ACW: Opportunistic Infections

Malaria - Life threatening during pregnancy

2008-01-08T10:55:00.000+07:00

By, Pushpa Jamieson, The Chronicle Newspaper (Lilongwe), December 31, 2007

With the continued high infections of HIV, opportunistic diseases like malaria have become life threatening, especially for women who are HIV positive.

Malaria infection during pregnancy can have adverse effects on both the fetus and the mother. These include sever anemia, miscarriage or fetal loss, retarded growth of the fetus, premature birth and delivery of a low birth-weight baby.

The more dangerous Plasmodium falciparum malaria parasite is found in sub-Saharan Africa where it has been estimated that malaria causes 400,000 cases of sever maternal anemia resulting in approximately 10,000 deaths annually.

Although malaria is considered a danger to expectant women, correct and effective interventions during pregnancy can reduce the risks of complications or death of both mother and infant.

Speaking at a recent Women Edition conference in London, Dr. Scott Filler from the Centre of Disease Control (CDC) in the United States expanding on the interventions for prevention and control of malaria in pregnant women recommended by the World Health Organization said women should be supplied with anti malarial drugs as Intermittent Preventative Treatment (IPT). All pregnant women living in malaria infection areas should receive at least two doses of IPT after the first trimester.

The recommended anti malarial drug is sulfadoxine pyrimethamine more commonly known as SP because of its ability to provide protection against infection for a longer period.

Reports of resistant of the SP by the malaria parasite has resulted in antenatal clinics being advised to provide the IPT at every clinical visit by pregnant women provided there has been a time laps of more than four weeks to ensure that she remains protected against malaria.

Providing IPT at antenatal clinic ensures that medical staff provide direct observation treatment (DOT) and physically observe that the woman has taken the medication.

The use of insecticide treated bed net by pregnant women was also highlighted. Where possible, insecticide treated nets (ITNs) should be provided to pregnant women at first visit to antenatal clinic. The use of the net should be encouraged through out pregnancy and after delivery. Providing ITNs to women before her first trimester would protect her from malaria until she is able to take SP.

Effective case management of malaria and anemia for all pregnant women should be guaranteed and iron supplements should be given to those who require it. Screening for anemia should be routine and cases of moderate to severe anemia should be properly manages.

Recommendations by WHO will see a reduction in maternal mortality due to malaria but the majority of countries with extremely high maternal mortality rates are some of the poorest and least developed and lack health systems to deliver.

It has been said that the provision of maternal health to women is the litmus test for the state of the health system of any country.

Insufficient staff, lack of medication and an improper and effective referral system have been major contributors to the non implementation of the recommendations so far.

Announcing an additional 100 million pound over five years to help prevent unwanted pregnancies and to make childbirth safer, the UK's Secretary of State for International Development Douglas Alexander said: "We need to ensure health services do not only function, but also reflect the needs of women. Women must have a voice to demand better services and to vote for an MP who puts women's health at the top of the political agenda".

The recent announcement of an aditional100 million pounds from Britain and contributions from donors and other development partners can make a difference to the high mortality rate in sub-Saharan Africa.

Acknowledgement of the importance of a good reproductive health system and the political will and commitment by leaders of poor and developing countries to addresses the issues of reproductive health is essential to the success of the reduction of maternal mortality in affected countries.

Source: http://allafrica.com/stories/200712310659.html

Vasculopathy common in HIV-related stroke

2007-12-18T11:43:00.000+07:00

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

Living and dying in South Africa

2007-12-07T14:14:00.000+07:00

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

2007-12-07T14:05:00.000+07:00

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

2007-12-07T13:52:00.000+07:00

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

HIV-Related Opportunistic Infections: Prevention and Treatment

2006-10-03T15:46:00.000+07:00

What are opportunistic infections?

People with advanced HIV infection are vulnerable to infections and malignancies that are called 'opportunistic infections' because they take advantage of the opportunity offered by a weakened immune system.

A partial list of the world's most common HIV-related opportunistic infections and diseases includes:

Bacterial diseases such as tuberculosis, MAC, bacterial pneumonia and septicaemia (blood poisoning)
Protozoal diseases such as PCP, toxoplasmosis, microsporidiosis, cryptosporidiosis, isopsoriasis and leishmaniasis
Fungal diseases such as candidiasis, cryptococcosis and penicilliosis
Viral diseases such as those caused by cytomegalovirus, herpes simplex and herpes zoster virus
HIV-associated malignancies such as Kaposi's sarcoma, lymphoma and squamous cell carcinoma.

Different conditions typically occur at different stages of HIV infection. In early HIV disease people can develop tuberculosis, malaria, bacterial pneumonia, herpes zoster, staphylococcal skin infections and septicaemia. These are diseases that people with normal immune systems can also get, but with HIV they occur at a much higher rate. It also takes longer for a person with HIV to recover than it takes for someone with a healthy immune system.

When the immune system is very weak due to advanced HIV disease or AIDS, opportunistic infections such as PCP, toxoplasmosis and cryptococcosis develop. Some infections can spread to a number of different organs, which is known as 'disseminated' or 'systemic' disease. Many of the opportunistic infections that occur at this late stage can be fatal.

Why is there still a need to prevent and treat opportunistic infections?

Highly Active Antiretroviral Therapy (HAART) can reduce the amount of HIV in someone's body and restore their immune system. The introduction of HAART has dramatically reduced the incidence of opportunistic infections among HIV-positive people who have received the drugs. Yet the prevention and treatment of opportunistic infections remains essential.

Around the world, millions of people living with HIV in resource-poor communities have no access to HAART. And even where the drugs are available, they do not entirely remove the need for preventing and treating opportunistic infections. Sometimes it is advisable for people with acute opportunistic infections to begin HAART right away, especially if the infection is difficult to treat. However in certain cases it may be better to delay beginning HAART and instead only to administer treatment for the opportunistic infection, especially if there are concerns about drug interactions or overlapping drug toxicities.

Those who have already started taking antiretrovirals may require other drugs in certain circumstances. In particular, some opportunistic infections may be unmasked shortly after the beginning of HAART as the immune system starts to recover, and these may require specific treatment. Measures to prevent and treat opportunistic infections become essential if antiretrovirals stop working because of poor adherence, drug resistance or other factors.

Providing prevention and treatment of opportunistic infections not only helps HIV-positive people to live longer, healthier lives, but can also help prevent TB and other transmissible opportunistic infections from spreading to others.

Prevention of HIV-related opportunistic infections

HIV-positive people can reduce their exposure to some of the germs that threaten their health. They should be especially careful around uncooked meat, domestic animals, human excrement and lake or river water. However there is no practical way to reduce exposure to the germs that cause candidiasis, MAC, bacterial pneumonia and other diseases because they are generally common in the environment.

Several HIV-related infections (including tuberculosis, bacterial pneumonia, malaria, septicaemia and PCP) can be prevented using drugs. This is known as drug prophylaxis. One particular drug called cotrimoxazole (also known as septra, bactrim and TMP-SMX) is effective at preventing a number of opportunistic infections. This drug is both cheap and widely available. The World Health Organisation (WHO) recommends that, in resource-limited settings, the following groups of people should begin taking cotrimoxazole:

HIV-exposed infants and children, starting at 4-6 weeks after birth, or at first contact with health care, and continued until HIV infection is excluded
HIV-positive children less than 1 year old
HIV-positive children aged 1-4 years who have mild, advanced or severe symptoms of HIV disease, or a CD4 count below 25%
HIV-positive adults and adolescents who have mild, advanced or severe symptoms of HIV disease, or a CD4 count below 350 cells per ml
HIV-positive people with a history of treated PCP.

According to WHO guidelines, treatment of HIV-positive people should continue until at least age 5, and in general should continue indefinitely, though it may sometimes be stopped following successful antiretroviral treatment.

Some of the worst affected countries may choose to treat all infants and children born to mothers confirmed or suspected of living with HIV, until HIV infection is excluded. They may also choose to treat everyone who is diagnosed with HIV, regardless of symptoms or CD4 count.

Drug prophylaxis is sometimes recommended even for those who have started HAART if they have very weak immune systems or are otherwise considered to be especially vulnerable. They may be advised to stop taking the drugs if their immune system recovers.

For people who have already contracted an opportunistic infection and undergone successful treatment, secondary prophylaxis may be advisable to prevent recurrence. This applies to diseases such as tuberculosis, salmonella, cryptococcosis and PCP.

Treatment of HIV-related opportunistic infections

Some opportunistic infections are easier to treat than others. Effective treatment depends on health services being able to procure, store, select and administer the necessary drugs and to provide related treatment, care and diagnostic services to monitor health status and treatment response.

A few opportunistic infections and symptoms such as candidiasis of the mouth, throat or vagina (thrush), herpes zoster (shingles) and herpes simplex can be managed effectively through home-based care. In a home-based care setting diagnosis is made by observing symptoms.

Some opportunistic infections may be diagnosed by observation or using a microscope, and treated where there is minimal health infrastructure. Such infections include pulmonary tuberculosis and cryptococcal meningitis.

In a medium infrastructure setting, the facilities available include X-ray equipment and culture facilities. Using these, opportunistic infections such as extra-pulmonary tuberculosis, cryptosporidiosis, isopsoriasis, PCP and Kaposi's sarcoma can be diagnosed and treated.

Opportunistic infections such as toxoplasmosis, MAC and cytomegalovirus infection can be diagnosed and treated in places with advanced infrastructure. Treating these infections is often impossible in resource poor countries. Many developing countries lack the advanced equipment and infrastructure (such as CT scanning) needed to treat these more complex infections.

Individual opportunistic infections

The following are just a few of the conditions that particularly affect people living with HIV.

Bacterial pneumonia

Pneumonia can be caused by various bacteria. Symptoms among HIV-positive people are much the same as in those without HIV infection, and include chills, rigours, chest pain and pus in the sputum. The vaccine PPV can protect people against some of the more common pneumonia-causing bacteria, and is recommended in the US.

Because other forms of respiratory infection including PCP are common among HIV-infected people, doctors must be certain of diagnosis before administering antibiotics. This may require a chest radiograph, blood cultures, a white blood cell count and tests to eliminate other infections. Treatment is usually aimed at the most commonly identified disease-causing bacteria.

Candidiasis

There are two main types of candidiasis: localised disease (of the mouth and throat or of the vagina) and systemic disease (of the oesophagus, and disseminated disease). The mouth and throat variant (commonly known as thrush or OPC) is believed to occur at least once in the lifetime of all HIV-infected patients. Occurence of the vaginal variant is common among healthy women and is unrelated to HIV status.

While OPC is not a cause of death, it can cause oral pain and make swallowing difficult. The main symptom is creamy white legions in the mouth that can be scraped away. Oesophageal (gullet) candidiasis is a more serious condition which can cause pain in the chest that increases with swallowing. Disseminated candidiasis causes fever and symptoms in the organs affected by the disease (for example, blindness when it affects the eyes), and can be life threatening.

Localised disease may be treated at first with relatively inexpensive drugs such as nystatin, miconazole or clotrimazole. Systemic candidiasis requires treatment with systemic antifungal agents such as fluconazole, ketoconazole, itraconazole or amphotericin.

Cryptococcosis

Cryptococcosis is caused by a fungus that primarily infects the brain. It most often appears as meningitis and occasionally as pulmonary or disseminated disease. Untreated cryptococcal meningitis is fatal.

Cryptococcosis is relatively easy to diagnose. However, its treatment (either amphotericin B with or without flucytosine or in mild cases with oral fluconazole) and secondary chemoprophylaxis are often impossible in developing countries because of high cost and limited availability of the drugs required.

Cryptosporidiosis and isosporiasis

Cryptosporidiosis (crypto) and isosporiasis are both caused by protozoan parasites. These diseases are easily spread by contaminated food or water, or by direct contact with an infected person or animal. Both crypto and isosporiasis cause diarrhoea, nausea, vomiting and stomach cramps. In people with healthy immune systems, these symptoms do not last more than about a week. However, if the immune system is damaged then they can continue for a long time.

Diarrhoea can interfere with the absorption of nutrients and this can lead to serious weight loss.
To confirm diagnosis of either disease, the stool is normally checked for parasites and their eggs. There is no cure for crypto, but antiretroviral therapy to restore immunity can effectively clear up the infection. For isosporiasis, TMP-SMX (trimethoprim-sulfamethoxazole) is often the preferred treatment.

Cytomegalovirus

Cytomegalovirus (CMV) is a virus that infects the whole body. It most commonly appears as retinitis, which causes blurred vision and can lead to blindness. CMV can also affect other organs, and is capable of causing fever, diarrhoea, nausea, pneumonia-like symptoms and dementia.

CMV infection may be treated with drugs such as ganciclovir, valganciclovir and forscarnet.

Herpes simplex and Herpes zoster

The usual symptoms of herpes simplex virus infection (HSV, which causes sores around the mouth and genitals) and herpes zoster virus infection ('zonal' herpes or shingles) are not life-threatening but can be extremely painful. Both viruses are also capable of causing retinitis and encephalitis (which can be life-threatening).

Both herpes simplex and herpes zoster are usually diagnosed by simple examination of the affected area, and may be treated with drugs such as acyclovir, famciclovir and valacyclovir.

Histoplasmosis

Histoplasmosis is a fungal infection that primarily affects the lungs but may also affect other organs. Symptoms can include fever, fatigue, weight loss and difficulty in breathing.

Disseminated histoplasmosis infection may be diagnosed using an antigen test, and can be fatal if left untreated. Treatment usually involves amphotericin B or itraconazole.

Kaposi's sarcoma

HIV-associated Kaposi's sarcoma causes dark blue lesions, which can occur in a variety of locations including the skin, mucous membranes, gastrointestinal tract, lungs or lymph nodes. The lesions usually appear early in the course of HIV infection.

Treatment depends on the lesions' symptoms and location. For local lesions, injection therapy with vinblastine has been used with some success. Radiotherapy can also be used, especially in hard-to reach sites such as the inner mouth, eyes, face and soles of the feet. For severe widespread disease, systemic chemotherapy is the preferred treatment.

Leishmaniasis

Leishmaniasis is transmitted by sandflies and possibly through sharing needles. The most serious of its four forms is visceral leishmaniasis (also know as kala azar) which is characterised by irregular bouts of fever, substantial weight loss, swelling of the spleen and liver and anaemia (occasionaly serious). In its more common forms, leishmaniasis can produce disfiguring lesions around the nose, mouth and throat, or skin ulcers leading to permanent scarring.

Treatment of leishmaniasis with pentavalent antimony is relatively expensive, partly because of the cost of drugs but also because hospital admission is recommended (in milder cases, trained health workers may administer the injections or infusions at a patient's home). If left untreated, visceral leishmaniasis is usually fatal.

MAC

The germs of the mycobacterium avium complex (MAC) are related to the germ that causes tuberculosis. MAC disease generally affects multiple organs, and symptoms include fever, night sweats, weight loss, fatigue, diarrhoea and abdominal pain.

MAC should be treated using at least two antimycobacterial drugs to prevent or delay the emergence of resistance. Such drugs include clarithromycin, azithromycin, ethambutol and rifabutin.

PCP

PCP is caused by a parasite that infects the lungs, which was formerly called pneumocystis carinii but has now been renamed pneumocystis jiroveci. PCP is a frequent HIV associated opportunistic infection in industrialised countries but appears to be less common in Africa. The symptoms are mainly pneumonia along with fever and respiratory symptoms such as dry cough, chest pain and dyspnoea. Definitive diagnosis requires microscopy of bodily tissues or fluids.

Severe cases of PCP are initially treated with TMP-SMX or clindamycin and oral primaquine. Mild cases can be treated with oral TMP-SMX throughout. With both of these regimens, toxicity (notably allergic-type reactions) often requires changes in therapy.

Prevention of PCP is strongly recommended for HIV-infected persons with very weak immune systems wherever PCP is a significant health problem for HIV-infected persons, and also after their first episode of PCP. The preferred drug is usually TMP-SMX.

Toxoplasmosis

Toxoplasmosis (toxo) is caused by a protozoan found in uncooked meat and cat faeces. This microbe infects the brain and can cause headache, confusion, motor weakness and fever. In the absence of treatment, disease progression results in seizures, stupour and coma. Disseminated toxo is less common, but can affect the eyes and cause pneumonia.

Definitive diagnosis of toxo requires radiographic testing (usually a CT or MRI scan). The infection is treated with drugs such as pyrimethamine, sulfadiazine and clindamycin. Leucovorin may also be used to prevent the side-effects of pyrimethamine.

Tuberculosis

Tuberculosis (TB) is a bacterial infection that primarily infects the lungs. Tuberculosis is the leading HIV-associated opportunistic disease in developing countries. For people who are dually infected with HIV and TB, the risk of developing active tuberculosis is 30-50 fold higher than for people infected with TB alone. And because mycobacterium can spread through the air, the increase in active TB cases among dually infected people means:

more transmission of the TB germ
more TB carriers
more TB in the whole population.

Tuberculosis is harder to diagnose in HIV-positive people than in those who are uninfected. The diagnosis of TB is important because TB progresses faster in HIV-infected people. Also, TB in HIV-positive people is more likely to be fatal if undiagnosed or left untreated. TB occurs earlier in the course of HIV infection than many other opportunistic infections.

A proper combination of anti-TB drugs achieves both prevention and cure. Effective treatment quickly makes the individual non-contagious, which prevents further spread of the TB germ. The DOTS (directly observed short course) treatment strategy recommended by WHO treats TB in HIV-infected persons as effectively as it treats those without the virus. A complete cure takes 6 to 8 months and uses a combination of antibiotics. In addition to curing the individual, it also prevents further spread of the disease to others. This is why treating infectious cases of TB has important benefits for society as a whole.

Isoniazid preventive therapy is recommended as a health-preserving measure for HIV-infected persons at risk of TB, as well as for those with latent TB infection.

Source: by Annabel Kanabus, Jenni Fredriksson-Bass and Rob Noble.

http://www.avert.org/aidscare.htm

WHO issues guidelines on use of cotrimoxazole prophylaxis

2006-08-24T12:13:00.000+07:00

Theo Smart, Thursday, August 10, 2006

Cotrimoxazole prophylaxis should be widely used by people with progressing HIV disease and by all HIV-infected or exposed infants (until it is clear that they are uninfected) according to guidelines issued this week by the World Health Organization (WHO).

In fact, where HIV prevalence is high, infectious diseases common and healthcare infrastructure is limited, governments may want to consider simply giving cotrimoxazole to everyone with HIV and to infants known or suspected of having been exposed to HIV, says WHO.

Background on cotrimoxazole prophylaxis

Cotrimoxazole prophylaxis has long been part of the standard care for people living with advanced HIV disease in industrialised countries, where it is primarily used to prevent illnesses such as Pneumocystis jiroveci pneumonia (PCP) and toxoplasmosis. Studies have also shown that cotrimoxazole prophylaxis prevents infections and prolongs life in resource-limited settings. However, even though the treatment is simple, quite inexpensive and potentially life-saving, most countries have been slow to adopt or implement cotrimoxazole prophylaxis as a routine part of their HIV programmes for a number of reasons.

There were several reasons for this. Firstly, PCP and toxoplasmosis are not as common in resource-limited countries — where people with HIV usually first die from other illnesses. Also, there were concerns about fostering resistance to the drug (a widely used antibiotic) and cross-resistance to sulfadoxine/pyrimethamine (used to treat malaria). In fact, in some parts of Africa, there are already high levels of bacterial resistance to cotrimoxazole — until recently, there was little evidence to show that cotrimoxazole prophylaxis would be effective in such settings. Furthermore, clinical studies were needed to answer questions about the safety and practical aspects of using cotrimoxazole in infants or pregnant women.
Finally, although WHO had put out a provisional statement on the use of cotrimoxazole in 2000, it has never previously issued clear technical guidelines on the operational aspects of implementing cotrimoxazole prophylaxis, especially in the context of scaling up HIV care in resource-limited settings.

However, over the last several years, the evidence base in support of cotrimoxazole prophylaxis has strengthened considerably. For instance, new studies have shown that PCP, which cotrimoxazole can prevent, is the leading cause of death in infants with HIV in all settings (and the incidence peaks during the first six months of life). Other new evidence has been drawn from recent clinical trials and observational cohort studies in a wide range of populations and settings, even in regions where malaria is endemic and background resistance to cotrimoxazole is common. Consistently, the studies have shown that cotrimoxazole prophylaxis reduces mortality and morbidity in adults, children and infants.

The new WHO guidelines review the clinical evidence as well as essential information needed to use cotrimoxazole safely; with annexes that summarise the criteria for recognising HIV-related clinical events used in the WHO staging system of HIV disease, as well as how to grade the seriousness of adverse events that may occur in persons taking cotrimoxazole.

Recommendations in infants and children

It is especially important that infants with, or suspected of having, HIV receive cotrimoxazole during the first six months of their life.

Cotrimoxazole prophylaxis is recommended for all HIV-exposed infants starting at 4–6 weeks of age (or at first encounter with the healthcare system) and should be continued until HIV infection can be excluded by HIV antibody testing (beyond 18 months of age) or virological testing (before 18 months of age) at least six weeks after complete cessation of breastfeeding.
Cotrimoxazole prophylaxis is recommended for all HIV-infected infants below one year of age regardless of symptoms or CD4 percentage. Treatment should continue until they are at least five years of age regardless of clinical symptoms or CD4 percentage or whether they have had a good immune response on antiretroviral therapy.

For children between one to four years old, cotrimoxazole prophylaxis is recommended for all children with WHO stage II, III or IV disease, or all children with a CD4 cell% <>
For children aged five or older, see adult recommendations in terms of starting or stopping cotrimoxazole prophylaxis.

In settings with limited infrastructure and high child mortality and HIV prevalence — and where HIV screening may not be possible, WHO recommends a universal option: giving cotrimoxazole to all children born to mothers with or suspected of having HIV.
However, cotrimoxazole should not be given to young children who have (or have a history of) severe adverse reactions (grade 4 reactions) to cotrimoxazole or other sulfa-containing drugs and children with glucose-6-phosphate dehydrogenase (although WHO does not recommend routine screening for glucose-6-phosphate dehydrogenase deficiency in resource limited settings). If a child cannot take cotrimoxazole, dapsone 2 mg/kg once daily should be used.

Recommendations in adolescents and adults

Where CD4 cell counts are available, WHO recommends that everyone with CD4 cell counts below 350 should take cotrimoxazole prophylaxis whether they have symptoms or not. In addition, those with stage III and IV disease should take cotrimoxazole regardless of their CD4 cell count.

Where CD4 cell counts are not available, cotrimoxazole prophylaxis should be taken by everyone with mild, advanced or severe symptoms of HIV disease (WHO stage II, III or IV disease).

Where infrastructure is even more limited, and HIV prevalence is high, WHO says countries can consider offering cotrimoxazole to everyone who tests HIV-positive.

Cotrimoxazole is recommended to HIV-positive pregnant women, regardless of the stage of pregnancy and should continue while she is breastfeeding. Women with HIV who live in an area where there is malaria, should take cotrimoxazole rather than sulfadoxine/pyrimethamine–based intermittent presumptive therapy for malaria.

For people with HIV who qualify for antiretroviral therapy, WHO recommends that they start cotrimoxazole two weeks before their ART regimen — in case there is rash or any other adverse reaction.

In industrialised countries, it is considered safe to discontinue cotrimoxazole in response to effective antiretroviral treatment (that increases the CD4 cell count to over 200). However, in resource limited settings where the primary causes of mortality are malaria or bacterial infections that strike people down with much higher CD4 cell counts, WHO’s “general recommendation is to continue cotrimoxazole prophylaxis among adults living with HIV indefinitely.” Even so, the guidelines (perhaps prematurely considering the evidence base) discuss the alternatives, such as discontinuing cotrimoxazole once the CD4 cell count has been over 350 for at least six months.

Recommended daily dosing

For infants below 6 months or <>30 kgs (800 mg/160 mg)
Cotrimoxazole suspension contains 200 mg/40 mg per 5 ml of syrup. Single strength tablets contain 400 mg/80 mg, double strength tablet twice that. It is possible to divide the tablets for children and infants.

Download at http://www.who.int/hiv/pub/guidelines/ctx/en/index.html

Source://http://www.aidsmap.com/en/news/F49B70EE-0089-4624-8C38-82AB06A800AF.asp

A cotrimoxazole goal role for WHO?

2006-07-29T21:20:00.000+07:00

by HDN Key Correspondent, Thailand
*********************************

On the eve of the International AIDS Conference held in Bangkok two years ago, a fellow Key Correspondent writing for Health and Development Networks noted that cotrimoxazole prophylaxis was not commonly being used by people living with HIV (PLHIV) in Asia. As the Toronto conference approaches this is a fitting time to consider what has changed.

Among the many actions that PLHIV can take while they are waiting for universal access to antiretroviral therapy to arrive, taking cotrimoxazole prophylaxis is the most readily available and affordable. Scientific studies and clinical experience have proven that taking a single tablet of double strength cotrimoxazole daily prevents opportunistic infections and saves lives. Cotrimoxazole can be taken by people living in the community without clinical supervision but it is best if it is offered as part of a package of services for PLHIV.

Cotrimoxazole prophylaxis is even more important for people with HIV who develop tuberculosis. People with dual infection, and who take cotrimoxazole, live longer and have a better quality of life. The ‘International Standards for Tuberculosis Care’ launched earlier this year incorporates cotrimoxazole prophylaxis into clear guidelines. If health workers do not give cotrimoxazole to patients who have dual infection then their practice falls below the current international standard of care. Recently a study from Uganda demonstrated that even the family members of people taking cotrimoxazole prophylaxis lead healthier lives.

Few HIV professionals doubt the usefulness of cotrimoxazole or oppose its wider use. Occasional challenges come from people who continue to clamour about potential drug resistance. They mostly live far removed from the everyday lives of PLHIV. The potential for resistance should be balanced against letting people continue to die without cotrimoxazole; in other words a person with HIV dying today compared with the possible harm to someone infected with a cotrimoxazole-resistant germ years from now.

Concerns have been raised that malaria parasites might develop resistance to cotrimoxazole, running the risk that other sulpha drugs might no longer work against them, though this concern appears to have decreased with the recently recommended use of artemisinin-containing combination drug regimens for malaria. People taking cotrimoxazole must, however, continue to take care not to take another sulpha-containing drug when they are trying to prevent or treat malaria.

Access to cotrimoxazole prophylaxis in the Asia Pacific region is still very low. Though it is now recommended in most national AIDS care and antiretroviral therapy guidelines, it is not generally used. There are no firm figures on its use as no targets have been set and thus no healthcare providers or governments feel compelled to report on usage. In Africa, too, there is little data on cotrimoxazole use. It has been several years since an estimate was made that 3% of adults living with HIV in Africa were taking cotrimoxazole.

In an effort to improve its image as an organisation leading the health sector response to HIV, the World Health Organization (WHO) is trying to increase its activities promoting human rights in relation to health. No other organisation can provide the same level of international guidance as to what must be done to help people exercise their right to health in HIV prevention and care. Cotrimoxazole prophylaxis is a vital aspect of HIV care on which the WHO is letting us all down. .

The WHO’s lack of urgency in actively promoting the use of cotrimoxazole for people with HIV is hardly news. In March 2000 both UNAIDS and the WHO recommended that cotrimoxazole prophylaxis should be used for PLHIV in Africa. That advice applied to all adults who had developed any opportunistic infection. Six years have passed. Despite the growth of the HIV epidemic in Asia, the World Health Organization headquarters still has not published any recommendations on cotrimoxazole use in Asia – or the rest of the world.

A WHO expert consultation that drafted new recommendations on cotrimoxizole prophylaxis was held over 14 months ago. Experts at the meeting recommended that the WHO develop clear and consistent messages about the need and value of cotrimoxazole prophylaxis and provide technical assistance for implementation of increased use. The meeting also recommended that targets be developed.
These actions have not happened.

In a letter to the team that authored the International Treatment Preparedness Coalition report ‘Missing the Target’, Dr Kevin de Cock, the new head of HIV/AIDS at WHO headquarters in Geneva, wrote: “… WHO will soon publish revised guidelines for … co-trimoxazole prophylaxis.” Months have passed and the guidelines are still not available.

Cotrimoxazole prophylaxis was identified as one of the building blocks of the ‘Three by Five’ initiative at its outset. The word cotrimoxazole, however, cannot be found in the final evaluation report of the WHO’s role in ‘Three by Five’. Cotrimoxazole makes few appearances in the final WHO ‘Three by Five’ report, and when it does, it is mostly in relation to malaria and tuberculosis.

The WHO can be commended for publishing guidance two years ago on cotrimoxazole prophylaxis for children with HIV. It has added clear recommendations on the use of cotrimoxazole prophylaxis to its draft TB/HIV comanagement manual for health workers treating people with both diseases. The TB department of the WHO has added 2004 data about the number of countries recommending cotrimoxazole prophylaxis in its Global Stop TB annual report this year. But not a single regional or global target for universal access to cotrimoxazole prophylaxis has yet been set.

Guidelines on cotrimoxazole prophylaxis need to be backed with promotion and targets need to be followed by action. Increasing access to cotrimoxazole prophylaxis is one area where the World Health Organization could take much more timely and effective action. In the meantime, people continue to die needlessly.

HDN Key Correspondent Team
Email: correspondents@hdnet.org
Web: www.healthdev.org/kc
HDN 2006 - Reproduction welcomed

Zimbabwe: Sanitation Crucial in Fight Against HIV/Aids

2006-05-21T10:08:00.000+07:00

The Herald (Harare), May 8, 2006

Harare--THIRTY-EIGHT percent of Zimbabwe's rural population has access to proper sanitation facilities, Health and Child Welfare Minister Dr David Parirenyatwa said last week.

The minister, who was addressing water experts from the Southern African Development Community region at an HIV and Aids mainstreaming workshop held in Harare, also said there was need for the establishment of an effective sanitation programme for rural communities to reduce HIV-related opportunistic infections.

Sadc region, the minister said, should fight against the pandemic in a collective manner. "We want stronger coordination and more openness in the fight against HIV and Aids. The media should not sensationalise Aids issues and should give the public right information," he said.

Dr Parirenyatwa attributed the reduction of the HIV and Aids prevalence in the country from 31 percent in 1999 to the current 20,1 percent to the collective approach in the fight against the pandemic. He, however, said the 20,1 prevalence rate was still very high and there should be educational campaigns on behavioural change.

Speaking at the same occasion, Minister of Water Resources and Infras tructural Development Engineer Munacho Mutezo said inadequate funding was stifling development in the water sector.

The minister paid tribute to the Swedish International Development Agency (Sida) for supporting water and sanitation programmes in the country. "We may differ or disagree with one another in other spheres of development but it is clear that in the area of water development, we should not," he said.

In response, Swedish Ambassador, Mr Sten Rylander said he was working round the clock with a view to ensure that there was an improvement in the relations between the two countries. "We must overcome our differences as soon as possible," he said.

Head of the Sadc Water Division Mr Phera Ramoel said fighting HIV and Aids was central to reducing poverty in the region. He said there was need for collaboration between all other sectors of the economy in the region in addressing the pandemic. The workshop, organised by Sida, sought to promote best practices on how to hande HIV and Aids and gender issues in water management.

Source: AllAfrica.com

Common Drug Treats Both HIV and Malaria

2005-10-28T10:43:00.000+07:00

By Joe De Capua Washington, 21 October 2005

Millions of people in Africa could be helped by using an old drug in a new way. A drug that’s normally used to protect people with HIV/AIDS from bacterial infections can also be used to protect them from malaria.

One of the researchers taking part in studying the drug is Dr. Christopher Plowe, a professor at the University of Maryland School of Medicine in Baltimore. Dr. Plowe spoke to English to Africa reporter Joe De Capua about the dual treatment.

He says, “Cotrimoxizole or Bacterim are common names for trimethoprim-sulfamethoxazole, the drug we’re talking about here. And it’s an anti-biotic that’s been around for a long time. It’s very cheap and it’s used to treat bacterial infections primarily, respiratory infections,
pneumonia, that sort of thing. And it’s just widely used across Africa.

And it’s used in the US and Europe to prevent opportunistic infections in people living with HIV and AIDS. But it hadn’t been used in this regard in Africa until relatively recently when some studies showed some promising benefits in Cote d’Ivoire in 1999.”

Asked how the drug protects against malaria, Dr. Plowe says, “It turns out that in addition to being a good drug to treat bacterial infections, which is the main thing that it’s used for routinely and also pneumocystis pneumonia and taxoplasmosis, more exotic infections that happen in people with HIV, it is also a good anti-malarial drug, very related, closely related to the anti-malarial drug SP that people are familiar with in Africa.”

Researchers do not recommend using the drug strictly for malaria, because it would have to be taken every day. But Dr. Plowe and others, including UNAIDS, say it should become part of standard treatment for those with HIV/AIDS who’s immune systems have been severely weakened. Research shows pregnant women would be among millions of people who could benefit from the dual therapy.

Source: VOA News

Co-Infection with HIV/Aids and Viral Hepatitis is Very Dangerous

2005-09-05T07:52:00.000+07:00

By Joe Dinga Pefok, The Post (Buea) NEWS, September 2, 2005

Cameroon- A resource person on HIV/AIDS and other sexually transmissible diseases, STDs, Dr. Christian Tzeuton, of Laquintinie Hospital, Douala, has disclosed that patients co-infected with HIV/AIDS and viral hepatitis run the risk of rapid death.Dr. Tzeuton was speaking during a seminar on how to take care of patients suffering from HIV/AIDS in Douala, recently.

Attended by 50 medical personnel, the seminar was organised by Comité Douala Antiretroviraux, commonly known as Comité DARVIR, a group of medical personnel specialised in HIV/AIDS and sponsored by MTN Cameroon.

Tzeuton disclosed that co-infection with HIV/AIDS and viral hepatitis is becoming rampant in Cameroon. He said the present infection rate in the country is 26 percent.

Both HIV/AIDS and viral hepatitis, Tzeuton explained, have similar ways of transmission, which are unprotected sex with infected blood and infected persons.

He advised that if a patient is diagnosed with co-infection of HIV/AIDS and viral hepatitis, all should be done, and quickly too, to eliminate the viral hepatitis so that the patient can hopefully continue to survive by taking anti-retroviral drugs for HIV/AIDS.

But he warned that if the viral hepatitis, especially Hepatitis C, which is the most dangerous is not rapidly treated, the chances of the HIV/AIDS patient surviving, even with the anti-retroviral drugs, would be very slim.

High Cost Of Treatment
But Tzeuton regretted that it is very difficult to wipe out viral hepatitis, especially Hepatitis C, in a patient in Cameroon. This, he said, is not only because the disease is often resistant to drugs, but more because the most effective drugs like Tenoforvir, are not available in the country and are very expensive, since they are not subsidised by government.

He said good drugs like Tenoforvir are available in France, and that it would cost a patient to treat a full-blown Hepatitis B or C, FCFA 7 million for drugs alone.

Tzeuton said the period of effective treatment of viral hepatitis, ranges from 1 - 48 weeks, depending on the type as well as the stage in a patient.

He assured that if the disease is diagnosed at an early stage, it can be handled with some available drugs in Cameroon.

The doctor said viral hepatitis has no specific symptom, and does not also quickly manifest in a human being. He said an infected person might have a fever, and the tendency for most people would be to assume that it is malaria, and thus resort to auto-medication.

Participants expressed gratitude to MTN Cameroon for sponsoring the seminar. In a press release, the Director of Communication of MTN Cameroon, Jean-Claude Ottou, noted that the seminar was organised within the framework of the partnership between Comité DARVIR and MTN Cameroon, which was initiated two years ago.

Ottou stated that the partnership had already led to the training of 450 medical and paramedical personnel, and other related groups, on taking care of HIV/AIDS patients.

"The engagement of MTN Cameroon with Comité DARVIR, is in line with the company's policy of social responsibility represented by MTN Foundation."

MTN Foundation
On the newly created MTN Foundation, Ottou said it is to ameliorate the lives of Cameroonians. He said the Foundation will be engaged in five major domains, which include: Health and HIV/AIDS, Education/Science and Technology, Community Development, Art and Culture and Environment.

The objectives of the MTN Foundation, Ottou stated, would include among others, to create access to education and new technology, to effectively contribute to health preservation as well as protection of the environment; to preserve as well as develop the rich culture of Cameroon, and above all to create employment opportunities.

The Corporate Communications Coordinator at MTN Cameroon, Bouba Kaélé, had asserted in a recent press release that the company has been engaged in many health and other social projects across the country.

He cited the donation of over FCFA 40 million to Lions Club by the company, for the construction of a centre for mentally retarded children in Douala. He further cited the contribution of funds to the construction of the building of Malimba Dispensary, in Sanaga Maritime Division, as well as equipping it. He also cited the construction of several water points in different provinces of the country, which were founded by MTN Cameroon.

Bouba recalled that MTN Cameroon supported the "No AIDS" caravan that embarked on a vast sensitisation campaign on HIV/AIDS across the country in 2003. MTN, he said, spent FCFA 250 million for health and other social activities.

Source: allAfrica.com

Price of key drug slashed in face of TAC pressure (Amphofericin B)

2005-05-24T14:50:00.000+07:00

By Emily Goligoski

A medication described as the most effective in treating a type of meningitis that can be fatal for people with HIV/Aids is soon to be available for a sixth of its price today.

From July 1, Bristol-Myers Squibb's drug Amphofericin B is to be priced at R22.60 for a vial instead of between R145 and R190, before VAT. It is used to treat cryptococcal meningitis, an opportunistic infection that is virulent in people with HIV/Aids.

The Treatment Action Campaign (TAC) has been working since February to get the cost of the drug, marketed as Fungizone, reduced after complaining that it is priced excessively in South Africa.The campaign was a combined effort with the Southern African HIV Clinicians Society, the Desmond Tutu HIV Centre and the Aids Law Project, which threatened to bring legal action against Bristol-Myers Squibb unless the price was cut.

"The price reduction was relatively quick and it made sense for (the company) to act right away because of the extent of blatant overpricing," said TAC spokesman Nathan Geffen.

Company general manager Michael Barry said the drug was produced at overseas plants at different costs.

The company has been talking to the Medicines Control Council (MCC) and the TAC since March and is awaiting the MCC's approval for sourcing and price changes.

Barry said the company was reducing the price because it was committed to expanding drug access to HIV/Aids patients who need it most.

Tihana Bicanic, a specialist in infectious diseases at the GF Jooste Hospital in Manenberg, said there was no data on the South African incidence of cryptococcal meningitis, but 13% to 44% of patients died. Even with optimum treatment, in the US up to 25% of people died.

Bicanic said Amphofericin B killed harmful organisms faster than another drug on the market. It is the first choice for hospitals that can give it. It required intravenous injection and in-patient treatment for seven days. Bicanic emphasised that, if the drug was to be effective, hospitals needed facilities to administer it.

(Published on the web by Cape Times on May 24, 2005)

Cochrane Review: Cotrimoxazole prophylaxis for opportunistic infections in adults with HIV

2005-05-06T10:42:00.000+07:00

Grimwade K, Swingler, G.

Abstract

[A substantive amendment to this systematic review was last made on 25 March 2003. Cochrane reviews are regularly checked and updated if necessary.]

Background

The prevention and early treatment of infections are the mainstay of the medical management of the majority of people with HIV infection, who live in low income countries without access to antiretroviral drugs. Cotrimoxazole is cheap and effective against a wide range of organisms. However, routine prophylactic treatment is difficult to deliver in low-resource settings, and could also lead to increased resistance to the drug.

Objectives

To assess the effects of routinely administered cotrimoxazole on death and illness episodes in HIV infected adults.

Search strategy

We searched the Cochrane HIV/AIDS Group register, the Cochrane Controlled Trials Register, MEDLINE, LILACS, AIDSLINE, AIDSTRIALS and AIDSDRUGS databases, and proceedings and abstracts from AIDS and tuberculosis (TB) conferences (search date July 2001). We checked reference lists for trials and other pertinent articles, and contacted pharmaceutical companies and experts in the field.

Selection criteria

Randomised or quasi randomised trials comparing routinely administered cotrimoxazole versus placebo or no treatment in adults (age greater than 13 years).

Data collection and analysis

Two reviewers independently assessed trial eligibility and quality, and extracted data. Where data were incomplete or unclear trial authors were contacted for further details.

Main results

Four trials involving 1476 people were identified. Three trials (1416 people) studied heterosexual men and women in West Africa. A fourth trial was of homosexual men on chemotherapy for Kaposi's sarcoma, in the United States. Meta-analysis of the three African trials showed a significant beneficial effect of cotrimoxazole for death: relative risk 0.69 (95% confidence interval 0.55 to 0.87); for morbid events: 0.76 (0.64 to 0.9); and for hospitalisation: 0.66 (0.48 to 0.92). There was no significantly greater risk of adverse effects: relative risk 1.28 (0.47 to 3.51). Effects were similar in people with early and advanced HIV disease. Insufficient evidence was found on effects in areas with higher bacterial resistance or in people on antiretroviral therapy.

Authors' conclusions

In the trials included in the review, cotrimoxazole prophylaxis had a beneficial effect in preventing death and illness episodes in adults with both early and advanced HIV disease. However, the wider applicability of these findings is unclear, in particular to areas with higher background bacterial resistance to cotrimoxazole. Further trials would be required in differing settings to widen applicability.

Citation

Grimwade K, Swingler, G.. Cotrimoxazole prophylaxis for opportunistic infections in adults with HIV. The Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.: CD003108. DOI: 10.1002/14651858.CD003108.

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Cotrimoxazole prophylaxis in Asia: What are we waiting for?

2005-03-14T19:08:00.000+07:00

Remember the days before antiretrovirals were available? The days before AZT? Just ten years ago there wasn’t much that could be done when someone developed AIDS. Some of us well remember the powerlessness and pain.

One thing we could do at the time was to give cotrimoxazole – an antibacterial agent that helps prevent and treat Pneumocystis carinii pneumonia. The two common brands, Septra or Bactrim, were cheap, widely available, and easy to administer. For years, cotrimoxazole was almost the only thing we knew that could help save lives.

In the clinical world the gold standard for determining whether a treatment is effective is a successful “Cochrane review”. The process is named after Archie Cochrane, who was one of the first to popularise reviews of scientific evidence. One of these reviews has recently been performed to examine evidence for the effectiveness of cotrimoxazole prophylaxis.

The results are very positive. Three African trials have shown a significant beneficial effect from cotrimoxazole, which prevents people from dying with a low incidence of side effects. The impacts of the drug are similar in people with both HIV and AIDS.

The results are not yet 100% conclusive: the Cochrane review found little information about cotrimoxazole’s effectiveness in areas with bacterial resistance to it, and not enough information about the effectiveness of cotrimoxazole prophylaxis in people taking antiretroviral therapy.

Cotrimoxazole not only prevents Pneumocystis carinii pneumonia, but is also effective against toxoplasma, which can cause encephalitis. It may also help fight deadly falciparum malaria – the most severe form of the disease, caused by Plasmodium falciparum. In Africa, cotrimoxazole has also been found to reduce other infections.

Side effects appear limited. A few people with AIDS who take cotrimoxazole develop a rash. But if they begin taking it three times a week, then increase to once a day after the first month, they probably reduce the chance of developing it.

Cotrimoxazole is commonly given to pregnant HIV-positive women. Also, trials in Africa have shown that people with TB who receive cotrimoxazole live longer than those who don’t receive the drug.

Some public health physicians in Africa are concerned that the widespread use of cotrimoxazole may accelerate drug resistance to sulfadoxine-pyrimethamine treatment, a combination therapy increasingly used for the treatment of acute, uncomplicated malaria.

Some are also concerned that the germ that causes simple, pneumococcal pneumonia will also become resistant to the drug. That may mean that Africa needs to adopt the use of Asia’s “superdrug” artemisinin.

For many, though, these theoretical possibilities are not so important when people are dying.

In March 2000, UNAIDS and the WHO jointly recommended that cotrimoxazole prophylaxis be used for people living with HIV/AIDS in Africa, to be administered as part of a package of care. The advice applies to all adults who have developed any opportunistic infection.

Four years have passed since then; why is cotrimoxazole prophylaxis not used more in Asia?

Official treatment guidelines are one place to start. Thailand and Cambodia both include cotrimoxazole prophylaxis in their official national treatment guidelines. Thai guidelines have included cotrimoxazole prophylaxis for at least ten years.

The only other Asian country with a generalised epidemic is Myanmar. Official national guidelines have yet to be released there. China, Malaysia and the Philippines have already included it in their guidelines. India will probably include it in its guidelines soon. It is thought that Vietnam, Indonesia and Sri Lanka will include the drug in their own guidelines in the near future.

But official guidelines are merely pieces of paper unless the recommendations are implemented. What is common practice?

Application varies widely from country to country. In Cambodia, cotrimoxazole has been promoted by non-governmental organisations for several years, and many people living with HIV are now taking it. In Myanmar, cotrimoxazole prophylaxis is almost unknown.

In Vietnam, despite intensive advocacy by international health organisations, and being recommended by the WHO for the last six years, national guidelines still do not include the drug. The germs are not resistant in Vietnam – it is the doctors who sit on the guidelines development committee who show resistance. Once again it is people living with HIV who are leading the way; word is out, and the medication is being taken. Health insurance is nonexistent, but fortunately, locally produced cotrimoxazole costs less than fifteen dollars a year.

In terms of effectiveness, Thailand is most instructive. Many people living with HIV began to take cotrimoxazole in 2001, when the health minister announced that drugs for prevention and treatment of opportunistic infection would be covered by health insurance. Non-governmental organisations then conducted an intensive patient education programme to promote widespread uptake of the medicine.

The WHO has two Asian regional offices, but neither has released any new regional treatment guidelines in the wake of the “3 by 5” initiative, launched in December 2003. The WHO already recommends cotrimoxazole in Southeast Asia, and these recommendations are being revised to include a wider range of people living with HIV/AIDS. There are, however, apparently no plans for the same revisions in western Pacific guidelines.

In any case, guidelines need to be backed with promotion. We already know that cotrimoxazole can save lives in Asia. What are we waiting for?

HDN Key Correspondent
Email: correspondents@hdnet.org

(July 2004)