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NANASI 30: September 2004

NANASI 30 September 2004
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In this issue of NANASI:

  • VERY SICK PATIENTS: Twelve important conditions
  • Fixed Dose ARV Combinations (FDCs)
  • FOR TRAINING YOUR STAFF: Two NANASI casebooks
  • VERY SICK PATIENTS: Pneumocystis pneumonia
  • Q & A: VCT for our own employees
  • COUNSELING SHEET "U": Unexplained behavior

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VERY SICK PATIENTS
Twelve important conditions

At Nazareth Hospital, large numbers of people living with HIV are first diagnosed while in-patients with advanced stages of AIDS. Everywhere in Kenya, in-patient care is critical as a major entry point to ARV treatment programs.

At Nazareth Hospital, more than 90% of the people living with AIDS requiring in-patient care are affected by only twelve conditions. We feel that recognition of these frequent conditions should be an essential part of staff training for the care of AIDS in-patients:

Aesophageal candidiasis
AIDS Dementia Complex (ADC)
Cryptococcal meningitis
Distal Sensory Paresthesias (DSP)
Fever of unknown origin (usually non-typhoid Salmonellosis)
Focal CNS signs (usually cerebral toxoplasmosis)
Persistent or recurrent diarrhea
Pneumococcal pneumonia
Pneumocystis pneumonia
Shingles (Herpes zoster)
Tuberculosis, (pulmonary and extra-pulmonary)
Weakness / fatigue and emaciation

Health care workers should be trained to recognize the signs and symptoms of these conditions and routinely to request an HIV rapid test when they present. For this reason, a cadre of HIV clinicians should be selected and trained to care for and treat these very sick patients, who are too sick to be handled as out-patients. If these common manifestations of advanced AIDS cannot be managed in the center where they present, then the patient should be referred to a hospital where staff are trained and equipped to manage these patients appropriately.

Fixed Dose ARV Combinations (FDCs) commonly used in Kenya -- September 2004

 

 

COMBINED DRUGS
Dose per tablet or capsule

 

NAME

 

COMPANY

lamivudine           150 mg.
stavudine                30 mg.
nevirapine            200 mg.

Triviro-LNS 30

Ranbaxy

Triomune-30

Cipla

Emtri-30

Emcare

lamivudine           150 mg.
stavudine                40 mg.
nevirapine            200 mg.

Triviro-LNS 40

Ranbaxy

Triomune-40

Cipla

Emtri-40

Emcare

lamivudine           150 mg.
stavudine               30 mg.

Lamivir-S 30

Cipla

Coviro-LS 30

Ranbaxy

lamivudine          150 mg.
stavudine               40 mg.

Lamivir-S 40

Cipla

Coviro-LS 40

Ranbaxy

zidovudine          300 mg.
lamivudine          150 mg.

Combivir

GSK

Avocomb

Ranbaxy

Duovir

Cipla

zidovudine          300 mg.
lamivudine          150 mg.
abacavir               300 mg.

Trizivir

GSK

lopinavir             133 mg.
ritonavir                33 mg.

Kaletra

Abbott

TWO NANASI BOOKS FOR TRAINING YOUR STAFF

1) HIV-AIDS CASE STUDIES
FOR NURSES, CLINICAL OFFICERS AND DOCTORS
Available now from AMREF and Textbook Center shops

2) HIV-AIDS COUNSELING CASE STUDIES
FOR COUNSELLORS, SOCIAL WORKERS, & CLINICAL STAFF
NEW -- available soon from AMREF
AMREF - Nairobi:    (020) 605220, 605331   ---   E-mail:   This e-mail address is being protected from spambots. You need JavaScript enabled to view it


COUNSELING SHEET "U": UNEXPLAINED BEHAVIOR
REBECCA'S PRESCRIPTION SLIP

Rebecca, a 20-year-old woman, is HIV positive and unemployed. At Rebecca's last visit to the clinic, the doctor decided it was time to start her on ARVs. He gave her a prescription slip to take to the hospital pharmacy and a note so the medicines would be given free of charge.

Today Rebecca is back in the clinic, with the prescription slip given to her at the last visit. The doctor does not understand why Rebecca does not pick up the medicine in the pharmacy, so he calls the counselor to talk with Rebecca.

Questions: How would you begin? What do you suspect the problems are - Rebecca, the doctor, the hospital procedures, the pharmacy or something else?

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KOECH LOST HIS MEDICINES

Koech, a 34-year-old farm hand, lives 250km away from the city hospital where he is under treatment. He came right on schedule today for his review appointment. He is now in his fifth month of TB treatment, and he is due for his third monthly prescription of ARV medicines. Koech, however, still has some troubling symptoms and complaints, and he is not putting on weight as expected. Koech says he has been taking his medicines, but he hasn't "eaten well" the last month. The doctor examined him but found nothing unusual.

On being pressed about exactly how he takes his medicines, Koech finally admitted that he has not taken ARVs during the past month, as he lost them in the matatu (public minibus) on his way home after his previous appointment.

"Why didn't you come back right away for a refill?" the doctor asked. "We would have replaced the medicines at no cost to you."

"I didn't have enough money for the matatu to come back," Koech replied, shrugging his shoulders.

The doctor called a counselor, who took Koech through a session on medicine adherence and problem solving. Koech was rather quiet but seemed cooperative. The doctor issued another prescription for TB medicines but decided to suspend ARVs for now. Koech left.

Three hours later, a matatu driver knocked on the clinic door and handed to the astonished doctor Koech's TB card, HIV clinic card and TB medicines. "These were left in my vehicle by one of my passengers this morning," he said.

Questions:

  • What is making Koech act in this way? Is he irresponsible?
  • Is he still denying his HIV positive status and the importance of ARVs?
  • Is he feeling hopeless and that there is nothing he can do?
  • Or is something else influencing his behavior and actions?

REBECCA'S PRESCRIPTION SLIP: COMMENTS BY A COUNSELOR

My first thoughts were these:

  • Rebecca may be young and irresponsible. Or she still denies that she is HIV positive. Or she felt hopeless. Or she just didn't want to take more medicines.
  • Maybe the doctor did not explain clearly what she was supposed to do
  • Maybe Rebecca was not able to find the hospital pharmacy, or she was too shy to show her prescription slip and ask for instructions.

However, there is another possible cause of Rebecca's strange behavior - she may be suffering from AIDS dementia. If that is the case, Rebecca was probably not able to focus and concentrate at the last clinic visit, even though the doctor's instructions were clear and simple. Perhaps Rebecca forgot right away what she had just heard. She was frustrated and confused. Her thoughts may have been something like this: "I know you're giving me important information but I can't remember what you've just told me to do. I feel bad about it, and I'm afraid you'll get angry with me. I don't know what I'm supposed to do."

The clinic staff and the counselors need to be aware that Rebecca (and perhaps other patients) is simply not able to function normally, because of her HIV infection. Rebecca needs a family member or close friend who can understand her ARVs and help her take them as directed.

KOECH LOST HIS MEDICINES - COMMENTS BY THE DOCTOR

I was indeed astonished when the matatu driver arrived. Then I began to reflect on Koech and his odd behavior.

Koech does not seem irresponsible. He comes on time for his appointments. Koech is probably not in denial. If he were, he would burn his card and medicines or throw them down a toilet. He would not leave the items (with his name on them) in a matatu.

If he were in a state of hopelessness, he would probably hide his feelings and his clinic papers. He wouldn't leave such private things in a public place, where strangers could find them.

Koech seems to be showing signs of AIDS dementia. He really wants his health back, but his concentration and memory are affected by the illness. Though he seems to be paying attention, he is not able to concentrate, and he is not focused.

Koech has truly forgotten and lost his medicines and papers. Thanks to a helpful matatu driver, we now have a much clearer idea of his problems.


VERY SICK PATIENTS
Pneumocystis Pneumonia (PCP)

Pneumocystis pneumonia is a common and dangerous opportunistic condition in people living with AIDS. It indicates Stage IV AIDS and usually comes only when CD4 counts are less than 100/mm3. Serious, untreated cases are fatal; treated cases sometimes do not respond, even to excellent care. The diagnosis of PCP usually is made by clinical signs and symptoms. 

The most common features of severe PCP that distinguish it from pneumococcal or TB pneumonia are:

  • Tachypnea (respiratory rates of 20-40/min)
  • Gradual onset of symptoms with severe weakness
  • Absence of chills or pleuritic pain
  • Dyspnea on mild exertion
  • Dry cough or white phlegm (not thick or bloody)

The chest x-ray may not be specific, and can even be normal. The X-ray picture can be confounded with pulmonary tuberculosis or infection with other bacterial pathogens. 

Sputum is scanty, and special stains may be required to see the organism. Oxygen saturation can be less than 70% which indicates the need for supplemental oxygen and steroids.

Drug treatment:

In severe cases, give cotrimoxazole tablets (400/80), one tablet per four kilograms of body weight in 3-4 divided doses each day.  For example, a 48 kg. patient should receive 12 tablets per day, given as 4 tablets 3 times a day.  Give at this dosage for 3-5 days, and then reduce the daily dose by 1/3. Continue this lower dosage for a total of 21 days. 

(Note: it is important to reduce the very high initial dose of CTX promptly in order to minimize the chance of rash and anemia, common side effects of high-dose CTX therapy. If rash does appear, do not stop CTX altogether, because it is life-saving. Antihistamines may be of benefit in this situation.)

After the patient has completed this CTX regimen, he/she should be given CTX prophylaxis (2 tabs daily) until the CD4 count is above 200/mm3 for 6 months. It is rare to get PCP relapse while taking this preventive therapy.

In particularly severe cases, parenteral or oral steroids may be life-saving. One could begin with:

  • Prednisone 40 mg. bid X 1-5 days, then
  • Prednisone 40 mg. daily X 6-10 days, then
  • Prednisone 20 mg. daily X 11-21 days

If steroids are given, it is advisable also to give drug coverage for tuberculosis. After the PCP crisis is past, begin ARV therapy without delay.

With thanks to Dr. Stephen Moore, CDC, Nairobi


Q and A: VCT FOR OUR OWN EMPLOYEES

During the April 2004 CHAK conference, NANASI staff members interviewed delegates from eight different church hospitals (Chogoria, Kijabe, Litein, Lugulu, Maseno, Maua, Nazareth & Tumutumu). Here are some of the questions and answers.

Q: Do you have many employees going for voluntary HIV counseling and testing (VCT)?

A: All 8 hospitals said employees did go for VCT. However, some considered the attendance low; they had different explanations for it. At Kijabe Hospital, confidentiality and fear of HIV+ test results were cited as the main reasons for poor attendance. At another hospital, only members of staff who suspected their husbands were promiscuous sought VCT services.

Q: What do you think motivates your staff (or would motivate them) to attend VCT?

A: Nearly all the respondents gave similar responses. They cited confidentiality of results, availability of ARVs at subsidized rates, and competent and trustworthy counselors. In addition to the above reasons, Maua cited the freedom to choose the person to do the test, and also confidential consultations with the physician who follows up drugs and payment for drugs for the employees.

Nazareth had just conducted an exploratory survey to find out what their employees preferred. While a few employees did not mind attending the Nazareth VCT center, the majority said they would prefer having VCT done by a counselor from outside the hospital, or else attending VCT at a place other than Nazareth Hospital. 

Q: What kind of set-up would you recommend to other hospitals to encourage their employees to go for VCT?

A: Confidentiality of results was considered paramount. Hospital-based VCT was the most recommended setting. Respondents emphasized that competent counselors should be easily available, and each employee should be allowed to choose the person to do the test. Two respondents suggested calling an external person to run VCT services for hospital staff members.

Nkatha Njeru, NANASI researcher

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