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NANASI 32: November 2004

NANASI 32: November 2004

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In this issue of NANASI:

  • CASE STUDY: Painful leg     
  • Q and A: Caesarean sections; When to tell a child he is HIV+
  • VERY SICK PATIENTS: Shingles       
  • What is the frangipani tree?  
  • Simple classification of ARV drugs       
  • COUNSELING SHEET "W": Without my knowledge, without my consent; On silence and listening

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CASE STUDY: Painful leg

A 48-year-old construction worker has suffered with a painful right leg for more than a year. At a previous clinic, he was treated with injectable chloramphenicol and streptomycin. Later the pain was associated with more swelling and difficulty walking, yet he kept reporting to work.

Today in clinic, you see a strong man who weighs 74 kilograms. His left leg and foot are darkened and swollen with a woody consistency. The leg is painful, but not tender. He cannot wear his left shoe.

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?

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We suggest you discuss this case in a group, and write your answers. Then read together a physician's comment (on another page of this NANASI).

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Q and A: Caesarean sections

Question from health workers in Nairobi: Many HIV+ pregnant women are worried about opting for a Caesarean section because of the high cost involved.  What would you advise?

Answer from Nanasi: In the past, a Caesarean section was recommended for HIV+ women.  Nowadays, since nevirapine plus other medicines are available for the mother to take before delivery, Caesareans are not done very often. Taking the medicine is much, much cheaper and is just as effective. Ask a PMCT counselor for details.


Q & A: When should a child be told?

Question from NANASI (July 2004): At what age should a child be told that he or she is HIV+?

Answers came from two readers:

No. 1 - Dr. Miriam Wanjala, Ortum Mission Hospital wrote: It is not really the age that is important but the knowledge the child has about HIV, and especially in relation to himself or herself.  A child who is HIV+ will discover with time that his lifestyle is somehow a bit different from that of other children.  He will note that he visits the doctor more often and takes medicines more often than other children. 

The child will therefore start asking questions, which the guardian should try to answer as honestly as possible. As the questions increase and the child's knowledge on HIV-AIDS increases, the guardian should then have a long chat with the child and reveal to him his HIV status. There should be not a cut-off age limit to do this, but it should depend on the child's development.  In other words, any child of school-going age with enough intelligence to know about his well-being can be told about his HIV status.

No. 2 - Rev. Janerose Muriuki, Kerugoya wrote: I would suggest the age of four years and above. Here are my reasons:

  • The child can understand the language.
  • To avoid the child's being misguided by relatives, age-mates, etc.
  • To let the child accept and understand oneself
  • As questions arise, the child knows that it's okay to ask, and that the questions will be properly answered.

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A PHYSICIAN COMMENTS ON THE CASE "Painful leg"

Request an HIV rapid test. If it is positive, then the painful, discolored, swollen leg probably is due to Kaposi's sarcoma.  A biopsy to confirm this diagnosis would be desirable, but in resource-limited settings, where HIV infection is prevalent, a biopsy is not necessary.

Kaposi's sarcoma is a tumor that is difficult to treat. Sometimes, if the tumor is localized, radiation therapy will help. Sometimes ARV therapy will halt the progression of the tumor and in some cases, cause it to shrink. Oncologists recommend treatment with chemotherapeutic agents such as vinblastine, injected directly into the tumor, if the lesion is small.

In any case, Kaposi's sarcoma indicates advancing HIV infection and considerable immuno-suppression. ARV therapy is indicated without further testing, if the man can afford it.

Be sure to prescribe cotrimoxazole for the man, whether he takes ARVs or not.


COUNSELING SHEET "W": WITHOUT MY KNOWLEDGE, WITHOUT MY CONSENT

Grace Ojiambo of Crisis Pregnancy Ministries Kenya sent us this disturbing story, told by a young woman she met not long ago.

"I recently discovered I am HIV positive. I didn't learn my status at a VCT site or in a clinic. I found out when one of my friends came to talk to me because of rumors circulating about me.

"The Christian organization I work for had requested that we all go for a medical check-up for insurance purposes. I went along with the others. I didn't hear anything from anybody until this friend spoke to me. I went on my own to another place for testing, and indeed I was HIV positive.

"I am very angry! Why didn't anybody talk to me? Does anybody care? Why did they test me without my consent? Why did they let out my status without my knowledge?"

Grace asks us to consider these questions:

  1. Does the insurance company have the right to do HIV tests without consent?
  2. Should the young woman have been told of her status by her organization or by the insurance company?
  3. How can she be counseled now?

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Comment from NANASI:

NASCOP (of the Kenyan Ministry of Health) is currently preparing "Guidelines for HIV Testing in Clinical Settings". Six different types of HIV testing are described:

1. Voluntary counseling and testing (VCT)
2. Routine testing and counseling
3. Diagnostic testing and counseling
4. Required testing
5. Testing for blood and tissue donation
6. Testing for medical research and surveillance

HIV testing by an insurance company falls into category 4. Required testing can be done without specific consent in a few particular settings, such as recruitment for the military, traveling to other countries, insurance and specialized employment. Whenever these types of required testing are done, the people tested are supposed to be informed of the test and may ask for the results, if they wish.

Thus the young woman's consent was not necessary for HIV testing by the insurance company, but she should have been informed of the test, and she should have been offered the test results (with appropriate counseling).

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...they spoke never a word...

The news of all the disasters that had fallen on Job came to the ears of three of his friends. Each of them set out from home and by common consent they decided to go and offer him sympathy and consolation...They sat there on the ground beside him for seven days and seven nights. To Job they never spoke a word, for they saw how much he was suffering. The Book of Job 2:11-13

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ON LISTENING

When I ask you to listen to me -
And you start giving me advice -
You have not done what I asked.

When I ask you to listen to me -
And you begin to tell m e why I shouldn't feel that way -
You are trampling on my feelings.

When I ask you to listen to me -
And you feel you have to do something to solve my problem -
You have failed me, strange as that may seem.

Listen! All I asked was that you listen -
Not talk or do -
Just hear me.

And I can DO for myself. I am not helpless.
When you do something for me that I myself can do,
You contribute to my inadequacy.

But if you can accept as a simple fact that I do feel what I feel,
Then I can quit trying to convince you
And get about the business of understanding
What's behind this irrational feeling.

And when that's clear,
The answers are obvious
And I don't need advice!

Attributed to Dr. Robert A. Hatcher, Georgia, USA



Very Sick Patients
SHINGLES
 

Shingles is a disease of the skin caused by infection with the Herpes zoster virus. When this same virus infects children and causes chicken pox it is called Varicella zoster. 

Children with chicken pox can infect other children. Most adults, however, already have been infected in childhood and their shingles usually is caused by a reactivation of the dormant chickenpox virus.

About 10% of HIV-infected patients experience an episode of shingles. Yet persons who are not HIV-infected also can suffer shingles, especially older people. Shingles is no indication of the degree of immuno-suppression of a patient, and it can occur with CD4 counts of less than 100/mm3 to more than 500/mm3.  Occasionally, the infection can be widespread and devastating when the immune system is severely suppressed.

Shingles first appears as vesicles which, after a week or so, dry and crust over. The vesicles and crust-covered skin are extremely painful. Eventually, the crusting drops off, yet the pain can persist at the infection site for months.

Shingles can be identified by its distribution over dermatomes. Rarely does it cross the midline of the body. Most frequently shingles follows nerves of the trunk, or on the face, it commonly follows a distribution of the ophthalmic branch of the Trigeminal nerve. The eye can be damaged, so where available, ophthalmic consultation should be requested.

Treatment:

Treatment for shingles is not very satisfactory, and patients will always complain of severe and prolonged pain. The earlier the treatment begins, the more effective it will be. The condition can be modified and shortened by giving:

Acyclovir 800 mg. (four 200 mg. tabs) five times a day for 7 days. (Some consultants recommend famciclovir or valacyclovir but these drugs are expensive and may be difficult to obtain.)

For pain relief, one should give paracetamol throughout the day and night, and add dihydrocodeine (DF-118) as needed. Sometimes amitriptyline is beneficial.

Effective topical treatment, if given early, has been reported by using:

Dimethyl Sulfoxide (DMSO) applied to the area four times daily.
Sap of the white frangipani tree, applied to the area twice daily.
Povidone-iodine 10% (Betadine) applied to the area twice daily.

What is the frangipani tree?

You may have seen it in gardens or along streets. The tree is 2 to 5 meters tall, with forking branches. The flowers are white or pink. The scientific name is Plumeria.

For treating shingles, use a tree with white flowers. Break off a small branch and collect the white, milky fluid in a clean jar with a tight lid. It will last 24 hours. Paint it onto the painful area twice daily.


CLASSIFICATION OF ANTI-RETROVIRAL (ARV) DRUGS
NANASI readers have requested a simple classification chart of familiar ARV drugs.

DRUG CLASS

-- two large classes --

DRUG
NAME

CODE
NAME

COMMERCIAL NAME

 

REVERSE TRANSCRIPTASE INHIBITORS (RTIs) 
       -- three types --

 

1.   Nucleotide RTIs

tenofovir

TDF

Viread

 

2.   Nucleoside (NRTIs)
       -
two types

       a.   thymidine analogues

zidovudine

AZT,ZDV

Retrovir

stavudine

d4T

Zerit

       b.   non-thymidine analogues

didanosine

ddI

Videx

lamivudine

3TC

Epivir

zalcitabine

ddC

Hivid

abacavir

ABC

Ziagen

 

3.   Non-nucleoside  (NNRTIs)

efavirenz

EFV

Stocrin,Sustiva

nevirapine

NVP

Viramune

 

PROTEASE INHIBITORS  (PIs)

indinavir

IDV

Crixivan

saquinavir

SQV

Invirase (hard gel) Fortovase (soft gel)

nelfinavir

NFV

Viracept

ritonavir

RTV

Norvir

lopinavir/RTV

LPV/RTV

Kaletra


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