NANASI 33: December 2004
In this issue of NANASI:
- VERY SICK PATIENTS: HIV and Cytomegalovirus (CMV) disease
- COMMUNITY OUTREACH: The three "T's"
- CASE STUDY: Rash
- SPOTLIGNT: Jamaa Hospital and teenage mothers
- Q and A: Training for chaplains; Viruses in breastmilk
- COUNSELING SHEET "X": Diagnostic HIV testing for sick patients
Very Sick Patients
HIV AND CYTOMEGALOVIRUS (CMV) DISEASE
Most of the world's people already are infected with CMV, but usually it causes no problem unless the person's immune system is greatly compromised. Patients with advanced HIV infection are at risk of developing CMV disease,particularly when the CD4 count falls below 50 cells/mm3. The most important CMV manifestation is destruction of the retina, and this disease is the most common cause of blindness in AIDS patients. Other, less common, CMV involvement can cause gastroenteritis, encephalitis and polyradiculitis.
Early eye disease may be asymptomatic. Later, there may be "floaters", field defects, scotomata or decreased visual acuity. Fundiscopic exam shows peri-vascular, yellow-white retinal infiltrates, with or without retinal hemorrhages.
Once the retina has been destroyed, there is no chance of reversing this destruction. However, prompt therapy can halt the progression of the disease and save vision that remains. The most effective drugs against CMV are ganciclovir, valganciclovir, foscarnet and cidofovir. These drugs are expensive and are best prescribed in a specialized eye unit. After the initial treatment, some drugs must be continued indefinitely or until the immune system is restored by ARV therapy, evidenced by a CD4 count >100 /mm3.
For all patients with advanced AIDS, it is good to institute routine funduscopic screening for CMV retinitis every 2-3 months. At the same time, one should begin ARV therapy with the intention of preserving vision by restoring immunity, shown by a rise in the CD4 count. When the CD4 count rises to >100/mm3, one may stop funduscopic screening.
In short, treat AIDS patients with ARVs before they have evidence of CMV disease. For those who already have evidence of CMV disease, treat that disease in a special eye unit and begin ARVs as soon as possible.
Immune recovery vitritis: Some patients, 4-12 weeks after starting ARV therapy, experience inflammation in the anterior chamber (vitreous) of the eye. This phenomenon is caused by the body's rising immune response against CMV. Do not stop ARV therapy. Send the patient to an eye unit for treatment with systemic or peri-ocular corticosteroids. Not all patients respond favorably.
(With thanks to Dr. Tony Walia, Director, Kikuyu Hospital Eye Unit.)
COMMUNITY OUTREACH: The Three T's
At one rural mission hospital, the community outreach team goes to flower farms, churches, and tea plantations with three types of activities and messages:
TEACHING: The team offers information about AIDS, the importance of being tested, current care and treatment available (and of course a review of the ways to prevent transmission).
TESTING: On the second or third visit, counselors go along to offer confidential VCT services to everyone wanting to be tested.
TREATMENT: From the first contact, the team stresses that good care for an HIV-positive person can prolong life and productivity. An HIV+ team member often tells his personal story. Persons who test HIV+ are directed to a hospital or health center where examination and follow-up care are available.
CASE STUDY: Rash
A 20-year old market woman with WHO Stage III AIDS started ARVs three weeks ago. She was prescribed a triple combination tablet bid, of stavudine 30 mg., lamivudine 150 mg. and nevirapine 200 mg.
Ten days after starting this medicine, the woman broke out with an itchy maculopapular rash, mostly on her trunk and upper extremities. She promptly stopped taking the ARV drugs and came to clinic as soon as she was able. Today her rash is much less than it was a week ago.
HOW WILL YOU MANAGE THIS PATIENT? What questions will you ask?
Will you request any tests? What drugs will you prescribe? What advice will you give?
After discussing this case, read a physician's comment (on another page of this NANASI).
SPOTLIGHT: Jamaa Hospital and teenage mothers
Theresa Masila of Jamaa Hospital, Nairobi, writes about her experiences in the PMCT program in the Ante-Natal Clinic:
The situation: Adjacent to the hospital is Jamaa Home that takes care of teenage unwed mothers, 14-18 years old. They are schoolgirls, housemaids, and school dropouts. Some of the girls are rape victims, others are incest cases, while others like the housegirls have been sexually abused by their employers. I observed that, because of their tender age, they were feeling out of place in groups of mature mothers during PMCT counseling sessions.
Action taken: I give them special sessions of their own, regarding motherhood and also pre-counseling for HIV-AIDS testing. My observation has been that, in their own sessions, they are free to express their fears about HIV testing.
COUNSELLING SHEET "X": Diagnostic HIV testing for sick patients
CATHY - A BARMAID
Cathy, a young woman 24 years old, is single and works as a barmaid. She also sells sexual favors to her customers. Lately her health has been poor, and today she has come to the health center with a severe headache.
The clinical officer recommends an HIV test. Cathy refuses, saying she only came for treatment and does not need an HIV test. The nurse-counselor tries to explain that it is dangerous to treat her without knowing the cause of her headache, so the test is very important.
- What would you have done if you were the clinical officer?
- Should he have ordered the HIV test without asking for Cathy's consent?
The clinical officer was correct in calling for a test in order to learn whether Cathy's headache and poor health might be related to AIDS. Cathy had the right to refuse and, unfortunately, she did.
Diagnostic testing is defined as testing requested by the health worker for people who have symptoms or signs that could be attributable to HIV disease. The main purpose is to provide appropriate care. Patients should be informed, if possible, that the test is being done. A patient has the right to decline testing. If she declines, however, the clinician (doctor, clinical officer or nurse) must make a choice: to proceed with treatment or to decline treatment until a proper diagnosis is made.
In a diagnostic testing, the counseling should focus on the diagnosis and management of illness. If time is limited, it is post-test counseling (not pre-test counseling) that is most important. HIV positive people must be advised about long-term clinical care and follow-up, and also about prevention of HIV transmission.
The clinician often has only limited time (perhaps only 2-5 minutes) to spend counseling HIV positive people on these important topics. If an HIV counselor is not available to spend more time, the clinician can at least give the person a paper with simple printed information about follow-up clinics and prevention, and also some words of encouragement.
Q and A: Training for chaplains
Question from Regina Paul, Tei wa Yesu Family Care Center, Mwingi: Where can our hospital chaplain be trained for AIDS counseling? He will then be able to give our patients spiritual help, and at the same time do HIV-AIDS counseling.
Answer from NANASI: We have found two courses that might be helpful to chaplains. We invite other NANASI readers to tell us about other training possibilities.
Amani Counselling Centre & Training Institute
Short courses "HIV-AIDS Counselling 1" and "HIV-AIDS Counselling 2"
Each course 2 hours per week for 4-5 weeks.
Approx. cost: Kshs 5000
Venue: Mbagathi Way (near Langata Road), Nairobi
For information: PO Box 41738, 00100 Nairobi
Phones (020) 602 672, 602 673, (0722) 656 290, (0733) 263 879
Servants of the Sick Training Centre
Intensive course: "Clinical Pastoral Education"
10 weeks, 40 hours per week
Approx. cost: Kshs 25,000 (plus room, board, transport)
Venue: Argwings Kodhek Close, Hurlingham, Nairobi
For information: PO Box 24585, 00502 Nairobi
Phone (020) 891 935 Fax (020) 890 261
Q and A: Viruses in breast milk
Question #1 from Patrick Mutai, St. Antony's Health Center Abusi: If a mother is HIV+, can the viruses in her breast milk pass through the gastro-intestinal (GI) tract or mucous membrane of her baby?
Answer from NANASI: It is possible, and it does happen sometimes. However, the lining of an infant's GI tract is very tough, and infection usually doesn't pass to an infant who is taking only breast milk, with no other food or milk. Other foods and milk can irritate his GI tract, and the irritation allows HIV viruses to enter. After 4-6 months of age, the infant can do quite well without mother's milk, so he can stop it completely and take other foods. Then he will no longer be at any risk of getting HIV viruses through his mother's milk. That's why we advise any HIV+ woman who wants to breastfeed to do this:
- For the first 4-6 months, give the baby ONLY breast milk - give no other milks or foods.
- When the baby is 4-6 months old, wean quickly and completely - give no breast milk at all.
Question # 2 from health workers in the Kibera slum in Nairobi: For HIV-infected mothers, is it advisable to express breast milk and boil it for the baby? Does this reduce the rate of HIV infection to the baby?
Answer from Dr. Dorothy Mbori-Ngatha, CDC-NASCOP: This method of killing the virus works very well, if it is done correctly, and if the mother has plenty of milk. Some mothers find that it is not practical, or that their milk diminishes if the baby is not sucking.
A PHYSICIAN COMMENTS ON THE CASE "Rash" (page 2) :
Compliment this young woman for stopping her medicines when she sensed that something was wrong and for coming to clinic as soon as she could.
Indeed, starting nevirapine 200 mg. bid often will provoke a rash. Nevirapine should be started at 200 mg. daily for the first two weeks of therapy. Then, if there are no signs of rash, increase the dose to twice daily thereafter.
This woman's rash does not mean that she never will be able to take nevirapine. Because the rash was not severe, restart her treatment at the 200 mg. once daily dose of nevirapine for another two weeks. Instruct her to return if the rash reappears. If it doesn't reappear, then increase to the 200 mg. bid dose, still warning her that if a rash appears, she should return promptly.
The above clinical case is from the book NANASI HIV/AIDS CASE STUDIES
Did you know that another casebook has just appeared?
NANASI HIV/AIDS COUNSELLING CASE STUDIES
=== 101 cases for training doctors, nurses and counsellors in health facilities ===
Both books available from AMREF (Kshs 200 per copy)
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