NANASI 31: October 2004
In this issue of NANASI:
- AIDS in Primary Health Care: Seven services you can provide
- World AIDS Day: Lessons learned about mass VCT testing
- VERY SICK PATIENTS: Toxoplasmosis
- Q & A: Food supplements
- COUNSELING SHEET "V": Paying attention to the needs of your counselors
AIDS in Primary Health Care:
SEVEN SERVICES YOU CAN PROVIDE
With the explosion of the AIDS epidemic, it is imperative that Primary Health Care units become more aggressive providers of AIDS care. Below are seven services that a Primary Health Care facility can and should offer in the expanded fight against AIDS. Churches, governments and NGOs should begin to train and equip their Primary Health Care units to offer these important services now.
1. Perform a rapid screening test for HIV infection.
Knowing if a patient is HIV sero-positive or negative is the first step in setting up a program to attack AIDS. The HIV rapid tests are inexpensive, easy to perform and reliable. Specially trained laboratory personnel are not required to perform these tests; nurses and counselors can perform them. Of course, one should provide appropriate counseling services to accompany the testing experience.
2. Recognize, treat and prevent common opportunistic infections.
The Primary Health Care provider should be trained to recognize and treat the most common opportunistic infections associated with HIV. Diagnoses usually are straightforward, and they require only a small supply of inexpensive medicines for their management and prevention.
3. Proactively monitor and systematically record the clinical evolution of disease in each HIV patient.
A patient's weight change and activity level give a good clinical indication of the progression of the disease. Periodically, whether sick or not, the patient should be examined and weighed, and this basic information should be recorded on his carry-home record card. Always schedule follow-up review visits. In this way, the primary care provider will know when to begin prophylactic measures such as cotrimoxazole and when to refer the patient for advanced care.
4. Advise patients and families on nutrition, personal hygiene, HIV prevention andtreatment possibilities.
Primary Health Care personnel should be a source of practical knowledge about prevention and the care of persons infected with HIV. Sometimes, they are the only ones in a community who have this knowledge and who know what to do. Primary Health Care personnel should be armed with current information about AIDS and prepared to give individual or community information sessions and answer questions.
5. Refer patients with signs and symptoms of HIV infection to designated treatment centers.
No Primary Health Care unit should function alone in the battle against AIDS. Each unit should be allied with a more advanced center, where better-equipped and more highly trained clinicians are available. These higher centers may have advanced laboratory back up, drugs and the capacity to start Anti Retroviral (ARV) therapy. Agreement between the Primary Health Care unit and the more advanced center should be made in writing, and it should specify frequent visits between personnel of these facilities to assure good collaboration. As the campaign against AIDS intensifies and the workload increases, the advanced centers will come to rely more and more upon the work done in Primary Health Care units.
6. Oversee the treatment of patients who started ARV drugs at designated treatment centers.
Because patient compliance is the most important determinant of the effectiveness of ARV therapy, a local Primary Health Care unit can help monitor patients on therapy. This monitoring is similar to DOTS monitoring for tuberculosis therapy, and the closer it is to the patient's home, the more effective it will be.
7. Provide & advise on palliative care measures for terminally ill patients.
The Primary Health Care unit often is the only place where a patient with terminal disease can receive care. Personnel should be trained to give care to the patient and give advice to the family caregivers. Sometimes this service will require a home visit and the provision of medicines to combat diarrhea, pneumonia, bedsores and pain. These medicines should be stocked in the Primary Health Care facility and made easily available to those who need them.
Have a lot of counselor-testers on site. Will you plan for group counseling first, then individual counseling and testing? What is the maximum number of clients one counselor can and should handle during the day? Your own VCT and PMCT counselors may not be enough. Some hospitals have asked local government health centers to send trained counselors to help.
Set limits in advance. What total number of clients will you serve that day? If attendance is much greater than you anticipated, give tickets for a later date.
Plan and budget realistically for these costs:
Transport, before and during the mass testing day
Publicity (banners, posters, letters, visits, etc.)
Staff snacks or lunch
Shelter (a building or a tent), with a separate room or screened area for each counselor
Tables and chairs
Receipt book and plenty of loose change
Tests & buffer (In advance, you should divide the buffer into several small bottles, so each counselor has a bottle in the booth)
Lancets, gloves, disinfectant, cotton
Running water (pouring from jerry cans is fine)
Sharps containers and rubbish bins
Plan how to follow up HIV+ clients. Will you provide clinical consultations on site or nearby? Will you give written information or a referral slip to your clinic? Losing track of HIV+ clients is one of the most discouraging parts of mass HIV testing. Plan your follow-up carefully.
For more information or advice, contact
WORLD AIDS DAY
Lessons learned about mass VCT testing
For World AIDS Day (1 December 2004), you may be planning special VCT sessions for large numbers of people - on the hospital grounds, in a marketplace or bus stand, at a church, etc. Here are lessons learned by groups that have done mass testing recently:
Talk with your local authorities well in advance. Suggest they volunteer to be the first people tested. Ask their advice on needs they can help with, for example, crowd control, how to manage drunks, long lines, curious schoolchildren.
Free testing can cause problems. A small charge (Kshs 20 or 30) helps people think about testing and value your service. Besides, the income will help cover your many expenses. (If someone seriously requests testing but has no money, you can make an exception and do it free.)
COUNSELING SHEET "V": PAYING ATTENTION TO THE NEEDS OF YOUR COUNSELORS
EUNICE - ANGRY
Eunice is a nurse-counselor, who has been working in the HIV-TB clinic for several months. This afternoon she became very angry and rushed out of the clinic room. "Our patients are really awful!" Eunice said to a friend. "Most of them got infected with AIDS by doing stupid things like sleeping around with a lot of different people. They come to use for medicine, but they stop taking it when they feel better. They don't come to clinic on the return date. It's their own fault they got sick, and it's their own fault they stay sick!"
- What can you say to Eunice?
- Could a counselor or chaplain help?
PATEL AND IDA - COLLEAGUES
Patel, a 29-year-old man, works in the hospital accounts office. Last month, during a campaign to encourage staff members to go for voluntary counseling and testing, Patel was tested by Ida, a VCT counselor. Patel was shocked to learn that he is HIV positive. Patel's wife is a friend of Ida's. Over tea one afternoon, she tells Ida she is concerned because Patel has not wanted to make love to her for several weeks.
- What should Ida do?
- How can she help this couple who are her own colleagues and friends?
Hospital counselors and staff see people all day long with serious problems - advanced illness, approaching death, grieving, family problems, lack of money or food or school fees, and on and on. Like Eunice, they sometimes have to deal with difficult patients with difficult illnesses.
Hospital counselors, particularly in a rural hospital, sometimes have to deal professionally with their friends and colleagues. That is the case of Ida, counseling Patel and his wife.
At the same time, counselors have problems of their own, often serious and overwhelming problems. One counseling supervisor says, "I have a team of six trained, experienced AIDS counselors. During the past six months, I have learned about some of the personal problems of my different counselors: a teenage son away at boarding school for the first time was doing poorly...excessive drinking by a counselor...excessive drinking by an adult relative in a counselor's household...a sick baby and a leaky roof...domestic violence...a counselor's sister died of AIDS...a counselor was trying to find ways to tell his children that he himself is HIV positive...a counselor needed frequent days off to go to her own ARV clinic appointments across town."
SAMUEL - GRIEVING
Samuel has worked for several years as a nurse in the male medical ward. Recently he has been very quiet and withdrawn. Today a counselor saw him leaving the ward with tears in his eyes. Samuel simply said, "I can't stand watching any more young men die!"
- What can the counselor do?
- What might Samuel need to do?
- Is there someone who can talk to Samuel?
- Today Samuel may need to cry, be alone, take a walk or go home early.
- Today or tomorrow, he may want to talk with an understanding family member, friend or colleague.
- Samuel may want to talk with a spiritual counselor - the hospital chaplain or someone of his own religious group.
- He may want to talk with a senior counselor, the matron or an understanding person in the hospital administration.
- During the coming weeks, Samuel may need to take time off from work or move to another duty post for a while.
Our counselors can meet the needs of others ONLY if they have help in meeting their own needs.
=== very sick patients ===
A treatable cause of hemiparesis and encephalitis in AIDS patients
Toxoplasma gondii is a protozoan parasite which infects 1/3 of the world's population. This parasite resides in the intestines of members of the cat family, and humans are infected by ingesting the cysts of Toxoplasma or by eating meat that is infected with the cysts.
Most people with an intact immune system suffer no ill effects of their infection. However, AIDS patients with CD4 counts of less than 100/mm3, are at great risk of Toxoplasmosis disease as their immunity declines. This organism has a predilection for the central nervous system, and the disease usually evolves gradually over several days to several weeks. The cardinal manifestations are: confusion, speech impairment, hemi paresis, cranial nerve disturbances, cerebellar signs, movement disorders and psychiatric abnormalities.
Reliable laboratory tests for Toxoplasma IgG and PCR antigen are expensive and difficult to resource in Africa. Though lumbar puncture always should be done in order to rule out other causes of CNS problems, the results will be non-specific for Toxoplasmosis. A differential diagnosis should include: CNS lymphoma, Progressive Multifocal Leucoencephalopathy (PML), Cytomegalovirus, Cryptococcus and Tuberculosis tuberculoma.
Because diagnosis is so problematic, it is quick and cheap just to give standard cotrimoxazole treatment for Toxoplasmosis right away. (Note: All symptomatic people living with HIV should be taking cotrimoxazole.)
The dose of cotrimoxazole is one tablet (80/400 mg.) per 8 Kg. body weight, given daily in divided doses. For example, a 48 Kg. patient should receive three tablets bid. Continue this treatment for 4-6 weeks after symptoms have subsided. Afterwards, give two tablets of cotrimoxazole daily indefinitely or for six months after the CD4 count has exceeded 200/mm3. If no improvement is noted within 10 days after the start of treatment, consider other diagnoses.
International consultants recommend the use of pyrimethamine plus sulfadiazine. One should add to this regimen folinic acid (leucovorin) in order to counter the anti-folate effect of pyrimethamine. Other regimens include treatment with clarithromycin, doxycycline, and atovaquone. (For details, see the LANCET article cited below.)
Toxoplasmosis patients are severely immuno-suppressed, so begin ARV therapy soon. Remember: HIV-positive patients, whether taking ARVs or not, who take cotrimoxazole prophylaxis faithfully, should never experience Toxoplasmosis.
(Comments extracted from THE LANCET, June 12, 2004)
Q & A: Food supplements
Question from Kibera health workers: Where can we get food supplements for our patients who have very little food of any kind?
Answer: Contact UNICEF-Kenya and ask about Unimix (corn, soya, & oil) Phone (020) 622 759 PO Box 44145, 00100 Nairobi
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