Opportunistic Infections

Tuesday, December 18, 2007

Vasculopathy common in HIV-related stroke

By, Will Boggs, Medicexchange.com, December 11, 2007

The cause of stroke in HIV patients can usually be determined, and many of those patients will have vasculopathy, according to a report in the December issue of the Journal of Neurology, Neurosurgery, and Psychiatry.

"There is still some niggling debate regarding whether HIV causes stroke itself -- we hoped to show that there was clear evidence of a vasculopathy in a significant proportion of HIV-infected stroke patients and thus tilt the evidence more in favor of the HIV/stroke relation," Dr. Brent Tipping from University of Cape Town, South Africa told Reuters Health. "We also wanted to show that the etiology of stroke in younger patients with HIV involves more than the traditional causes of stroke."

Dr. Tipping and colleagues documented the nature of stroke in 67 HIV-infected patients and 1020 non-HIV-infected patients, and further defined HIV-associated vasculopathy.

Mean age of the HIV-infected stroke patients (33.4 years) was considerably lower than the mean age of the patients determined not to be HIV infected (64.0 years), the report indicates, and recent or intercurrent infection was 6.4 times more likely to be associated with HIV-related stroke.

More than a third of HIV-infected stroke patients (37 per cent) had an intercurrent or recent opportunistic infection, the authors report, and somewhat more patients (54 per cent) had CD4 counts above 200 cells/microliter than below (46 per cent).

HIV-positive stroke patients had cardioembolism as a cause of cerebral infarction less commonly than did HIV-negative young stroke patients, but experienced significantly more inpatient confirmed deep venous thrombosis.

In this cohort, 20 per cent of the HIV-infected stroke patients had extracranial (11 per cent) or intracranial (nine per cent) nonaneurysmal vasculopathy, the investigators found, whereas young stroke patients who were not HIV-positive showed no similar vasculopathy on angiography.

"In our stroke unit, HIV-associated stroke affected a young stroke population with a risk factor profile that differed from the HIV-negative young stroke population in that hypertension, diabetes, hyperlipidemia, and smoking were not significant risk factors," the researchers note.

"Patients with stroke and HIV in our setting tended to have comorbid infective diseases that required management in addition to the stroke," Dr. Tipping said. "All HIV positive stroke patients require lumbar puncture because of the comorbid CNS infections."

"Management is also more challenging," Dr. Tipping added, "particularly since those with immunosuppression require antiretroviral therapy, which requires intensive adherence and the logistic challenges of obtaining therapy in our third world setting."

"Given the epidemic of HIV infection and the increasing burden of stroke in Africa, we need large, well designed, prospective, community-based case-control studies, if possible with post-mortem examination," writes Dr. Myles Connor from Queen Margaret Hospital, Dunfermline, UK in a related editorial.

"We also need further investigation of the nature of HIV vasculopathy, and to guard against a blind assumption that HIV infected stroke patients must have a vasculopathy if there is no other obvious cause for their stroke," the editorial concludes.

Dr. Tipping's group concurs, pointing out, "The occurrence of stroke in the younger patient who is HIV positive should not preclude a comprehensive workup, as HIV status may be incidental, particularly in a population with a high HIV seropositive prevalence in the general population."

Source: http://www.medicexchange.com/mall/departmentpage.cfm/MedicExchangeUSA/_81675/3291/departments-contentview

Friday, December 07, 2007

Living and dying in South Africa

By, Kerry Cullinan, Health-e (Cape Town), December 6, 2007

The health indicators, which provide a snapshot of our nation's health, still paint a picture of a violent, racially divided country where women bear the brunt of disease. Kerry Cullinan reports on the latest SA Health Review.

African women still bear the brunt of virtually all the major health problems in the country, and over half can expect to die by the age of 60 in comparison to only 15% of white women.

This is according to a wide range of health indicators that are analysed by the SA Health Review.

The huge discrepancies between private and public sector services are best illustrated by the caesarean rates. A shocking 62% of births were by caesareans in the private sector in 2005 in comparison to 17.7% in public hospitals. Countries such as the UK, US and Australia have a rate of slightly more than 20%.

Mental health remains the neglected Cinderella of our health services. Almost a third (30.3%) of South Africans reported a psychiatric disorder with 16.5% reporting that it occurred within the past 12 months, according to the country's first nationally representative mental health survey.

Anxiety and mood disorders and substance abuse were the most common problems. Access to treatment was very poor with almost three-quarters (72.4%) receiving no treatment in the past year. Perhaps this is not surprising as there are only 419 psychologists in the public sector in comparison to the 6 310 registered with the Health Professions Council of SA. There is an average of only one psychologist per 100 000 people in the public sector.

HIV/AIDS continues to cut a swathe through the population, and the number of women dying between the ages of 20 and 39 in 2004 tripled over an eight year period.

The death rate for men between the ages of 30 and 44 doubled over the same period.

The HIV rate among Africans was at least double that of whites and Indians, with an estimated 16% of Africans aged 15 to 49 living with HIV, in comparison to 5.6% of whites and 2.7% of Indians.

By February this year, slightly more than a third of those in need of antiretroviral medicine were actually on the treatment. Children in need of ARVs were particularly underserved.

KwaZulu-Natal continues to be worst affected by HIV, with close on 40% of pregnant women testing HIV positive in 2006. The worst affected districts are Amajuba (Newcastle area) Umgungundlovu (Pietermaritzburg) and Ethekwini (Durban), where HIV prevalence among pregnant women was over 40%.

However, while the Western Cape's HIV prevalence rate is relatively low, there are huge differences in the same health districts. For example, in the Cape Town metro, 32.6% of pregnant women in Khayelitsha were HIV positive in comparison to only 5.1% of Mitchell's Plain women.

Between 2001 and 2005, the rate of children whose mothers have died doubled. There are now an estimated 1,2-million maternal orphans, with African children in KwaZulu-Natal being worst affected. Some 8.3% of African children in KZN under 14 and 6% nationally are motherless. Nationally, 16% (almost two out of every ten??)of children have lost either their mother or father.

The child mortality rate is increasing, mainly as a result of HIV. Four out of five children under the age of 5 who died in hospitals in 2005 were linked to HIV. The previous year, three out of five deaths were HIV-related.

The Eastern Cape had by far the worst infant mortality rate (68.3 deaths per 1000 births) in 2003, and while this had improved to 60 per 1000 three years later, it remains the worst in the country.

Tuberculosis continues to have a serious effect on South Africans, with South Africa having the 7th worst TB rate in the world. TB is the most common opportunistic infection associated with HIV.

Although the Department of Health has been treating TB using the Directly Observed Treatment (DOT) system, research showed that there was "no assurance" that taking treatment in front of someone in DOTS was better than self-administered treatment.

KwaZulu-Natal has by far the highest TB rate in 2006 with 88 271 reported cases - almost double the number of the next highest province, the Western Cape, with 43 155 cases.

While HIV affects women more than men, men are far more at risk of dying in homicides than women.

The homicide death rate for men in 2004 - 96 deaths per 100 000 - was the second highest in the world, after Colombia.

According to 2000 statistics, South Africa is one of the most violent societies on earth with nine times the global average for violent deaths of young men aged 15 to 29. Assault rates are worst in the Northern and Eastern Cape.

Road accident fatalities are also climbing, with 32.5 deaths per 100 000 people last year (as opposed to 26.8 in 2003).

Maternal deaths - women who die as a result of childbearing - more than doubled between 1997 and 2004. By 2005, there were 1 258 maternal deaths.

Teen pregnancy continues to be a problem, with at least 15% of teenage girls having fallen pregnant. The Kaiser national survey of 4 000 South Africans aged 15-24 found that 57% of sexually active young women had fallen pregnant - and 61% described their pregnancies as being "unwanted".

Obesity is a growing problem, with South Africa following trends in the US of increased levels of obesity in children and women particularly. In 2003, over a quarter (28.4%) of African women were obese while over a fifth of white men were also obese. In contrast, more than one in 10 African men were underweight.

A host of health problems are associated with obesity, the most prevalent in South Africa being hypertension (high blood pressure) and diabetes.

The prevalence of hypertension is very high for women, with over 40% of women aged 55 and over suffering from it. Women were also disproportionally affected by diabetes, with a prevalence rate of over 12% in women over 55.

However, indicators are never fool proof and the need for caution is perhaps best illustrated by the malaria statistics. While the Department of Health statistics claim that only 64 people died of malaria in 2005, StatsSA records 756 deaths in the same period.

Source: http://allafrica.com/stories/200712060678.html

HIV - Antiretroviral treatment alone is not enough for children

By, Rwanda News Agency/Agence Rwandaise d'Information (Kigali), December 5, 2007

"People say Aids is a deadly disease. That we die as soon as we get it, but I am still alive!", says Clarisse. She is 14 years old, aware of her status but has not given up on life - instead believes she is got nothing that could deny her right to be like any other child.

Clarisse is among the 315 children that are on ARV treatment at two Medicin sans Frontier supported clinics in Kigali - Kimironko and Kinyinya Health Centers. They range between 2 months and just under 21 but are organized in several age groups - that according to MSF - are meant to have them in groups because they require different support approaches.

The organization has come up with an HIV response that entails medical care specifically adapted to people infected with HIV.

The 'comprehensive care' as it has been called included voluntary counselling and testing, information and awareness activities, treatment of opportunistic infections and sexually transmitted infections, a mother-to-child transmission prevention programme. In October 2003, MSF started giving out free antiretroviral therapy (ARV).

In total at the moment, the organization supports up to 6200 HIV positive patients at the same centers with some 2700 on ARV doses. The patients are supported from their homes.

Since the year 2000 when the organization moved into the latest program, there has only been 2.6% mortality rate among children and just 4.9% for the adults. In other countries, according to Dr. Johan Van Griensvem - head of the HIV program, mortality runs at 10% or even more.

Dr. Johan says the solution here has been simple: apply the medical component - where ARVs are given to the patients along with psychosocial support. "This means that patients not only recover medically but also improve psychologically - from feeling stigmatized, depressed and no future", he says.

However, as he explains, responding to the medical needs of the children - has been the most moving experience and success factor for the MSF HIV program - with targeted and well-thought out mechanisms. The organisation actually wants the 'Amagambo y'Abana' (Children's Voices) program adopted countrywide and internationally.

The innovative approach focuses on the specific needs of children living with HIV in Rwanda - targeting their mental well-being.

The Psychosocial support component, as it has been called, gives these children a voice, allows them to play an active role in the treatment of their condition and helps them develop a 'positive attitude towards life' by gives them a chance to express themselves. The results, as Dr. Johan put it, have been very encouraging.

But again, the children live in the communities and helping them heal may not be that effective because they have the outside world, the families, the strangers and non-infected friends. MSF believes Communities can help end discrimination and make children feel part of society.

One of the major barriers for a paediatric HIV programme to overcome, according to the organisation is the reluctance of both caretakers and healthcare staff to test children for HIV. This reluctance stems largely from what has been dubbed the "fear of the result."

The solution has been to have regular sessions at the health centers whereby the parents or guardians are encouraged to come along with the children. There has also been the 'home-based care' approach - where MSF teams move down to the communities to meet the affected families.

By letting the caregiver and child know their status, as this approach suggests ensures every child is adequately informed and his or her questions and concerns addressed. From the many child-groups that the organisation supports, HIV status is only disclosed to children aged seven years and older.

Ms. Jeannine Uwera - a Psychologist with the program, says the child-parent relationship is very important and needs to be respected by exploring ways for them to communicate with each other about HIV.

After the child knowing that they are infected, they are encouraged to join support group sessions organized monthly - where they get to express themselves freely and ask anything on their minds. The health works at the centers - trained specifically by the organisation to handle such situation - are expected to give them answers that suit their level of understanding.

"Which essentially means that the way you talk to a 7-year-old cannot be similar to the tools you apply when exchanging with an adolescent", says Uwera. With a child, as she explains, you may need games, story telling and drawing sessions to convey the messages.

However, according to the MSF Psychologist, the issues discussed are raised by the children and often reflect their deeper feelings. The children raise questions about the virus such as the 'what, why and how'- life and death - sexuality - difficulties in the parent-child relationship - stigma - and discrimination.

The different support groups in the country provide same medical protocols, as Dr. Johan explains, involving same medications and counseling - which approach needs a more responsive approach to children. The Psychosocial support is quite original, he says adding that though everybody provides that counseling, this approach comes as a focused additional effort.

"People say that we are sick with Aids, but we are not sick", echoes 14-year old Jean Paul - who has been on ARVs since 2004 - an indication that he understands the dynamic of the situation he finds himself. "We have the Aids virus. That is all".

As for 14-year old Alphonse: "Many people talk rubbish because they are ignorant. It is because they do not understand what Aids is and they do not know ARVs exist."

However, for 13-year-old Jean-Claude, all has not been that simple in a family where he lives with an 'aunt and uncle' with two younger cousins - with whom he always fights - just like any other children of that age.

"They tell me to go back to where I come from. They insult me all the time because of my disease (HIV)", he says. With the understanding that he needs a family that accepts him - Jean-Claude prefers to live with another relative - who he visits during holidays. There, as he says, I feel respected.

Among the children includes orphans from HIV/Aids living with guardians. There are those with single parents as well - but there also others that have both of their parents. In addition to availing support that enables the communities help themselves such as small self-help income projects.

MSF leaving

Médecins Sans Frontières (MSF) has been in Rwanda since 1991. Through the years, the medical humanitarian organization provided medical assistance to displaced and refugee populations during years of crisis and conflict. When the cholera hit, the organisation was there. As the needs of the country evolved, it moved dealing with mental health issues after the genocide especially among women.

Sixteen years down the road, the organisation is ending operations this December and has already handed its HIV program - the last of its activities to government. According to Dr. Johan Van Griensvem, the priorities that government has set itself suggest that the country is ready to continue with program.

The hope we have is that they will continue to focus on care for children - in particular psychosocial support to the (affected) children, says Dr. Johan.

The organisation wants government to stay put on the plan to increase its human resource capacity especially the health sector with particular need for social workers that help communities overcome challenges such as HIV/Aids.

MSF also calls for a scale-up of a similar 'comprehensive approach' to HIV to other areas around the country and not just Kinyinya and Kimironko health centers - though these have been supporting victims from across the country.

"We have the medical analysis - where we have compared this program with others - and it (MSF approach) does bring a lot of added value" says Ms. Syviane Bachy, the Communications officer. "It does not require too much input and yet it gives amazing results - that is why we really believe it should be an integrated part of comprehensive care."

MSF has also provided direct nutritional supplies such food and supplements for children in collaboration with other organizations - the WFP included.

Source: http://allafrica.com/stories/200712050790.html

Uganda: Aluvia to treat HIV positive children

By, Jane Nafula, The Monitor (Kampala), December 5, 2007

Uganda is the first African country to use the Aluvia paediatric drug that improves the health of children whose bodies are resistant to the first line of ARVs treatment.

8-year-old Tim (not real name) was born with HIV/Aids. He survived on Antiretroviral Drugs for six years after which the virus became resistant to the drugs. And for the last two years, Tim's life has been hanging in balance because there was no alternative drug that would reduce the viral load (the level of the virus in the blood).

"We have been giving him septrin tablets to treat the opportunistic infections like cough but his health has been deteriorating every other day. I really don't know why he became resistant to ARVs," said Tim's mother who prefers to be identified as Namubiru.

As Tim's parents were still searching for a way to prolong their son's life, the government through the Joint Clinical Research Centre (JCRC) contacted Abbott Laboratories in the United States to supply Uganda with Aluvia, a paediatric Aids drug that improves the health of children whose bodies are resistant to the first line of ARVs treatment.

The World Health Organisation recommends use of Aluvia (lopinavir/ritonavir) as options for the treatment of children who no longer respond to the first line of HIV medicines. The US department of Health and Human Medicine also recommends the same medicine for initial treatment of children with HIV.

Abbott is a global health care company involved in the discovery, development, manufacture and marketing of pharmaceuticals and medical products.

Uganda is the first African country to use the Aluvia paediatric drug and Tim was privileged to be the first child living with Aids in Africa to receive the drug.

President Yoweri Museveni handed over a packet of Aluvia to Tim after launching it at JCRC on December 1.

Parents thronged to JCRC on World Aids day to register their children for this medication. About 60 children will be the first people to benefit and there after, the drug will be distributed countrywide. More than 2 million children living with HIV in the endemic countries stand to benefit from the drug.

Better option

The Director of JCRC, Dr Peter Mugyenyi said the introduction of the second line treatment for children living with HIV/Aids will help restore hope for millions of parents and children who would otherwise face a bleak future, adding that the new drug will enforce compliance because it is easy to swallow, doesn't need to be refrigerated, and one doesn't have to take a meal before taking it as is the case with other medicines.

"Adherence to ARVs has been difficult especially among children because of lack of paediatric formulation," he said.

According to him, JCRC will get a grant of $1m (about Shs1.8b) from President Bush's Emergency Plan for Aids Relief (PEPFA) to restock all their branches with life saving drugs and also establish new ones to reach out to more people.

The Regional Director of Abbott International, Mr Angelo Kondes said Abbott's effort to provide for African children is part of its five point global strategy to expand access to HIV treatment around the world.

"We developed Aluvia with distinct needs of children in the developing world in mind," Kondes said, explaining that nine of every 10 children with HIV live in Sub-Saharan Africa where Uganda falls.

According to the Joint United Nations Programme on HIV/Aids (UNAIDS) and the World Health Organisation (WHO), in 2006, an estimated 2.5 million children under the age of 15 were living with HIV/Aids worldwide.

Last year alone, an estimated 530,000 children were infected with HIV, and 380,000 others died of Aids.

Kondes also said that HIV/Aids is a global problem that demands shared commitment and responsibility, adding that Abbott and Abbott Fund are investing more than $100m (about Shs180b) in developing countries through their global Aids care programmes focusing on strengthening health care systems, helping children affected by HIV/Aids, preventing mother to child transmission of HIV, and expanding access to counselling and testing.

According to Mr Dirk Van Eeden, The director of HIV/Aids communication and policy at Abbott international, it took them seven years to develop this drug, which is being supplied to Uganda at a cheaper price. "The government will spend about $250 per child per year. Aluvia is cheaper than any other generics. We are giving a bigger discount to African countries than to Europe," he added.

Statistics indicate that about 110,000 children who are less than 15 years in Uganda are living with HIV/Aids and of these, 47,000 have advanced Aids and are in need of antiretroviral therapy.

Only 9,500 children were accessing treatment by the end of September 2007.

President Museveni said children who are well treated can live a pain free life, grow normally, and become responsible adults.

"Children should not lose hope. We are going to protect them so they can grow up, study and exploit their talents."

Protecting the children

He believes poor adherence to antiretroviral drugs is one of the factors responsible for drug resistance.

Health experts say patients are not adhering to treatment due to stigma associated with the disease, drug exhaustion and lack of defined formulations especially for children.

Mr Museveni also says the management of paediatric Aids in Uganda has lagged behind that of the adults and that it should be given the necessary attention, adding that prevention of mother to child transmission of HIV/Aids is an important intervention in preventing the spread of the virus among children.

"We should stop children from contracting the disease than waiting for them to get infected to seek treatment. Supposing all Ugandans become infected, will we manage the burden of treating them?"

Mother to child transmission of Aids is the second largest mode of transmitting the virus and it accounts for about 21 percent of the new infections while sexual transmission accounts for 76 percent and the 3 percent is through other modes including blood transfusion. Every year, about 250,000 children are born with HIV in Uganda.

A mother who is HIV positive can transmit the virus to her baby during pregnancy, labour and delivery, or breastfeeding.

Women who have reached the advanced stages of the disease require a combination of ARVs for their own health.

Doctors say ARVs reduce the risk of mother-to-child transmission by 50- 60 percent. The Director General of Uganda Aids Commission, Dr Kihumuro Apuuli says currently, mothers are being encouraged to test for HIV whenever they go for routine antenatal care at health centres and that those found with HIV are given treatment to improve their health and also avoid passing on the virus to their unborn babies.

The First Lady, Ms Janet Museveni said Ugandans have become complacent due to availability of ARVs, cautioning that these drugs are not a cure but they simply reduce the viral load and that preventive strategies should be re-activated instead of relying on the drugs.

"Relying of treatment alone is negligence. These drugs simply treat opportunistic infections but they don't cure Aids," she said, adding that although more children get the virus from their mothers, very few HIV-positive pregnant women have access to drugs that reduce the risk of mother to child infection like Neverapin.

"We need to do more even if Uganda has been applauded as a success story in the fight against HIV/Aids. "The prevalence rate that has stagnated at 6.4 percent is bad enough and we should not allow this to continue," she advised.

Source: http://allafrica.com/stories/200712060372.html