
nausea and vomiting
loss of appetite and weight loss
burning or tingling sensation
The diagnosis of lactic acidosis is made properly by laboratory analysis of the blood lactate level. This test is difficult to perform and must be done in specialist laboratories.
In resource-limited settings, patients who take NRTIs and who experience the above symptoms can be suspected of suffering lactic acidosis if there is:
elevation of liver enzymes: SGPT (ALT) or SGOT (AST).
low blood bicarbonate (HCO3-) levels
- stop all ARVs immediately
- ensure adequate blood pressure with intravenous saline
- give vitamin B complex, orally or intravenously, twice daily
- general supportive therapy
- Continue this supportive care for some weeks or until the patient shows clinical improvement. Do not restart the same NRTI drugs. Choose another ARV regimen instead.
(with thanks to Dr. T. Macharia and Dr. S. Moore)
A DOCTOR COMMENTS ON THE CASE "Genital Ulcers" (page 1):
This woman has a return of her genital Herpes simplex ulcers. One may reduce the severity and duration of these lesions with acyclovir 400 mg. tablets tid for 1-2 weeks. Some consultants find that topical DMSO (dimethyl sulfoxide) gives good results.
The woman reports tiredness and thus should be tested for HIV. If the HIV rapid test is positive, a CD4 count or total lymphocyte count should give a general idea of the degree of immuno-suppression of this woman. Give her prophylactic cotrimoxazole, and have her return for weighing and review every two months. Eventually she will need ARVs.
It is likely that the woman also has vaginal candidiasis and should be given appropriate treatment.
1) New guidelines for post-rape care:
Available from Ministry of Health (NASCOP or Division of Reproductive Health) and from Liverpool VCT, Hurlingham, 020-2714590 or 2723612
2) A pair of casebooks:
NANASI HIV/AIDS CASE STUDIES 2004
NANASI HIV/AIDS COUNSELLING CASE STUDIES 2005
Available from AMREF (Kshs 200 per copy) E-mail:
Tel: 020-605220 or 605331 (extension 110) Fax: 020-609518
Also on sale in Nairobi bookshops
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