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NANASI 35: February 2005

NANASI 35: February 2005
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In this issue of NANASI:

  • Q & A: When ARVs are stopped 
  • The future of NANASI
  • Q & A: Vaccinations for babies of HIV+ mothers
  • VERY SICK PATIENTS: Fever
  • CONDOMS: Who is more moral ?

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Q & A: When ARVs are stopped

Question from staff of a Nairobi project: What happens when a person stops taking ARVs?

Answer from NANASI:

HIV viruses begin to multiply very rapidly. 
CD4 cells ("immunity cells") begin to die.
Opportunistic infections arise.
The ARV medicines become less effective, because the viruses mutate (change) and are less susceptible to the medicines.

Don't let your patients stop taking ARV medicines !

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The future of NANASI

NANASI will soon complete its third year of publication. The yellow newsletter now has a circulation of 500 copies, and we are indeed grateful to Action Aid for photocopying and mailing it every month.  The special characteristics that have made NANASI useful and well-liked throughout Kenya are these:

  • Writers and readers are people doing AIDS work in health programs in resource-limited settings.
  • Topics are suggested by needs on the ground.
  • The articles mention only products and procedures that are available and affordable in Kenya.
  • The writing style is simple, direct English.

The next issue, NANASI No. 36 (March 05), is the last issue that will be edited by Richard and Judith Brown. (They will be based in Kenya for only a few months of the coming year.) 

A search is on for new editors. Do you know a person or group who could take over the editing of NANASI, following the principles outlined above? If so, the Browns will be happy to share the know-how, mailing list, and lessons learned over the past three years.


Q & A: Vaccinations for babies of HIV+ mothers

QUESTION from nurses at an MCH clinic: We have many HIV+ mothers bringing babies for post-natal care and immunizations. Should we give those babies the routine vaccines during the first year of life?

ANSWER from an article by Dr. Elizabeth Obimbo: Yes, they should receive all the routine vaccinations prescribed by the Kenyan Ministry of Health. 

The problem with children born to HIV+ mothers is that it is difficult to know if they really have HIV infection.  The usual antibody tests that we use (Determine, Unigold, Capillus, ELISA, etc.) are not helpful in giving this information, because antibody tests all show "positive" in children of HIV+ mothers for up to 18 months after birth (whether the child is actually HIV-infected or not). An expensive test (PCR) sometimes is available in advanced laboratories, but it is difficult to access for most Kenyan families.

So, because of the possibility of some of the babies being infected with HIV, every baby born to an HIV+ mother should get an extra measles vaccination at age 6 months, plus the routine measles vaccination at 9 months. Measles can be a particularly serious infection in children who happen to be HIV+.

If at birth the baby of an HIV+ mother appears sick, then the baby should get all the routine vaccines as scheduled, except BCG.

About cotrimoxazole:

All women who are HIV+ should receive cotrimoxazole, 960 mg. per day for life.

All infants born to HIV-infected mothers should receive cotrimoxazole prophylaxis, beginning at 4-6 weeks of age.   Because of their immature immune system, prophylaxis should continue at least through the first year of life (or until the infant is found not to be infected with HIV).

Age 1-6 months: give 100/20 mg cotrimoxazole daily (½ tsp. suspension)
Age 6-12 months: give 200/40 mg cotrimoxazole daily  (1 tsp. suspension)
10 Kg child: give 200/40 mg daily (1 tsp. suspension or 1 pediatric tablet)
15 Kg child: give 300/60 mg daily (1½  tsp. suspension or 1½  ped. tabs.)
>20 Kg child: give 400/80 mg daily (2 pediatric tabs or 1 adult tab.)

MEDS supplies generic cotrimoxazole in three formulations:

tablets (400/80mg)   
pediatric tablets-flavored (200/40mg)      
suspension (200/40mg/ 5 ml) 

(Excerpted from the excellent article by Dr. Elizabeth Obimbo in the April-June 2004 edition of Vaccines Quarterly) 


VERY SICK PATIENTS
Fever

Fever is a common manifestation of AIDS and its opportunistic infections. Fever is not always a bad sign, and usually it does not require immediate treatment. Fever often is a valuable sign to tell us that something is wrong! The best clinicians first try to find the cause of the fever and treat the cause rather than treat the fever itself.

If a patient comes to hospital with fever, take a good history to know how many days he/she has had the fever, when in the day or night the fever is worse, and if it is associated with other symptoms such as cough, chills, headache, dysuria, etc.

Do a  thorough physical examination, giving special attention to the lungs, abdomen, skin and lymph nodes.

Order a few basic laboratory tests:

malaria parasite smear
CBC with differential
urinalysis
sputum examination

Sometimes the cause of fever cannot be found for certain, but four possible causes should be considered:

1. Malaria is the most common cause of fever in Kenya. Consider treating first for malaria, unless evidence indicates otherwise.

2. Non-typhoid Salmonella septicemia is a very common cause of fever in AIDS patients, but it is not easily diagnosed. If you suspect fever may be caused by non-typhoid Salmonella septicemia, you may give a therapeutic trial with:

chloramphenicol, oral or parenteral, 60 mg. per Kg. in four divided doses each day.       

For example, give to a 50 Kg. patient three caps (250 mg. each) chloramphenicol, every 6 hours, for 1-2 weeks.
OR
cotrimoxazole 960 mg (two tablets), twice a day, for  2-4 weeks.

NOTE: If the patient has always taken cotrimoxazole, 2 tabs daily, he/she should have very little risk of suffering from non-typhoid Salmonellosis.

OR

ciprofloxacin (Cipro) 500 mg. twice a day, for 1-2 weeks.  You may extend this treatment longer if the patient is severely immuno-suppressed (CD4<200 / mm3).

NOTE:  Cipro (as with other fluoroquinolones)  usually is effective against most

Salmonella organisms.  However, Cipro also is effective against tuberculosis. If one gives Cipro for Salmonella, and the patient also has a tuberculosis infection, then one risks creating a strain of tuberculosis that is resistant to a drug that may be required for tuberculosis in the future. Be sure that your Salmonella patient does not have tuberculosis before you use Cipro!

3. Fever due to HIV infection: Infection with HIV sometimes can be the cause of fever.  Yet, it is not wise to assume that HIV is the cause until all other possibilities have been exhausted and therapeutic trials have been attempted.

4. Drug fevers: these sometimes perplex the clinician because the clinician believes he is helping the patient with his medicine, while it is the medicine that is the cause of the fever. Antibiotics, sulfonamides and anticonvulsants often are the cause of drug fever. As a trial, stop some of the medicines that the patient is taking and see if the fever subsides in a few days.
 
Other causes of fever, which might require additional tests are:

extra-pulmonary tuberculosis   leishmaniasis (kala-azar)
sepsis      typhoid
urinary tract infections    viral hepatitis
meningitis/encephalitis   abscess of the viscera
brucellosis     malignancies
pneumonia (streptococcal, pneumocystis, tuberculous)

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CONDOMS - Who is more moral ?

From The East African, 27 Dec 2004 - 2 Jan 2005

Rev. Gideon Byamugisha of Uganda was the first African Anglican priest to declare openly that he was living with the HIV virus....  Rev. Byamugisha told The East African that HIV/AIDS prevention strategies are not moral issues of right and wrong and that people who choose to use condoms should not be condemned as being immoral.

He said, "Being faithful alone is not enough; the fight against HIV/AIDS should not be a hierarchical moral order. Morality is not only restricted to abstinence and being faithful.

"A person who ensures that he always uses a condom is morally superior to someone who is faithful to one person but infects that person because he does not know his status. 

People who use condoms are very moral; they are conscientious and plan their sexual lives."

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