HAQOCI - HIV/AIDS Standard Treatment Guidelines

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HIV/AIDS Standard Treatment Guidelines

1st Edition 2003

Published by: HIV/AIDS Quality of Care Initiative (HAQOCI) in collaboration with The National Drug and Therapeutics Policy Advisory Committee (NDTPAC) and the Ministry of Health & Child Welfare Republic of Zimbabwe.

The information presented in these guidelines conforms to current medical nursing and pharmaceutical practice. It is provide in good faith. Whilst every effort was made to ensure that drug doses are correct, no responsibility can be taken for errors and omissions.

Foreword, Development process and Acknowledgements, Preface, Contents

1. Prevention and Care of HIV Infection 2. Psychosocial Care and Support3. Nutritional guidelines 4. Testing for HIV infection5. Antiretroviral Therapy6. Preventing Opportunistic Infections7. Post-Exposure Prophylaxis8. Fungal Opportunistic Infections9. Bacterial Opportunistic Infections10. Protozoan and Parasitic Opportunistic Infections11. Viral Opportunistic Infections12. Sexually Transmitted Infections13. Ocular Manifestations of HIV Infection14. Gastrointestinal Manifestations of HIV Infection15. Neurologic Manifestations of HIV Infection16. Neuropsychiatric manifestations of HIV infection17. Home based care18. Palliative care19. Oral manifestations of HIV infection20. HIV-related malignancies21. Skin manifestations of HIV infection22. ENT conditions 23. Women with HIV/AIDS 24. Prevention of mother-to-child transmission of HIV25. Paediatric HIV infection26. Haematologic Disorders27. Cardiomyopathy28. Nephropathy29. Discharge planning guidelines

Appendix 1

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HAQOCI - HIV/AIDS Standard Treatment Guidelines

Appendix 2Appendix 3Appendix 4

Index 1

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HAQOCI - Contact Details

2nd floor

Mbuya Nehanda Maternity Unit,Parirenyatwa Hospital,P.O. Box A178, Avondale,Harare, ZimbabweTelephone: +263 4 791631 / 707445-6Fax: +263 4 791995. 707445Email: haqoci@mweb.co.zw

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HAQOCI - Links

LINKS:

● SAFAIDS - www.safaids.org.zw

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HAQOCI - Publications

Publications

Reports

Newsletters

Guidelines

Training Material

The following publications have been developed to date:

● Adherence To Drugs● Basic Facts About Tuberculosis (Tb)● Caring For A Child With HIV● Caring for Somebody with HIV/AIDS● Cryptococcal Meningitis● Fatigue● Managing Your Food and Water to Ensure Safety● Cryptosporidiosis● Candidiasis● Toxoplasmosis● Prevention of Mother to Child Transmission of HIV● Management of Pain in HIV● Tuberculosis (TB) Among Patients Infected with HIV● Oral Care in HIV Infection (Care of the Mouth)● When to See a Health Worker (For HIV/AIDS Patients)● Cotrimoxazole Prophylaxis● Diarrhoea● Fluconazole● Nutritional Guideline for People Living With HIV● Nutritional Advise for People Living With HIV● What To Do When You Have Diarrhoea● What To Do When You Have a Heartburn or Are Feeling Bloated● What To Do When You Are Constipated● What To Do When You Feel Nauseous● What To Do When Food Doesn’t Taste the Same● What To Do When You Have No Appetite● Side Effects of Drugs

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HAQOCI - News and Information

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HAQOCI - Activities

Introduction

Training on discharge

planning, opportunistic infection prevention, use of

standard treatment guidelines

Information dissemination on HIV/AIDS

Opportunistic Infection

Prevention Program (OIPP)

National Standard Treatment Guidelines (STGs) for

HIV/AIDS

Pilot Project To Improve PMTCT Service Utilization

Introduction

● Training on discharge planning, opportunistic infection prevention, use of standard treatment guidelines

● Information dissemination on HIV/AIDS● Opportunistic Infection Prevention Programme (OIPP)● Development of HIV/AIDS care standard treatment guides● Setting up Opportunistic Infections (OI) prevention clinics● Pilot Project to improve PMTCT Service Utilization

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About HAQOCI

About HAQOCI

Mission, Objectives

Staff

Committee Members

Our Partners

CERTC

HAQOCI is an initiative that started in October 2001 and is being funded by the Centers

for Disease Control and Prevention, Atlanta, with technical support from CDC-Zimbabwe AIDS Program and is housed in the Clinical Epidemiology Resource & Training Centre (CERTC), College of Health Sciences - University of Zimbabwe. The initiative is a 5-year commitment to improve HIV/AIDS care in Zimbabwe.

HAQOCI is a non-profit making coalition of health care professionals committed to assisting with the delivery of high quality HIV/AIDS care in Zimbabwe.

Mission

Our mission is to promote the highest standards and quality of HIV/AIDS care in Zimbabwe, through evaluation of HIV/AIDS care services, development and integration of models of improved care, dissemination of evidence based health information on HIV/AIDS care, training and advocacy.

HAQOCI Objectives

The following are the objectives of this initiative:

1. To develop the infrastructure and capacity for HIV/AIDS quality of care improvement.

2. To characterize the HIV/AIDS quality of care situation through consensus meetings and surveys.

3. To identify, develop, pilot and evaluate high priority, achievable models of improved HIV/AIDS care.

4. To develop standard treatment guidelines on HIV/AIDS care.5. To develop and implement an HIV/AIDS care information dissemination plan6. To promote, support and advocate for high quality HIV/AIDS care in Zimbabwe.

These objectives will be achieved through;

● The development of effective partnerships with Ministry of Health and Child Welfare, National AIDS Council, Non-Governmental Organisations (NGOs), Institutions and individuals involved in HIV/AIDS care.

● The use of the multidisciplinary expertise that exists in the CEU, the Faculty of Medicine as a whole and beyond.

● Conducting stakeholder meetings to build consensus on critical HIV/AIDS care issues.

● Providing support for operational research and research projects on health services that pertains to HIV/AIDS care.

● Capacity building for HIV/AIDS care and research.● Information dissemination.

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HAQOCI

HAQOCI is a non-profit making coalition of health care professionals committed to assisting with the delivery of high quality HIV/AIDS care in Zimbabwe.

Newsletters of updates to Health Policies.

The information presented in these guidelines conforms to current medical nursing and pharmaceutical practice. It is provided in good faith. Whilst every effort was made to ensure that drug doses are correct, no responsibility can be taken for errors and omissions.

Brochures and information on health and care of people living with or caring for persons with HIV/AIDS status.

2nd floorMbuya Nehanda Maternity Unit,Parirenyatwa Hospital,P.O. Box A178, Avondale,Harare, ZimbabweTelephone: +263 4 791631/ 707445/6Fax: +263 4 791995. Email: haqoci@mweb.co.zw

.

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HAQOCI - Newsletter

Publications

Reports

Newsletters

Guidelines

Training Material

Newsletters

● Anti Retroviral Therapy Practical Issues and Policy Considerations – Issue 1● Opportunistic Infections (OIs) in HIV Disease – Issue 1● Preventing Parent to Child Transmission of HIV – Issue 2● Strategies for Sustaining Community Involvement

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HAQOCI - Reports

Publications

Reports

Newsletters

Guidelines

Training Material

Reports

HAQOCI annual report – 2001/02

HAQOCI annual report - 2002/03

HAQOCI annual report - 2003/04

HAQOCI annual report - 2004/05

HAQOCI annual report - 2005/06

First Stakeholders Report - 2002

Second Stakeholders Report - 2003

THE HIV AND AIDS RESEARCH AGENDA REPORT - 2005

Integrating HIV prevention, care and support into pre-service medical and nursing curriculum Report 2006

HAQOCI Home Based Care report 2005/2006

Best Practices in HIV Care Report June 2006

National Situational Analysis Reports - 2002

Laboratory services in Zimbabwe

Use of ARVs and management of OIs

HIV/AIDS psychosocial care in Zimbabwe

Maternal and Child Health

Hospital discharge planning in Zimbabwe

Community home based care in Zimbabwe

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HAQOCI - Reports

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HAQOCI - Training Material

Publications

Reports

Newsletters

Guidelines

Training Material

Training Material

Trainers Module – Prevention of Opportunistic Infections

Acknowledgements, Introduction, Course Components

● Overview of the HIV/AIDS Epidemic in Zimbabwe● Specific opportunistic infections● Tuberculosis and other bacterial infections● Viral infections● Malignancies associated with immunosuppression● Prevention of opportunistic infections● Service provision ● Clinical management of common medical problems● Counseling for Opportunistic Infection Prevention● Discharge Planning● Nutrition Care and Support● Laboratory tests for OI s● Guidelines for Antiretroviral Therapy (ART) in Zimbabwe● Care of the HIV EXPOSED or infected infant of child● Antiretroviral drugs and their side effects

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1

HIV/AIDS STANDARD TREATMENT GUIDELINES 1ST EDITION 2004 PUBLISHED BY: HIV/AIDS Quality of Care Initiative (HAQOCI) in collaboration with The National Drug and Therapeutics Policy Advisory Committee (NDTPAC) and the AIDS and TB Unit - Ministry of Health & Child Welfare Republic of Zimbabwe. The information presented in these guidelines conforms to current medical nursing and pharmaceutical practice. It is provided in good faith. Whilst every effort was made to ensure that drug doses are correct, no responsibility can be taken for errors and omissions.

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PREFACE This is the first edition of the HAQOCI standard treatment guidelines, which

will serve as the national HIV/AIDS care guidelines. The selection of drugs

is in accordance to our national drug policy with the essential drug policy

concept and the rational use of drugs remaining of paramount importance.

The use of the Vital, Essential and Necessary (VEN) classification has been

maintained as there is need to prioritise the drugs that we recommend that

you use.

The guidelines have been kept simple. They are a tool to help us achieve an

improvement in the quality of life of HIV/AIDS infected and affected clients

cost-effectively. These national guidelines are compIimentary to EDLIZ and

hence it is our hope that you will use them as much as you have been using

EDLIZ.

Suggestions or comments which may be of assistance in compiling future

editions will be appreciated. Comments can be emailed to

<ndtpac@healthnet.zw> or <haqoci@mweb.co.zw>.

Minister of Health &Child Welfare

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DEVELOPMENT PROCESS & ACKNOWLEDGEMENTS The national HAQOCI Stakeholders’ meeting to build consensus on

HIV/AIDS quality of care improvement was held in February 2002. The need

to improve the quality of HIV/ AIDS care through provision of up-to-date,

evidence based standard treatment guidelines for health care providers at all

levels was highlighted. The meeting noted that there was no minimal

package of HIV /AIDS interventions.

The first guideline development workshop occurred at Kadoma in

September 2002 when a group on healthcare workers from various parts of

Zimbabwe met and agreed on the plan that had been developed by the

NDTPAC. The topic leaders for the various topics/conditions to be covered

were endorsed. It was agreed to have a guideline development email

discussion group whose address was <zimguideline@ yahoogroups.com>.

The topic leaders handed in their draft guidelines. The second and final

workshop occurred nearly a year later (July 2003) in Harare – where the

topic leaders met to finally review their topics after they had been edited and

reviewed by Professor Ahmed Latif, Dean at the University of Zimbabwe

College of Health Sciences, who had been identified as the overall editor of

the book.

The final result was meant to be a document that all healthcare delivery

service providers could refer to and use when confronted with an HIV

infected individual. The document covers all aspects of HIV/AIDS care and

is tailored to what is feasible and practical in our Zimbabwean setting.

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The principle of consensus was used in the improvement of the currently

available guidelines as well as in the production of new guidelines where

they were none available. The method used has produced both research–

based and consensus-based recommendations. The core guideline

development group involved members of the AIDS and TB Unit – Ministry of

Health and Child Welfare, NDTPAC as well as other members identified by

the steering committee of HAQOCI. A modified Delphi technique was used.

The members of the working groups included people working at A (central

and provincial hospitals), B (district hospitals) and C (rural health centres)

levels as per EDLIZ style.

The AIDS & TB Unit – Ministry of Health and Child Welfare, HAQOCI

Steering Committee and the NDTPAC would like to acknowledge all the

people who contributed in one way or another to produce this book and, in

particular, the following:

Professor Ahmed S Latif – Overall Editor

Nutrition Unit, Ministry of Health & Child Welfare and

HAQOCI reviewers (includes those who attended the final review in Harare):

Alfredo Dr C Mahomva Dr A

Basopo Mr Victor Masanganise Mr R

Borok Dr M Mawera Dr G

Bwakura Dr M Mielke Prof J

Cakana Dr AZ Mujuru Dr H

Chidzonga Prof Mupanomunda Dr M

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Chingono Mr A Nathoo Prof K

Chinyanga Mrs E Ndhlovu Dr CE

Dixon Dr M Ndlovu Dr N

Gangaidzo Prof IT Nyathi Dr M

Gwanzura Prof L Reid Dr A

Kambarami Dr R Sebit Dr MB

Kasule Prof J Sibanda Dr E N

Kumire Mr C Stanzcuk Dr G

Latif Prof AS Tsikai Mrs F

Lawrence Hicks Ms M Tumishime-Buturo Mr CG

Malaba Dr L Wilson Mrs E

Kadoma Participants:

Basopo Mr Victor Kambarami Dr R Nathoo Prof K

Bwakura Dr T Kasule Prof J Ncube Mrs E

Cakana Dr AZ Latif Prof AS Ndhlovu Dr CE

Chadenga MrsS Madonko MrsMS Ndlela Mrs T

Chaire Mr Magure Dr T Ndlovu Dr J

Chawatama Dr E Makotore Ms A Nkomo Dr B

Chemhuru Dr MA Makuba Mr S Nyamakura Mrs R

Chibgage MrsR Makurira Mr E Nyathi Dr M

Chidarikire Mr A Mandisodza Mrs M Nyazema Prof N

Chidzonga Prof M Maponga Dr C Osewe Dr P

Chingono Mr A Maradzika Mrs J Patrikios Mrs H

Chinyanga Mrs E Masanganise Mr R Sam-Abbenyi Dr A

Chirara Dr M Matenga Prof JA Sebit Dr MB

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ChitsikeDr I Mawera Dr G Sifeku Mrs F

Chitsungo MrsS Mhembere Mrs Simoyi Ms T

Cirera Dr A Mhlanga Dr G Tamangani Mrs

Dhliwayo Mr B Mpofu Mr D Thuso Ms A

Diez Orla la Ms Mudzi Mr Tisocki Dr K

Dixon Dr M Mukodzani Mr L Torongo Mrs M

Gwanzura Prof L Mupambo Dr AC Tshuma Dr C

Gwatiringa MrsC Mupanomunda Dr M Tsikai Mrs F

Haruzivishe Dr C Mushonga Dr RP Wilson Mrs E

Hernandez M Mr Mutangadura Dr Zvinavashe Dr M

Hove MrsR Mwazha Dr Xaba Dr E

Kadzirange Dr G Mwazha Mrs

Members of some of the working groups:

Fairall Ms C

Garanganga Ms E

Kawadza Ms C

Mashiri Ms B

Meda Ms M

Mkwananzi Ms S

Ndlela Mrs T

Poulton Ms B

Williams Dr S H.

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Most sincere gratitude goes to ZIM-CDC – Global AIDS program without

whose support this effort would not have been possible.

Thank you all!

Dr C E Ndhlovu,FRCP Dr R Kambarami,FRCP Dr O Mugurungi

Chairperson,NDTPAC Director,HAQOCI AIDS & TB Unit

Ministry of Health &

Child Welfare

(MOH&CW)

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CONTENTS Preface 2 Development process and acknowledgements 3 1. Prevention and Care of HIV Infection 10 2. Psychosocial Care and Support 15 3. Nutritional guidelines 27 4. Testing for HIV infection 35 5. Antiretroviral Therapy 40 6. Preventing Opportunistic Infections 69 7. Post-Exposure Prophylaxis 71 8. Fungal Opportunistic Infections 75 9. Bacterial Opportunistic Infections 84 10. Protozoan and Parasitic Opportunistic Infections 94 11. Viral Opportunistic Infections 100 12. Sexually Transmitted Infections 104 13. Ocular Manifestations of HIV Infection 151 14. Gastrointestinal Manifestations of HIV Infection 158 15. Neurologic Manifestations of HIV Infection 167 16. Neuropsychiatric manifestations of HIV infection 180 17. Home based care 188 18. Palliative care 200 19. Oral manifestations of HIV infection 210 20. HIV-related malignancies 219 21. Skin manifestations of HIV infection 233 22. ENT conditions 259 23. Women with HIV/AIDS 269 24. Prevention of mother-to-child transmission of HIV 274 25. Paediatric HIV infection 279 26. Haematologic Disorders 298 27. Cardiomyopathy 303 28. Nephropathy 306 29. Discharge planning guidelines 311 Appendix 1 – Rapid cotrimoxazole desensitization 319 Appendix 2 – Laboratory diagnosis 321 Appendix 3 – Preparation of therapeutic products needed 327 Appendix 4 – Antiretroviral drugs doses 335 INDEX 340

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1. PREVENTION AND CARE OF HIV INFECTION The main mode of transmission of HIV infection is sexual intercourse and hence sexual behaviour modification plays a key role in reducing transmission. However, the pandemic of HIV infection continues to grow despite nationwide efforts to increase awareness of the infectious nature of the infection and ways to prevent transmission of infection. A number of social, behavioural and biological factors, shown in Table 1.1, are responsible for perpetuating the epidemic. Table 1.1: Factors responsible for driving the epidemic of HIV infection Social and behavioural factors: Frequent partner change amongst the adult population Overlapping sexual partnerships – as opposed to serial monogamous relationships Engaging in commercial sex Separation of marital partners that occurs as a result of moving back and forth

between home and distant workplaces Use of alcohol in public places Sex across age groups; older men having sex with young women and girls Women’s economic dependence on marriage Poverty Unwillingness to use condoms consistently Cultural practices, such as, wife inheritance

Biological factors: High rates of sexually transmitted infections in communities where HIV is prevalent Low rates of male circumcision Women, especially women and girls, are at greater risk for infection when

compared to men Prevalence of more virulent strains of HIV, such as clade C, in the southern Africa

Region People living with HIV infection and AIDS (PLHA) need clinical care and support, as well as social support including, housing, food and education for themselves and their dependents, job security, psychological support to

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cope with a life-threatening condition, confidentiality and protection against discrimination and stigmatization. The main burden of disease in persons with HIV infection is related to a number of common infections, such as, tuberculosis, pneumonia, diarrhoeal diseases and oropharyngeal thrush. PLHA should have easy access to care and the following care-related activities should be available nationwide: Treatment of common HIV-related infections including, pneumonia,

diarrhoeal diseases, candidiasis, TB, herpes simplex virus infections, varicella zoster virus infections and other fungal infections

Prophylaxis against opportunistic infections Access to high quality primary and reproductive health care Access to STI care Detection and treatment of HIV-related opportunistic infections Detection and treatment of HIV-related cancers including Kaposi’s

sarcoma, lymphoma, cervical cancer Detection and treatment of neurological problems and mental

illnesses complicating HIV infection Highly active antiretroviral therapy Psychological support and counseling

Table 1.2 summarises primary prevention strategies and activities that have been demonstrated to work.

Table 1.2: HIV Primary Prevention Strategies and Activities Strategies Activities Public health education Inform and educate the public about the nature

of HIV and other STIs including danger of infection, complications, modes of transmission, methods of prevention and treatment

Counter myths about HIV infection and its transmission

Promote safer sexual behaviour

Delay sexual debut until one has found one’s lifelong mutually faithful partner

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Educate and empower adolescents, especially girls, to avoid sex with high-risk older partners

Have sex only with one’s lifelong mutually faithful partner

Avoid situations that may promote casual sexual liaisons

Promote safer sexual activity Abstain from sexual activity altogether Use condoms if engaging in casual sex Use condoms correctly and consistently Engage in non-penetrative sexual activities Promote and provide condoms widely

Promote early STI-care seeking

Promote good STI-care seeking behaviour Make STI services accessible and acceptable

Promote voluntary counseling and testing for HIV

Knowing one’s HIV status promotes behaviour change, provided appropriate education and counseling are also offered

Provide accessible and acceptable services for the voluntary testing for HIV

Provide HIV counseling services Prevent mother-to-child transmission of HIV

Provide education and counseling to pregnant women and their partners

Implement activities for the prevention of mother-to-child transmission of HIV using antiretroviral drugs

Promote appropriate infant feeding practices Provide appropriate family planning services Promote appropriate labour and delivery

techniques Adolescent friendly health services

Education on health and hygiene, sexuality and sexual health

Promoting good health care seeking behaviour Providing accessible and acceptable

adolescent-friendly health services Providing adolescent-friendly services for

reproductive health Prevent transmission through blood and blood products

Promote appropriate use of blood and blood products

Provide safe blood supplies and safe blood transfusion practices

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Promote avoidance of sharing of needles and syringes

Promote avoidance of skin piercing practices Institute programmes for post-occupational

exposure prophylaxis In addition the following support activities have been shown to mitigate the impact of HIV infection in PLHA and should be implemented nationwide: Psychosocial support for PLHA, their families and carers Recognition, establishing and facilitation of community activities supporting

PLHA and their families including: Legal structures against discrimination and stigma Support for orphans including, access to health care and educational needs Nutritional advice and support for PLHA and their families Public services that reduce the economic and social impact of HIV/AIDS,

including social security, legal aid, and matters relating to inheritance

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2. PSYCHOSOCIAL CARE AND SUPPORT 2.1 Introduction HIV/AIDS is more than just a medical problem as it brings with it a host of psychosocial issues at the personal, inter-personal, family and social levels. The impacts and ramifications of HIV infection and disease run throughout the whole course, from the time of infection through the development of disease to the terminal stages. Psychosocial support (which is an all- encompassing concept that includes counseling, spiritual support, welfare support and social/interpersonal support) should therefore be part and parcel of the continuum of care from prevention to treatment and care to discharge planning right up to home based care. It forms the crosscutting glue that binds the provision of holistic HIV/AIDS prevention, care and support. 2.2 Counseling for primary prevention of HIV infection Primary prevention counseling is indicated in a number of situations, which may include the following: During treatment for STIs Before and after HIV testing When deciding to have a baby Before marriage Suspected HIV infection in adults and infant

It usually entails an in-depth exploration of risk during which the client is encouraged to identify, understand and acknowledge the behaviours and circumstances that put him/her at increased risk for acquiring HIV/AIDS as well as assisting clients in taking maximum responsibility for risk prevention/reduction. Primary prevention counseling includes the following:

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1. First task: Provide clients with general information on HIV AIDS, including modes of HIV transmission and clarify any misinformation and misconceptions about means of preventing transmission of HIV/AIDS with respect to: Use of condoms Multiple partners Safer sex Injecting drugs and sharing needles

2. Second task: Facilitate a process whereby clients engage in a personalised HIV/AIDS risk assessment by establishing an atmosphere that conveys a non-judgemental, collaborative and creative interest in the exploration of those HIV/AIDS related issues that have relevance to the client. This requires communication skills and the requisite attitudes of respect and acceptance that will make it easier to: Facilitate client’s awareness of their personal risk for HIV infection

by reviewing the client’s sexual, medical and drug use history. Collaborate with the client in identifying the categories and range of

behaviours in his/her past that could have placed him/her at risk of HIV infection.

Review client’s current circumstances and behaviours and again identify those aspects of his/her lifestyle that pose real and potential risk for HIV infection.

3. Third task: Facilitate personalised risk-reduction decision-making and planning where you: Focus on risk reduction measures that relate to the client’s specific

HIV related risk behaviours and the circumstances that affect these behaviours.

Help the client identify current and potential barriers to implementing and sustaining risk-reducing behaviours.

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Help the client come up with a reasonable personalized risk-reduction plan towards HIV/AIDS prevention

Help clients anticipate possible barriers to the implementation of the risk-reduction plan and rehearse ways of overcoming them.

POINTS TO REMEMBER DURING COUNSELING • Keep the session focused on HIV risk assessment and reduction.

(Goal is risk reduction). • Include an in-depth personalized risk assessment. • Explore previous attempts to reduce risk and identify successes

and challenges. • Acknowledge and provide support for positive steps already

made. 2.3 Counseling in relation to HIV testing Counseling related to HIV testing has been given quite a lot of attention and this has led to the development of various protocols for Voluntary Counseling and Testing (VCT). This is so because VCT for HIV infection is often seen as an entry point for HIV prevention, care and support. For the yet uninfected, it often helps them to stay HIV negative by reinforcing risk-free behaviours. It encourages clients to come up with personalized risk reduction plans and to put them into practice. For those who are HIV positive, VCT helps them to deal with the immediate psychosocial impacts of their positive HIV status. In the long term however, VCT needs to be complimented or supplemented by supportive, crisis and bereavement counseling in order to help clients deal with the chronicity and roller-coaster nature of their illness as well as the possibility of premature deaths.

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2.3.1 Pre-test counseling Pretest counseling is counseling offered to clients before they take an HIV/AIDS test. Anyone considering being tested for HIV for whatever reason should be counseled before testing regardless of whether it is the clients themselves who have requested the test or whether it is the health worker who is suggesting the test. Pre-test counseling requires a supportive, non-judgemental and caring environment in which the clients will feel free to talk about their risk-related behaviours, their fears, worries and their motivation for HIV- testing. For pre-test counseling to be comprehensive the following areas need to be covered during the session: Client’s history of HIV counseling and testing. Why the HIV test is being considered/suggested. Client’s understanding of HIV transmission and prevention. As part of considering whether HIV testing is indicated, it is

important to assess client’s risk-history by exploring the following: o Sexual history including STIs o Exposure to invasive medical procedures (modern and

traditional) o History of intravenous drug use

To help clients arrive at an informed decision on whether or not to be tested they should be provided with information with regards to the following: The HIV testing procedure to be followed The Window period The meaning of positive, negative and indeterminate test results Length of time between testing and the availability of results Confidentiality of test results within the testing context.

In addition client’s decision on testing will be aided by

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Discussing the possible implications of test results (be they positive, negative or indeterminate).

Exploring the issue of confidentiality as it relates to significant others in the client’s life, who might need to be informed for whatever reasons and discussing the potential benefits and adverse consequences of shared confidentiality.

Reviewing client’s history of dealing with personal crises (what crisis, how handled, who helped) and discussing possible reactions to a positive HIV result.

Identifying social support systems (the family, support groups, fellowships) that are potentially available to the client and which the client may choose to access in times of need.

Having done all this, one should ascertain if the client still wants to go ahead with the test and then obtain the necessary informed consent (verbal or written) before commencing testing.

NOTE Pre-test counseling is intended to provide the client with the necessary informational and relational support to make a truly informed decision about whether or not to be tested for HIV. It is not intended to persuade the client to be tested. Therefore, regardless of whether or not the client decides to be tested, the pre-test counseling process undergone should have an empowering effect on the client (vis-à-vis risk assessment and risk reduction planning both of which are crucial in primary and secondary prevention of HIV infection).

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2.3.2 Post-test counseling Post-test counseling is counseling given to clients coming to receive their test result. It is designed to help the client deal with any immediate emotional reactions to the HIV test results and to come to terms with their sero-status and ultimately, to support clients in risk reduction. In order for clients to benefit from post-test counseling it is recommended that the client should receive results in person, as it is crucial to assess the client’s understanding of test results as well as facilitating client’s expression of reactions and feelings. A number of health workers and counselors may be apprehensive about giving clients their test results (especially when the results are positive) and undertaking the necessary post-test counseling as they feel ill-prepared to deal with the resultant emotional reactions. It is important to stress here that when pre-test counseling has been done adequately post-test counseling will be easier to do. NOTE: Take time with pretest counseling, do it well, do not rush to test, make sure the consent the client gives is truly informed and what follows thereafter should be that much easier to deal with. 2.3.3 If the test result is positive If the HIV test is positive proceed as follows: Assess client’s readiness to receive results. Give results in simple and clear terms and check understanding Allow time for expression of emotions. Discuss what the results mean to the client and their implications at

the personal, relational, social and other levels. Revisit the discussion on client ’s social support systems and explore

the pros and cons of disclosure of status to significant others (whom, how, when, and their likely reactions)

Revisit the personalized risk assessment and reinforce risk reduction plans and decisions on positive living i.e. (safer sex,

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exercise, drug and alcohol use, smoking, nutrition, early treatment of opportunistic infections, use of ARVs, stress management etc).

Note that the client may not be in a psychological state to absorb a lot of information at this stage. It is therefore necessary to arrange follow up sessions for additional psychological and social support as needed. Before terminating the post-test counseling session with an HIV positive client it is necessary to: Assess the client psychological reactions to and coming to terms

with being HIV positive Provide realistic reassurance about clients status Discuss client’s immediate plans following the session. Provide information on available psychosocial support networks e.g.

ZNNP+, The Centre, MAC, NAC and others in the client’s catchment areas.

2.3.4 If the test result is negative or indeterminate If the test result is negative or indeterminate then do the following: Assess client’s readiness to receive results. Give results in simple and clear terms and check client’s

understanding of the test result. Allow time for expression of emotions. Discuss what the results mean to the client and their implications at

the personal, relational, social and other levels Revisit the issue of the window period and discuss any need for

retesting. Revisit the personalized risk assessment and discuss risk reduction

plan so as to reinforce client’s commitment to remaining negative.

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Provide information on psychosocial networks in the client’s catchment area that are committed to the prevention of HIV transmission.

2.4 Counseling in relation to on-going care and support for the infected and affected

2.4.1 Information giving The HIV/AIDS scenario is forever changing. New information is coming to light everyday and new developments in the areas of care and support are the order of the day. One of the fundamental needs that arise from this is the need for up- to- date information. Yet uncertainty still pervades the field and impacts on many lives. A key ingredient in supportive counseling is empowering clients with the necessary factual information that enables them to make timely decisions, access needed care and support and to live positive lives. Supportive counseling should therefore provide clients with information on: Disease progression and importance of early treatment of O.I

(immunity). Nutrition/hygiene, exercising and how to live positively. Antiretrovirals, their availability or otherwise, how they work, side

effects and cost. 2.4.2 Psychological Support Due to the roller coaster and episodic nature of HIV disease clients may require on-going psychological support. For many of them more than one session may be required as a follow up on issues discussed in pre-test and post-test counseling. Such psychological support aims to help clients develop problem-solving skills so that they can assume/resume authority over their lives by taking clients through the following stages: Problem identification – the client is helped to articulate what

exactly is the current problem/issue/concern

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Problem exploration – how is it a problem, for whom is it a problem, when is it a problem, etc

Exploring possible solutions – weighing the pros and cons of alternative solutions to the problem.

Decision making and implementation – choosing the most pragmatic options and coming up with realistic plans that are most likely to be achievable and supporting clients in implementing their decision through either being there for them or be working with them with other support services in the community.

2.4.3 Social and Welfare support HIV infection and disease tends to be chronic. In the early phases clients are able to carry on leading independent and productive lives. However, there comes a time when clients and their primary care givers may need social and welfare support. Such support may be available from Government Services such as Social Services, and the National AIDS Trust Fund through District, Ward and Village AIDS Action Committees. It may also be available from the many non-governmental and AIDS Service Organizations that are operating in many communities. However, clients in need can only access such social and welfare support if they are aware of its existence and where and how to access it. Those involved in supportive counseling should therefore have up to date information on the range of support services that are available in their catchment areas. At the very least, they should have the latest copies of the directories of counseling and psychosocial support services that are published annually. Supportive counseling should therefore facilitate: Client’s identification and articulation of social needs – food,

transport, health services, financial support. Exploration of the support systems that are and could be available

to the clients (family members, neighbours, support groups e.g. churches, NGOs, CHBC group, social welfare).

Planning of how clients can best manage their problems through accessing and/or mobilization of resources for their benefits.

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2.5 Counseling in relation to prevention of opportunistic infections Although the supportive counseling discussed previously will help clients to come to terms with their HIV infection and to live positive lives, the nature of HIV disease is such that at some point in time they may succumb to opportunistic infection. When this happens it may constitute a blow that may precipitate a psychological crisis. It is therefore important to offer clients psychosocial support aimed at preventing and/or delaying the onset of opportunistic infections. In this regard clients need to be furnished with: Information on immunosuppression and depletion, common

opportunistic infections, modes of infections and how to recognize early warning signs of opportunistic infections.

Information on healthy life style to prevent OIs. Advice on the importance of seeking early treatment for OIs.

This information needs to be complimented by counseling that is aimed at motivating clients towards the secondary prevention of opportunistic infections. Such counseling will cover: The benefits, for the individual client, of seeking early treatment

and emphasising that most OIs can treated and that prophylaxis treatment is available e.g. cotrimoxazole for PCP.

The burden of disease for the individual and caregivers in the family and what help is potentially available to lessen the burden e.g. home based care.

Adherence issues related to pill burden, cost and accessibility of treatments that may become obstacles to prevention of opportunistic infections.

In addition counseling for secondary prevention of OIs will include: Supporting care givers by providing them with necessary information Providing clients and caregivers with the necessary supplies for

infection control, treatment and care.

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A care-management approach that facilitates a well co-ordinated discharge plan that networks clients with service providers at the various levels, from the hospital to the clinic to the community and ultimately to the home.

2.6 Counseling in relation to terminal issues in HIV/AIDS With HIV/AIDS, there are multiple losses that are experienced by both the infected and the affected clients throughout the whole continuum from the day one finds out that one is infected with HIV to the development of opportunistic infections up to the terminal stages of the disease. Clients experiencing such losses are likely to benefit from bereavement counseling aimed at helping them navigate their way through the following stages of bereavement: Shock Anger Denial Bargaining Depression Acceptance

For many people, diagnosis with HIV infection /AIDS throws into bold relief the issue of their own mortality and when people contemplate death, spiritual issues tend to come to the fore. When this happens they may benefit from spiritually focused counseling. Many health workers / clinicians and counselors however feel ill equipped to offer such counseling. In such instances they should: Recognise and acknowledge the client’s spiritual needs Identify the client’s spiritual affiliation. Encourage them to discuss issues with members of the spiritual

religion that they are comfortable with and to seek spiritual support whenever needed.

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2.6.1 Bereavement counseling Bereavement counseling may be necessary to help clients deal with unfinished business and will usually involve: Discussing cultural issues that are important and need to be

attended to, e.g., rituals, customs, spiritual, and how and when. Helping the client settle any outstanding grievances between

him/herself and others (clearing the air). Making or revising a will and planning the future for those

dependents who will be left behind 2.6.2 Letting go In addition clients may need help with letting go and coming to terms with dying. Talking about death and dying is very difficult for a lot of people as the subject is considered taboo. Many dying patients/clients are therefore denied the opportunity by their relatives, friends and even health workers to ventilate their concerns about their dying. It is for this very reason therefore that counsellors need to either work through their own issues about death that may become obstacles in their work or to be honest enough about their shortcomings and make appropriate referrals so that the client is not denied a needed service. To help dying clients let go and come to terms with their dying the following issues may need to be discussed during counseling: Their fears and feelings about dying. Whether or not to die at home. Funeral and memorial arrangements Support available after client’s death – for individual members of

family to help them deal with the relative’s death. In providing bereavement-related psychosocial support there may be need to involve other significant members of the client’s family in order to provide

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them with the necessary psychological preparation on the realities of death and to help maintain a balance between living and dying within the family system. Where indicated referrals to appropriate organizations /counselors that specialize in bereavement (such as Island Hospice) should be made. NOTE: Refer to the section on the The Dying Patient in Chapter 17 on Home Based Care for more details.

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3. NUTRITIONAL GUIDELINES 3.1 Principles of Nutrition in PLWHA It is important that all people living with HIV/AIDS eat more of

every thing but maintaining a balanced diet. The following are recommended: Intervene at an early stage. Do not wait until patients look like they need nutrition intervention. The early stages of the disease are more responsive to nutrition support than later stages, therefore allowing for decreased morbidity and an improved quality of life.

Increase energy intake by means of dietary counseling and use of supplement. Patients who consume an adequate diet (30-35kcal/kg) may consume an additional 600 kcal/day.

Increase micronutrient intake. Assess the patient’s diet and make sure he/she is consuming 100 percent of the Recommended Dietary allowance for all vitamins and minerals. Additional multivitamin/mineral supplement may be necessary.

Consume more and frequent meals. Keep energy intake up by consuming many meals, snacks, and enteral supplements throughout the day.

Increase protein intake (2mg/kg) Starchy (carbohydrate) food: These foods supply energy to the body. A large proportion of the diet should be made up of carbohydrates. Whole grain starches contain some vitamins and minerals as well as protein, e.g., maize meal, bread, rice, sweet potatoes/ potatoes Legumes, beans, peas, lentils and nuts: These are foods of vegetable origin and are good sources of vitamins, minerals and proteins.

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Vegetables and fruits: Fruits and vegetables are an important part of a healthy and balanced meal. They provide essential vitamins and minerals that are necessary for normal body function. It is essential to consume a variety of fruits and vegetables every day as each type provides different vitamins and minerals. The vegetable content of the diet should be varied with different varieties being consumed. Dark green and orange or red vegetables and fruits are best, e.g., spinach, rape, cabbage, carrots, pumpkins, mangoes, guavas, bananas Animal products, fish, poultry and alternates: Meat, fish, and foods from animals must be eaten as often as possible. They supply good quality proteins, extra energy, vitamins and minerals. They are body-building foods that strengthen muscles and the immune system. Fats and oils as well as sugar and sugary foods: Fats, oils and sugary foods, in moderate amounts, are part of a healthy and balanced diet. They provide extra energy. Clean and safe water: It is necessary to drink about 8 cups of water or fluids per day. Alcoholic drinks should be avoided. Always boil your water for 10 minutes if your source is not protected. 3.2 Introduction The principles described above are applied as follows: Intervene at an early stage. Do not wait until patients look like they

need nutrition intervention. The early stages of the disease are more responsive to nutrition support than later stages, therefore allowing for decreased morbidity and improved quality of life.

Increase energy intake by means of dietary counseling and use of supplement. Patients who consume an adequate diet (30-35kcal/kg) may consume an additional 600 kcal/day.

Increase micronutrient intake. Assess the patient’s diet and make sure he/she is consuming 100 percent of the Recommended Dietary

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allowance for all vitamins and minerals. Additional multivitamin/mineral supplement may be necessary.

Consume more and frequent meals. Keep energy intake up by consuming many meals, snacks, and enteral supplements throughout the day.

Maintain cholesterol and fat intake. In HIV patients, low serum cholesterol level was found to have adverse clinical outcome

3.3 Food safety People living with HIV/AIDS are immunocompromised and therefore food-borne infections pose an increased risk and must be prevented. The symptoms of such infections include diarrhoea, nausea, vomiting, fatigue and abdominal pain. These can be severe and the source of infection can be difficult to identify. It is important to follow good hygiene and food safety recommendations. 3.3.1 Food handling Some recommendations for safe food handling are: Always wash hands with soap or ashes after using the toilet, before

food preparation and eating. Keep your nails short and clean Keep all preparation surfaces and utensils clean Cook all raw animal products until well done. Peel fruits Never thaw and then re-freeze foods. Pack meat into daily portions

before refrigeration. Thaw frozen meat at refrigerator and not at room temperature Where there is no refrigerator, dry meat as biltong and store in a

cool dry place until ready for use Do not use wooden boards for cutting animal products instead use

plastic boards or plates

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Wash cutting boards and knives thoroughly with soap before using them for other foods

Wash fruit and vegetables in plenty of clean water from a safe source

Pour from a container/jug (kuchururudza/ukucengelana) when washing hands.

Always boil your water for 10 minutes if your source is unprotected Use clean cups for feeding babies and never use bottles

3.3.2 Food Storage It is important to store food properly to prevent spoilage and loss of nutrients. Temperature and humidity controls and ventilation are necessary to retain the quality of stored food. Dry storage Non- perishable food that does not require refrigeration is stored dry. Storage areas should be dry, cool and properly ventilated. Wall vents are important for the circulation of air. Allowing circulation of air around bags and cartons of food aids the removal of moisture, reduces temperature and eliminates odours. Food should be stored using the FIFO (first in-first out) method. This means that new supplies should be placed at the back to ensure use of oldest stock first. Refrigeration and freezer storage Fresh and frozen foods should be refrigerated immediately after purchase and kept at these temperatures until ready to use. For safe food storage follow recommendations: Fruit and vegetables should be checked regularly for ripeness and

decaying pieces removed to prevent further spoilage. Food that absorbs odours, such as eggs and milk should be stored

away from those that give off odours, like fish, onions and leeks.

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Cooked food should be stored above raw meat in the refrigerator to ensure that foods are protected from raw meat drippings.

Cleanliness is vital to food safety. Refrigerators should be cleaned thoroughly at least weekly and spillage wiped up immediately.

Leftovers, to be consumed later, should be kept in covered containers in the refrigerator and used as soon as possible – at the latest within two days. Where there is no refrigerator, use leftovers the same day. Reheat all leftovers thoroughly before serving. Leftover chicken and fish should be avoided. 3.4 Dietary management of food intake problems HIV disease is complicated by a number of symptoms such as anorexia, nausea, vomiting, diarrhoea, malabsorption and hypermetabolism that affect food intake and nutritional status of an individual. These symptoms need to be investigated medically before dietary measures are instituted for symptomatic care. Table 3.1 summarises ways to alleviate some common food and diet related symptoms in persons with HIV infection.

Table 3.1 HIV-related problems and dietary measures that may alleviate them HIV-related problem Dietary management a. Diarrhoea Diarrhoea can cause dehydration and weight loss

Drink sufficient fluids such as water, diluted fresh fruit juices.

Take oral rehydration solution Eat small frequent meals. Eat fermented foods like mahewu, sour porridge Avoid fatty foods. . If milk and dairy products cause cramps use-fermented

products like lacto and yoghurt. Include soluble fibre (pectin) found in bananas, peeled

apples and pears, oats, carrots, pumpkin, paw-paw, potatoes.

Avoid insoluble fibre like in whole grain foods and beans

b. Fat intolerance Eat soft, mashed, liquid foods like soup, porridge

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Diarrhoea or steatorrhoea (fat in the stool) caused by malabsorption of fat and incomplete digestion of fat, can lead to malnutrition

Bake, boil, steam or roast food Squeeze lemon juice on meat or fish to improve

digestion, eat lean meat Do not fry foods. Remove skin from chicken before

cooking Avoid fatty foods such as potato chips, butter/margarine,

mayonnaise and cream c. Nausea and vomiting Nausea and vomiting will cause dehydration and weight loss

Avoid greasy, high fat or spicy food. Avoid taking fluids with meals. Take small frequent meals. Avoid the smell of cooking and foods with strong aromas

such cabbage, guru, onion. Eat slowly and chew well. Cool or cold meals are better tolerated than hot Savoury food are better tolerated than sweet foods. Eat a slice of toast or dry biscuits before getting up in the

morning. Do not lie down immediately after eating.

HIV-related problem Dietary management d. Taste Changes

Add seasoning to give more flavour to a meal.

Try different meals (variety) Practice oral hygiene by brushing teeth

after meals. If meat tastes strange try monitoring it. Use lemon, raw tomatoes or tonic water

stimulates tastes buds. Replace disliked dishes with preferred

dishes. Use a straw to bypass your taste buds.

e. Oral thrush / mouth sores / chewing difficulties

Try soft non-irritating foods e.g. scrambled eggs, custard, pureed pumpkin, paw-paws, or porridge.

Fermented food like mahewu, lacto, yoghurt

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relieves oral thrush. Suck a lump of ice or have an ice cold drink

before a meal. Practice good oral hygiene. Adding custard reduces acidity. Use a straw to avoid contact with the

affected part. Use garlic in food or prepare garlic tea Avoid sticky or dry foods such as peanut

butter on white bread, popcorn, roasted nuts, dry toast

Avoid sweet or sugary drinks Avoid hot foods; cold food can be soothing. Avoid acidic food e.g. citrus fruit, vinegar

and spicy food. f. Loss of appetite, anorexia

Eat with friends or family Eat small frequent meals and nutritious

snacks throughout the day in between meals.

Try to make meals attractive and appetising.

Avoid drinking liquids before taking a meal and during a meal.

Eat food with pleasing aroma. Avoid fatty foods, and sweets. Avoid smoking. Brush your teeth after a meal. Avoid preparing meals or stay in the kitchen

the smell can satisfy.

HIV-related problem Dietary management g. Weight loss

Increase energy intake Eat regular balanced meals. Eat nutritious snacks in between meals e.g.

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roasted peanuts, boiled eggs, fruits and sandwiches.

Exercise regularly to increase lean body mass and appetite.

Increase nutrient density of foods by adding peanut butter, skimmed milk powder, or eggs in soups or porridge.

Add grated cheese or fresh cream in a casserole.

Increase fat intake if tolerated. h. Fatigue

Have someone else to prepare food for the sick individual to avoid fatigue.

Eat food that is easy to prepare and easy to chew.

Eat fresh fruits that do not require preparation e.g. banana, paw-paw etc.

Drink high protein high energy liquids e.g. High Energy Milk, mahewu/amahewu etc

i. Fever

Eat high energy high protein meals e.g. mutakura/inkobe, nhopi/inopi with plenty of fluids and fruit juice.

Drink nutritious liquids often e.g. milk, sour milk, mahewu.

j. Heartburn, and fullness Feeling of fullness, discomfort or pain, after eating may be caused by indigestion, antibiotics, some anti-inflammatory, drugs, constipation, spicy and fatty foods

Eat small frequent meals. Avoid gas-forming foods such as: cabbage,

cauliflower, beans, carbonated drinks, and onion.

Avoid greasy, fried, spicy foods. Eat slowly and chew foods well. Drink fluids an hour before or after a meal. Eat long before you plan to go to sleep. Eat high fibre foods Exercise

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4. TESTING FOR HIV INFECTION 4.1 Introduction HIV infection is usually diagnosed by testing for antibodies against HIV. Screening tests for HIV antibody include the enzyme-linked immunosorbent assay (ELISA) test or the simple/rapid tests. Samples of sera that are found to be positive by screening tests are then tested for confirmation of the presence of HIV antibodies using a supplementary test. A supplementary test may be another ELISA test or another simple/rapid test based on a different antigen preparation or a different test principle. The objectives of HIV testing include: Screening of donated blood for transfusion Surveillance of HIV prevalence or trends over time in a given

population Diagnosis of infection in individuals

4.2 Laboratory tests Persons who become infected with HIV produce HIV antibodies over the next 3 to 12 weeks. Numerous different tests are available for the detection of HIV antibody. 4.2.1 ELISA tests The most commonly used type of test for screening is the ELISA. ELISA tests are most efficient for testing large numbers of samples per day. They are used widely in large blood banks and in surveillance studies. ELISA tests are usually performed on serum or plasma and hence a specimen of venous or capillary blood is needed. 4.2.2 Simple/rapid tests These tests are easy to perform. They do not require highly trained staff and require simple equipment. They can easily be performed in a VCT centre and results are obtained within the hour. They are suitable for use in small laboratories and for emergency testing.

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4.2.3 Diagnosis of HIV infection For diagnosis of HIV infection, all samples that test positive on screening should be subjected to a second test. This can be another ELISA or a simple/rapid test based on a different antigen preparation and a different test principle. 4.2.4 Tests to detect the virus itself New technologies based on the amplification of viral nucleic acids, such as polymerase chain reaction (PCR) and nucleic acid sequence based assay (NASBA), have made it possible to detect minute amounts of viral material. These sensitive procedures are well suited to early diagnosis of mother-to-child transmission and to monitoring the viral load of patients who are taking antiretroviral therapy. However, the tests are very expensive, need complex equipment, rigorous laboratory conditions and highly trained staff. 4.3 Measuring immunosuppression Among the white blood cells, lymphocytes are responsible for cellular immunity. There are two main types of lymphocytes in circulation: the B lymphocytes, which produce natural antibodies, and the T lymphocytes which are responsible for cell-mediated immunity. T lymphocytes bearing the CD4 molecule play a crucial role in the immune response and are the target cells for HIV. With the destruction of the CD4+ lymphocytes by the virus, their levels in the peripheral blood drop leading to immune deficiency. The severity of HIV infection is related to the level of CD4+ lymphocytes concentrations in the peripheral blood. The normal range of CD4+ lymphocytes in the peripheral blood varies tremendously, ranging between 500 and 1500/mm3. When the peripheral blood CD4+ lymphocyte count falls below 200/mm3, the incidence of opportunistic infections increases. It has also been shown that the peripheral blood total lymphocyte count of less than 1200/mm3 is an approximate indication of peripheral blood CD4+ lymphocyte level of less than 200/mm3 in symptomatic patients. Methods for measuring CD4+ lymphocytes counts require sophisticated equipment, costly reagents and need well-trained laboratory personnel.

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4.4 Interpreting results of HIV antibody tests The serologic diagnosis of HIV infection can be made by examining the test results and considering the clinical findings in the patient. Table 4.1 summarises the interpretation of results of HIV antibody tests. Table 4.1: Interpreting results of HIV tests

Interpretation of results of HIV ELISA and rapid tests Result of Test

HIV-related symptoms/signs present

Client at risk for HIV infection

Interpretation of result

Action to be taken

No No Negative Nil

No Yes Negative (possible window period)

Repeat test in 6 to 12 weeks

First ELISA or rapid test negative

Yes Yes or No Negative (possible false negative result)

Repeat test

First ELISA or rapid test positive and second test negative

Yes or No Yes or No Indeterminate Repeat tests. If positive, patient is positive

First ELISA or rapid test positive and second test positive

Yes or No Yes or No Positive Patient is positive and should be counselled

4.5 HIV testing algorithm The following algorithm summarises the approach to HIV testing in adults and children over the age of 18 months.

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Pre-test counselling: The process

The implications of testing Risk assessment Risk prevention

Coping strategies

Decision to test

No

Perform rapid test

Yes

Community awareness: Education

Counselling Condom promotion

Self-perception of risk Behaviour change

Negative Positive

Repeat test by another method

Negative Positive

Educate: Window period

Re-test in 6 weeks Counselling

Condom promotion Behaviour change

Indeterminate result:

Re-test in 6 weeks

Counselling Condom

promotion Behaviour change

HIV positive: Educate

Counselling Condom promotion Behaviour change

Refer for care

Decision to attend for testing

Testing for HIV

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4.6 Laboratory diagnosis of HIV infection in children using antibody tests The vast majority of children with HIV acquire the infection through mother-to-child transmission. Without any prevention interventions such as ART in pregnancy, caesarean section and replacement feeding, about thirty per cent of infants born to mothers with HIV infection become infected. However all children born to women with HIV infection will have antibody transferred from their infected mothers. Therefore tests that detect antibodies, such as, the ELISA and the rapid tests, cannot tell whether the child is infected or not until the age of 18 months when the child loses maternal antibodies. In a child who has stopped breastfeeding, maternal HIV antibodies may still be present and antibody tests will pick these. If however a child has stopped breastfeeding for at least 3 months and his/her HIV antibody tests are negative on two occasions 1 month apart then it may be concluded that the child is HIV negative as he/she has lost the maternal antibodies and has no antibodies of his/her own. 4.7 Laboratory diagnosis of HIV infection in children using virologic tests HIV PCR tests are the preferred virologic method for diagnosing HIV infection during infancy. If the child is not breastfeeding, HIV infection can be excluded with two or more negative tests performed at the age of 3 months and at the age of 6 months. HIV infection in non-breastfed infants can be diagnosed by age three to six months using viral diagnostic assays. A positive virologic test (i.e., detection of HIV by culture or DNA or RNA polymerase chain reaction [PCR]) indicates possible HIV infection and should be confirmed by a repeat virologic test on a second specimen as soon as possible after the results of the first test become available. If the child is being breastfed a negative virologic test at 3 to 6 months does not exclude infection because the risk of HIV transmission continues throughout the duration of breastfeeding. In such an infant, once breastfeeding has ceased for at least 3 months and if the child is over 18 months of age an HIV antibody test can be used to make a diagnosis of infection.HIV culture can also be used for diagnosing HIV infection during infancy. However, HIV culture is more complex and expensive to perform than PCR, and definitive results may not be available for two to four weeks.

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5. ANTIRETROVIRAL THERAPY Though antiretroviral therapy (ART) does not eradicate HIV infection it is possible to prevent the development of opportunistic infections and delay the onset of AIDS with effective management. ART allows PLHA to live a more productive life and to enjoy a better quality of life. The antiretroviral (ARV) agents are not without side effects and the management of HIV infection has become increasingly complex for a number of reasons: A large number of drugs and drug combinations are available for the treatment of HIV

infection Some antiretroviral drugs may not be used in combination with drugs commonly used for

treating infections such as tuberculosis Antiretroviral drugs are associated with significant toxicities The ease with which the virus develops resistance to antiretroviral agents The monitoring of response to therapy is based on measuring the amount of virus

present in plasma (HIV plasma viral load). This is a complex and costly procedure, and, currently, reliable clinical indicators of viral load are not available.

Until such a time when the efficacy of scheduled interrupted treatment regimens becomes known it is advisable to continue ART for life

Strict adherence to treatment regimens and schedules is necessary to avoid the development of viral resistance to antiretroviral agents

Despite the emergence of the antiretroviral agents, HIV

infection remains incurable and the mainstay in the control of the epidemic remains primary prevention.

5.1 Characteristics of antiretroviral drugs 5.1.1 Mechanism of action Antiretroviral agents act either by blocking fusion of the virus with the cell or by blocking the enzymes responsible for the reproduction and functioning of HIV. Antiretroviral drugs belong to three classes:

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Reverse transcriptase inhibitors (RTIs) – these drugs block HIV reverse transcriptase and prevent the copying of the viral genetic code (RNA) into the genetic code (DNA) of infected host cells. Within the class of RTIs there are three types of drugs: nucleoside RTIs (NsRTIs), non-nucleoside RTIs (NNRTIs) and the nucleotide RTIs (NtRTIs)

Protease inhibitors (PIs) – these drugs block the enzyme protease and prevent the assembly and release of HIV particles from infected cells

Fusion inhibitors – these drugs block the fusion of HIV with the CD4 cell membrane and hence prevent the entry of HIV RNA into the cell.

The different categories of antiretroviral drugs are shown in Table 5.1. Table 5.1: Classes of Antiretroviral Drugs Nucleoside reverse transcriptase inhibitors

Non-nucleoside reverse transcriptase inhibitors

Protease inhibitors

Zidovudine (ZDV) Nevirapine (NVP) Saquinavir* (SQV) Didanosine (ddI) Efavirenz (EFZ) Ritonavir (RTV, r) Abacavir (ABC) Delavirdine (DLV) Indinavir (IDV) Stavudine (d4T) Nelfinavir (NFV) Lamivudine (3TC) Lopinavir/ritonavir (LPVr) Zalcitabine (ddC) Amprenavir (APV) Other classes of ARVs: Nucleotide reverse transcriptase inhibitors – tenofovir Fusion inhibitors – enfuvirtide (this drug is newly on the market, its use has been mainly in salvage therapeutic regimens and currently it is only available for parenteral use Adding a small dose of ritonavir to other protease inhibitors, such as saquinavir, indinavir and lopinavir may enhance their action. A lower dose of the drug may then be used and the drug may be administered twice a day rather than three times a day.

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5.1.2 Toxicity profiles Antiretrovirals may produce a number of side effects. Some side effects are class-related (Table 5.2) whilst others are individual drug-related (Table 5.3). In addition, significant drug interactions may occur when using some antiretrovirals in combination with each other and with other drugs as well.

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Table 5.2: Class specific side effects of antiretroviral agents Nucleoside reverse transcriptase inhibitors (NsRTIs): Lactic acidosis Hepatic toxicity (steatosis) Pancreatitis Myopathy Cardiomyopathy Peripheral neuropathy

Non-nucleoside reverse transcriptase inhibitors (NNRTIs): Rash Hepatitis Nevirapine can cause hypersensitivity rash, including Stevens Johnson syndrome

Protease inhibitors (PIs): Hyperglycaemia, new diabetes mellitus, insulin resistance, diabetic ketoacidosis Hyperlipidaemia with elevated triglycerides and cholesterol Lipodystrophy – central obesity with peripheral wasting, lipomas, buffalo hump Hepatitis Bleeding in haemophiliacs Osteopaenia, osteoporosis Renal problems e.g renal sones

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Table 5.3: Some important side effects of antiretroviral agents Drug More common Less common

side effects side effects Nucleoside reverse transcriptase inhibitors (NsRTIs): Zidovudine Anaemia, neutropaenia myopathy, myositis Didanosine diarrhoea, nausea, vomiting, peripheral neuropathy,

abdominal pain pancreatitis Zalcitabine Headache, GIT disturbances Oral ulceration,

malaise peripheral neuropathy Stavudine Headache, GIT disturbances Peripheral neuropathy,

Skin rashes neuromuscular weakness, hepatitis, pancreatitis

Lamivudine Usually nil, occasionally headache, pancreatitis and fatigue, GI upset peripheral neuropathy

Abacavir Nausea, vomiting, fever Severe potentially fatal Headache, diarrhoea, anorexia hypersensitivity reactions

Non-nucleoside reverse transcriptase inhibitors (NNRTIs): Nevirapine severe hypersensitivity reactions, Abnormal liver function

tests life threatening rashes

Efavirenz CNS symptoms of dizziness, insomnia or somnolescence, vivid dreams, depression, teratogenesis, depersonalization

Delavirdine Headaches Protease inhibitors (PIs): Saquinavir Diarrhoea, abdominal pain, nausea exacerbation of chronic

Headache parasthesia liver disease Ritonavir Nausea, vomiting, abdominal pain, circumoral paraesthesia,

anorexia, headache hepatitis

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Indinavir headaches, blurred vision, jaundice, Renal stones,exacerbation alopecia, dry skin, dry lips, rash, of chronic liver disease metallic taste in mouth, nausea

Nelfinavir Diarrhoea abdominal pain, flatulence, rash

Amprenavir GI intolerance, diarrhoea, rash, increase in cholesterole, circumoral parasthesia diabetes, bleeding

Lopinavir/ Ritonavir

Diarrhoea, vomiting, headache, bleeding, pancreatitis, Increased lipids hepatitis

Nucleotide reverse transcriptase inhibitors (NtRTIs): Tenofovir GI symptoms, rash 5.2 Principles of Antiretroviral therapy The principles of ART include efficacy, freedom from serious adverse effects, ease of administration and affordability of the drugs and drug combinations. Ongoing viral replication drives the disease processes and leads to immunosuppression. Hence a target for ART is to reduce viral replication. Viral replication is assessed by measuring periodically the plasma viral load and the effect on the immune system is assessed by measuring the number of CD4+ lymphocytes present in peripheral blood. The aims of antiretroviral therapy (ART) are: Maximal and durable suppression of replication of HIV, Restoration and/or preservation of immune function, Reduction of HIV-related morbidity and mortality, and Improvement of quality of life.

5.2.1 Using antiretroviral agents: guiding principles When treating persons with antiretrovirals the following principles should be strictly adhered to:

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Any treatment regimen should contain no less than three effective antiretroviral agents.

Antiretroviral therapy is given as a dual nucleoside combination to which another nucleoside RTI, a non-nucleoside RTI, a nucleotide RTI or a protease inhibitor are added.

Zidovudine must not be used with stavudine Adherence to treatment must be guaranteed Monitoring for drug toxicity using clinical and laboratory parameters

should be performed Consider class-sparing regimens to allow mobility when treatment

failure occurs 5.2.2 Zidovudine and lamivudine containing regimens Zidovudine and lamivudine is available in a combined formulation. This makes for easy administration of medications and better treatment adherence. To this basic treatment combination, it is necessary to add EITHER: A third nucleoside RTI other than stavudine, OR A non-nucleoside RTI, such as, nevirapine or efavirenz, OR A nucleotide RTI, such as, tenofovir, OR A protease inhibitor, such as Nelfinavir, OR A protease inhibitor boosted with ritonavir, such as,

saquinavir/ritonavir, indinavir/ritonavir, lopinavir/ritonavir 5.3 Initiation of antiretroviral therapy in adults Based on currently available evidence it is recommended that ART be commenced in: All HIV-infected patients who have fall into WHO HIV Clinical

Stages III and IV (See Table 5.4)

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All patients with HIV infection who have a peripheral blood CD4+ lymphocyte count of less than 200/mm3

All HIV-infected patients who have a peripheral blood total lymphocyte count of less than 1200/mm3

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Table 5.4: WHO Staging System for HIV Infection and Disease in Adults Clinical Stage I:

1. Asymptomatic 2. Persistent generalised lymphadenopathy Performance Scale 1: Asymptomatic, normal activity

Clinical Stage II: 1. Weight loss less than 10% body weight 2. Minor mucocutaneous manifestations (seborrhoeic dermatitis, prurigo,

fungal nail infections, recurrent oral ulcerations, angular stomatitis) 3. Herpes zoster within the last 5 years 4. Recurrent upper respiratory tract infections, e.g., bacterial sinusitis And/or Performance Scale 2: Symptomatic but normal activity

Clinical Stage III: 1. Weight loss more than 10% body weight 2. Unexplained chronic diarrhoea for more than 1 month 3. Unexplained prolonged fever, intermittent or constant, for more than 1

month 4. Oral candidiasis 5. Oral hairy leukoplakia 6. Pulmonary tuberculosis within the past year 7. Severe bacterial infections such as pneumonias, pyomyositis And/or Performance Scale 3: Bed-ridden for less than 50% of the day during the last month

Clinical Stage IV: 1. HIV wasting syndrome – weight loss of more than 10%, and either

unexplained chronic diarrhoea for more than 1 month, or chronic weakness or unexplained prolonged fever for more than 1 month

2. Pneumocystis pneumonia(PCP) 3. Toxoplasmosis of the brain 4. Cryptosporidiosis with diarrhoea for more than 1 month 5. Extrapulmonary cryptococcosis 6. Cytomegalovirus (CMV) disease of an organ other than liver, spleen or

lymph nodes 7. Herpes simplex virus (HSV) infection, mucocutaneous for more than 1

month, or visceral of any duration 8. Progressive multifocal leukoencephalopathy (PML) 9. Any disseminated endemic mycosis such as histoplasmosis,

coccidioidomycosis

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10. Candidiasis of the oesophagus, trachea, bronchi or lungs 11. Atypical mycobacteriosis, disseminated 12. Non-typhoid salmonella septicaemia 13. Extrapulmonary tuberculosis 14. Lymphoma 15. Kaposi’s sarcoma 16. HIV encephalopathy – disabling cognitive and/or motor dysfunction

interfering with activities of daily living, progressing slowly over weeks or months, in the absence of concurrent illness or condition other than HIV infection that could account for the findings

And/or Performance Scale 4: Bed-ridden for more than 50% of the day during the last month

5.4 First line ART recommendations for adults The following is the first line treatment recommendation for adults with proven HIV infection who fall into the categories described above.

FIRST-LINE REGIMEN Symptomatic HIV infection in adults Drug Codes Dose Frequency Route Duration Stavudine V

B 30mg

or 40mg

BID PO Long term

AND Lamivudine V B 150mg BID PO Long term

AND Nevirapine V B 200mg OD PO 2 weeks

THEN Nevirapine V B 200mg BID PO Long term

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ALTERNATIVE FIRST-LINE REGIMEN Symptomatic HIV infection in adults Drug Codes Dose Frequency Route Duration Zidovudine V

B 300mg

BID PO Long term

AND

Lamivudine V B 150mg BID PO Long term AND

Nevirapine V B 200mg OD PO 2 weeks THEN

Nevirapine V B 200mg BID PO Long term NOTES: All patients with HIV infection should take cotrimoxazole 2 tablets

orally once daily to prevent opportunistic infections unless it is known that the CD4+ lymphocyte counts are more than 200 / mm3.

It is essential to provide education and counseling on treatment adherence to all patients who commence ART.

For those allergic to nevirapine, give efavirenz 600mg once daily. For those allergic to stavudine replace with zidovudine and vice

versa. 5.4.1 Second Line Treatment Recommendation for Adults

A second line regimen is to be used only when there is documented evidence of treatment failure with the first line regimen, i.e., if there is evidence 6 months after commencing first line treatment of falling CD4+ lymphocyte counts, or rising HIV plasma viral load, or if there is worsening of symptoms and signs of opportunistic infection or cancer 12 months after initiating treatment if CD4 counts and viral loads are not available. The second line treatment regimen should only be initiated after consultation with a specialist. Patients who fail

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to respond to first line treatment should be treated with a different regimen that contains drugs that were NOT included in the first regimen.

GENERAL NOTES ABOUT SOME ARV DRUGS: Zidovudine and stavudine MUST not be taken together Use Stavudine 40 mg orally twice daily if body weight is more than

60 kg, or 30 mg orally twice daily if body weight is less than 60 kg Use Didanosine 400 mg orally once daily if body weight is more than

60 kg, or 250 mg orally once daily if body weight is less than 60 kg Didanosine must be taken on an empty stomach; the patient should

not take food two hours before and one hour after taking the medication

Patients taking indinavir should take at least 1.5 litres of water a day in order to prevent the formation of renal calculi. Indinavir should be taken 1 hour before or two hours after taking food

Patients receiving rifampicin should not be given a protease inhibitor All patients with HIV infection, unless it is known that the CD4+

lymphocyte counts are more than 200 / mm3, should take, on a long term basis, cotrimoxazole 2 tablets orally once daily to prevent other opportunistic infections

Combination products can enhance adherence by reducing the pill burden that the patient has to take.

5.4.2 Adult patients with HIV infection who have TB and in whom ART is indicated Tuberculosis is the commonest opportunistic infection encountered among persons with HIV infection in Zimbabwe. Since the advent of the pandemic of HIV infection, TB has re-emerged as a serious public health problem. Studies have shown that up to 50% of persons with HIV infection develop TB and that up to 85% of persons with TB have HIV infection. The rifamycin antibiotics, rifampicin and rifabutin, are highly active against TB. However

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they interact adversely with some antiretroviral agents such as protease inhibitors, and therefore cannot be used concomitantly with some ART regimens. Patients with HIV infection and TB may be treated with the first line treatment recommendations described above. All patients that are already on ART and develop TB while on ART should be referred for specialist assessment and advice on management. The following treatment may be given to patients with HIV infection and TB: FIRST-LINE REGIMEN Symptomatic HIV infection in adults coinfected with TB Drug Codes Dose Frequency Route Duration Stavudine V

B

30mg or40mg

BID

PO

Long term

AND Lamivudine V B 150mg BID PO Long term

AND Nevirapine V B 200mg OD PO 2 weeks

THEN Nevirapine V B 200mg BID PO Long term 5.4.3 Antiretroviral therapy during pregnancy ARVs may be used in pregnant women provided certain precautions are kept in mind: It is preferable to commence ART after the first trimester of pregnancy

so as to minimize the possible risk of teratogenesis Certain drugs, such as, efavirenz should not be used during pregnancy and in

women at risk of falling pregnant NsRTIs and NNRTIs cross the placenta and hence, there is a potential for

mitochondrial toxicity in the foetus

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By reducing the maternal HIV plasma viral load with highly active antiretroviral therapy the risk of transmission of infection to the baby is reduced

Do not use the combination of stavudine and didanosine in pregnant women as there is an increased risk of lactic acidosis with this combination of drugs

With treatment during pregnancy, there is a theoretical risk of drug resistance occurring in the baby and of masking the diagnosis in the child particularly while less than 6 weeks of age. Resistance development after a single dose of nevirapine has been reported however the resistance is generally lost after a year. The following treatment regimen is recommended for pregnant women: FIRST-LINE REGIMEN Symptomatic HIV infection in pregnant women Drug Codes Dose Frequency Route Duration Stavudine V B 30mg

or 60 mg BID PO Long term

AND Lamivudine V B 150mg BID PO Long term

AND Nevirapine V B 200mg OD PO 2 weeks

THEN Nevirapine V B 200mg BID PO Long term 5.5 Principles of management of HIV infection in children The principles of ART in children are similar to those in adults. However there are certain important points that need to be considered: Prevention of mother-to-child transmission of HIV should take high priority Babies born to mothers with HIV infection should receive cotrimoxazole

prophylaxis from the age of 4 to 6 weeks

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Standard ELISA antibody test is not diagnostic of HIV infection below the age of 18 months

Nutritional support is a crucial intervention in managing HIV infected children

Lymphocyte counts vary considerably with age especially before the age of 6 years. Therefore absolute lymphocyte counts are not useful and CD4+ lymphocyte percentage of less than 15% should be used.

Some ARV agents, especially PIs, are not available in paediatric formulations Clinical monitoring in children should include growth velocity and

neurodevelopment assessments Choice of regimens must take into account drugs to which the baby was

exposed in utero or soon after birth 5.5.1 Initiation of antiretroviral therapy in children It is advisable to commence ART in the following categories of HIV infected children: A. Children less than 18 months of age Positive HIV virologic test and WHO Paediatric Stage III (See Table 5.5)

regardless of CD4+ lymphocyte levels Positive HIV virologic test and CD4+ lymphocyte percent <20% in WHO

Paediatric Stages I and II (See Table 5.5) HIV virologic test not available, but mother known to be HIV positive and

child in WHO Paediatric Stage III with CD4+ lymphocyte percent <20% (Note: HIV antibody test must be obtained at the age of 18 months to obtain a definitive diagnosis)

B. Children aged 18 months or more HIV antibody positive and WHO Paediatric Stage III HIV antibody Positive and CD4+ lymphocyte percent <15% in WHO

Paediatric Stages I and II (See Table 5.5)

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Table 5.5: WHO Staging System for HIV Disease in Children Clinical Stage I: Asymptomatic Persistent generalised lymphadenopathy

Clinical Stage II: Unexplained chronic diarrhoea Severe persistent or recurrent candidiasis outside the neonatal period Weight loss or failure to thrive Persistent fever Recurrent severe bacterial infection

Clinical Stage III: AIDS-defining opportunistic infections, i.e., cryptococcal meningitis,

histoplasmosis, toxoplasmosis, non-typhoid salmonellosis, Pneumocystis carinii pneumonia, cryptosporidiosis, cytomegalovirus (CMV) disease, disseminated herpes simplex virus (HSV) infection, coccidioidomycosis, candidiasis of the oesophagus, trachea, bronchi or lungs, atypical mycobacteriosis, extrapulmonary tuberculosis

Severe failure to thrive Progressive encephalopathy Malignancy Recurrent septicaemia or pneumonia

5.6 First line ART recommendations for children Recommendations for children need to take into consideration the age and weight of the child, the availability of paediatric formulations of medications, and also the palatability of medications and the effect of food on absorption of drugs. The following first line recommendations are made for symptomatic children:

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FIRST-LINE REGIMEN Children Drug Codes Dose Frequency Route Duration Stavudine Over 3months under 30kg: 30kg and over:

V B 1mg/kg 30/40mg

BID BID

PO PO

Long term Long term

AND Lamivudine Age less than 30 days: Age more than 30 days or weight less than 60kg: More than 60kg weight (Maximum dose)

V B 2mg/kg 4mg/kg 150mg

BID BID BID

PO PO PO

Long term Long term Long term

AND Nevirapine Child 2 months – 8 years

(If no rash present)

8 – 16 years under 50kgs (if no rash present) Over 50kg

V B 4mg/kg 7mg/kg twice daily 4mg/kg once daily 4mg/kg twice daily Use adult dose

OD BID OD BID BID

PO PO PO PO

2 weeks 2 weeks 2 weeks Long term

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5.6.1 Alternative treatment for children:

ALTERNATE REGIMEN Children Drug Code

s Dose Frequency Route Duration

Zidovudine Age less than 28 days Age 4 weeks to 13 years

V B 4mg/kg 180mg/m2

BID BID

PO PO

Long term Long term

AND Lamivudine Age less than 30 days: Age more than 30 days or weight less than 60kg: More than 60kg weight (Maximum dose)

V B 2mg/kg 4mg/kg 150mg

BID BID BID

PO PO PO

Long term Long term Long term

AND Nevirapine Child 2 months – 8 years (If no rash present) 8 – 16 years under 50kgs (if no rash present) Over 50kg

V B 4mg/kg 7mg/kg twice daily 4mg/kg once daily 4mg/kg twice daily Use adult

OD BID OD BID BID

PO PO PO PO

2 weeks 2 weeks 2 weeks Long term

Second line Regimen in children This should only be prescribed after specialist consultation:

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5.7 Counseling for treatment adherence When it is decided that the patient receives antiretroviral therapy it is important that the patient be educated and counselled regarding ART. This is an important component of patient management as it has been shown that ART is effective if strict compliance is adhered to and adherence to treatment is greater than 90%. The patient should receive counseling on the following issues: Treatment compliance should be strict and adherence to

recommended treatment regimens should be greater than 90% Treatment has to be continued for life and that there may have to

take some drugs with food, others on an empty stomach and that some drugs require an increased intake of water

Costs of drugs and the social and economic situation of the family The need to identify financial and social support structures including

family members, employers and medical insurance companies Need to attend regularly for monitoring. The meaning of CD4

lymphocyte counts and viral load levels need to be understood Drug side effects Need to continue using condoms Family planning and child bearing issues

5.8 When to change treatment regimens The treatment regimen may need to be changed if there has been treatment failure or if the patient is unable to tolerate the drugs due to toxicity. Patients in whom it is felt that treatment needs to be changed should be referred for specialist opinion. 5.8.1 In the event of treatment failure

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Patients that fail to respond to first-line treatment should be treated with a different regimen that contains drugs that were not included in the first regimen, see list of drugs in Table 5.1 above. 5.8.2 In the event of drug toxicity If the patient has drug toxicity, therapy may be altered as follows: Change of a single drug in a multi-drug regimen is permitted, i.e., the offending drug may be replaced with an alternative drug of the same class. 5.9 Monitoring patients on ART Patients on ART need close monitoring to assess treatment compliance and adherence to treatment regimen, tolerance and side effects of the medications and efficacy of the treatment. 5.9.1 Initial evaluation Before commencing ART all patients should have a detailed history taken, a physical examination carried out (See Table 5.6), and basic laboratory tests performed. Prior to commencing ART it is essential to perform some laboratory tests. These include: HIV serology – No patient should be started on ART without first

establishing that the patient is infected with HIV Full blood count – It is necessary to have a baseline haemoglobin,

peripheral blood white cell count, lymphocyte count and red cell indices performed

Liver function tests Blood urea, electrolytes and creatinine Urinalysis – Urine chemistry and microscopy should be performed

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Chest x-ray – It is essential to search for tuberculosis in all patients prior to commencing ART

If it is possible, also arrange to have the following tests performed prior to commencing ART: CD4+ lymphocyte count HIV viral load Syphilis serology Hepatitis B virus screening Pregnancy test

Table 5.6: Important clinical findings to note prior to initiating ART From the history note the following:

From the examination note the following:

Date of diagnosis of HIV infection Patient’s weight Current symptoms Mental state of patient Past illnesses and treatments Presence of oral candidiasis, oral Kaposi’s

sarcoma, oral hairy leukoplakia History of past TB Presence of lymphadenopathy, skin

Kaposi’s sarcoma, herpes zoster scars, dermatitis

History of TB contacts Presence of chest signs Current symptoms suggestive of TB

Presence of abnormality in the CVS, GIT, abdomen, CNS, fundi

Past or current symptoms of STI Abnormalities in the genital tract Possibility of pregnancy Social habits and sexual history

5.9.2 Monitoring treatment compliance Strict adherence (at least 90% adherence) to recommended treatment regimens is important if treatment efficacy is to be expected. The importance of counseling and the provision of accurate information to all patients is an important determinant of treatment compliance. Information on side effects should be provided and patients should be told what to expect from the

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treatment. A treatment timetable, e.g., like the TB card, should also be provided and patients and carers should be instructed how to fill out the card. Counseling should be provided at each visit and patients should be allowed to seek help between visits as well. Patients should be encouraged to bring with them all tablet containers at each visit. Providers should carry out a tablet count in order to determine whether the medications have been taken as per schedules provided. 5.9.3 Monitoring drug side effects A patient on ART may develop new symptoms whilst on treatment. These symptoms may be indicative of intercurrent illnesses, adverse drug side effects, or immune reconstitution syndrome. All patients should be examined carefully at each visit and a diagnosis should be made. Any intercurrent illness should be treated appropriately. Once ART has been commenced the patient should be seen 2 weekly for a month after initiating treatment, and then every month for 3 months and then every 3 months. The patient should be provided with written and verbal information on side effects that may occur and should be requested to report immediately for examination should side effects occur. Side effects may be class specific or drug specific. Most side effects are mild and most occur within the first 15 days of initiating ART. Mild side effects such as headache, fatigue, gastrointestinal upsets and diarrhoea occur fairly frequently, but the serious side effects occur rarely. Usually these are worst in the first 2 weeks of treatment and can be treated symptomatically with paracetamol, anti-emetics, or antidiarrhoeal agents such as loperamide. See Tables 5.2 and 5.3 for side effects of ARVs. 5.9.4 Monitoring efficacy of ART Efficacy of ART may be monitored by assessing clinical improvement as well as immunologic function and HIV viral load. The ideal would be to monitor on a regular basis the CD4+ lymphocyte count and the HIV viral load. However these tests are not widely available throughout the country and are also extremely costly to perform. It is necessary to make an assessment of response to treatment through regular careful clinical examinations backed where possible by simple laboratory tests.

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Clinical monitoring Clinical monitoring on its own has not yet been validated, but studies are on-going. The following clinical indices suggest that the patient is responding to ART: The patient feels better and has more energy to perform daily

tasks. This may be assessed quantitatively by calculating the Karnofsky performance score at each visit

The patient is gaining weight – Record the patients weight at each visit

There is an improvement in symptoms and signs of the original presenting illness

Infections such as oral thrush, hairy leukoplakia, genital herpes, skin rash, molluscum contagiosum have improved

There has been an improvement in chronic diarrhoea There has been an improvement in Kaposi's sarcoma or other

malignancy The patient is free of new moderate or severe infections

The following symptoms and signs may be indicative of treatment failure or poor response to treatment. However before diagnosing treatment failure it is important to assess adherence to treatment. If adherence has been satisfactory then the following clinical criteria may indicate treatment failure: Patient feels he is deteriorating with loss in energy levels and loss in

activity level and a deteriorating Karnofsky performance score Loss of weight Worsening of symptoms and signs of original presenting illness Development of new and recurrent minor opportunistic infections

such as oral thrush, hairy leukoplakia, genital herpes, skin rash, molluscum contagiosum

Return or worsening of chronic diarrhoea

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Return of features of HIV encephalopathy Exacerbation of Kaposi's sarcoma Appearance of new moderate or severe infections or malignancy Development of bacterial pneumonia or tuberculosis with other

AIDS-defining illnesses Treatment should not be changed for at least 12 months if CD4 counts and viral loads are not available. Immunological, peripheral blood CD4+ lymphocyte monitoring With successful ART the rate of increase in CD4+ lymphocyte levels depends on the initial CD4+ lymphocyte count. If the CD4+ lymphocyte count was very low to start with, e.g., if the initial CD4+ lymphocyte count was less than 50 / mm3, then it can take more than one year to increase to more than 200 / mm3. Persistently declining CD4+ lymphocyte counts as measured on two occasions and clinical deterioration as described above is suggestive of treatment failure. A greater than 30% decline in CD4+ counts should be considered significant. Virological, HIV viral load monitoring The HIV viral load decreases to undetectable levels within 6 months of successful ART. However this response also depends on the initial, pre-treatment, viral load. The viral load measurement is useful in assessing treatment failure. If there has been a three-fold increase in the viral load from the lowest point following treatment, then this is an indication of treatment failure. In such situations it is necessary to review the treatment regimen and consider changing the regimen. 5.9.5 Monitoring of ART in children In children growth and development are important clinical monitoring indicators. These are assessed using growth charts. Laboratory indices of CD4+ lymphocyte counts and HIV viral load levels may also be used in assessing response to therapy.

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5.9.6 Changing ART in children In the event of treatment failure or drug toxicity there may be a need to change or modify therapy. If therapy is to be changed then drugs that have not been used in the first regimen should be used. Note that in the presence of neurodevelopmental deterioration the new regimen should contain at least one drug that is known to penetrate the blood brain barrier, i.e., zidovudine, stavudine or nevirapine. The following clinical criteria warrant consideration of a change in antiretroviral therapy: Disease progression, occurrence of new opportunistic infections and

advancement from one paediatric HIV clinical category to another Occurrence of new symptoms and signs and HIV-related diseases Progressive neurodevelopmental deterioration (i.e., repeated

demonstration of two or more of the following: impairment in brain growth, decline of cognitive function documented by psychometric testing, or clinical motor dysfunction)

Growth failure, i.e., persistent decline in weight-growth velocity despite adequate nutritional support and without other explanation

In the event of treatment failure the ART regimen should be changed and drugs that were not used previously should be used. However change of regimen should only be undertaken if poor adherence is not the cause of failure, in which case treatment should be withheld until all adherence issues have been addressed. ADULTS AND CHILDREN IN WHOM IT IS FELT THAT TREATMENT FAILURE HAS OCCURRED SHOULD BE REFERRED FOR SPECIALIST OPINION BEFORE SECOND LINE TREATMENT IS COMMENCED

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5.10 Flowchart and checklist before commencing ART in Adults

Take history and examine patient

Patient is a pregnant woman

Follow flowchart for the management of pregnant women with HIV infection

Patient has:

CD4+ lymphocyte count <200/mm3, OR,

Has Who stages 3 and 4 disease

Perform baseline tests: Full blood count Blood creatinine, electrolytes, glucose Liver function tests Urine chemistry and microscopy Chest x-ray

Provide education and counselling Provide adherence counselling Arrange for treatment supervision by relative or friend Commence ART Arrange for follow up examination and on-going

counselling for treatment adherence

Arrange for regular follow up

YES

NO

YES

NO

Adult found to be HIV positive

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5.11 Flowchart and checklist before commencing ART in Pregnant Women

Pregnant woman found to be HIV positive

Take history and examine patient

Patient has:

CD4+ lymphocyte count <200/mm3, OR,

Has WHO stages 3 and 4 disease

Perform baseline tests:

Full blood count

Blood creatinine, electrolytes, glucose

Liver function tests

Urine chemistry and microscopy

Provide education and counselling

Counsel on infant feeding options, other than breast feeding

Provide adherence counselling

Arrange for treatment supervision by relative or friend

Commence ART

Arrange for PMTCT

Arrange for follow up examination and on-going counselling for treatment adherence

Arrange for regular follow up and review Counsel on PMTCT and infant feeding options other than breast feeding Arrange for PMTCT Consider commencing ART if patient becomes ill and develops criteria for ART listed in previous box

NO

YES

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5.12 Flowchart and checklist before commencing ART in Children

Child found to be HIV positive

Child is aged less than 18 months

Child is:

HIV positive by virologic test AND is in WHO Paediatric Clinical Stage III, OR

HIV positive by virologic test AND is in WHO Paediatric Clinical Stage I or II AND has CD4+ lymphocyte percent <20%, OR,

In WHO Paediatric Clinical Stage III AND has CD4+ lymphocyte percent <20% AND mother is HIV positive but virologic tests not available

Perform baseline tests: Neurodevelopmental assessment Full blood count, blood creatinine, electrolytes, glucose Liver function tests Urine chemistry and microscopy Chest x-ray

Provide education and counselling to parents and child if appropriate Counsel on feeding options and treatment adherence Commence ART Arrange for mother and father to be examined and tested Arrange for regular follow up examination and assessment Assess treatment adherence and provide counselling

Child is aged 18 months or more

Child is:

HIV antibody positive AND is in WHO Paediatric Clinical Stage III, OR

HIV antibody positive AND is in WHO Paediatric Clinical Stage I or II AND has CD4+ lymphocyte percent <15%

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6. PREVENTING OPPORTUNISTIC INFECTIONS The majority of HIV related opportunistic infections (OIs) in Zimbabwe are bacterial due to Streptococcus pneumoniae and Mycobacterium tuberculosis. Non-typhoid salmonella infection is also thought to be important. The rest of the OIs are fungal infections which include skin infections, oral candida, Pneumocysitis pneumonia and Cryptococcal meningitis. Protozoal infections are next most common, mainly causing chronic diarrhoea. Microsporidial infections cause 40% of chronic diarrhoea in Zimbabwe. Cryptosporidial and isospora diarrhoea are less common. Central nervous system protozoal infection with toxoplasma does not appear to be common in Zimbabwe but this could be due to diagnostic bias as CT scans of the head are not done often enough. Viral infections such as herpes simplex infection causing genital herpes and varicella zoster causing herpes zoster (shingles) are common. Cytomegalovirus infection causing CMV retinitis is not common in Zimbabwe perhaps because people die before reaching this level of severe immunosuppression (usually occurs at CD4 counts of <50). This is also possibly true for Mycobacterium avium intracellulare (MAI) infections. Antiviral medication is expensive and out of the range of affordability for most people in Zimbabwe. Immunosuppressed persons are prone to develop opportunistic infections such as Pneumocystis pneumonia, toxoplasmosis and bacterial lower respiratory tract infections, septicaemia and bacterial skin infections. Studies have shown clearly that taking prophylaxis in the form of cotrimoxazole on a long-term basis may prevent many of these infections. Cotrimoxazole prophylaxis can potentially prevent the following opportunistic infections: Streptococcus pneumoniae pneumonia Non-typhoid salmonelloses Pneumocystis pneumonia Cerebral toxoplasmosis Nocardiosis

Isosporiasis It is therefore recommended that all persons with HIV infection who have clinical evidence of immunosuppression ( WHO stages 3 and 4 described in Table 5.4), or laboratory evidence of CD4+ lymphocyte depletion (CD4+

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lymphocyte counts less than 200/mm3), and therefore all patients who are to commence ART should also receive: Cotrimoxazole (sulphamethoxazole 800 mg and Trimethoprim 160

mg) once daily orally. This treatment is continued indefinitely or until such a time that the CD4+ lymphocyte counts are greater than 200 / mm3.

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7. POST-EXPOSURE PROPHYLAXIS In persons who have been accidentally exposed to HIV through needle-stick inoculation or through contamination of mucous membranes by secretions it has been shown in a limited number of studies that immediate administration of antiretrovirals may prevent infection from occurring. In this situation ART needs to be continued for one month. The following guidelines should be followed in the event of accidental occupational exposure to material, i.e., blood, secretions, excretions, that may contain HIV. Occupational exposure to potentially infectious material may occur through an injury with a sharp object that has been used on a patient or through the contamination of mucous surfaces with patients’ blood or secretions. The following types of exposures should be considered for post-exposure prophylaxis: Needle-stick injury or injury with a sharp object used on a patient Mucosal exposure of the mouth or eyes by splashing fluids Broken skin exposed to a small volume of blood or secretions

7.1 Prevention of occupational exposure in health facilities All health facilities in the private and public sector should adopt a policy for the prevention of occupational accidental exposure to blood borne pathogens. Health facilities should implement universal precautions for the prevention of exposure to potentially infectious material. The programme should include training of all employees in handling and disposal of infectious material. All personnel should be made aware of the risks involved in improper handling of such material and the steps necessary for preventing exposure should be clearly displayed in posters. The greatest risk for accidental exposure is with the handling of sharp objects that have been used on patients. All personnel should be taught how to safely handle sharp objects and how to safely dispose of them. Messages should promote the avoidance of re-capping of needles, using “sharps bins” for disposing of sharps, using gloves, goggles and gowns, and taking care in performing procedures.

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Health personnel should also be conscious that blood and secretions from patients may be infectious and that simple contamination of unbroken skin does not comprise a significant risk but contamination of intact mucous surfaces of the mouth and eyes does. The health facility should ensure the continuous supply of education materials, gloves, disposable syringes and needles and sharps bins. 7.2 Procedure to be followed in the event of injury with a sharp object In the event of an injury with a sharp object such as a needle or scalpel that has been used on a patient or in the event of a mucous surface being contaminated with blood or secretions from a patient, the following steps should be followed: 1. Wash exposed area thoroughly with soap and water. 2. Rinse eye or mouth with plenty of water if contaminated. 3. Report the injury to a senior member or staff or the supervisor. 4. Take antiretroviral drugs recommended for post-exposure prophylaxis

immediately – these should be started within 1 hour if possible and at the latest within 72 hours of the exposure (persons presenting after 72 hours of exposure should also be considered for post exposure prophylaxis).

5. Ascertain the HIV status of the patient and the injured health worker after providing appropriate counseling – the standard rapid HIV antibody tests that are currently used in the Voluntary Counseling and Testing programme should be used and the results of tests should be obtained as quickly as possible.

6. Depending on the results of the HIV tests the following actions should be taken:

If the source patient is HIV negative no further post-exposure prophylaxis is necessary for the exposed health worker.

If the exposed health worker is HIV positive, no further post-exposure prophylaxis is necessary for the health worker, but the health worker should be referred for further counseling and management on a long-term basis of his/her HIV infection which has not occurred as a result of the exposure.

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If the health worker is HIV negative and the source patient is HIV positive then continue antiretrovirals for a period of one month; repeat the health worker’s HIV tests at 3 months and at 6 months after the initial test. If the health worker should seroconvert during this time then provide appropriate care and counseling and refer for expert opinion and long term treatment.

Counsel health worker regarding condom use, and side effects and toxicity of drugs.

Also do baseline investigations before initiating ARVs for post exposure prophylaxis.

7. If it is not possible to determine the HIV status of the source patient then

assume that the source is positive and proceed according to guidelines in the previous bullet.

8. Determine the health workers hepatitis B virus immune status and if non-immune, passive immunization with hepatitis B globulin followed by active immunization with hepatitis B vaccination should be carried out.

7.3 Antiretroviral Drugs to be used in Post-Exposure Prophylaxis Immediately after exposure all exposed health workers should take: Zidovudine 300 mg orally twice daily, Plus Lamivudine 150 mg orally twice daily, Plus A Protease Inhibitor e.g. Indinavir 800mg PO TID OR

Lopinavir/ritonavir 400mg/100mg PO BID This regimen is continued until the results of HIV tests for patient and injured health worker are known: If the source is HIV negative or the health worker is HIV

positive then drug administration should be discontinued. If the health worker is HIV negative and the source is HIV

positive or the source’s HIV status is not determined then continue this regimen for 4 weeks.

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Alternate antiretroviral regimens for post-exposure prophylaxis may be used such as: Stavudine 40 mg orally twice daily if body weight is more than 60

kg, or 30 mg orally twice daily if body weight is less than 60 kg for 4 weeks, Plus

Didanosine 400 mg orally once daily if body weight is more than 60 kg, or 250 mg orally once daily if body weight is less than 60 kg for 4 weeks, Plus

Nevirapine 200mg orally daily for 2 weeks then 200mg orally twice daily for 2 weeks

7.4 Post-sexual exposure prophylaxis There is not enough evidence to recommend prophylaxis against infection following casual sexual exposure. However in the event that there has been sexual abuse or rape then it is recommended that the victim be counselled and provided with the drugs recommended for post-occupational exposure prophylaxis. It is important to try and determine the HIV status of the perpetrator. If this is not possible then it may be assumed that the perpetrator is HIV positive and the victim is provided with the treatment as listed in the preceding paragraph.

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8. FUNGAL OPPORTUNISTIC INFECTIONS 8.1 Introduction Fungal infections are quite common in HIV infected patients ranging from mild skin infections to debilitating disorders such as oesophageal candidiasis and lethal infections such as cryptococcal meningitis. Management of some of the milder fungal infections, such as body ringworm, is well documented in EDLIZ. Through the Diflucan Pfizer Program (DPP), fluconazole is available as a donation in the public sector. It is free for use only for two conditions: oesophageal candidiasis and cryptococcal meningitis. (See also Chapter 21- Skin Conditions) 8.2 Oesophageal candidiasis Oesophageal candidiasis occurs commonly in persons with HIV infection, occurring in up to one third of HIV infected individuals. This condition is most likely to occur in persons who have peripheral blood CD4 lymphocyte counts of less than 200/mm3. 8.2.1 Diagnosis Patients with oesophageal candidiasis usually present with odynophagia (pain on swallowing) and dysphagia (difficulty with swallowing). If odynophagia (not dysphagia) is the most prominent symptom, the patient is most likely to have ulcerative oesophagitis which could be due to candidiasis or herpes simplex virus infection. Heartburn can also occur. The clinical diagnosis is usually made after a history is taken and a clinical examination is carried out. However the diagnosis can only be confirmed after an upper GI endoscopy is carried out and the oesophageal mucosa visualized directly. Endoscopy should be carried out only after empiric treatment for oesophageal thrush has failed in HIV positive patients with dysphagia and/or odynophagia. Upper GI barium studies should not be used to diagnose oesophageal candidiasis. 8.2.2 Management Non-drug related treatment

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A soft diet may reduce the symptoms of dysphagia. Avoid drinks that are either too hot or too cold when there is odynophagia. Drug related treatment Preferred therapy - Fluconazole 200mg daily for two to three weeks. Alternative therapy – Ketoconazole 200mg twice a day for two weeks. Consider endoscopy if there is no response after 4 weeks from starting Fluconazole therapy. TREATMENT OF OESOPHAGEAL CANDIDIASIS Drug Codes Adult dose Route Frequency Duration Fluconazole C V 200mg PO OD 2-3 weeks

(Max 4 weeks) OR

Ketoconazole C V 200mg PO BID 2 weeks 1. There is no role for maintenance fluconazole therapy 2. There is no role for topical anti-fungal therapy 3. Consider referral for endoscopy if there is no response in 4 weeks after

starting treatment Nursing Care Requirements Encourage adequate nutrition by emphasizing eating of small soft but frequent meals. Counsel regarding treatment compliance and adherence to therapy. Regular cleaning of the mouth / brushing of the teeth should be advised. Educate the patient to recognise the symptoms suggesting recurrence of the infection so that they can promptly return for further treatment. Note that there are potential drug interactions between fluconazole and rifampicin, warfarin and antiepileptic drugs such as phenytoin. Counseling Requirements Note that oesophageal candidiasis is an AIDS defining illness and hence, refer the patient for VCT if they have not undergone HIV testing before.

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Post Admission care / Discharge plan There is no place for maintenance fluconazole therapy here, but long-term cotrimoxazole prophylaxis should be commenced. Social Services Support Consider referral to the local National/District Aids Council for material assistance. If the patient cannot afford the hospital/ medication fees, refer to the Social Services Department for possible “free” treatment cover note. 8.3 Cryptococcal meningitis This is a fungal CNS infection which is quite common in our wards and, in some instances, will be the first AIDS defining illness that the patient will present with. There may, occasionally, be skin involvement with lesions resembling molluscum contagiosum. CNS involvement may also occur in the form of single or multiple intracranial masses (cryptococcomas). The prognosis without specific treatment is poor with survival being less than six months following diagnosis in most instances. Management of raised intracranial pressure is necessary for optimal care. 8.3.1 Diagnosis Symptoms- Patients presents with headaches of varying severity -usually of a fairly chronic duration. There is a fever and perhaps altered mental status. This disease has to be suspected in HIV positive patients who present with unexplained neurological signs. Meningeal symptoms causing neck stiffness are usually present. Do a lumbar puncture and send the CSF for India ink staining for the cryptococcus organism. A serum cryptococcal antigen test can also be carried out where possible if the CSF results are negative. The cryptococcal antigen is positive in > 99 percent of cases of cryptococcal meningitis. 8.3.2 Management Non-drug related treatment Daily lumbar puncture taps have been shown to relieve the headache and improve the survival of these patients by relieving raised intracranial pressure. This will involve taking off at least 10 – 20ml of CSF initially and

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may need to be repeated on a daily basis. The aim is to keep the CSF pressure at less than 20cm. Drug related treatment: First Line - Ideally Flucystosine (100mg/kg/day in 4 divided doses) and Amphotericin B (0.7mg- 1mg/kg/day daily) are the best combination in the first two weeks of treatment. Thereafter, Fluconazole 400 - 800mg daily for 8 weeks and then reduce to maintenance Fluconazole at 200mg /day indefinitely. Maintenance Fluconazole should be continued for life. Alternative therapy – Amphotericin B 0.7mg- 1mg/kg/day daily for 2 weeks and then Fluconazole 400 – 800mg daily for 6 – 8 weeks followed by maintenance therapy. Maintenance Amphotericin B weekly or biweekly is a poor alternative.

TREATMENT OF CRYPTOCOCCAL MENINGITIS – INDUCTION PHASE Drug Codes Adult dose Route Frequency Duration Amphotericin B B V 0.7mg/kg to 1mg/kg IV OD 14 days

PLUS Flucytosine A V 25mg/kg PO QID 14 days

OR Fluconazole B V 400-800mg PO OD 6-8 weeks

TREATMENT OF CRYPTOCOCCAL MENINGITIS – MAINTENANCE Drug Codes Adult dose Frequency Duration Fluconazole B V 200mg Once daily Long term

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Adjunctive therapy: 1. Mild or Moderately strong analgesia eg. Paracetamol or Codeine

Phosphate or Morphine 5mg every four hours may be required if codeine is not relieving the headache

2. There is need to make sure that the patient’s headache is controlled using adequate analgesia. Watch out for the development of further symptoms such as the side effects of Amphotericin B such as nausea, vomiting, fever, chills and rigors as well as hypokalaemia and renal dysfunction

Nursing Care Requirements Maintain hydration and nutritional status. Fluconazole can cause hepatotoxicty. Counseling Requirements Cryptococcal meningitis may be the first AIDS defining illness that the patient presents with. They may not be aware of their HIV status. Hence they will need to undergo pre-counseling for HIV testing as well as the post-counseling if the test is carried out. The patient needs to be aware of the lifelong nature of the maintenance therapy. Use of HAART is expected to favourably alter the course of the disease. Post Admission care / Discharge plan Refer to the National Discharge plan section as well as the Community Home Based Care section. Social Services Support Consider referral to the local District Aids Council for material assistance. If the patient cannot afford the hospital/ medication fees, refer to the Social Services Department for possible “free” treatment cover note. 8.4 Disseminated histoplasmosis Cases of histoplasmosis are increasingly being seen. It is assumed that these represent disseminated histoplasmosis as the patients tend to be quite debilitated with fever and weight loss. The patients have also been HIV positive. Hepatomegaly and splenomegaly also suggest disseminated disease.

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8.4.1 Diagnosis The usual clinical scenario is that of a patient who appears to have nodular skin lesions which look like molluscum contagiosum. The lesions tend to be bigger and are more disseminated. Perforating gum and palatal lesions have also been described. A skin biopsy and microbiological investigation for fungi is the definitive test. Buccal mucosal lesions should be referred to the dentists for biopsy. Further investigations such as full blood count and liver function tests may help in assessing the patient. A chest x-ray should be performed to assess for pulmonary disease. 8.4.2 Management Non-drug related treatment Keep the lesions clean to prevent superadded bacterial infection Drug related treatment Patients with histoplasmosis need induction treatment and long-term suppressive therapy: TREATMENT OF HISTOPLASMOSIS- INDUCTION THERAPY Drug Codes Dose Route Frequency Duration Amphotericin B A B 0.7-1.0 mg/kg IV OD 12 weeks

OR Ketoconazole B E 600 – 800mg PO OD 12 weeks

OR Itraconazole A N

200mg PO BID 12 weeks

TREATMENT OF HISTOPLASMOSIS- MAINTENANCE THERAPY Drug Codes Dose Route Frequency Duration Amphotericin B A B 50 mg IV Once a week Long-term

OR Itraconazole B V 200mg PO BID Long-term

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OR Fluconazole B V 200mg PO BID Long-term NOTE: In the presence of meningitis or septicaemia amphotericin should be used Nursing Care Requirements A holistic approach to the patient’s problem requires that other issues such as nutrition be addressed. Counseling Requirements Consider sending for VCT. If the patient is HIV positive, they will need to be considered for prophylaxis against other opportunistic infections. Counsel the patient about the importance of adherence to therapy and the need to report any problems such as vomiting, abdominal pain and yellowing of eyes which may be indicative of hepatic drug side effects. Post Admission care / Discharge plan Make sure that the patient’s discharge note is clear about the duration of therapy. The patient will need to be reviewed in the Outpatient department after two weeks of starting the antifungal therapy to assess the response as well as to assess for side effects of the drugs. Social Services Support For those who cannot afford their drug treatment, refer them to their nearest Social Welfare Department/local NAC offices for appropriate assistance. A letter of introduction will be required. 8.5 Pneumocystis pneumonia Pneumocystis pneumonia (PCP) is caused by the fungus Pneumocystis jiroveci. The infection is seen mainly in those people whose CD4 count is less than 200/mm3. It is an important cause of pneumonia in immunocompromised people and has a high mortality. It is an AIDS defining condition. 8.5.1 Diagnosis PCP should be suspected in an HIV positive person who presents complaining of dry cough, tachypnoea, increasing shortness of breath and a fever. The patient may appear to be fine at rest but easily get breathless

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after slight exertion such as dressing. Examination of the chest shows minimal findings or is normal. The CXR may be normal or classically shows a ground glass appearance. Arterial blood gases that show a low PO2 in the setting of the above history and a clear CXR is suggestive of PCP. The organism is not easily isolated from the sputum. Where possible, a bronchoscopy with transbronchial biopsy and bronchoalveolar lavage should be performed. The microscopy of the fluid may show the cysts of Pneumocystis. 8.5.2 Management Non-drug related treatment High dose oxygen therapy is mandatory Drug related treatment: High dose cotrimoxazole 4 tablets of 480mg each (i.e., 1920mg) orally three times a day, and Prednisolone 60mg PO OD for 14-21 days Alternative therapy – Clindamycin 600mg four times a day with Primaquine 15mg orally daily. All patients who have been treated for PCP should receive life long cotrimoxazole prophylaxis if they are not allergic to sulphonamides TREATMENT OF PNEUMOCYSTIS PNEUMONIA Drugs Codes Dose Route Frequency Duration Cotrimoxazole C V 1920mg PO TID 21 days

OR Clindamycin B V 600mg PO QID 21 days

AND Primaquine B N 15mg PO OD 21 days Plus steroids as follows: STEROID THERAPY Drugs Codes Dose Route Frequency Duration Prednisolone B V 60mg PO OD 21 days

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Long-term prophylaxis therapy: COTRIMOXAZOLE PROPHYLAXIS Drugs Codes Dose Route Frequency Duration Cotrimoxazole C V 960mg PO OD For life or until

CD4+ count is consistently >200/mm3

Nursing Care Requirements If there has been a reaction to cotrimoxazole in the past, consider referral for rapid desensitization (see Annexe 2). Ensure that the patient is receiving their oxygen at high doses. Counseling Requirements Referral for VCT should be done where appropriate. Emphasise the importance of adherence to therapy and compliance. Post Admission care / Discharge plan Make sure that the patient is aware of their review date in the outpatients department. Also ensure that the need for prophylactic cotrimoxazole is clearly documented in the patient’ s discharge card and that the patient knows where to get their supplies from. Social Services Support Arrange for the patient to get financial assistance where appropriate.

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9. BACTERIAL OPPORTUNISTIC INFECTIONS 9.1 Streptococcus pneumoniae (Pneumococcus) Streptococcus pneumoniae is a gram positive coccus and is responsible for a large number of infections in both immune competent and immunosuppressed persons, including, pneumonia, septicaemia, meningitis, sinusitis and otitis media. 9.1.1 Pneumococcal pneumonia Patients usually present with cough, fever, chest pain and dyspnoea. The onset is generally over 3 to 14 days. The diagnosis is made on the clinical finding of an area of consolidation in one or more lobes of the lungs. A chest x-ray will show the areas of consolidation if present. Sputum and blood cultures may be useful in isolating the organism and assessing the resistance of the organism to antibiotics. Patients should be admitted to hospital if they are very ill and have any of the following signs: Respiratory distress – respiratory rate more than 30/minute Cyanosis Tachycardia - Pulse greater than 125 /min Hypotension – systolic blood pressure less than 90mm Hg Temperature less than 35o C or more than 40o C Altered mental state

Management Non-drug related treatment Bed rest Fluids – if hypotensive give fluids intravenously Nutritional advice Oxygen by face mask if patient is dyspnoeic

Drug related treatment

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First line treatment Treatment of lobar pneumonia Drugs Codes Dose Route Frequency Duration Benzyl penicillin C V 2.5 Mu IV QID 7 days

OR Amoxycillin B V 500mg PO TID 7 days

OR Erythromycin C V 500mg PO QID 7 days Second line treatment Second line treatment of lobar pneumonia Drugs Codes Dose Route Frequency Duration Doxycycline C V 100mg PO BID 7 – 10 days

OR Ceftriaxone A N 1 to 2g IM OD 7 – 10 days

OR Chloramphenicol B V 500mg PO QID 7 – 10 days NOTE: Tuberculosis and Pneumocystis pneumonia should be kept in mind In the presence of septicaemia the dose of penicillin should be increased to

5Mu QID 9.1.2 Pneumococcal meningitis S. pneumoniae is a common cause of meningitis and is not limited to persons with HIV infection. Affected patients usually present with headache, fever, neck stiffness, with or without altered level of consciousness. The illness develops over a period of 1 to 7 days. The diagnosis is made on clinical grounds and confirmed by the examination of the cerebrospinal fluid which shows polymorphonuclear leucocytes that appear in large numbers in the fluid. If there has been prior antibiotic treatment there may be a mixture

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of polymorphs and mononuclear cells in the CSF. The protein content of the CSF will be elevated and the glucose level will be reduced. Microscopic examination of gram stained preparations of CSF may show gram-positive diplococci. The CSF should also be examined for cryptococci by India ink stain and for TB bacillus by Ziehl Nielsen stain. SEE CHAPTER ON NEUROLOGIC MANIFESTATIONS. Management Non-drug related treatment Patients who are unconscious or confused may require special care Intravenous fluids need to be given Blood slides should be examined for malaria parasites

Drug related treatment First line treatment of pneumococcal meningitis Treatment of pneumococcal meningitis Drugs Codes Dose Route Frequency Duration Benzyl penicillin C V 5 Mu IV QID 14 days

AND Chloramphenicol B V 500mg IV QID 14 days If patient is not better in 5 days refer for investigations Second line treatment of pneumococcal meningitis Second line treatment of pneumococcal meningitis Drugs Codes Dose Route Frequency Duration Ceftriaxone A N 2g IV BID 14 days

AND Rifampicin C V 600mg PO BID 14 days

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NOTE: DO NOT PERFORM A LUMBAR PUNCTURE IF: There are focal neurologic signs and the patient is deeply unconscious There is a rapidly falling level of consciousness Fundoscopy shows papilloedema One pupil is large and not reacting to light If in these situations a CT scan is not available then a careful lumbar

puncture should be performed 9.1.3 Pneumococcal septicaemia S. pneumoniae can cause septicaemia in susceptible hosts. Patients are very ill and present with fever, tachycardia, hypotension, tachypnoea. Initially, the peripheries are warm but becoming cold as the disease progresses and hypoperfusion ensues. There may be pneumonia, oliguria, confusion or a reduced level of consciousness. The diagnosis is made on clinical grounds and upon the isolation of the organism from blood cultures. Drug related treatment: Treatment of pneumococcal septicaemia Drugs Codes Dose Route Frequency Duration Benzyl penicillin C V 5 Mu IV QID 14 days

AND Chloramphenicol B V 500mg IV QID 14 days

OR Ceftriaxone A N 2g IV BID 14 days 9.1.4 Sinusitis and otitis media SEE CHAPTER ON OTOLOGIC MANIFESTATIONS. 9.2 Non-typhoid salmonellosis

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Infection with non-typhoid salmonella species is much more frequent in HIV infected individuals. Organisms responsible for infection include: Groups C, B, D, and G salmonellae Salmonella paratyphi Salmonella typhimurium Salmonella enteritidis

Patients present with fever, enterocolitis, bacteraemia, enteric fever, localised infection outside of the gastrointestinal tract, weight loss and diarrhoea, and some patients become asymptomatic carriers of the infection. The organisms usually invade the gut mucosa and then disseminate into the systemic circulation via the lymphatics. Infection usually occurs as a result of ingestion of contaminated water or food, particularly infected poultry, eggs, meat and dairy products. Person to person transmission occurs via the faecal oral route. Animals may be the reservoirs of infection and household pets may harbour the infection. The diagnosis is made upon the isolation of the organisms in blood, urine or stool cultures. Management Antibiotic treatment should be guided by sensitivity of the organism isolated. Various antimicrobials have been used with varying effect. These include, amoxycillin, chloramphenicol, nalidixic acid and cotrimoxazole. The aminoquinolones seem to be drugs with the best action against most salmonella species. Treatment of non-typhoid salmonelloses Drugs Codes Dose Route Frequency Duration Ciprofloxacin A E 500mg PO BID 14 days

OR Chloramphenicol B V 500mg PO QID 14 days

OR Norfloxacin C V 400mg PO BID 14 days

OR Ceftriaxone A N 2g IV BID 14 days

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9.3 Bacillary Angiomatosis Bacillary angiomatosis or bacillary peliosis is caused by Bartonella henselae and B. quintana, which can cause cat scratch fever and trench fever, respectively. They can also cause vascular proliferative lesions that can form in many different organs including lymph nodes, skin, GI tract, lungs, bone, blood, heart, spleen, bone marrow, liver and brain. Most of these problems are due to B. henselae. Liver lesions, or bacillary peliosis (BP) may be concomitant with other systemic manifestations or skin lesions. Dermatologic presentations are variable, from red, vascular lesions with smooth or friable surfaces, to cellulitic plaques, Kaposi’s sarcoma-like lesions, dry scaly plaques on erythematous bases, or subcutaneous nodules. Lesions of bacillary angiomatosis (BA) may be chronic and present for up to a year. They can be differentiated from KS, since a collar of scale is usually present around the border of the BA lesion. Skin lesions are usually tender and there may be fever, weight loss and abdominal pain. The patient may admit to having had exposure to cats and may or may not recall flea bites. Hepatosplenomegaly or anaemia may be present, in addition to or in absence of the skin lesions described above. BA or BP usually occur with CD4 counts <50, although cat-scratch fever may manifest in immunocompetent individuals. Heart murmurs may indicate endocarditis. In patients with these symptoms and/or signs, the following other conditions should be borne in mind: Kaposi's sarcoma Angiosarcoma Pyogenic granuloma Septicaemia of other aetiology

The diagnosis is made on biopsy and the organism may be isolated in special types of blood culture media. Management Treatment must be prolonged to reduce the risk of relapse, generally 12 weeks or more for skin manifestations alone.

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For systemic manifestations, evaluate for hospitalization and consider longer course of treatment: Treatment of bacillary angiomatosis Drugs Codes Dose Route Frequency Duration Clarithromycin A N 500mg PO BID 12 weeks

OR Azithromycin A N 250mg PO QID 12 weeks

OR Ciprofloxacin A E 500-750mg PO BID 12 weeks

OR Erythromycin C V 500mg PO QID 12 weeks

OR Doxycycline C V 100mg PO BID 12 weeks NOTE: For seriously ill patients, hospitalise and start antibiotics

intravenously. Rifampicin 300mg PO BID is usually added to their treatment regimen, although this may necessitate interruption of the antiretroviral regimen due to drug interactions.

Relapsed patients are re-treated for 16 weeks or more. Medications must be taken for the full 12 (or more) weeks, and on

schedule, in order to control the infection. After course of medication is complete, return for any recurrent

symptoms such as fever or new lesion growth. Antiretroviral therapy may be added (if patient is not already on it,

and is ready to try it) after continuing the antibiotics for 4 or 5 weeks.

Careful flea control for pets will help prevent exposure to these infections.

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9.4 Dermatologic staphylococcal infections Staphylococcus aureus is the most common cause of bacterial skin infections in patients with HIV. Staphylococcal infection may present as bullous impetigo, cellulitis, folliculitis, hidradenitis suppurativa. Presentation and treatment are determined by the depth of the infection. Patients with HIV are at risk from superinfection and bacteraemia from infections that, in other patients, might be thought to be trivial. Hospital admission for IV antibiotic therapy is indicated when systemic toxicity accompanies a staphylococcal skin infection. The patient complains of itchy rash and there is inflammation of the skin and subcutaneous tissue with or without pustules or abscesses. There may be fever if systemic spread has occurred. Bullous impetigo: facial, groin or axillary superficial blisters or erosions, often with yellow crusts. Ecthyma: a superficially ulcerated “punched out” or eroded lesion with an extremely adherent crust. A purulent layer of material can usually be found under the crust. Folliculitis: follicular pustules (pruritic, often very painful lesions) are visible on the face, trunk, in the axillae or groin. A tiny central pustule may be visible when the skin is stretched, although sometimes lesions are almost urticarial. These may extend below the skin surface, forming abscesses, or in rare cases, large, violaceous hidradenitis-like plaques with pustules. Note that excoriations may obscure primary lesions. Cellulitis: findings include swelling, tenderness, erythema and warmth of localized tissue, most commonly on the face and extremities. May be associated with other types of lesions. Rule out other causes of skin ulcerations/eruptions such as: Candida albicans Cutaneous hypersensitivity reactions to drug therapy Streptococcal infection Deep vein thrombosis (DVT) in lower extremity cellulitis Kaposi’s sarcoma

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Pyogenic granuloma Angiosarcoma Drug reaction

Diagnosis is usually made after isolating Staphylococcus from lesions. A microscopic examination of purulent material should be performed. Blood cultures should also be performed if bacteraemia is suspected. Management Impetigo: Cloxacillin, 500mg PO QID for 7 - 14 days), or

erythromycin, 500 mg PO QID for 7 - 14 days, may be given. Deeper or refractory/recurrent lesions: Add rifampicin, 600mg PO

OD to above. Drain loculated abscesses and remove crusts on ecthymatous areas. Recurrent lesions may indicate nasal carriage, which can be treated

with topical mupirocin or bacitracin ointment to anterior nares TID for 7 days.

If extensive cellulitis is suspected, admit for inpatient IV antibiotic therapy.

Wash area with antibacterial soaps. Impetigo is highly contagious. Avoid hand contact with lesions, and

do not allow other people to touch the areas. If not improved in 3-5 days, return to clinic.

9.5 Mycobacterium avium complex Disseminated Mycobacterium avium complex (DMAC) is an opportunistic infection caused by the Mycobacterium avium intracellulare (MAI) microorganism. These organisms occur worldwide, and have been isolated from soil, water, animals, birds and foods. The estimated prevalence of disseminated MAC disease is 15-25% of patients with advanced HIV infection; this epidemic has arisen concurrently with the AIDS epidemic.

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Unlike Mycobacterium tuberculosis, DMAC results from primary infection with the organism, not reactivation. DMAC is diagnosed when the organism is isolated from blood, lymph nodes, bone marrow, or liver. While MAC colonization occurs in many patients, disseminated disease occurs late in HIV disease, contributing to general disability, cachexia and death. The patient complains of one or more of the following symptoms: persistent fever, night sweats, weight loss, anorexia, chronic diarrhoea, weakness, fatigue, and/or abdominal pain. Often the patient has abdominal tenderness and hepatosplenomegaly. To establish the diagnosis, Mycobacterium avium must be isolated from a normally sterile site. Biopsy of the lymph node, liver or bowel may establish the presence of DMAC. Management Clarithromycin 500mg PO BID, or azithromycin 500-600mg PO OD; PLUS Ethambutol 15 mg/kg PO OD; PLUS Rifabutin 300mg PO OD, or ciprofloxacin 750mg PO BID, or ofloxacin 400 mg PO BID 9.6 Tuberculosis Follow the Zimbabwe National Guidelines on the Management of TB.

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10. PROTOZOAN AND PARASITIC OPPORTUNISTIC INFECTIONS Microsporida is responsible for 40% of chronic diarrhoea in PLWHA in Zimbabwe, Cryptosporidia for 10%, Isospora for 2% and Giardia for 2%. 10.1 Cryptosporidiosis Cryptosporidiosis is an intestinal infection caused by a protozoan parasite, usually self-limiting in immunocompetent patients. It produces profuse, watery diarrhoea with abdominal cramping in immunocompromised patients. Cryptosporidium may also cause cholangitis, and, rarely, infection in sites outside the GI tract. Patients complain of some combination of diarrhoea, abdominal pain and cramping, flatulence, nausea, vomiting, fever, anorexia, weight loss, and/or malaise. Diarrhoea may be acute and self-limiting or chronic and recurrent. Infection is spread by ingestion of contaminated water, including swimming / boating / rafting incidents. Symptoms usually last more than 2 weeks. Stools are watery and without gross blood. The diagnosis is made on finding oocysts in appropriately stained stool preparations and in aspirates obtained from upper and lower GI endoscopy. If cholangitis suspected, consider abdominal ultrasound to detect biliary ductal dilatation, and/or endoscopic retrograde cholangiopancreatography (ERCP) Management Non-drug related treatment As most chronic diarrhoeas relating to HIV are not treatable, the most important thing is to prevent them. This can be done by hand hygiene, boiling all drinking water (including that which is used to brush teeth), peeling all fruit, cooking all meat and vegetables and not eating raw lettuce, cabbage or salads. Drug-related treatment No specific therapy is available for treating the infection. Most

patients experience symptom improvement or remission on ART.

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Provide supportive care and symptomatic relief through: Fluid and electrolyte replacement Antidiarrhoeals, such as loperamide Antispasmodics Antiemetics

Paromomycin sulfate 1gm PO BID, PLUS azithromycin 600 mg PO OD for 4 weeks has helped some patients; after four weeks give paromomycin alone, 500 mg po bid. This regimen has not been curative.

10.2 Microsporidiosis A number of different strains of microsporidia are pathogenic in humans (Table 10.1). Table 10.1 Different species of microsporidia and illnesses caused by them

Microsporidian species Clinical manifestation Enterocytozoon bieneusi Diarrhoea, acalculous cholecystitis

Encephalitozoon intestinalis (syn. Septata intestinalis)

Infection of the GI tract causing diarrhoea, and dissemination to ocular, genitourinary and respiratory tracts

Encephalitozoon hellem and Encephalitozoon cuniculi

Keratoconjunctivitis, infection of respiratory and genitourinary tract, disseminated infection

Vittaforma corneae (syn. Nosema corneum), Nosema spp. (N. connori and N. ocularum) Ocular infection

Trachipleistophora hominis and Pleistophora sp. Muscular infection Microsporidium (M. ceylonensis and M. africanum) Infection of the cornea Human microsporidiosis represents an opportunistic disease, occurring mainly, but not exclusively, in severely immunocompromised patients with AIDS. The clinical manifestations of microsporidiosis are very diverse, varying according to the causal species with diarrhoea being the most common.

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Enterocytozoon bieneusi and Encephalitozoon intestinalis are commonly associated with diarrhoea in persons with HIV infection and are difficult to eradicate. Diarrhoea may be acute and self-limiting or chronic and recurrent. Microsporidia can cause infection in sites other than the GI tract including the bronchial tree, the paranasal sinus, the cornea and conjunctivae and the gall bladder and renal tract. Management Non-drug related treatment Prevention of infection by avoiding ingesting spores of microsporidia is most important. This may be achieved by safe and hygieninc practices, including drinking uncontaminated water, peeling all fruit, cooking all meat and vegetables and not eating raw lettuce, cabbage or salads. Avoid close contact with pets. Drug-related treatment Albendazole is useful in treating the infection: Albendazole 400mg PO BID for 4 weeks. In relapses after treatment should be given a second course of

treatment (this may have to be for 6 weeks in resistant cases). If the patient relapses after stopping the acute therapy the patient

should then be maintained on 400mg once a day, long term. Metronidazole 400mg PO TID for 10-14 days has also been shown to be useful. 10.3 Isosporiasis Isosporiasis is caused by the coccidian parasite Isospora belli. Infection causes acute, non bloody diarrhoea with crampy abdominal pain, which can last for weeks and result in malabsorption and weight loss. In immunosuppressed patients, and in infants and children, the diarrhoea can be severe. Eosinophilia may be present. The diagnosis is made by the microscopic demonstration of the large, typically shaped oocysts. If stool examinations are negative, examination of duodenal specimens by biopsy or string test may be needed. The oocysts can be visualized on wet mounts by

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microscopy with bright-field, contrast microscopy and can also be stained by modified acid-fast stain. Management Cotrimoxazole 960mg QDS for 10 days, then BD for 3 weeks, followed by maintenance treatment of 960mg daily. 10.4 Cyclosporiasis Cyclospora cayetanensis is a unicellular parasite. It is spread by ingesting water or food that is contaminated with infected stool. It is not passed on from one person to the next. Cyclospora infects the small intestine and causes watery diarrhoea, with frequent, sometimes explosive, bowel movements. Other symptoms can include loss of appetite, substantial loss of weight, bloating, increased gas, stomach cramps, nausea, vomiting, muscle aches, low-grade fever, and fatigue. Some people who are infected with Cyclospora may not have any symptoms. Symptoms usually begin 7 days after infection. If not treated, the illness may last from a few days to a month or longer. Symptoms may seem to go away and then return one or more times (relapse). The diagnosis is made on the finding of cysts of cyclospora in the stools. Management Cotrimoxazole given in a dose of 960mg PO QID for 10 days then 960mg OD for 3 weeks is the recommended treatment for infection with Cyclospora. Avoiding water or food that may be contaminated with stool may help prevent Cyclospora infection. People who have previously been infected with Cyclospora can become infected again. 10.5 Giardiasis Giardiasis is responsible for 2% of chronic diarrhoea in Zimbabwe. The condition is caused by Giardia intestinalis, a protozoan flagellate. Acute giardiasis develops after an incubation period of 5 to 6 days and usually lasts 1 to 3 weeks. Symptoms include diarrhoea, abdominal pain, bloating, nausea, and vomiting. In chronic giardiasis the symptoms are recurrent and

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malabsorption and debilitation may occur. The clinical spectrum ranges from asymptomatic carriage to severe diarrhoea and malabsorption. Giardiasis is diagnosed by the identification of cysts or trophozoites in the faeces, using direct mounts as well as concentration procedures. Repeated samplings may be necessary. In addition, samples of duodenal fluid or duodenal biopsy may demonstrate trophozoites. Alternate methods for detection include antigen detection tests by enzyme immunoassays, and detection of parasites by immunofluorescence. Management Metronidazole is the drug of choice for giardiasis. It is given in a dose of 400mg PO TID for 5 days. NOTE: Cotrimoxazole and metronidazole (a trial of one course of one drug

at a time) should be tried in all chronic diarrhoeas realizing they will treat a total of only 4% of diarrhoeas. If cotrimoxazole and metronidazole fail then it should be assumed that the diarrhoea is either E. bienenusi (when albendazole may be used) or cryptosporidium and symptomatic treatment is given.

For symptomatic control a stepwise approach should be used: Step 1 Loperamide 4mg initially then 2mg with every unformed stool Step 2 Loperamide and codeine phosphate 30mg PO QID Step 3 Morphine 5mg PO QID Step 4 Loperamide and morphine If loperamide is not available then: Step 1 Codeine phosphate 30mg PO PRN Step 2 Codeine phosphate 30mg PO TID Step 3 Codeine phosphate 30mg PO QID Step 4 Codeine phosphate 60mg PO QID Step 5 Morphine starting at 5mg PO every 4 hours Antiemetics such as prochlorperazine 10mg PO TID PRN (or 12.5mg

TID if given IM), or, metoclopramide 10mg TID PRN (PO/IV/IM), or

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cyclizine 50mg TID PRN (PO/IV/IM), or chlorpromazine 25mg every 4 to 6 hours PO/IM, or Promethazine 25mg PO BID can be used.

Ensure adequate rehydration, potassium replacement (either through oral potassium supplements, or orange crush and bananas), and also adequate nutrition through small nutritious meals taken frequently, i.e., 4 - 6 small palatable meals a day.

10.5 Cerebral toxoplasmosis: SEE CHAPTER ON CNS MANIFESTATIONS

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11. VIRAL INFECTIONS Viral infections occur commonly in immunosuppressed persons and often cause death. A large number of viral infections occur in persons with HIV infection and AIDS. 11.1 Herpes simplex virus Herpes simplex virus (HSV) infection is commonly encountered in clinical practice. It usually presents with vesicles and painful superficial sores around the mouth, nose, lips and genitals. Following an initial attack of herpes simplex infection, recurrences occur frequently. In immunosuppressed persons the infection may be extensive and persistent and may become disseminated. Dissemination may lead to infection of the lungs, the oesophagus, and the brain. Herpes simplex virus may also cause meningoencephalitis, meningitis and myelitis. Diagnosis The diagnosis of herpes simplex virus infection is usually made on the typical clinical presentation. It is often difficult to make a diagnosis of disseminated herpes and special laboratory tests, such as viral culture, radioimmunoblot assay and fluorescent and monoclonal antibody tests, may be necessary. Herpes simplex encephalitis leads to the development of multiple lesions in different parts of the brain and typical changes may be seen on CT scan studies of the brain. Management Treatment is summarised below: HERPES SIMPLEX VIRUS MILD INFECTION First line treatment Antiviral agent Codes Dose Frequency Route Duration Acyclovir B E 400mg TID PO 7-10 days

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HERPES SIMPLEX VIRUS RECURRENCES First line treatment Antiviral agent Codes Dose Frequency Route Duration Acyclovir B E 800mg BID PO 7-10 days HERPES SIMPLEX VIRUS SEVERE AND VISCERAL INFECTION First line treatment Antiviral agent Codes Dose Frequency Route Duration Acyclovir B E 10mg/kg TID IV 7-10 days HERPES SIMPLEX VIRUS SEVERE AND VISCERAL INFECTION Second line treatment Antiviral agent Codes Dose Frequency Route Duration Foscarnet S N 60mg/kg BID IV 14 days 11.2 Herpes zoster Herpes virus varicella zoster often causes disseminated infection after initial exposure. In children initial infection results in the development of chicken pox, though most persons that become infected develop no symptoms and signs of infection. The virus lays dormant in the paraspinal ganglia for years. However, with immunosuppression from whatever cause, the virus replicates and produces lesions along the length of a cutaneous nerve in a dermatomal distribution. Dissemination can also occur at this time with involvement of skin, nervous system, lungs and mucous membranes. In immune suppressed persons zoster is often multidermatomal in distribution and is persistent and extensive. It is associated with severe pain and debility. The diagnosis is usually made on clinical grounds. Management Treatment is summarised in the tables below:

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DERMATOMAL ZOSTER First line treatment Antiviral agent Codes Dose Frequency Route Duration Acyclovir B E 800mg 5 times a day PO 7-10 days DISSEMINATED, VISCERAL, OPHTHALMIC ZOSTER First line treatment Antiviral agent Codes Dose Frequency Route Duration Acyclovir B E 30-35mg/kg OD IV 7-10 days DERMATOMAL, DISSEMINATED, VISCERAL, OPHTHALMIC ZOSTER Second line treatment Antiviral agent Codes Dose Frequency Route Duration Foscarnet S N 60mg/kg OD IV 14 days Post-herpetic neuralgia is a common and serious debilitating problem. It causes severe pain in a dermatomal distribution usually at the site of the lesions. Pain control is often necessary and be achieved with mild analgesics such as paracetamol. If pain control is not achieved with this, then non-steroidal anti-inflammatory drugs may be used or failing this amitryptiline, carbamazepine or phenytoin may be tried. 11.3 Cytomegalovirus infection (CMV) Cytomegalovirus may affect multiple systems and organs in the body in immunosuppressed individuals. Symptoms include fever and diarrhoea from CMV colitis, dyspnoea from CMV pneumonitis, and blindness caused by CMV retinitis. CMV infection can lead to the appearance of painful ulcers in the mouth resulting in difficulty in eating. Confirming the diagnosis requires costly tests, such as tissue biopsies and DNA hybridization studies and sophisticated equipment. Management

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1. CMV GI disease and neurologic disease: CMV GI DISEASE AND NEUROLOGIC DISEASE First line treatment Antiviral agent Codes Dose Frequency Route Duration Ganciclovir S N 5mg/kg BID IV 2-3 weeks Long term treatment with ganciclovir 5mg/kg given IV daily may be necessary.

CMV GI DISEASE AND NEUROLOGIC DISEASE Second line treatment Antiviral agent Codes Dose Frequency Route Duration Foscarnet S N 90mg/kg BID IV 3 weeks Long term treatment with foscarnet 90mg/kg given IV daily may be

necessary. 2. CMV retinitis: SEE CHAPTER ON OCULAR MANIFESTATIONS 11.4 Epstein Barr Virus-related conditions Infection with Epstein Barr Virus (EBV), a herpes virus, occurs commonly in persons with HIV infection as well as in persons without HIV infection. Patients with HIV have increased amounts of EBV in their oropharyngeal secretions and have higher EBV antibody titres than HIV-seronegative persons. No specific treatment is available for treating the infection. EBV is thought to cause a number of conditions including, Oral hairy leukoplakia Non-Hodgkins lymphoma Burkitt-type lymphoma

Nasopharyngeal carcinoma

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12. SEXUALLY TRANSMITTED INFECTIONS

12.1 General Guidelines Effective management of sexually transmitted infections (STIs) is one of the cornerstones of STI and HIV control, as it prevents the development of complications and sequelae, decreases the spread of these diseases in the community, reduces the transmissibility of HIV and offers a unique opportunity for targeted education about HIV prevention. Appropriate treatment of STI patients at their first encounter with a health care provider is, therefore, an important public health measure. When this involves adolescent patients, there is the potential to influence future sexual behaviour and care-seeking practices at a critical stage of development. Accurate laboratory-proven diagnosis of STI is not always possible. Management guidelines recommended in this section are based on the diagnosis of STI-associated syndromes and the provision of a comprehensive management package including provision of antibiotics for the STI syndrome, provision of health education, promoting treatment compliance through education, promoting risk reduction behaviour, provision of condoms, providing information on partner referral and treatment and arranging for follow-up examination. To prevent further spread it is essential that all contacts of persons with STI be treated. 12.2 STI Case Management STI case management is the care of a person with an STI-related syndrome or with a positive test for one or more STI. The components of case management include: history taking, examination, correct diagnosis, early and effective treatment, advice on sexual behaviour, promotion and provision of condoms, partner notification and treatment, case reporting and clinical follow-up as appropriate. Thus, effective case management consists not only of antimicrobial therapy to obtain cure and reduce infectivity, but also comprehensive care of the patient’s needs for reproductive health.

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12.3 Syndromic management Aetiological diagnosis of STI is problematic in many settings. It places constraints on time, resources, costs and access to treatment. In addition, the sensitivity and specificity of commercially available tests can vary significantly, thus, affecting negatively, the reliability of laboratory testing for STI diagnosis. In settings where laboratory facilities are available there must be suitably qualified personnel with adequate training to perform technically demanding procedures, and the establishment of external quality control is mandatory. Syndromic management is based on the identification of consistent groups of symptoms and easily recognized signs (syndromes), and the provision of treatment that will deal with the majority of organisms responsible for producing a syndrome.

STI-related syndromes and their causes STI syndrome STI-related causes of syndrome Urethral discharge Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas

vaginalis, Ureaplasma urealyticum Genital ulcer Herpes simplex virus, Treponema pallidum, Haemophilus

ducreyi, C. trachomatis Vaginal discharge T. vaginalis, Candida albicans, anaerobic bacteria (bacterial

vaginosis), N. gonorrhoeae, C. trachomatis Lower abdominal pain in women

Anaerobic bacteria, N. gonorrhoeae, C. trachomatis, group B streptococci

Inguinal lymphadenitis (bubo)

Haemophilus ducreyi, C. trachomatis (Types L1, L2, L3)

Acute scrotal swelling Neisseria gonorrhoeae, Chlamydia trachomatis (Note: Non-STI causes include infection with pyogenic bacteria such as E.coli and viruses such as mumps virus)

Neonatal conjunctivitis Neisseria gonorrhoeae, Chlamydia trachomatis (Note: Non-STI causes include infection with pyogenic bacteria such as staphylococci and streptococci)

12.4 Selection of drugs Antimicrobial resistance of several sexually transmitted pathogens has been increasing in many parts of the world and this has rendered some low-cost regimens ineffective. Recommendations to use more effective drugs frequently raise concerns about cost and possible misuse. A two-tier drug policy with the provision of less effective drugs at the peripheral health care

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level and the most effective and usually more expensive drugs only at a referral level may result in an unacceptable rate of treatment failures, complications and referrals, and may erode confidence in health services. This approach is not recommended. The drugs used for STI in all health care facilities should be at least 95% effective. Drugs selected for treating STI should meet the following criteria: High efficacy (at least 95%) Low cost Low toxicity levels Acceptable tolerance Organism resistance unlikely to develop or likely to be delayed Single dose Oral administration Not contraindicated for pregnant or lactating women

12.5 Principles of management of STIs Persons with STIs have become infected as a result of risky sexual behaviour and activity. When managing persons with STIs the opportunity should be taken to educate and counsel patients about the nature of the infection, its modes of transmission and its relationship to HIV infection and AIDS. During the consultation an assessment must be made of the patient’s perception of risk and the reasons for engaging in risky behaviour should be determined. With this information patients may be educated individually and counseled to modify behaviour. The general principles of managing patients with STIs are summarised in the following table:

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Principles of management of STIs Diagnosis of STI syndrome Diagnosis based on history and clinical examination. The

clinical finding of abnormal signs is necessary in order to make a diagnosis

Non-drug related treatment Primary prevention through safer sexual behaviour and safer sexual activity.

Special requirements Room where patient can be interviewed and examined in private; examination couch; light source; specula; disinfectant to soak used instruments; disposable gloves; autoclaving equipment

Provide education All patients should be provided with education regarding the nature of the infection and its modes of transmission and be informed that HIV, the cause of AIDS, is acquired in the same way as other STIs are

Counseling Assess reasons for engaging in unsafe sexual activities and counsel according to risk, i.e., influence of alcohol, separation from spouse. Counsel on abstaining from casual sex, having sex with only one lifelong mutually faithful partner and to avoid situations that may promote unsafe sexual activity.

Treatment compliance All patients should be counselled on treatment compliance and adherence to treatment

Promote condom use Educate on the correct use of condoms by carrying out a condom demonstration and on the correct disposal of used condoms. Provide the patient with a supply of condoms. Inform the patient as to where condoms, both male and female condoms, may easily be acquired in future

Partner treatment Arrange for all sexual partners to be treated Follow-up plan Arrange to review patient in 7 days time Social services support Drugs for STI treatment may not be affordable by all patients

and should be provided First line treatment Is the recommended treatment given when the patient makes

first contact with the health facility Second line treatment Is the recommended when the patient returns with symptoms

and signs after having been given first line treatment.There is no likelihood of re-infection or poor treatment compliance

Third line treatment Is given after the patient has had first and second line treatment and has been seen by an expert and laboratory tests have been carried out

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12.6 Urethral Discharge in Men The commonest causes are Neisseria gonorrhoeae and Chlamydia trachomatis. The two commonly co-exist. Uncommonly Trichomonas vaginalis causes a urethral discharge in men. Therefore all males with urethral discharge should be treated for both gonorrhoea and chlamydial infection. Often the two infections coexist and both infections present with similar symptoms and signs in men. All contacts of men with urethral discharge syndrome should be treated. 12.6.1 Treatment of urethral discharge Male patients complaining of urethral discharge and/or dysuria should be examined for evidence of discharge. If none is seen, the urethra should be gently massaged from the base of the penis towards the meatus.

First line treatment for urethral discharge Drug Codes Adult dose Route Frequency Duration Kanamycin (for gonococcal infection)

C V 2g IM Once Single dose

AND Doxycycline (for chlamydial infection)

C V 100mg PO BID 7 days

Alternative treatment for urethral discharge Drug Codes Adult dose Route Frequency Duration Norfloxacin (for gonococcal infection)

C C 800mg PO Once Single dose

AND Doxycycline (for chlamydial infection)

C V 100mg PO BID 7 days

If the recommended first line and alternative drugs are not available refer the patient to the next level

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12.6.2 Flowchart for the management of urethral discharge in men

Patient complains of urethral discharge or dysuria

Take a history and examine (squeeze the urethra forwards if no obvious discharge is present

Urethral discharge confirmed?

Educate on treatment compliance

Counsel on risk reduction

Promote and provide condoms

Partner management Offer HIV counselling

and testing Advise to return in 7

days

TREAT FOR GONORRHOEA AND CHLAMYDIAL INFECTION

Any other STI present?

Treat according to appropriate flowchart

NO

YES

NO

YES

Educate and counsel Promote and provide

condoms Offer HIV counselling and

testing Review if symptoms persist

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12.7 Treatment of Persistent/Recurrent Urethral Discharge If the patient still has a urethral discharge, or evidence of urethritis 7 days after start of treatment, suspect re-infection or poor treatment compliance, and if this is the case re-start first line treatment. In some cases there may be infection with Trichomonas vaginalis. Therefore if re-infection is not suspected and treatment compliance is good give the patient treatment for trichomoniasis. If symptoms still persist the patient must be referred for expert opinion and investigations. Treatment for persistent urethral discharge Drug Codes Adult dose Route Frequency Duration Metronidazole (for trichomoniasis)

C V 2g PO Once Single dose

If the patient fails to respond to this refer the patient for investigations and appropriate treatment

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12.7.1 Flowchart for the management of persistent/recurrent urethral discharge in men

Patient complains of persistent / recurrent urethral discharge

▪ Educate and counsel ▪ Promote and provide condoms ▪ Offer HIV counselling and testing if

available ▪ Review if symptoms persist

Take a history and examine patient

Urethral discharge confirmed?

Any other STI present?

Treat according to appropriate flowchart

Does history confirm re-infection and/or poor treatment compliance?

Repeat urethral discharge treatment

NO

NO

YES

YES

YES

NO

TREAT FOR TRICHOMONIASIS

Educate Counsel Promote and provide

condoms Partner management Advise to return in 7 days if

symptoms persist

Review in 7 days

Patient has improved?

Refer patient

YES NO

Educate and counsel Promote and provide

condoms Offer HIV counselling

and testing

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12.8 Genital Ulcers with or without bubo in Men and Women The commonest cause of genital ulcers in both men and women is genital herpes simplex virus infection. Syphilis and chancroid also cause genital ulcers but their prevalence has dropped significantly. Clinical differentiation between the causes of genital ulcers is inaccurate except if the patient gives a clear history of recurrent attacks of vesicular lesions that may crust and heal spontaneously or the clinical appearance of lesions that are superficial ulcers, when the diagnosis of genital herpes may be suspected. It should be noted that syphilis may remain undetected in the body for long periods of time and clinical manifestations may only occur when long-term sequelae develop. It is therefore felt that patients with genital ulcers be carefully interviewed and examined to rule out syphilis. Immunosuppressed persons with HIV infection frequently develop attacks of genital herpes that produce lesions, which persist and become secondarily infected. Hence it is important to bear in mind all three diagnosis whenever managing persons with genital ulcers syndromically.

12.8.1 Recurrent or vesicular genital lesions

These are usually due to genital herpes simplex virus infection. 12.8.2 Treatment of genital ulcers In persons with genital ulcers take a history and examine patients, and determine whether the lesions could be genital herpes. If the lesions are vesicles or superficial ulcers suggestive of genital herpes then the only treatment to offer is counseling for genital herpes and advice on local hygiene such as washing twice a day with soap and water. If the patient has overt genital ulcers then it is possible that the patient has syphilis, chancroid or infected genital herpes lesions. Granuloma inguinale and lymphogranuloma venereum may also cause genital ulceration, but these infections are not commonly encountered in clinical practice.

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It is therefore recommended that all persons with obvious genital ulcers are advised on local hygiene and are given erythromycin 500mg PO QID for 7 days and then re-assessed. If at the end of 7 days of treatment the ulcers show signs of healing or are healed then the patient should receive another 7 days treatment with erythromycin 500mg PO QID, in case the lesions are caused by syphilis. If the ulcers persist after 7 days of treatment then the patient is treated for persistent genital ulcers as described in the next section. First line treatment for genital ulcers Drug Codes Adult dose Route Frequency Duration Erythromycin (for chancroid, syphilis and secondary bacterial infection)

C V 500mg PO QID 14 days

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TREAT FOR CHANCROID / SECONDARY BACTERIAL INFECTION WITH ERYTHROMYCIN 500mg PO QID FOR 7 DAYS

Vesicles or small ulcers with history of recurrent

YES

Patient complains of genital sore or ulcer

▪ Educate and counsel▪ Promote and provide condoms ▪ Offer HIV counselling and

testing if available ▪ Review if symptoms persist

Take a history and examine patient

Sore/Ulcer/Vesicle present? NO

Any other STI present?

NO

YES

Treat according to appropriate flowchart

YES

HERPES SIMPLEX MANAGEMENT: - Local hygiene - Educate and counsel for risk reduction - Counsel on living with genital herpes - Promote and provide condoms - Offer HIV counselling and testing

NO

Ulcer present? NO

Educate and counsel Promote and provide condoms Offer HIV counselling and testing

YES

Local hygiene Educate and counsel on risk

reduction Promote and provide condoms Offer HIV counselling and testing Partner management Advise to return in 7 days

Review in7 days

Ulcer healed or healing?

NO YES

CONTINUE ERYTHROMYCIN 500mg PO QID FOR 7 MORE DAYS

MANAGE AS PERSISTENT GENITAL ULCER

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12.8.4 Treatment of Persistent Genital Ulcers Patients who present with genital ulcers that show no signs of healing after 7 days treatment with erythromycin may have persistent genital herpes and should be managed with a specific anti-herpes virus drug, and should continue with erythromycin in case syphilis is also present. The following treatment should be given to persons presenting with persistent genital ulcers: First line treatment for persistent genital ulcers Drug Codes Adult dose Route Frequency Duration Erythromycin (for bacterial infection and syphilis)

C V 500mg PO QID For total 14 days

AND Acyclovir (for herpes simplex infection

B E 400mg PO TID 7 days

AND, LOCAL HYGIENE

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NOTE: The patient would already have received 7 days of erythromycin, and so will need treatment for another 7 days, making the total duration of erythromycin 14 days

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Patient complains of persistent genital ulcer Educate and counsel

Promote and provide condoms Offer HIV counselling and testing if available Review if symptoms persist

Take a history and examine patient

Ulcer present? NO

Any other STI present?

NO

YES

Treat according to appropriate flowchart

TREAT FOR HERPES / SECONDARY BACTERIAL INFECTION WITH ACYCLOVIR 400mg PO TID FOR 7 DAYS AND ERYTHROMYCIN 500mg PO QID FOR 7 MORE DAYS

YES

Educate Counsel on risk reduction Promote and provide

condoms Offer HIV counselling and

testing Partner management Advise to return in 7 days Refer if necessary

Review in

7 days

Ulcer healed or healing?

YES NO

Educate and counsel Promote and provide

condoms Offer HIV counselling

and testing

REFER

12.8.5 Flowchart for the management of persistent genital ulcers in men and women

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12.8.6 Alternative Treatment for Genital Ulcers using Intramuscular Penicillin Alternatively patients may be managed for genital ulcers by being given treatment for syphilis, chancroid and bacterial infection using erythromycin 500mg PO QID for 7 days (for chancroid and bacterial infection) and benzathine penicillin 2.4 million units IM as single dose (for syphilis). Patients are then reviewed and if genital ulcers persist then they should receive herpes simplex virus treatment with acyclovir 400mg PO TID. If patients fail to respond to this they should be referred for expert opinion and investigations. This regimen is summarized below. Alternative treatment for genital ulcers Drug Codes Adult dose Route Frequency Duration Erythromycin (for chancroid, and secondary bacterial infection)

C V 500mg PO QID 7 days

AND Benzathine penicillin (for syphilis)

C V 2.4 million units

IM (half dose into each buttock)

ONCE only Single dose

On review in 7 days: Genital ulcers have healed no further treatment is given Genital ulcers persist give: Acyclovir (for genital herpes)

B E 400mg PO TID 7 days

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12.9 Vaginal Discharge in Women A spontaneous complaint of abnormal vaginal discharge is most commonly due to a vaginal infection such as candidiasis, trichomoniasis or bacterial vaginosis. It may also be the result of muco-purulent cervicitis caused by N. gonorrhoeae or C. trachomatis. The clinical detection of cervical infection is difficult because women with gonococcal or chlamydial cervical infection are often asymptomatic. Among women presenting with discharge, one can attempt to identify those with an increased likelihood of being infected with N. gonorrhoeae and/or C. trachomatis. Microscopy adds little to the diagnosis of cervical infection and is not recommended. It is therefore recommended that all women with vaginal discharge confirmed on clinical examination should be treated for both gonococcal and chlamydial infection, and in addition depending on the type of discharge they should be treated for either candidiasis or trichomoniasis. 12.9.1 Treatment of vaginal discharge Patients complaining of vaginal discharge should be examined for evidence of vaginal discharge and a decision should be made on the type of discharge found. Patients should be treated according to the type of discharge present.

CAUTION IN PREGNANCY: Doxycycline, tetracycline, norfloxacin and ciprofloxacin should not be used during pregnancy, or in lactating women. In pregnant women chlamydial infection is best treated with erythromycin while kanamycin should be used for gonococcal infection.

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First line treatment of profuse/frothy/malodorous/purulent vaginal discharge Drug Codes Adult

dose Route Frequency Duration

Kanamycin (for gonococcal infection)

C V 2g IM (1g into each buttock)

Once Single dose

AND Doxycycline (for chlamydial infection)

C V 100mg PO BID 7 days

AND Metronidazole (for bacterial vaginosis and trichomoniasis)

C V 400mg PO BID 7 days

First line treatment of white/curd-like vaginal discharge Drug Codes Adult

dose Route Frequency Duration

Kanamycin (for gonococcal infection)

C V 2g IM (1g into each buttock)

Once Single dose

AND Doxycycline (for chlamydial infection)

C V 100mg PO BID 7 days

AND Miconazole (for candidiasis)

C V 200mg Intravaginally

TID 3 days

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Alternative gonorrhoea treatment is norfloxacin 800mg PO in a single dose

Alternative chlamydial treatment is erythromycin 500mg PO QID for 7 days

Alternative candida treatment is: Clotrimazole, 200 mg intravaginally, daily for 3 days Clotrimazole, 500 mg intravaginally, as a single dose Fluconazole, 150 mg orally, as a single dose Nystatin, 100 000 IU intravaginally, daily for 14 days

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12.9.2 Flowchart for the management of vaginal discharge in women Discharge is profuse, and/or frothy and/or malodorous? Discharge is profuse, and/or frothy and/or malodorous? Discharge is profuse, and/or frothy and/or malodorous?

Patient complains of vaginal discharge or vulval itching/burning

Take a history and examine patient

lower abdominal tenderness and / or cervical excitation tenderness present?

Vaginal discharge is present?

Discharge is profuse, and/or frothy and/or malodorous?

NO

YES

Manage according to flowchart for Lower Abdominal Pain

Manage according to flowchart for Lower Abdominal Pain

NO

TREAT FOR GONORRHOEA, CHLAMYDIA, BACTERIAL VAGINOSIS, AND TRICHOMONIASIS Educate on treatment compliance Counsel on risk reduction Promote and provide condoms Offer HIV counselling and testing Review in 7 days

TREAT FOR CHLAMYDIA, GONORRHOEA, AND CANDIDIASIS

Educate on treatment compliance Counsel on risk reduction Promote and provide condoms Offer HIV counselling and testing Review in 7 days

Educate about physiological discharge

Counsel on risk reduction Review if symptoms persist

Discharge is white/curdlike?

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12.10 Lower Abdominal Pain in Women There are many causes of lower abdominal pain in women. Some of the causes are trivial and need only re-assurance after examination, while others are serious requiring immediate surgical or gynaecologic intervention. An STI-related cause is pelvic inflammatory disease (PID). This is a serious complication of STI as it is associated with significant morbidity and mortality as well as serious long-term sequelae, such as, predisposition to ectopic pregnancy and infertility. PID is defined as infection the female genital tract above the internal os of the cervix. Acute primary PID is caused by ascending infection from the cervix of gonococcal, chlamydial or anaerobic bacterial infection resulting in endometritis, salpingitis, salpingo-oophoritis and pelvic peritonitis. Women presenting with lower abdominal should be carefully assessed and examined to rule out the possibility of a gynaecologic or surgical emergency, such as, threatened, septic or incomplete abortion, retained products of conception, ectopic pregnancy, and acute appendicitis. Women with acute PID usually present with a history of lower abdominal pain, often associated with vaginal discharge and irregular menstruation and on examination there is lower abdominal and pelvic tenderness and cervical excitation tenderness. Women with PID who do not have features of peritonitis, such as, abdominal guarding, rigidity or rebound tenderness, and do not have abdominal masses, vaginal bleeding or shock, may be treated for PID on an outpatient basis. Those women with lower abdominal pain who have any of the following features should be referred for expert opinion and management: History of missed, delayed or overdue period Recent (in the last 6 weeks) history of delivery or abortion Abdominal guarding, rigidity or rebound tenderness Abdominal mass Vaginal bleeding Shock

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12.10.1 Treatment of pelvic inflammatory disease The outpatient management of PID should include treatment for gonococcal chlamydial and anaerobic bacterial infection. All patients should be reviewed 72 hours after initiating treatment and if there is no significant improvement then the patient should be referred for expert opinion. If the patient has responded to treatment then treatment should be continued for at least 10 days. First line treatment of PID Outpatient basis Drug Codes Adult dose Route Frequency Duration Kanamycin (for gonococcal infection)

C V 2g IM (1g into each buttock)

Once Single dose

AND Doxycycline (for chlamydial infection)

C V 100mg PO BID 14 days

AND Metronidazole (for anaerobic bacterial infection)

C V 400mg PO BID 14 days

Alternative gonorrhoea treatment: Ceftriaxone 250mg IM in a single dose Ciprofloxacin 500mg PO in a single dose

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Second line treatment of PID Inpatient basis Drug Codes Adult dose Route Frequency Duration Ceftriaxone (for gonococcal infection)

C V 250mg IM Once daily 5 days

AND Doxycycline (for chlamydial infection)

C V 100mg PO BID 14 days

AND Metronidazole (for anaerobic bacterial infection)

C V 400mg PO BID 14 days

Alternative gonococcal treatment: Ciprofloxacin 500mg PO BID for 4 days Spectinomycin 1g IM QID for 4 days

Alternative chlamydia treatment: Doxycycline 100mg IV BID for 4 days followed by 100mg PO BID

for 10 days Tetracycline 500mg IV QID for 4 days followed by doxycycline

100mg PO BID for 10 days Alternative anaerobic bacterial treatment: Metronidazole 400mg IV BID for 4 days then 400mg PO BID for 10

days Chloramphenicol 500mg IV or PO QID for 4 days then

metronidazole 400mg PO BID for 10 days

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Third line treatment of PID Inpatient basis Drug Codes Adult dose Route Frequency Duration Clindamycin C V 900mg IV TID 4 days

AND Gentamicin C V 1.5mg/kg IV TID 4 days

THEN Metronidazole C V 400mg PO BID 14 days

AND Doxycycline 100mg PO BID 14 days

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12.10.2 Flowchart for the management of lower abdominal pain in women

Patient complains of lower abdominal pain Educate and counsel on risk reduction

Promote and provide condoms Offer HIV counselling and testing

Review if symptoms persist

Take a history (including gynaecological) and examine (abdominal and vaginal)

Any of the following present: Missed/overdue period Recent delivery, abortion, miscarriage Abdominal guarding and / or rebound tenderness Abnormal vaginal bleeding

NO

Is there any other illness?

YES Manage appropriately or refer

NO

Is there cervical excitation tenderness or lower abdominal tenderness or vaginal discharge?

YES

MANAGE FOR PID AND REVIEW IN 3 DAYS

Refer patient for surgical or gynaecological opinion and management

Before referral set up an IV line and apply resuscitatory measures if necessary

YES

REVIEW IN 3 DAYS

Patient has improved?

CONTINUE TREATMENT UNTIL COMPLETED

Educate and counsel Offer HIV counselling and testing

YES NO Refer patient

NO

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12.11 Inguinal Bubo without Genital Ulcers An inguinal bubo is defined as acute suppurative inguinal lymphadenitis. Affected lymph nodes are enlarged, tender, and hot and may be fluctuant if pus formation occurs. A number of conditions can cause acute suppurative inguinal lymphadenopathy including, septic skin lesions on the thighs, buttocks, lower abdomen, lower back and perineum. STI-related causes of inguinal buboes include chancroid and lymphogranuloma venereum (LGV). In persons with buboes caused by chancroid, genital ulcers are usually present, while in LGV buboes may develop without the appearance of genital ulcers. LGV is an infection of the lymphatics and infected patients may develop genital lymphoedema which will resolve if early effective treatment is instituted or may develop into permanent elephantiasis if treatment is not given and fibrosis of the lymphatics occurs. The bubo on chancroid is usually unilocular while the bubo in LGV is multilocular.

12.11.1 Treatment of inguinal buboes

In managing persons with inguinal buboes a careful examination should be performed in search of skin lesions on the lower limbs, lower back and abdomen, and the perineum. If a genital ulcer is present then the patient should be treated as for genital ulcer disease. If septic skin lesions are found these should be managed appropriately. If a bubo is found in person and no genital ulcers are found then the patient should be treated for LGV and chancroid. Fluctuant buboes should be aspirated with a wide bore needle every 3 days if necessary. First line treatment of LGV Drug Codes Adult dose Route Frequency Duration Doxycycline C V 100mg PO BID 14 days Alternative treatment for LGV: Erythromycin 500mg PO QID for 14 days Tetracycline 500mg PO QID for 14 days

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First line treatment of chancroid Drug Codes Adult dose Route Frequency Duration Erythromycin C V 500mg PO QID 7 days It may be most convenient to treat all patients with inguinal buboes with erythromycin 500mg PO QID for 14 days.

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12.11.2 Flowchart for the management of bubo

Patient complains of inguinal swelling

Educate and counsel Promote and provide

condoms Offer HIV counselling and

testing

Inguinal/femoral bubo(s) present?

Take a history and examine patient

Any other disease present?

Treat appropriately or refer

TREAT FOR LYMPHOGRANULOMA VENEREUM AND CHANCROID, WITH ERYTHROMYCIN 500mg PO QID FOR 14 DAYS

If fluctuant aspirate through healthy skin Educate on treatment compliance Counsel on risk reduction Promote and provide condoms Partner management Offer HIV counselling and testing Advise to return in 7 days, and continue

treatment If worse refer for specialist opinion and

further management Treat according to genital ulcer flow chart

Ulcers present?

NO

NO

YES

YES

YES

NO

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12.12 Acute Scrotal Swelling Acute scrotal swelling may occur in persons with acute epididymo-orchitis, testicular torsion and scrotal trauma, and in those with irreducible or strangulated inguinal hernia. Patients should be examined carefully in order to exclude these conditions. The STI-related causes of acute scrotal swelling include gonococcal and chlamydial infection. Infection with mumps virus and bacteria such as Escherichia coli, Klebsiella spp, Pseudomonas aeruginosa, Brucella spp, can also lead to epididymitis. In areas of high prevalence filariasis in the early stages may cause epididymo-orchitis. 12.12.1 Treatment of acute scrotal swelling In managing persons with acute scrotal swelling it is important to exclude surgical causes, and to refer those who may have a surgical cause for appropriate management. A history should be taken and patients should be examined carefully. If no surgical cause is found and it is suspected that the patient has acute epididymo-orchitis then the patient should be treated as follows: First line treatment for acute scrotal swelling Drug Codes Adult dose Route Frequency Duration Kanamycin (for gonococcal infection)

C V 2g IM Once Single dose

AND Doxycycline (for chlamydial infection)

C V 100mg PO BID 14 days

Alternative gonorrhoea treatment is Norfloxacin 800mg PO in a single dose

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Alternative chlamydia treatment is Tetracycline 500mg PO QID for 14 days Erythromycin 500mg PO QID for 14 days

For pain relief give Paracetamol 500mg PO TID, and if necessary, Scrotal support

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12.12.2 Flowchart for the manaement of acute scrotal swelli

12.13 Purulent Neonatal Conjunctivitis Ophthalmia neonatorum is defined as conjunctivitis with discharge (purulent neonatal conjunctivitis) occurring in a neonate within the first month of life.

Patient complains of scrotal swelling/pain

Take a history and examine patient

Scrotal swelling / pain present?

Reassure patient Educate and counsel Provide analgesics if

necessary Promote and provide

condoms Offer HIV counselling and

testing if available

Testis is rotated or elevated or there is history of trauma?

YES

Any other illness / condition present?

Treat appropriately or refer

Refer immediately for surgical opinion

YES

NO

YES

NO

12.12.2 Flowchart for the management of acute scrotal swelling

NO

TREAT FOR GONORRHOEA AND CHLAMYDIAL INFECTION

Educate Counsel on risk reduction Promote and provide condoms Offer HIV counselling and

testing Partner management Review in 7 days or sooner - if

getting worse, Refer

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The condition is commonly caused by gonococcal, chlamydial and bacterial infection. STI-related causes include N. gonorrhoeae and C. trachomatis. Gonococcal ophthalmia neonatorum if not treated early and effectively can lead to blindness in babies. The condition is preventable by detecting and treating maternal gonococcal and chlamydial infection during pregnancy and by instilling 1% tetracycline eye ointment carefully into the conjunctival sacs of every baby as soon as possible after birth. Other bacterial infections, such as, Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus spp. And Pseudomonas spp can also cause purulent neonatal conjunctivitis. 12.13.1 Treatment of purulent neonatal conjunctivitis Once a diagnosis of ophthalmia neonatorum is made the baby and the parents should be treated. The treatment is summarised below: First line treatment for acute scrotal swelling Drug Codes Infant

dose Route Frequency Duration

Kanamycin (for gonococcal infection)

C V 25mg/kg IM Once Single dose

AND Erythromycin (for chlamydial infection)

C V 16mg/kg PO TID 14 days

The mother should receive kanamycin 2g IM single dose and

erythromycin 500mg PO QID for 7 days The father should receive kanamycin 2g IM single dose and

doxycycline 100mg PO BID for 7 days

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12.13.2 Flowchart for the management of purulent neonatal conjuctivis 12.14 Recurrent or Vesicular Genital Lesions These are usually due to genital herpes. Advise the patient to wash frequently with soapy water and give the patient analgesics if the lesions are

Baby presents with discharging eyes

Take a history and examine baby

Ophthalmia neonatorum present?

Reassure parents Educate and counsel Advise to return if symptoms

persist in 3 days and treat or refer as necessary

Educate and counsel parents on risk reduction and condom use

Offer parents HIV counselling and testing

Review baby in 14 days or sooner - if getting worse and refer if necessary

TREAT BABY AND PARENTS FOR GONORRHOEA AND CHLAMYDIAL INFECTION

Any other illness / condition present?

Treat appropriately or refer

NO

NO

YES

YES

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very painful. In patients with genital ulcers, manage them as detailed in the section on management of genital ulcers. 12.15 Granulating Ulcers Without Buboes These are most likely to be lesions of granuloma inguinale, a condition also known as Donovanosis and caused by Calymmatobacterium granulomatis. This condition is not commonly seen in patients in Zimbabwe. It should be remembered that persons who are immunosuppressed may not develop a bubo and occasionally persistent genital ulcers without bubo formation may occur as a result of genital herpes or chancroid in persons with immunosuppression and HIV infection. Patients should be managed as for genital ulcers. Specific treatment for granuloma inguinale is: First line treatment for granuloma inguinale Drug Codes Adult dose Route Frequency Duration Doxycycline C V 100mg PO BID 14 days Alternative treatments for granuloma inguinale include: Tetracycline 500mg PO QID for 14 days Eryhtromycin 500mg PO QID for 14 days Trimethoprim 160mg/sulphamethoxazole 800mg PO BID for 14 days Azithromycin 1g PO initially, then 500mg PO OD for 14 days

12.16 Genital warts (Condylomata acuminata) Genital warts are caused by the human papilloma virus (HPV). A large number of different strains of the virus are known to cause disease in

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humans. Some HPV strains are associated with cervical cancer and anogenital cancers. 12.15.1 Treatment of genital warts Treatment of external genital and perianal warts: First line treatment for external genital and perianal warts Drug Codes Adult dose Route Frequency Duration Podophyllin paint 20%

B N Apply to warts and wash off after 4 hours

Apply to warts

Once weekly

3 weeks

CAUTIONS: For external use only. Do NOT use podophyllin in pregnancy. Do not apply to the cervix, urethra or anal mucosa. 12.16.2 Cervical, urethral and vaginal warts: These should not be treated with podophyllin. Patients should be referred for electrocautery, cryotherapy or surgical excision 12.17 Molluscum Contagiosum Molluscum contagiosum is caused by the molluscum contagiosum virus. The infection is not always acquired sexually, commonly being transmitted through contaminated towels. The lesions of molluscum contagiosum may occur on any part of the body. The condition presents as papules with a central umbilication. The contents of the papules when expressed are seen as a white cheesy material. 12.17.1 Treatment of molluscum contagiosum The lesions of molluscum contagiosum may resolve spontaneously. If not, then each lesion should be pricked with a sharpened “orange-stick” or

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needle and the contents of the lesion expressed. This alone may be sufficient, or each lesion can then be touched carefully with liquefied phenol. Lesions of molluscum contagiosum may become extensive and large in immunosuppressed persons with HIV infection. If the lesions are very extensive and are very large then the patient should be referred for specialist attention. 12.18 Pediculosis pubis (Pubic lice) Pediculosis pubis is caused by the pubic louse Phthirius pubis. This is a parasitic infestation and may be transmitted sexually from person to person or may be transmitted through bed clothes. Patients usually complain of itchiness in the hairy areas around the genitals and often excoriations are present. Careful visualization will reveal the lice as dark spots on the skin and the nits (egg containing sacs) at the junction between the skin and the hairs. Patients with pediculosis pubis and their sexual partners should be treated as follows: First line treatment for pubic lice Drug Codes Adult dose Route Frequency Duration Gammabenzene hexachloride 1%

C V Apply to hairy areas below umbilicus and wash off after 24 hours

Two applications 10 days apart

Caution: Do not use gammabenzene hexachloride in pregnancy and lactation - refer mothers to district level for benzyl benzoate. Alternative in pregnancy, lactating mothers or children < 6 months: First line treatment for pubic lice Drug Codes Adult dose Route Frequency Duration Benzyl benzoate emulsion 20%

B N Apply to hairy areas below umbilicus and wash off after 24 hours

Two applications 7 to 10 days apart

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For children dilute the benzyl benzoate 1:1 with water For infants dilute the benzyl benzoate 1:3 with water Alternative treatments include, lindane, 1% lotion or cream, rubbed gently but thoroughly into the

infested area and adjacent hairy areas and washed off after 8 hours. Lindane must not be used during pregnancy or lactation

Permethrin 1%, applied as above Re-treatment is indicated after 7 days if lice are found or eggs are observed at the hair-skin junction. Clothing or bed linen that may have been contaminated by the patient in the two days prior to the start of the treatment should be washed and dried well, or dry-cleaned. 12.19 Scabies Scabies is caused by the mite Sarcoptes scabei. The infection is often sexually transmitted in adults. However, there clearly are situations in which scabies is transmitted through close body contact not related to sexual activities. This is true in circumstances in which people are living in very close quarters such as in schools, poor housing complexes and in institutions such as nursing homes and psychiatric hospitals. Patients with scabies usually present with pruritus associated with a papular eruption on the forearms, web spaces of the hands, buttocks, umbilicus and genitals. Patients with scabies may be managed as follows: First line treatment for scabies Drug Codes Adult dose Route Frequency Duration Gammabenzene hexachloride 1%

C V Apply from neck down to toes and wash off after 8-12 hours in children and 24 hours in adults

Single application is sufficient

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Caution: Do not use gammabenzene hexachloride in pregnancy and lactation - refer mothers to district level for benzyl benzoate. Alternative in pregnancy, lactating mothers or children < 6 months: First line treatment for scabies Drug Codes Adult dose Route Frequency Duration Benzyl benzoate emulsion 20%

B N Apply from neck down to toes and wash off after 24 hours

Two applications 24 hours apart

For children dilute the benzyl benzoate 1:1 with water For infants dilute the benzyl benzoate 1:3 with water

Alternative treatments include, lindane, 1% lotion or cream, rubbed gently but thoroughly into the

infested area and adjacent hairy areas and washed off after 8 hours. Lindane must not be used during pregnancy or lactation

Permethrin 1%, applied as above Crotamiton 10%, lotion, applied to the entire body from the neck

down, nightly for 2 nights and washed off thoroughly 24 hours after the second application; an extension (crotamiton has the advantage of an antipruritic action).

Sulphur 6%, in petrolatum applied to the entire body from the neck down, nightly for 3 nights; patients may bathe before reapplying the product and should bathe 24 hours after the final application.

12.20 Syphilis The following sections describe the management of syphilis when a specific diagnosis has been made.

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12.20.1 Treatment of early syphilis Early syphilis is defined as syphilis that has less than 2 years duration and includes primary, secondary and early latent stages of syphilis. Early syphilis is managed as follows: First line treatment for early syphilis Drug Codes Adult dose Route Frequency Duration Benzathine penicillin C V 2.4 million units IM Once only Single dose

OR Doxycycline C V 100mg PO BID 14 days

OR Erythromycin C V 500mg PO QID 14 days 12.20.2 Treatment of late syphilis Late syphilis is defined as syphilis that has more than 2 years duration and includes latent, gummatous, cardiovascular and neurologic syphilis, and syphilis of unknown duration. Late syphilis is managed as follows: Late latent syphilis

First line treatment for late latent syphilis Drug Codes Adult dose Route Frequency Duration Benzathine penicillin

C V 2.4 million units IM Once weekly

3 weeks (i.e., 3 doses)

OR Doxycycline C V 100mg PO BID 30 days

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2. Latent syphilis in pregnancy

First line treatment for latent syphilis in pregnancy Drug Codes Adult dose Route Frequency Duration Benzathine penicillin

C V 2.4 million units

IM Once weekly

3 weeks (i.e., 3 doses)

OR Erythromycin C V 500mg PO QID 30 days 3. Neurosyphilis, cardiovascular syphilis and Gummatous syphilis

Neurosyphilis includes meningovascular syphilis, optic atrophy, syphilis meningitis, tabes dorsalis, general paresis and also abnormalities found in the cerebrospinal fluid without clinical signs (i.e., latent neurosyphilis) in a person with positive blood serologic tests for syphilis. First line treatment for neurosyphilis, cardiovascular and gummatous syphilis Drug Codes Adult dose Route Frequency Duration Benzyl penicillin (aqueous)

C V 5 million units

IV QID 14 days

OR Doxycycline C V 100mg PO BID 30 days

OR Erythromycin C V 500mg PO QID 30 days 4. Babies born to mothers who were found to have positive syphilis serology during pregnancy Babies born to women found to have syphilis during pregnancy should be treated even if the mother had been adequately treated during pregnancy as follows:

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First line treatment of babies born to mothers found to have syphilis during pregnancy Drug Codes Infant dose Route Frequency Duration Benzathine penicillin C V 50 000 units/kg IM Once Single dose 5. Congenital Syphilis (babies clinically infected): Congenital syphilis is also divided into the early and late stages. Early congenital syphilis is less than 2 years duration while late congenital syphilis is more than 2 years duration. First line treatment of early congenital syphilis Drug Codes Adult dose Route Frequency Duration

Benzyl penicillin (aqueous)

C V 50 000 units/kg IV TID 10 days

OR Procaine benzyl penicillin

C V 50 000 units/kg IM OD 10 days

First line treatment of late congenital syphilis Drug Codes Adult dose Route Frequency Duration Benzyl penicillin (aqueous)

C V 50 000 units/kg IV QID 14 days

OR Procaine benzyl penicillin

C V 50 000 units/kg IM OD 14 days

OR Erythromycin C V 16mg/kg PO TID 30 days

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12.21 STIs during pregnancy All pregnant women attending for antenatal care should have a history taken and should be carefully examined. A diagnosis of STI may be made on the syndromic basis depending on the symptoms and signs. If a diagnosis of STI is made then the patient should be managed according to the guidelines and flowcharts provided in this document. Comprehensive syndromic case management should be given. If the patient does not have symptoms then a diagnosis of STI can be made using laboratory tests.

12.21.1 Managing pregnant women found to have positive syphilis serology All pregnant women attending for antenatal care should have blood tests for syphilis. The rapid plasma reagin (RPR) test is a non-treponemal screening test for syphilis and is easy to perform without the need of sophisticated equipment. The test is performed on a card and the result of the test may be obtained in less than 10 minutes. False positive results do occur in some patients and the test does not distinguish between syphilis and yaws (framboesia). Some laboratories may carry out different laboratory tests for syphilis including the Venereal Diseases Research Laboratory (VDRL) test or the Treponema pallidum haemagglutination assay (TPHA). The latter test is a specific test for syphilis and is usually carried out as a confirmatory test after finding a positive RPR or VDRL test. In order to prevent the development of congenital syphilis all pregnant women found to have a positive RPR test or a positive VDRL should be treated for syphilis immediately. If subsequently the TPHA is found to be negative then the treatment may be discontinued. However there should be no delay in commencing treatment as the patient may not return for another antenatal visit and may be lost to follow up. The following treatment regimen is recommended in managing pregnant women found to have a positive RPR test result during pregnancy: Patient is NOT allergic to penicillin

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Give benzathine penicillin 2.4 million units intramuscularly each week for 3 weeks. Because of the volume of injection to be given it is advisable to give half the volume into each buttock at each session. Patient is allergic to penicillin Give patient erythromycin 500 mg orally 4 times a day for 14 days. 12.21.2 Managing the baby born to a mother who had a positive syphilis test during pregnancy All babies born to women who had a positive blood test for syphilis during pregnancy should be given treatment for syphilis regardless of whether or not the mother had received full treatment during pregnancy. The baby should receive: Benzathine penicillin 50 000 units / kg body weight by intramuscular injection 12.21.3 Managing partners of women found to have a positive blood test for syphilis Partners of women found to have positive blood test for syphilis should be referred for treatment. If the partner has symptoms of STI then he should be treated for the STI and should also receive benzathine penicillin 2.4 million units. If the partner has no symptoms or signs of STI and there is no recent history (in the last 9 months) of STI then a blood test for syphilis should be carried out. If the test is positive then he should receive benzathine penicillin 2.4 million units intramuscularly weekly for 3 weeks. It is important to counsel both partners regarding the need for treatment. It is also important to explain that a discordant result does not indicate infidelity and that such results occur because pregnancy itself may lead to false positive results and also because the tests currently in use cannot distinguish between yaws and syphilis. 12.21.4 STI drugs that should not be used during pregnancy

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A number of drugs are harmful to either the mother during pregnancy or to the foetus. These should not be used during pregnancy and lactation. The STI drugs that should not be used during pregnancy and lactation include: Doxycycline Tetracycline Ciprofloxacin Norfloxacin Podophyllin

It is advisable not to use metronidazole during the first trimester of pregnancy. 12.22 STIs in Children During the past decade, sexual abuse of children and adolescents has come to be recognized as a serious public health problem. The management of the victims is emerging as an important aspect of child and adolescent health care throughout the world. A standardized approach to the management of sexually transmitted infections in children and adolescents who are suspected of having been sexually abused is important because the infection may be asymptomatic. An STI which remains undiagnosed and untreated may result in complications at a later stage. All children suspected of having been sexually abused should be screened routinely for STI, and all children diagnosed with an STI should be investigated for the source of infection. The identification of a sexually transmissible agent in a child beyond the neonatal period, in the vast majority of cases, is suggestive of sexual abuse. However, exceptions do exist, e.g. rectal or genital infection with C. trachomatis in young children may be due to perinatally acquired infection, which may persist for up to 3 years. In addition, bacterial vaginosis and genital mycoplasma have been identified in both abused and non-abused children. Genital warts, although suggestive of assault, are not specific for sexual abuse without other evidence. When the only evidence of sexual abuse is the isolation of an organism or the detection of antibodies to a sexually transmissible agent, findings should be carefully confirmed and considered.

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Health workers who suspect abuse must consider the options available for specialized counseling, social support and redress. It must be stressed that the psychological and social support services should be included for complete management of these patients. Children should be examined carefully and gently and should be assured that they will not be hurt. The sexually abused child has already been traumatized both physically and emotionally and the examination should not add to this agony. It is preferable not to use any form of instrumentation and definitely not to use a speculum to examine the cervix. Specimen collection should be carried out painlessly and swabs for collection of specimens should not be inserted into the vagina or penis. 12.22.1 Initial examination At the initial examination a history should be taken and the child should be examined. An inspection of the external genitalia should be carried out and findings should be recorded. Specimens should be taken of any discharge that is present in the vagina and anus and the urethral meatus. Specimens should be sent for gram stain and microscopy, culture for N. gonorrhoeae and identification of C. trachomatis and T. vaginalis. A sample of venous blood should also be collected for baseline testing for syphilis, hepatitis B virus and HIV. These tests will need to be repeated three weeks and three months after the sexual abuse. At the initial visit, if it very soon after the sexual abuse, swabs and smears may reveal negative results as the organisms may not have had enough time to multiply to sufficient concentrations to be able to be identified and hence the swabs and cultures will need to be repeated at least one week after the event. The perpetrator of the crime, if possible, should also be examined for STIs and have an HIV test performed.

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12.22.2 Managing children with STIs and those exposed to STIs and HIV infection In all children with STIs recruit the help of experts early during the cause of the illness. It is also necessary to enroll the services of counsellors and social workers in all cases. 1. Post-exposure prophylaxis for HIV infection There are insufficient data to make an evidence-based recommended on prophylactic treatment to be offered to children that have been sexually abused. However it is felt that post-sexual exposure and if the HIV status of the perpetrator is positive or unknown then sexually abused children should be commenced on antiretroviral therapy as soon as possible after the event and no later than 3 days of the event. The following regimen is recommended: RECOMMENDED POST SEXUAL EXPOSURE PROPHYLACTIC REGIMEN IN CHILDREN Drug Dose Frequency Route Duration Zidovudine Less than 28 days age 4 weeks to 13 year age

4mg/kg 180mg/m2

BID BID

PO PO

4 weeks 4 weeks

AND Lamivudine Age less than 30 days Age more than 30 days or weight less than 60kg More than 60kg weight (Maximum dose)

2mg/kg 4mg/kg 150mg

BID BID BID

PO PO PO

4 weeks 4 weeks 4 weeks

AND Nevirapine Aged 15-30 days: first 2 weeks Aged 15-30 days: after 2 weeks Aged >30 days: first 2 weeks Aged >30 days: after 2 weeks

5mg/kg 120mg/m2 120mg/m2 200mg/m2

OD BID BID BID

PO PO PO PO

2 weeks 2 weeks 2 weeks 2 weeks

2. Children found to have positive syphilis serology

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Children found to have positive syphilis serology should be treated for syphilis as follows: First line treatment of acquired syphilis in children Drug Codes Adult dose Route Frequency Duration Benzyl penicillin (aqueous)

C V 50 000 units/kg IV QID 10 days

OR Procaine benzyl penicillin C V 50 000 units/kg IM OD 10 days

OR Erythromycin C V 16mg/kg PO TID 14 days 3. Children found to have vaginal discharge After specimens have been collected for gram-stain microscopy, wet prep microscopy and gonococcal culture and chlamydial identification, the following treatment should be given: First line treatment of vaginal discharge in children Drug Codes Adult dose Route Frequency Duration Ceftriaxone C V 50mg/kg IM Once Single dose

AND Erythromycin C V 16mg/kg PO TID 10 days

AND Metronidazole C V 5mg/kg PO TID 7 days 4. Children found to have genital ulcers If the child presents within 1 week of the event with genital ulcers treat him/her as follows: First line treatment of genital ulcers in children within 7 days of abuse Drug Codes Adult dose Route Frequency Duration Ceftriaxone C V 50mg/kg IM Once Single dose

AND Erythromycin C V 16mg/kg PO TID 10 days

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If the child presents with genital ulcers after 1 week of the event treat him/her as follows: First line treatment of genital ulcers in children after 7 days of abuse Drug Codes Adult dose Route Frequency Duration Ceftriaxone C V 50mg/kg IM Once Single dose

AND Procaine benzyl penicillin

C V 50 000 units/kg IM OD 10 days

OR Erythromycin C V 16mg/kg PO TID 14 days 5. Children found to have genital warts These children should be referred for expert opinion and treatment with podophyllin, excision, cauterization or cryotherapy.

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13. OCULAR MANIFESTATIONS Ocular manifestations of HIV infection are serious conditions as many of these occur at the time of severe immunosuppression and often lead to blindness. The diagnosis of some ocular infections is difficult to make and expertise and laboratory tests are necessary. It is important to keep in mind that all persons presenting with failing vison and loss of vision should be referred for specialist opinion. 13.1 Cytomegalovirus retinitis Cytomegalovirus (CMV) infection occurs commonly in the general population. The virus is a herpes virus that can remain latent in the body for many years after initial infection. In immunosuppressed patients viral replication may occur and a number of clinical manifestations, such as, retinitis, pneumonitis, oesophagitis, meningoencephalitis, colitis and retinitis may occur. CMV retinitis leads to visual problems and blindness. This complication usually occurs with advanced immunosuppression and usually patients with CMV retinitis have CD4+ lymphocyte counts of less than 100 cells/mm3. 13.1.1 Diagnosis The diagnosis of CMV retinitis is usually made clinically on the finding of yellowish white areas of retinal necrosis and oedema that follow a vascular distribution. There may be haemorrhagic areas in the retina (salad cream and tomato sauce appearance), and severe posterior and mild anterior uveitis. The diagnosis may be confirmed by identifying CMV DNA in vitreous biopsies, aqueous humour aspirates, or endoretinal biopsies. 12.1.2 Management Non-drug related treatment: All patients need counseling and psychological support. Family support should also be provided. Nutritional deficiencies should be corrected and the patient advised on good nutritional and healthy life styles.

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Drug treatment: Treatment of CMV retinitis Drug Codes Adult dose Route Frequency Duration Ganciclovir A V 5mg/kg IV BID 14 – 21 days

THEN Ganciclovir A V 1.5 to 2g PO TID Long term

OR Ganciclovir A V 4.5g to 6g PO OD Long term

OR Foscarnet A E 90mg/kg IV BID 14 – 21 days

THEN Foscarnet A E 120mg/kg IV OD Long term NOTES: 1. Patients receiving cidofovir should also receive probenecid 2g PO 3

hours before the infusion and 1g PO at 2 hours and at 8 hours after the infusion

2. Intravitreal implants of ganciclovir may be inserted and have been found to be efficacious

3. For intra-ocular inflammation topical steroid (e.g., neodexone or sofradex eye drops and atropine eye drops may be used

4. Antiretroviral therapy should be initiated/continued Nursing care requirements 1. Nutritional advice and food security 2. Mobility training if blind. Counseling All patients undergoing HIV testing should receive pre- and post-test counseling. Post admission care / discharge plan 1. Arrange for long term treatment with ganciclovir or foscarnet 2. Need anti-retroviral drugs 3. Regular Ophthalmic follow-up 4. Early detection and treatment of other opportunistic infections.

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Social Services Support Patients should be encouraged to join AIDS support organisations as they may require long term social, educational and financial assistance. Social support for mobility training for visually impaired persons is necessary. Financial support to purchase drugs and medicines will be necessary. 13.2 Herpes Zoster Ophthalmicus 12.2.1 Diagnosis The diagnosis of herpes zoster ophthalmicus is made after taking a history and carrying out a clinical examination. The finding of painful vesiculobullous dermatitis following the distribution of the ophthalmic branch of the trigeminal nerve is highly suggestive of the diagnosis. Fever, malaise and headache may also occur. Ocular involvement usually occurs when the nasociliary branch of the trigeminal nerve is affected. No specific tests are routinely available for confirming the clinical diagnosis. Herpes zoster occurs as a result of reactivation of latent infection with the varicella-zoster virus. The condition occurs more commonly and is more extensive and persistent in immunosuppressed patients. It is therefore advisable to perform baseline tests such as blood count, electrolyte, glucose, creatinine and HIV antibody test in all patients. 13.2.2 Management Non-drug related treatment All patients need supportive therapy including advice on good nutrition and preventing transmission of infection to household contacts. Counseling All patients undergoing HIV testing should receive pre- and post-test counseling.

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Treatment of Herpes zoster ophthalmicus Drug Codes Adult dose Route Frequency Duration Acyclovir A V 800mg PO Five times a day 7 days

OR Famiciclovir A E 500mg PO TID 7 days NOTES: 1. The antivirals recommended are effective only if administered within 5

days of onset of symptoms 2. For pain control indomethacin, 25mg PO TID may be given 3. For the prevention of post-herpetic neuralgia amitryptiline, 25mg PO TID

may be given 4. For intra-ocular inflammation topical steroid (e.g., neodexone or

sofradex eye drops and atropine eye drops may be used 5. Antiretroviral therapy should be initiated/continued. Nursing Care Requirements 1. Wound care with topical capsaicin 0.25% or 2. Wound care with topical calamine or 3. Wound care with topical povidone iodine 4. General nursing care. 5. Isolation during acute phase of illness. Post Admission Care and Discharge Plan 1. Long term analgesia and/or amitryptiline to treat post-herpetic neuralgia

should be given. 2. Patients should have ophthalmic follow-up as they may develop ocular

and adnexial involvement and other complications that need to be treated.

3. Early detection and treatment of other opportunistic infections. Social Services Support Patients should be encouraged to join AIDS support organisations as they may require long term social, educational and financial assistance.

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13.3 Kaposi’s sarcoma Kaposi’s sarcoma (KS) is aetiologically linked to the human herpes virus type 8 (HHV8 or KSHV). This cancer is found more commonly in immunosuppressed individuals and with the onset of the epidemic of HIV infection this tumour is the commonest cancer encountered in Zimbabwe. 13.3.1 Diagnosis Lesions are painless purple-brown papules or nodules found on skin; when they appear on the mucous membranes lesions are reddish-blue vascular papules. They are commonly found on the buccal mucosa and the conjunctiva. The diagnosis should always be confirmed by histologic examination of biopsied tumour tissue. Patients should also be tested for HIV infection and where possible for HHV8 DNA. 13.3.2 Management Counseling All patients undergoing HIV testing should receive pre- and post-test counseling. Non-drug related treatment 1. All patients need supportive therapy including advice on good nutrition. 2. Visually impaired persons may require additional support and care. 3. Localised lesions may be surgically excised or removed by cryotherapy 4. The tumour responds to radiotherapy Drug related treatment Localised lesions should be treated by excision, cryotherapy or radiotherapy. Intralesional vinblastine may reduce the size of individual lesions. Most patients with mucosal KS have disseminated disease and hence will require combination cytotoxic chemotherapy with etoposide, daunorubicin, vincristine and bleomycin. Nursing Care Requirements Supportive role and ensuring treatment compliance and regular follow up attendance. General nursing care and support for patient with cancer.

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Post Admission Care and Discharge Plan Long-term follow-up by ophthalmologist / oncologist to monitor progress. Early detection and treatment of other opportunistic infections. Social Services Support Patients should be encouraged to join AIDS support organisations as they may require long-term social, educational and financial assistance. 13.4 Ocular Surface Squamous Neoplasias A strong association has been noted between HIV infection and ocular surface squamous neoplasia. There has been a marked increase in the incidence of this cancer over the last 10 years in Zimbabwe. The exact aetiology is not known but it has been suggested that the cancer may be associated with human papilloma virus(HPV) infection. 13.4.1 Diagnosis Ocular surface squamous neoplasia appear as persistent, progressively enlarging tumours on the conjunctiva that lead to the eventual erosion of the cornea. Lesions are highly vascular, painful and irritating. The diagnosis should be confirmed by histologic examination of tumour tissue. Conjunctival cytology may be useful in identifying malignant cells. 13.3.2 Management Counseling All patients undergoing HIV testing should receive pre- and post-test counseling. Non-drug related treatment All patients need supportive therapy including advice on good nutrition. Visually impaired persons may require additional support and care. Localised lesions may be surgically excised or removed by cryotherapy. The tumour may respond to radiotherapy.

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Drug related treatment Neodexone / sofradex eye drops/ ointment should be used initially to treat inflammatory lesions like phylectenulosis. Systemic cytotoxic chemotherapy is usually necessary once the diagnosis has been confirmed or in the presence of metastasis. Analgesics should be given for pain and discomfort. Nursing Care Requirements Supportive role and ensuring treatment compliance and regular follow up attendance. General nursing care and support for patient with cancer. Post Admission Care and Discharge Plan Long-term follow-up by ophthalmologist / oncologist to monitor progress. Early detection and treatment of other opportunistic infections. Patient should be commenced on long-term prophylactic treatment with cotrimoxazole. Social Services Support Patients should be encouraged to join AIDS support organisations as they may require long term social, educational and financial assistance. 13.5 Molluscum Contagiosum See Skin chapter- section 21.8.4.

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14.GASTROINTESTINAL MANIFESTATIONS Gastrointestinal (GI) and hepatobiliary symptoms are common in HIV/AIDS. They are often the initial AIDS defining illness. The use of aggressive antiretroviral regimens alters the nature of GI complications. The common GI symptoms are: intolerance to medications thrush diarrhoea (often chronic and associated with weight loss and

malnutrition) odynophagia and dysphagia abdominal pain jaundice anorectal disease

14.1 Important general principles The following general principles should be kept in mind when assessing and managing gastrointestinal problems in persons with HIV infection: Clinical signs and symptoms alone are rarely diagnostic. Multiple infections are common. The main objectives of management are to identify treatable

disorders and control symptoms The absence of a specific diagnosis after adequate evaluation is not

unusual. Less invasive diagnostic investigations should precede more invasive

procedures. Likely diagnoses can be predicted based upon the stage of HIV

disease in the patient.

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In the late stages of AIDS, GI manifestations are often part of systemic infection such as CMV infection or atypical mycobacteriosis.

Common GI neoplasms are lymphomas, Kaposi’s sarcoma and anal carcinoma.

14.2 Diarrhoea Diarrhoea is a very common symptom in persons with HIV infection and immunosuppression. A large number of pathogens may cause the problem. Tables 14.1 and 14.2 summarise some of these. Table 14.1 Causes of diarrhoea in persons with HIV infection Agent Course Clinical findings Diagnosis Salmonella spp Acute or

subacute Enteric fever, gastroenteritis Blood and stool culture

Shigella spp Acute Dysentery, fever, colitis Stool culture Campylobacter jejuni

Acute Watery stools, dysentery, fever, colitis

Stool culture

Clostridium difficile

Acute or chronic

Watery stools, abdominal pain, fever, colitis

C. difficile toxin

Small bowel overgrowth

Chronic Watery stools, malabsorption Small bowel aspirate for quantitative culture, hydrogen breath test

Mycobacterium avium

Chronic Watery diarrhoea, fever, abdominal pain, enteritis, hepatomegaly

Blood culture, small bowel biopsy, AFB stain

Cryptosporidia Acute or chronic

Profuse watery diarrhoea up to 20L/day

Oocytes in stool found on AFB stain

Cyclospora Chronic Watery diarrhoea Stool AFB stain for oocysts

Microsporidia Chronic Watery stools, fever, enteritis Trichrome stain of stool, small bowel biopsy

Isospora Chronic Watery stools Stool AFB stain for cysts Giardia lamblia Chronic Watery stools,

malabsorption, bloating, flatulence

Stool microscopy

Entamoeba histolytica

Subacute or chronic

Dysentery, fever, asymptomatic carriage

Stool microscopy, fresh stool, serologic tests

CMV Subacute or Watery stool, bloody, fever, Intestinal biopsy

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chronic abdominal pain, enteritis, colitis, colonic perforation

Enteric viruses Subacute or chronic

Watery stools, enteritis Major agents cannot be detected by clinical laboratories

Idiopathic Chronic Watery stools, malabsorption Intestinal biopsy, villous atrophy, decreased villus:crypt ratio

14.2 Causes of acute and chronic diarrhoea Causes of acute diarrhoea (usually less than 2 weeks duration)

Comments

Shigella spp Dysentery, abdominal cramps Salmonella spp Fever Campylobacter Fever, blood in stool Clostridium difficile Common after antibiotic use, especially ampicillin Enteric viruses Watery stools, may become chronic Staphylococcal Food poisoning Causes of chronic diarrhoea (usually more than 2 weeks duration)

Comments

Cryptosporidiosis Profuse watery diarrhoea, marked dehydration Isosporiasis Watery stools Microsporidiosis Watery stools, fever Giardiasis Bloating, flatulence Cyclosporiasis Watery stools Entamoeba histolytica Dysentery Cytomegalovirus Watery bloody stools, fever, abdominal pain, intestinal

perforation Mycobacterium avium complex Watery stools, fever, abdominal pain, hepatomegaly NOTE: Critical factors are the degree of immunosuppression, the CD4 cell count, history of recent antibiotic use, and establishing whether the diarrhoea is acute or chronic. Certain symptoms and signs may suggest a diagnosis: Upper or mid-abdominal cramps, bloating, and nausea suggest gastric

and/or small bowel involvement, consider MAC, Cryptosporidiosis or Isosporiasis.

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Severe watery diarrhoea, with dehydration and electrolyte disturbances and weight loss suggests intestinal cryptosporidiosis.

Haematochezia and lower abdominal cramps imply colonic infection, consider CMV, Clostridium difficile, Shigella, E. histolytica, or Campylobacter infection.

Tenesmus most frequently occurs in bacterial colitis. Weight loss accompanying chronic diarrhoea suggests an

opportunistic infection, e.g. giardiasis 14.2.1 Diagnosis Initial investigation should be stool examinations, i.e., microscopy,

culture and sensitivity, C. difficile toxin assay, and 3 stools for ova and parasites. An acid-fast smear should also be requested to look for Cryptosporidium, Isospora, and Cyclospora. Microsporidium can be diagnosed by trichrome staining of a stool specimen.

If stool results are negative, sigmoidoscopy with biopsy is often the first procedure.

Salmonella is the most frequent GIT bacterial pathogen in AIDS. C. difficile associated diarrhoea is common in patients receiving

antibiotics, especially ampicillin, clindamycin, or cephalosporins. If stool evaluations and sigmoidoscopy are non-diagnostic, consider

up to seven days trial of empiric antibiotics with a quinolone and metronidazole to treat possible small bowel overgrowth, culture-negative Campylobacter, Salmonella, Giardia, or C. difficile infection.

Indications for more vigorous investigation rather than empiric therapy are the presence of severe symptoms and associated fever or abdominal pain.

Endoscopy of upper and/or lower GIT may be necessary if the above are not helpful, but the investigations are often not available.

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Radiographic contrast studies generally are not useful in evaluating diarrhoea in these patients since most disorders require mucosal biopsy.

CT scan may show colitis caused by CMV or C. difficile, abdominal adenopathy, e.g., caused by lymphoma, MAC, TB, histoplasmosis, hepatic disease, or biliary tract disease.

14.2.2 Management Non-drug related treatment Most critical therapy is rehydration, preferably using oral solutions of water, salt, and sugar. Many proprietary fluids used for sweat replacement, diluted fruit juices and flavored soft drinks are suitable only if the individual is not severely ill. Intravenous fluids, e.g., Ringer’s lactate or normal saline, are necessary for severe dehydration or if the patient is vomiting or unable to take orally. Adequate nutrition is important although patients may be anorectic. Boiled starches and cereals (e.g., porridge, potatoes, noodles, rice, wheat, and oat) with salt are advised. Biscuits, bananas, yogurt, soup, and boiled vegetables also suitable. See Table 3.1 in nutritional chapter for appropriate dietary advice. Drug therapy If diarrhoea is acute, especially with fever or blood in stool or if stool examination shows blood or leucocytes: FIRST LINE Norfloxacin 400 mg PO BID 5 days ALTERNATIVE Chloramphenicol 500mg PO QDS 5 days If stool results are negative and no response to initial treatment

consider sigmoidoscopy with or without biopsy.

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If stool evaluations and sigmoidoscopy are non-diagnostic, consider up to seven days trial of empiric metronidazole to treat possible small bowel overgrowth, culture-negative Campylobacter, Salmonella, Giardia, or C. difficile infection.

If diarrhoea is chronic Consider up to seven days trial of empiric metronidazole to treat possible small bowel overgrowth, culture-negative Campylobacter, Giardia, or C. difficile infection. Use antimotility agents e.g. loperamide or diphenoxylate for the symptomatic treatment of diarrhoea (in the absence of fever or bloody stool). Loperamide is given in a dose of 4 mg initially, then 2 mg after each

unformed stool, not to exceed 16 mg/day. Diphenoxylate is given in a dose of 4 mg PO QID. Diphenoxylate has

central opiate effects and may cause cholinergic side effects. Oral fluids should be taken aggressively with antimotility agents. 14.3 Odynophagia and dysphagia The symptoms of odynophagia (pain on swallowing) and dysphagia (difficulty on swallowing) occur in more than a third of all persons with HIV infection. These symptoms are more common in persons in the advanced stages of AIDS and are uncommon while CD4 lymphocyte counts are more than 200/mm3. 14.3.1 Diagnosis The presence of oral thrush can be predictive of candidial oesophagitis. The commonest cause of dysphagia in HIV disease is candidiasis. In persons with odynophagia the patient is more likely to have ulcerative oesophagitis. Endoscopy with biopsy (for histology) is the only way to establish a specific aetiology for dysphagia and/or odynophagia. Barium swallow radiography is not recommended because of low sensitivity and specificity.

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14.3.2 Management Non-drug related treatment A soft diet may reduce symptoms of dysphagia Avoidance of drinks at the extremes of temperature for

odynophagia Drug therapy(See Fungal Opportunistic infection chapter) Empiric treatment with fluconazole 200mg daily for 14 days or

ketoconazole 200mg PO BID for 14 days. Improvement in symptoms may be expected in 7 days.

14.4 Abdominal pain The cause of abdominal pain in the majority of patients is directly related to HIV and its complications, but the more common causes of abdominal pain in the general population also need to be considered. 14.4.1 Diagnosis The history is important in localizing the origin of the abdominal

pain. Perforation of the distal small bowel or colon is most commonly caused by CMV and obstruction by tumors.

Infectious enteritis can produce dull, intermittent abdominal pain or acute pain in the absence of obstruction or perforation; diarrhoea usually accompanies the pain.

Pancreatitis is common in AIDS patients. It often occurs as a complication of anti-retroviral drugs ( e.g. didanosine), and less frequently it is part of primary HIV infection (CMV and, less often, mycobacteria, Cryptococcus, and herpes simplex). The presentation is similar to that in non-HIV patients.

The diagnostic workup of abdominal pain is the same as for a patient without AIDS:

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abdominal ultrasound scanning is useful early in the assessment of abdominal pain, and may detect disease not suspected clinically, e.g., gallbladder or colonic wall thickening, focal hepatic lesions, biliary ductal dilatation, pancreatic infiltration, abdominal adenopathy, peritoneal thickening.

Paracentesis is safe in ascites. Causes include spontaneous bacterial peritonitis, tuberculous or fungal peritonitis, and lymphoma. High-protein ascites of uncertain aetiology is recognised.

14.5 Evaluation of anorectal symptoms Anorectal diseases are common in heterosexuals with advanced AIDS and in the subset of AIDS patients who are homosexual or bisexual. The common lesions are perirectal abscesses, anal fistulae, nonspecific ulcerations and infectious proctitis. The commonest identifiable cause of ulcerations in late stage disease is HSV infection. Other causes include, lymphoma, CMV, tuberculosis, or histoplasmosis. NOT all HIV patients with ano-rectal pain have haemorrhoids. Ensure you LOOK and examine properly. 14.5.1 Diagnosis Weight loss, fever, fatigue, and night sweats suggest a neoplasm or

anorectal opportunistic infection. Herpes simplex infection involving the distal rectum can present with tenesmus, occasional bleeding, and, less commonly, with associated bladder or bowel dysfunction.

Visual inspection of the anus for fissures and masses should precede digital examination.

Presence of severe pain on rectal examination strongly suggests ulcerative disease, haemorrhoids or a neoplasm

All patients with anorectal symptoms should have proctoscopy and sigmoidoscopy (rigid or flexible) with mucosal biopsy

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Patients with tenesmus, rectal discharge and anorectal pain should in addition have evaluation of anorectal pus for PMNs, gram stain and culture for gonococci, chlamydia tests, Tzanck prep, and culture for HSV, and should have tests to rule out syphilis

14.5.2 Management Standard management according to the diagnosis.

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15. NEUROLOGICAL MANIFESTATIONS 15.1 Introduction In addition to being lymphotropic, HIV is a neurotropic virus as well. Invasion of the nervous system occurs soon after infection is acquired. HIV infected persons are prone to developing opportunistic infections, including infections affecting the nervous system, and are also prone to developing manifestations related to the effects of the virus on the central and peripheral nervous system. A large range of clinical neurologic syndromes may therefore occur in persons with HIV infection. Neurological symptoms are common in persons with HIV infection. It is therefore important for the care provider to carefully assess all patients with symptoms related to the nervous system. The health worker should determine when a symptom is serious and what to do about it. 15.2 Headache A common form of headache is the tension-type headache (TTH). This is very common in the general population, and even more common in persons with HIV infection. Serious causes can usually be excluded from the history. A few patients with headache should be referred for investigations and specialist management. An approach to the diagnosis and management of headache in persons with HIV infection is shown in section 15.2.1.

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15.2.1 Guidelines for the assessment of headache in persons with HIV infection

Take a history and examine the patient Urgent referral for

neurological examination and possibly lumbar puncture

If neck stiffness present give Benzyl penicillin and chloramphenicol intravenously before referral

YES

NO

YES

NO

Patient complains of headache

Urgent referral for neurological examination and possibly CT scan and Neurosurgical opinion

Manage as for PRIMARY headache

NO

Take appropriate history, examine and manage as for the other system disorder.

The headache is almost certainly SECONDARY to the other system disorder. YES

15.3 Confusion an Acute confusional eurgent treatment inintellectual (cognitivcauses of dementiadiagnostic plan for whom they know tosection 15.3.1. Thehome-based care s

Any of the following present: Confusion Altered level of consciousness Neck stiffness

Any of the following present: Focal weakness, numbness, paraesthesia, seizures, ataxia, tremors, other involuntary movements

Any of the following present: Fever, cough, rash, diarrhoea, vomiting, abdominal pain or distension

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15.3.1 Guidelines for the assessment of confusion in persons with HIV infection

Patient presents with confusion

Take a history and examine the patient Urgent transfer to secondary care (must be evaluated by a medical officer) Look for and manage the following appropriately:

Meningitis (stiff neck, fever, headache)

Pneumonia (rapid breathing, cough)

Septicaemia (low blood pressure, fever)

Alcohol or other drug intoxication/ side effect

Brain lesions (e.g. abscess) – focal neurological signs

No evidence for any of the above? Do: Lumbar puncture Malaria slide Blood count Blood culture Chest x-ray Serum biochemistry

Treat empirically as occult infection – Give Penicillin IV, and Chloramphenicol IV

Re-evaluate after 48 hours Review results of investigations Assess clinical progress Refer to next level if necessary for

further assessment and investigations

NO

NO

YES

YES

YES

Is the patient fully conscious all the time?

Confusion is of recent onset (less than 14 days)

Is there a history of Taking drugs that can cause confusion, anaemia, focal neurological signs, chronic meningitis, cardiac failure, uraemia, multiple CVAs, brain lesions

Give Vitamin B12 1mg IM Refer for home based care Review regularly

NO

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15.4 Weakness – focal or generalised Persons with HIV infection commonly complain of weakness, and the causes are often not related to the nervous system but other conditions (like chronic diarrhoea, anaemia or pulmonary tuberculosis) they suffer from. Focal weakness (like one arm and leg, or just the legs), or an abrupt onset, as well as accompanying sensory symptoms (numbness or parasthesiae) suggest a neurological cause, and are often best evaluated at a tertiary centre where imaging of the brain or spinal cord can be considered. A diagnostic plan for the assessment of HIV infected persons who present with weakness is shown in section 15.4.1.

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15.4.1 Guidelines for the assessment of weakness in persons with HIV infection

Patient complains of weakness

Take a history and examine the patient

Resuscitate and transfer urgently to a hospital with intensive care facilities

YES

NO

YES

NO Transfer to a secondary care centre. Look for: Stroke (if patient is

improving, no need to refer)

Postinfectious polyneuropathy (Guillain-Barre syndrome) – refer if patient cannot lift head, swallow, or cannot stand within 24 hours of onset)

Progressive focal deficit – needs imaging: refer

Paraplegia: urgent referral if less than 48 hours duration (exclude cord compression)

Uncertain diagnosis: refer to a tertiary centre

Does the patient have: Weakness in one arm and/or leg? Weakness only in the legs? Numbness or “chiwewe” as well as weakness? Any other neurological abnormality? (double vision, difficulty with speech or swallowing, incontinence[but not due to weakness])

Does the patient have: Altered level of consciousness Difficulty in breathing Signs of shock (very low blood pressure)?

Is there: Chronic diarrhoea? Chronic cough? Severe weight loss? Marked pallor (anaemia)? Chronic infection (PID, skin sepsis, osteomyelitis, etc.)? Another illness that could account for generalised weakness? Manage appropriately as for

underlying condition NO

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15.5 Peripheral paraesthesia (chiwewe) A burning sensation involving both feet is typical of the distal symmetrical polyneuropathy (DSP) seen in persons with HIV infection. Simple drug treatments may improve this symptom, but other causes of paraesthesiae need to be excluded. In section 15.5.1 a diagnostic and management plan for peripheral parasthesiae is given.

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15.5.1 Guidelines for the assessment of paraesthesia in persons with HIV infection

Patient complains of paraesthesia

Take a history and examine the patient

YES

NO

Needs neurological examination by a medical officer. Look for: Guillain-Barre syndrome (progressive

weakness, areflexia) Spinal cord disease (upper motor neurone

signs, sensory level) Mononeuropathy or monoradiculo- pathy

(distribution) e.g. zoster, carpal tunnel syndrome

Focal signs for intracranial lesion (hemisensory loss)

Manage appropriately

NO

YES NO

YES NO If on isoniazid: give pyridoxine 50mg If on other drugs: consider stopping

Probably DSP: Vitamin B12 1mg IM, one dose Aspirin 600mg TID for one week If no relief: amitriptyline 25mg nocte for one week If no relief: increased dose weekly to a maximum of

100mg nocte or intolerable side effects If no relief: refer to secondary care: trial of

carbamazepine up to 400mg TID or intolerable side effects

YES

Paraesthesia affects feet only?

Weakness, or other neurological signs ,or local rash present?

Less than 2 weeks duration

Receiving isoniazid, antiretrovirals, phenytoin, or chemotherapy

Involves hands and feet, one foot or one hand only, hands only, other body parts.

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15.6 Seizures (fits) Seizures occurring for the first time in persons with HIV infection should be investigated at a tertiary centre for a possible focal cause, if possible by CT head scan. Recurrent seizures, the first of which occurred more than six months prior to presentation, may be treated as epilepsy (see EDLIZ ). 15.7 Involuntary movements Involuntary movements of different types may occur in persons with HIV infection. It is important to identify the type of involuntary movement and to determine the nature of onset and progression. Involuntary movements include the following. Each symptom should be assessed carefully: Tremor – this may be intention, positional or at rest, and may be fine

or coarse, symmetrical or asymmetrical Chorea – this may be unilateral or bilateral, often it occurs in

association with dementia Dystonia – this may be focal (blepharospasm, torticollis) or

generalised Tardive dyskinesia - this may occur in association with

phenothiazines administration or may occur without a known precipitating factor

The differential diagnosis of causes is wide, and includes opportunistic infections as well as direct brain involvement by HIV. These patients are best assessed at a tertiary care level, for optimal management.

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15.8 Management of neurologic conditions in persons with HIV infection HIV is both a lymphotropic and a neurotropic virus. Effects on the nervous system by HIV infection may be through the direct effect of the virus on nerve cells and tissue or through the effect of opportunistic infections. Table 15.1 gives a summary of the neurologic manifestations of HIV infection. Table 15.1 Neurologic manifestations of HIV infection Directly HIV-related Seroconversion syndromes Cognitive impairment Neuropathy:

Distal symmetrical polyneuropathy Acute demyelinating polyneuropathy (Guillain Barre syndrome) Mononeuropathy Autonomic polyneuropathy

Myopathy (Polymyositis) Indirectly HIV-related Opportunistic infections:

Meningitis Toxoplasmosis Bacterial cerebral abscess Tuberculoma and spinal TB Transverse myelitis Radiculopathy (herpes zoster, CMV) Progressive multifocal leukoencephalopathy Pyomyositis

Malignancy (primary CNS lymphoma) Cerebrovascular disease Thromboembolic stroke Intracranial haemorrhage

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15.8.1 Management of directly HIV-related conditions 1. Neuropathy This is most commonly distal symmetrical polyneuropathy (DSP), presenting as “burning feet”. It is important to exclude drugs, such as isoniazid, anticonvulsants, antiretroviral agents and vitamin B12 deficiency as causes. If B12 level assay is not available, three doses of Vitamin B12, 1mg IM on successive days, are given. In the case of motor signs (any distal weakness out of proportion to the patient’s overall state of health), referral to a tertiary centre to exclude chronic inflammatory demyelinating polyneuropathy (CIDP), which responds to prednisolone, is indicated. Symptomatic treatment for pain is with amitriptyline, 25mg at night increasing in 25 mg steps every two weeks up to 100mg or until there is adequate pain relief. If pain persists on 100mg amitriptyline (or the dose is not tolerated), carbamazepine starting at 200 mg daily and increasing by 200mg per week to 400mg TID (if tolerated) may be added. If pain still persists on the above, oral morphine starting at 20mg qid should be substituted for the carbamazepine and doubled until there is adequate pain relief. 2. Polymyositis and acute polyneuropathy (Guillain-Barre syndrome) These conditions present in a similar fashion with progressive generalised weakness. Because of the risk of respiratory arrest, both should be managed in hospitals with facilities for intensive care (ventilation). The diagnosis is made by the presence of sensory signs, increased CSF protein and signs of demyelination on nerve conduction studies in the case of polyneuropathy; and by muscle tenderness, increased serum muscle enzymes and EMG as well as muscle biopsy changes in the case of polymyositis.

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Both conditions benefit from intensive physiotherapy support, to prevent complications and to increase the rate of recovery. Patients are often kept in hospital for this. 15.8.2 Management of Indirectly HIV-related conditions 1. Meningitis Table 15. 2 summarises the approach to the management of meningitis in HIV Infected individuals.

Table 15.2: Management of meningitis in HIV-infected individuals CSF findings Likely diagnosis Treatment WBC: < 50 (<10 polymorphs) Protein: <100 mg/dl Glucose: > 50% of blood glucose level

Possibly HIV infection only, without other cause of meningitis

Symptomatic

WBC: > 50 (more than 90% lymphocytes) Protein: normal or high Glucose: > 50% of blood glucose level

Most likely viral meningitis. Possibly: partially treated bacterial, cryptococcal or syphilitic meningitis, encephalitis, or seroconversion illness

Symptomatic. Observe in hospital. Repeat lumbar puncture if still symptomatic after one week

WBC: >50 (more than 90% lymphocytes) Protein: Normal or high Glucose: < 50% of blood glucose level

TB meningitis likely. Differential: includes bacterial, cryptococcal meningitis

Start Anti-TB drugs and prednisolone 40 mg daily for two weeks Repeat lumbar puncture after one week

WBC: > 50 (more than 10 polymorphs) Protein: normal or high Glucose normal or low

Bacterial meningitis. Differential includes TB, cryptococcal meningitis

Continue antibacterial drugs. Add anti-TB drugs if no better in 48 hours.

India ink stain shows cryptococci

Cryptococcal meningitis Amphotericin B and flucytosine or fluconazole if available (see Section 8.3) Otherwise symptomatic only: analgesia and terminal care

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2. Toxoplasmosis Fever and focal neurological signs are indications for referral to a central hospital and CT scan of the head. The differential diagnosis includes cerebral abscess, toxoplasma encephalitis, tuberculoma, and other parasitic infection. If a single focal contrast-enhancing lesion < 2cm in diameter or multiple lesions are present on scan and the patient is known to be HIV infected or is suspected to be HIV-infected on clinical grounds, start treatment for toxoplasmosis: Treatment of cerebral toxoplasmosis Drug Codes Adult dose Route Frequency Duration Pyrimethamine B E 50mg PO OD 6 weeks

AND Sulphadiazine S E 2g PO QID 6 weeks Clindamycin 600mg PO TID PLUS pyrimethamine 50mg PO OD OR

cotrimoxazole 1600mg/320mg PO TID may be used. Long-term chemoprophylaxis with cotrimoxazole should be given after the initial 6 weeks of treatment

If there is no response clinically and on CT scan in two weeks, or if the lesion appears atypical, consider neurosurgical intervention

3. Bacterial cerebral abscess When this diagnosis of cerebral abscess, is suspected - fever and focal neurological signs - referral to a central hospital and CT scan of the head are indicated. If a single, focal, contrast-enhancing lesion > 2cm in diameter is present on CT head scan, or an area suggestive of focal inflammation, start treatment as for bacterial meningitis and consider surgical drainage: Treatment of cerebral abscess Drug Codes Adult dose Route Frequency Duration BenzylPenicillin C V 5 million units IV QID 2 weeks

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AND Chloramphenicol B V 500mg IV QID 2 weeks

OR Ceftriaxone S N 1g IV BID 2 weeks

Joint neurosurgical and medical monitoring to react to complications (rising intracranial pressure, acute hydrocephalus) is essential.

4. Transverse myelitis If a patient develops rapidly progressive weakness of both legs, with or without involvement both arms, it is important to rule out spinal cord compression urgently, as surgical intervention within 24 hours of paraplegia may restore neurological function. The hallmark of a spinal cord lesion is a sensory level (loss of sensation below the distribution of a spinal segment, usually on the trunk). All patients with acute onset of bilateral leg weakness require referral to a tertiary centre for evaluation by physicians and/or neurosurgeons. If spinal cord compression has been excluded, usually by imaging techniques (myelogram or MRI), transverse myelitis is diagnosed clinically. Many different viruses (herpesviruses, CMV, echoviruses), as well as Cryptococcus neoformans and Toxoplasma gondii may cause transverse myelitis. Lumbar puncture is necessary to exclude treatable causes such as spinal meningitis (commonly tuberculous or cryptococcal), herpes zoster and toxoplasma. The nursing and rehabilitation management of patients with transverse myelitis depends on their neurological status. About one third remain paraplegic, and these need high levels of care, usually with a period of inpatient management in a rehabilitation unit. The remainder have varying levels of recovery, and benefit from close attention to prevent complications (pressure sores, urinary infections) while still symptomatic.

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16. NEUROPSYCHIATRIC MANIFESTATIONS Invasion of the central nervous system by HIV occurs soon after infection takes place. The management of neurologic manifestations of HIV infection is discussed in the previous chapter. In this chapter the neuropsychiatric manifestations are discussed. It is important that a holistic approach is followed when managing persons with HIV associated organic mental disorders (HIV-OMD). 16.1 General principles of management The following general principles should be kept in mind when managing HIV infected persons with OMD: Antipsychotic drugs usually tranquillize without impairing

consciousness and without causing paradoxical excitement. Chlorpromazine has pronounced sedative effects, moderate anticholinergic effects and extrapyramidal side effects. Trifluoperazine and haloperidol have fewer sedatives and anticholinergic effects, but more pronounced extrapyramidal effects. Prescribing of more than one antipsychotic or antidepressant drug for the same indication is not recommended.

Attempts should be made to involve the patient’s family, partner and close friends in the management of the patient. This helps everybody cope with the illness and with the impending loss of a friend or family member.

Educating the patient on the mode of transmission of HIV infection, natural history and complications of infection, safer sexual behaviour and practices, and treatment options, provides the patient with the opportunity to make informed decisions about their lives.

Confidentiality should be assured and maintained and stigmatization and discrimination should never be practiced.

Education of caregivers and group discussions among caregivers should be encouraged.

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Patients should be advised on leading healthy lifestyles, and on good and safe nutrition, taking adequate rest and exercise, and minimizing the use of alcohol and psychoactive substances.

16.2 HIV-negative worried well clients Often patients present as they are worried that they may have become infected. Such patients may have engaged in risky behaviour while others believe that they may have become infected through toilet seats, contact with a co-worker, or they are obsessed with the fact that they are infected. Such patients may have subjective mental slowing, forgetfulness, apathy, lethargy, social withdrawal, and personality change. A thorough psychiatric history and mental examination is needed to elicit any psychiatric disorder at this earlier stage or to rule out other physical conditions. The “worried well” may present with dysphoria, panic attacks, free-floating anxiety, phobic symptoms and hypochondriasis. The diagnosis may be: Panic Anxiety Disorder (PAD), Generalised Anxiety Disorder (GAD), Depression, Obsessive Compulsive Disorder (OCD), Hypochondriasis

16.3 Psychological reactions to knowing ones HIV-positive result Patients who have learnt that their blood test result for HIV infection is positive may react in a number of different ways: Denial and disbelief Hopelessness and uncertainty Intense anger Shame Guilt and blame

In addition they may develop symptoms and signs of anxiety, such as, palpitations, tremors of hands, restlessness, dyspnoea, sweating and fear,

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or depression, such as, depressed mood, fatigue, forgetfulness, loss of interest in daily activities and hopelessness, together with suicidal ideation, abandonment and social isolation. It is important to make a diagnosis and manage the patient accordingly. Usually many of these syndromes develop in patients who have not been subjected to thorough pre-test counseling. 16.3.1 Management Non-drug related treatment Psychotherapy and counseling is crucial at this stage. It can never be over-emphasised that all patients that are to be tested for HIV infection are adequately and professionally pre-test counseled. Patients should be reassured and made to understand the nature of the disease and its short and long term effects and the various different treatment options should be explained. Patients with marked symptoms and suicidal ideation will benefit from referral to a mental health worker.

Treatment of anxiety Drug Codes Adult dose Route Frequency Duration Lorazepam B E 1 – 2 mg PO At night 2 weeks

OR Oxazepam B E 15 – 30 mg PO At night 2 weeks All patients should also receive psychotherapy for impulse control Heavy sedation is not necessary Use for short-term only, i.e., less than 3 weeks

Alternative Treatment Alternative treatment of anxiety Drug Codes Adult dose Route Frequency Duration Amitryptiline B E 25 – 50 mg PO OD Long term

OR Imipramine A E 25 – 50 mg PO OD Long term

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Note: This is indicated only for long- term therapy

Treatment of depression Drug Codes Adult dose Route Frequency Duration Amitryptiline B E 25 – 50 mg PO OD Long term

OR Imipramine A E 25 – 50 mg PO OD Long term Note: The starting dose of antidepressants is 25 mg/day. The dose

for HIV-OMD should be about one quarter of that normally used in adults and the dosage should be raised in small increments every 2 to 3 days until a therapeutic effect is reached. Imipramine is indicated only when sedation is not needed.

Alternative treatment of depression Drug Codes Adult dose Route Frequency Duration Fluoxetine S N 10 – 20 mg PO OD Long term Note: Electroconvulsive therapy (ECT) should be considered if a

neurological examination confirms the absence of raised intracranial pressure or space-occupying lesions.

16.4 Psychotic symptoms in HIV-associated organic mental disorder Patients with HIV infection may present with a broad range of symptoms indicative of CNS involvement other than those that are caused by opportunistic infections. Patients may present with: • Mania: delusions of grandiosity elated mood, flight of ideas, pressure of

speech and inflated self esteem. • Schizophrenia: Delusion of persecution, blunted affect, incoherent

speech, bizarre behaviour (stripping naked in public, destruction of

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property), auditory/ visual hallucination, agitation, aggression and confusion

• Psychotic depression: Delusion and auditory hallucination i.e., depressed mood, insomnia, lack of concentration, fatigue and loss of interest in daily usual activities.

Patients should have biomedical investigations (e.g., FBC, serum electrolytes), social investigations (e.g., a social worker to visit the house and collect more information about the patient’s relationships) and psychological investigations (e.g., IQ). 16.4.1 Management Non-drug related treatment Psychotherapy and counseling is crucial at this stage. Patients should be reassured and the nature of the illness should be explained together with treatment options. The assistance of family members should be secured. Patients with marked symptoms need to be managed by specialists. Drug related treatment Treatment of organic mental disorder Drug Codes Adult dose Route Frequency Duration Chlorpromazine C V 25 – 100 mg PO OD Long term

OR Thioridazine B E 50 – 100 mg PO OD Long term

OR Haloperidol A V 1.5 to 3 mg PO OD Long term NOTE: Lower-potency neuroleptics may be more effective in

producing acute sedation and control grossly disorganized behaviour or to reduce delusions and hallucinations. The dose should start small and be increased gradually to avoid patient developing extrapyramidal effects and neuroleptic malignant syndrome. HIV-

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infected patients are particularly liable to develop adverse effects of the drugs. Therefore, both initial and maintenance dosages should be lower than usual.

Alternative Therapy Alternative treatment of depression Drug Codes Adult dose Route Frequency Duration Trifluoperazine A E 5 – 10 mg PO OD Long term

OR Lithium carbonate (for Mania)

S N 250 – 500mg PO OD Long term

OR Carbamazepine (for Mania)

S N 200 – 400mg PO OD Long term

Caution: Mood stabilizing drugs such as lithium carbonate require

monitoring through regular plasma drug levels. The level should be maintained at 0.6 - 1.2 mmol/L and thyroid function tests should be done initially.

16.5 AIDS dementia complex and HIV encephalopathy Patients with HIV encephalopathy and AIDS dementia present with a variety of mental symptoms. These include: Subtle mood and personality changes Poor concentration Disorientation and confusion Social withdrawal Psychomotor slowing, apathy and distractibility Memory impairment

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A progressive subcortical dementia, that is typical of AIDS encephalopathy, without focal neurological signs is the typical presentation. Investigations should include a CT scan of the brain, and social, psychiatric and biomedical investigations. As the dementia progresses, the patient may present with: muteness, incontinence of urine, seizures and coma, and death follows. 16.5.1 Management Drug related treatment Alternative treatment of ADC Drug Codes Adult dose Route Frequency Duration Haloperidol A V 5 – 10mg IM OD Starting dose

THEN Haloperidol A V 1.5 – 3mg PO OD Long term OR Chlorpromazine C V 25 – 50mg IM OD Starting dose Chlorpromazine C V 100 – 200mg PO OD Long term NOTE: Haloperidol 1,5 mg/day is used to control grossly

disorganized behaviour or to reduce delusions and hallucinations. This dose may be increased gradually to avoid the development of extrapyramidal effects and neuroleptic malignant syndrome. It is the best drug to treat a delirious patient.

Alternative treatment of depression Drug Codes Adult dose Route Frequency Duration Trifluoperazine A E 1 – 5 mg PO BID Long term

OR Sulpiride S E 100 – 200mg PO OD Long term

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NOTE: Avoid heavy sedation in a delirious patient. This will allow periodic assessment of the patient. Refer all delirious patients for specialist opinion. 16.6 Social Services Support Patient and their carers may need assistance from the AIDS levy and Social Welfare.

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17. HOME-BASED CARE AND CONTROL OF COMMON SYMPTOMS Control of symptoms at all stages of HIV/AIDS will improve quality of life. When treating symptomatically, always remember that opportunistic infections (OI’s) occur often and may need specific treatment. Refer to the relevant chapter. 17.1 Respiratory system It is important to identify the cause of the symptom and to treat it. The following sections describe the management of common symptoms related to the respiratory system. 17.1.1 Management of cough Dry cough Cough suppressant treatment - codeine 15 - 30mg four to six hourly, (codeine is a mild anti-tussive), or morphine start with 2.5 - 5mg 4 hourly and increase as necessary Bronchodilators – salbutamol, inhaled or nebulized, 5mg 4 hourly, oral 2 – 4mg tid, or steroids, prednisolone 30 – 40mg daily (also useful for bronchospasm) Non pharmacological methods eg. radiotherapy, pleural aspiration and pleurodesis Productive cough Mucolytics, such as, cough mixtures (eg. Flemex which contains carbocisteine 250mg/5ml, use 10 – 15 ml tid), or nebulized acetylcysteine to loosen tenacious sputum, or steam inhalation – loosens tenacious sputum, or nebulized saline – loosens tenacious sputum Hyoscine – dries secretions - 0.4mg im, 1.2 – 3.6mg sc/24hrs Antibiotics – if purulent sputum; use metronidazole for halitosis or foul-smelling sputum Diuretics – for heart failure

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Nursing Position which is most comfortable for the patient- often propped

up on 2-3 pillows in a semi-recumbent position Physiotherapy – gentle percussion, forced expirations, postural

drainage, breathing exercises Reassure, use a table fan, open windows and doors, discourage

smoking around the patient Refer patient if: Distressing cough continues Fever develops Haemoptysis is severe and persistent Distressing dyspnoea continues

17.1.2 Management of breathlessness Dyspnoea is extremely frightening and panic will worsen it (patients

imagine suffocating to death) – reassurance and explanation will help.

Morphine – start with 2.5 – 5 mg 4 hourly (or increase the dose currently used for pain.

Steroids – prednisolone 40 – 60mg daily reduces bronchospasm, peri-tumour oedema

Bronchodilators – nebulized salbutamol 2.5 – 5mg 4 hourly Anxiolytics – diazepam 2 – 10mg or lorazepam 0.5 - 1mg nocte, prn or

tid Oxygen – be careful of inducing oxygen dependence

Nursing care Reassurance and relaxation techniques

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Physiotherapy – breathing exercises Position which is most comfortable for the patient

17.1.3 Management of pleural effusion Asymptomatic No specific treatment

Symptomatic Analgesics for pain control Treatment for cough and breathlessness Aspirate for relief of breathlessness (1 – 1.5 L should be removed

and repeat as necessary) NB. Tapping may increase the rate of fluid accumulation. Consider pleurodesis with bleomycin for recurrent malignant

effusions (40 – 60mg in 100ml saline with 20ml 1% lignocaine after drainage to dryness)

17.1.4 Superior vena caval obstruction Radiotherapy with steroid cover Chemotherapy – for responsive tumours Dexamethasone 8 – 12mg daily (iv dexamethasone 20mg for

emergency treatment) Oxygen 100% - for emergency treatment Frusemide 40 – 80mg for emergency treatment

17.1.5 Haemoptysis Reassurance Radiotherapy controls haemopytsis in 90%

Transfusion if symptomatic anaemia develops

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17.1.6 Stridor Steroids dexamethasone 8 – 12mg daily, short course Local radiotherapy NB radiotherapy may worsen stridor initially as a result of tissue

oedema; use steroids or chemotherapy initially if possible Chemotherapy if sensitive tumour

17.1.7 Hiccups Identify and treat the cause if possible chlorpromazine 5 – 25mg tid prn (use syrup 50mg in 5ml) metoclopramide 10mg tid orally

17.2 Gastrointestinal system 17.2.1 Management of oral ulcers / sore mouth Refer to chapter on oral manifestations. Nursing care Instruct patient in oral care – use soft toothbrush, clean mouth with

dilute solution of salt or bicarbonate three or four times daily and at bedtime

Diet – soft diet, textured food, avoid very hot or cold or spicy foods

Dry mouth – suck on ice, pineapple or citrus fruit 17.2.2 Management of anorexia Treat the cause if possible; often secondary to intercurrent illness.

Altered taste sensation may be a problem

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Metoclopramide 10mg tid before meals Steroids – prednisolone 10 – 30mg daily for 1 – 2 weeks may help,

then withdraw Multivitamins may help use 1-2 tablets daily

Nursing care Eat small amounts frequently and when hungry Help patient to sit up at meal times and eat with others Eliminate odours Maintain fluid intake

Use food supplements if affordable (sip feeding 50-100ml hourly)17.2.3

17.2.3 Management of nausea and vomiting Many therapies may induce nausea. Identify the reason for nausea and treat the cause if possible. Anti-emetics – for prevention of nausea – use oral prochlorperazine

5 - 10mg tid, metoclopramide 10mg tid, cyclizine 50mg tid or haloperidol 1.5mg nocte. For established nausea, use im route eg. prochlorperazine 12.5mg or cyclizine 50mg or metoclopramide 10 mg, or rectal route eg. cyclizine suppositories 50mg tid if medication available and then convert to oral route, or SC infusion with a syringe driver eg metoclopramide 60mg per 24hrs, cyclizine 150mg per 24 hrs, or haloperidol 5mg per 24 hrs in frail patients. SC infusion may also be used for severe nausea and vomiting.

Steroids - consider use of dexamethasone – 4 to 8mg per 24hrs

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Nursing care Eat small amounts Choose foods that the patient likes Maintain fluid intake – sip cold clear liquids slowly and give oral

rehydration solution made up as follows: 750ml boiled cooled water, Plus 6 teaspoonfuls of sugar, Plus half teaspoonful salt

17.2.4 Diarrhoea Many cases of diarrhoea have a treatable cause. Refer to Chapter on GI manifestations of HIV disease Identify and treat cause. Remember that drugs can induce diarrhoea and that spurious diarrhoea may occur in persons with severe chronic constipation. Diarrhoea may be treated as follows: loperamide 2 – 4 mg qid, Or codeine 30mg tid to maximum dose of 60mg 4 hourly, And antibiotics if indicated morphine start with 5mg 4 hourly orally

Nursing care Encourage oral fluids and use oral rehydration solution Use cooked starchy food Careful care of perianal area to prevent skin problems – clean and

dry well after each bowel movement, sit in a bowl of warm, clean water, inspect area, water repellant cream locally

Refer patient if: Fever develops There is blood in the stool Vomiting develops as well as diarrhoea There is severe dehydration or low potassium If there is severe malnutrition

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17.2.5 Constipation Poor food and fluid intake and poor general health are common causes of constipation. Drugs such as codeine and opioids lead to constipation and when such drugs are used the patient may require concomitant use of laxatives unless the patient is already liable to diarrhoea. Constipation may be managed as follows: Liquid paraffin (softener) 10 – 15ml nocte Laxatives – bisacodyl (stimulant laxative) 2 - 4 tablets nocte Glycerine suppository – can be used with bisacodyl

Nursing care Ensure adequate fluid intake and correct dehydration Encourage a high fibre diet May need manual removal of stool May need enema

17.3 Genitourinary system 17.3.1 Urinary incontinence Look for a treatable cause eg. infection, urinary retention and correct this Nursing In males – use peniflow, skin care, eliminate odours (frequent

emptying of bag), catheterization In females, use of incontinence pads/sanitary towels,

catheterization General hygiene and instruct family about catheter care

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Very frail patients may need simple measures like a bottle/bedpan at the bedside

17.3.2 Urinary retention Identify and treat cause, the condition may be due to drugs such as, anticholinergic drugs, tricyclic antidepressants and occasionally opioids. Most patients will require catheterization initially. 17.3.3 Vaginal and urethral infections Identify cause if possible and treat according to guidelines given for the management of STIs. Nursing care Keep perineum clean with weak saline or bicarbonate solution Use natural yogurt on a sanitary pad to get rid of smell

17.4 Central nervous system 17.4.1 Insomnia Assess cause and treat appropriately, note that drugs may cause

insomnia Nitrazepam 2.5 – 5mg nocte or lorazepam 0.5 – 1mg nocte

(anxiolytic) Amitryptiline 25 – 50mg nocte (sedative anti-depressant) Chlorpromazine 25 - 50mg if intractable insomnia

Nursing care Often reassurance and talking to the patient helps

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17.4.2 Leg cramps Quinine 300mg nocte for up to 4 weeks Diazepam 5 – 10mg nocte prn

17.4.3 Confusion Identify and treat cause. Drugs often cause confusion. Therefore, remove the offending drug. Add a drug only if the patient needs calming or sedation and choose the drug according to the degree of sedation required. trifluoperazine 1 – 2mg tid haloperidol 1.5 mg bd chlorpromazine 25 – 50mg tid

Nursing care Keep the environment familiar Speak normally and in short simple sentences A clock and calendar may help orientation Ensure that patient is escorted wherever he/she goes Do not restrain physically

17.4.4 Depression See CHAPTER ON NEUROPSYCHIATRIC MANIFESTATIONS 17.4.5 Anxiety See CHAPTER ON NEUROPSYCHIATRIC MANIFESTATIONS 17.4.6 Weakness Identify cause and treat if feasible Always provide explanation and emotional support

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Provide occupational therapy Arrange for physiotherapy If severe anaemia, Hb < 6.0gm/L, give blood transfusion. Note that

transfusions only have a short-lived effect Multivitamins use 1- 2 tablets daily (?placebo effect) Steroids (eg dexamethasone 2 – 4mg daily) may improve well-being

rather than physical strength though there is a risk of proximal myopathy. Discuss with the doctor first.

17.5 Skin problems See SKIN CHAPTER 17.5.1 Itching Avoid scratching Keep skin cool and encourage clean, loose clothing Use petroleum jelly to prevent dryness Anti-pruritic drugs

17.5.2 Ulcers/wounds/tumours Clean with salt solution (1 teaspoon salt in 1L cool boiled water) or

betadine If infected, use icing/brown sugar paste on ulcerated areas and

tumours If smelly and infected, use metronidazole powder on ulcerated areas

or tumours Give antibiotics

17.6 The dying patient Most patients prefer to die at home.

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What to do: Prepare the family for death but do not predict an exact time Check that the family can cope with the dying patient at home and

refer to hospital if the family is unable to cope. If the patient wishes, he/she should be allowed to go to his/her

rural home in order to die there. Continue nursing care as appropriate. Counsel the family and the patient – this is a time to let go and to

say good-.bye 17.7 Bereavement, grief and loss The caring support of those willing to listen to their experience of grief is most important to the bereaved. When a terminal illness is diagnosed the family begins to grieve. While caring for the needs of the patient the carer has to think about a future after the person dies. This is called anticipatory grief and can be a confusing and difficult time. It is important that family members do not detach from the dying person before death occurs as this will result in abandonment and loss of care. It is useful when family members visit to remain with the patient as the disease progresses and death draws near. What to do: At the time of death allow family members to stay with the

deceased for a while. Do not refer to the deceased as “the body”, but by their name. If the family were not present at the death give as much detail as

possible. Involve children and allow them to express their feelings. Allow feelings, e.g. crying, shouting, wailing, both at the time of

death and later.

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Allow repetition of the story of the illness and death. Encourage the bereaved to talk about their experience.

Encourage family members to talk to each other and to share feelings, such as guilt, relief, pain or anger.

Listen rather than talk. Discourage a bereaved person from making big decisions, e.g. change

of job, home, town. Sometimes changes are a way of escaping from painful thoughts and feelings.

Be aware that your own grief may affect your communication with others.

Some practices and rituals can be helpful, e.g. the telling of the story many times to the mourners.

What not to do: Do not tell the person what they should do and what they should not

do. Do not say you know how the other person feels because every

experience is unique Do not tell your own experience. Do not make a bereaved person feel you are in a hurry. Avoid euphemisms e.g. “God only takes the best” or “time will heal”

as the bereaved do not find them useful. There is no specific time when grief should end. Each loss is different

and specific for the individuals concerned. See CHAPTER ON PSYCHOSOCIAL CARE AND SUPPORT

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18. PALLIATIVE CARE 18.1 Introduction Palliative care is a philosophy of care that combines a range of therapies with the aim of achieving the best quality of life for patients who are suffering from life threatening and ultimately incurable illness. Central to this philosophy is the belief that everyone has a right to be treated and to die with dignity and that the relief of pain – physical, emotional, spiritual and social - is essential to the process. In order to enhance quality of life all symptoms including pain need to be addressed. Palliative care ideally combines the professionalism of a multi-disciplinary team that includes the patient and his family. It should be provided both in hospitals and in the community – that is, there should be a continuum of care. This care should continue from diagnosis and throughout a patient’s illness and death and it should extend to the family during the period of bereavement. 18.2 Principles of palliative care The goal is the provision of the best possible quality of life. The principles include: Reinforcing life and accepting that dying is a normal process. Death is neither hastened nor postponed. Palliative care extends throughout an illness from diagnosis to

death. Normal medical treatment continues. Investigations are kept to a

minimum Providing a support system for the patient and for the family that is

easily applicable in a home care situation. Palliative care usually requires teamwork. Advance planning is preferable to crisis management.

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18.3 Classification of pain Pain may be nociceptive or non-nociceptive: Nociceptive – due to stimulation of pain receptors in afferent

nerves somatic – involving skin, soft tissue, muscle, and bone visceral – involving internal organs and hollow viscera

Non-nociceptive or neuropathic 18.4 Aetiology of pain in AIDS Pain in AIDS may be: related to the HIV/AIDS or to the consequences of

immunosuppression (45%) related to HIV/AIDS therapy (15-30%) unrelated to AIDS (25-40%)

Many patients have multiple sources of pain 18.5 Principles of management Pain is a dual phenomenon: perception of pain emotional response to pain

Optimal management requires a multi-disciplinary approach that depends on the patient’s pain threshold level: Factors that reduce threshold of pain: Insomnia, fatigue, fear of dying, anger, boredom, abandonment

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Factors that raise the threshold of pain Relief of pain and symptoms, sleep/adequate rest, sympathy,

reduction of anxiety, companionship, diversion 18.6 Categories of Pain physical psychological

o emotional o social o spiritual

18.6.1 Physical pain Physical pain in AIDS patients is a clinically significant problem. About two thirds of patients complain of pain at some time during their illness. Pain is invariably accompanied by other symptoms. Assessment Assess all patients for pain at every visit or contact

Diagnose the pain assess location (see diagram of body chart) severity (see pain scales) quality onset and duration timing alleviating and aggravating factors interference with daily life associated symptoms if possible determine the cause of the pain – for new pain and any

change in pain.

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Treat the pain With analgesics With adjuvant medication for specific problems With non-medical treatments

18.6.2 Psychological pain Mental/emotional pain This involves mostly symptoms of anxiety related to: Fear of pain and suffering Fear of death and dying Anger at the illness and the failure of treatment to cure it

Management Active counseling and /or appropriate referral for psychosocial support Social pain This involves dealing with loss: Loss of job and income Loss of position in the family Loss of effectiveness in the community, of status Loss of body image

Management Active counseling and/or appropriate referral for psychosocial support Spiritual pain This involves questioning the meaning of life and the significance of the illness.

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There may or may not be a religious dimension and this needs specific counseling and support. Active counseling is needed. 18.7 Analgesics Analgesics should be prescribed rationally. The main objective of analgesic therapy is to provide pain relief without producing unwanted side effects. It is important to adhere to the following principles in managing chronic pain: By the mouth Use oral medication where possible By the clock Give painkillers at fixed time intervals. The next dose should happen before the effect of the previous dose wears off.Use extra doses (50-100% of the four-hourly dose) if breakthrough pain occurs By the ladder (see Figure 18.1) Figure 18.1

Prog

ress

up

the l

adde

r as p

ain p

ersis

ts

or in

crea

ses

Non-opioids (paracetamol, ibuprofen or aspirin) Step 1

Add opioids for mild to moderate pain (codeine or dextropro-poxyphene) Step 2

Use opioid for moderate to severe pain – morphine, PLUS Non-opioids Step 3

Mild pain – non-opioid Moderate pain – weak opioid plus non-opioid &/or adjuvant Severe pain – strong opioid plus non-opioid &/or adjuvant

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Individualize treatment Titrate the dose against patient’s pain Teach the patient and the family how to administer the drugs Write out the drug regime in full or make a chart Link the first and last doses to waking and sleeping times

ANALGESIC USUAL STARTING DOSE RANGE SIDE-EFFECTS /

DISADVANTAGES Non-opioid Paracetamol 500mg – 1gm (1 –

2tabs) every 4 – 6 hrs

should not exceed 8 tablets in 24 hours

Opioids for mild to moderate pain+ Codeine 30 mg every 4 - 6

hours 30-60mg every 4-8 hrs

Constipation Cost

Dextropopoxyphene*

65mg 4 – 6 hrly 65 – 130mg every 4 hrs (1 – 2 tabs)

Drowsiness Ceiling dose

+Do not move from one weak opioid to another *Doxypol contains paracetamol 300mg and dextropopoxyphene 65mg per tablet Opioids for moderate to severe pain Morphine

5 – 10 mg every 4 hrs

according to need, no ceiling dose – increase dose by 50% in 24 hrs if not pain-free

Constipation

18.7.1 Side effects of morphine or other opioids Constipation Prevent by using regular laxatives routinely. Give liquid paraffin 15-45ml once or twice daily & stimulant laxative and increase fluids and bulk in diet. Nausea Prevent by using anti-emetics for 3-5 days. This occurs in approximately 30% of patients in the first three days.

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Respiratory depression Unlikely to occur if doses started at appropriate level. Caution with frail or dehydrated patients. Confusion/drowsiness Usually resolves within a few days of starting morphine. Can occur at the end of life with renal failure; reduce the dose. Itching This is usually temporary and responds to antihistamines. It is not necessarily an allergic reaction Sleepiness If persists two days after starting regular morphine reduce the dose Twitching Consider reducing the dose. This may indicate toxicity. 18.7.2 How to reduce morphine when cause of pain is controlled If only on for a short time: stop or rapidly reduce If on for longer than 3 weeks: reduce gradually to avoid withdrawal

symptoms 18.7.3 Routes of administration of morphine Morphine can be used by various routes: Oral Subcutaneous (using a syringe driver) Rectal (unreliable absorption) Intra-venous Intra-spinal Intra-muscular

Routes of administration most commonly used are oral, sub-cutaneous or intra-muscular. There are specific indications for using these alternative routes. Other opioids eg. Fentanyl can be used transdermally.

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18.7.4 Addiction, tolerance, dependence In practice tolerance seems not to occur. An increase in morphine requirement usually means increase in the tumour mass. Physical dependence does occur after 2-3 weeks of regular morphine administration; if it is possible to remove the cause of the pain, (as often occurs in AIDS patients) the patient can be weaned off the morphine. Psychological dependence (addiction) has not been observed to happen in cancer patients. 18.8 Adjuvant drugs (co-analgesics) These enhance analgesic efficacy of opioids, provide independent analgesia and treat concurrent symptoms that exacerbate pain. Non steroidal anti-inflammatory drugs (NSAID’s) – useful for bone,

joint and soft tissue pain. Use ibuprofen (200 – 400mg eight hourly) or aspirin (300 – 600mg 4 to 6 hourly). AIDS patients may have more toxicity from NSAID’s including gastric ulceration, renal impairment, liver dysfunction, bleeding as a result of inhibition of platelet function. Prophylaxis for NSAID related GI symptoms includes taking tablets with food or antacids.

Anti-depressants – used for neuropathic pain. Use low dose amitriptyline (12.5 - 25mg nocte), wait 2 weeks for response and then increase gradually to a maximum of 75mg nocte. Carbamazepine can be used (start with 200mg nocte and increase gradually to 200mg – 400mg bd, max dose 400mg tid) but with caution in AIDS patients who have low platelets; it is also more expensive than amitryptiline.

Antibiotics – for infection of soft tissues. Drugs most commonly used include chloramphenicol 500mg qid, metronidazole 400mg tid or cloxacillin 500mg qid.

Corticosteroids – used for raised intracranial pressure (dexamethasone 12mg daily in divided doses for a week), swelling

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around a tumour, nerve compression (8mg daily). Use prednisolone in equivalent doses if dexamethasone is not available (dexamethasone 1mg = prednisolone 7.5mg).

Diazepam – for muscle spasm. Use 5 - 20mg nocte. 18.9 Other modalities of treatment Radiotherapy – may be used to reduce bone pain, soft tissue pain,

cerebral metastases Chemotherapy may be used palliatively. Nerve blocks can be used for localized pain Surgical procedures may be helpful Hormone therapy is used in certain tumours

18.10 Non-pharmacological interventions Emotional support – listening, counseling, expressive therapies

support groups, relaxation techniques Physical methods – massage, exercise, touch, hot or cold

compresses, acupuncture. 18.11 Specific pain syndromes in HIV/AIDS patients oropharyngeal pain oesophageal pain abdominal pain biliary tract and pancreatic anorectal chest pain syndromes headache

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neuropathies arthritis and arthropathies myopathy and myositis

IMPORTANT POINTS:

Listen to the patient and answer questions honestly Do not be afraid to talk about dying and preparing for death. Every patient is different and has different coping mechanisms with illness and dying Don’t talk down to the patient, or treat them as if they were children Hope is an important part of living even when dying but it must be balanced against

reality. Hope can be re-defined e.g. for a pain-free existence as opposed to cure, and ultimately for a peaceful death.

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19. ORAL MANIFESTATIONS Oral lesions are among the earliest clinical indicators of HIV infection in both adults and children. Lesions are usually quite typical and a diagnosis may be made from their characteristic clinical appearance. Table 19.1 lists the lesions more commonly encountered in adults and children with HIV infection.

Table 19.1 Oral lesions that occur more frequently in adults and children with HIV infection Candidiasis - including pseudomembranous, erythematous or hyperplastic

candidiasis or angular cheilitis Hairy leukoplakia Herpes simplex virus infection Herpes zoster virus infection Molluscum contagiosum Kaposi’s sarcoma Gingival and periodontal lesions - including linear gingival erythema,

necrotising ulcerative gingivitis, necrotising ulcerative periodontitis, necrotising stomatitis

Salivary gland disease – including parotid gland enlargement and lymphoepithelial cysts

Dental caries Submandibular, submental and cervical lymphadenopathy Cancrum oris Non-Hodgkins lymphoma

19.1 Candidiasis Candidiasis is strongly associated with immunosuppression. The clinical presentation varies considerably:

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Pseudomembranous candidiasis This is commonly known as thrush. Lesions may be located anywhere in the oral cavity including the palate, dorsum of tongue and cheek buccal mucosa. Lesions are creamy white or yellow loosely adherent plaques that are removable and can be wiped off leaving a reddened or occasionally bleeding surface. The condition may persist for months. Erythematous candidiasis This form appears as red areas and patches or spots that are not removable or as white spots or plaques that are adherent to the dorsum of tongue. Lesions can be interspersed with pseudomembranous candidiasis. Angular cheilitis This conditions appears as fissures and reddening at the angles of the mouth. It is often associated with itching and burning. Often there is bleeding from the angles of the mouth and crusting in this area. Hyperplastic candidiasis This appears as raised, firm, adherent and unscrapable white plaques on the buccal mucosa that appears thick red. 19.1.2 Management The following treatment is recommended for oral candidiasis: Treatment of oral candidiasis Drug Codes Adult dose Route Frequency Duration Nystatin oral suspension

B E 200000 units

PO Five times a day

14 days

OR Nystatin lozenges B E 200000

units Sucked Five times

a day 14 days

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In severe cases or if the above treatment fails the following regimens may be used:

Alternate treatment of oral candidiasis Drug Codes Adult dose Route Frequency Duration Miconazole oral gel 2% B N Applied to

mouth BID 10 days

OR Ketoconazole B E 200mg PO OD 7 days

OR Amphotericin B lozenges A N 10mg Sucked QID 10 days

OR Fluconazole B N 100mg PO OD 7 days

OR Itraconazole S N 200mg PO OD 7 days

19.2 Kaposi’s sarcoma Lesions of Kaposi’s sarcoma in the mouth appear as red, blue or purplish flat or raised, solitary or multiple plaques or nodules and may be found anywhere on the buccal mucosa. Common lesions are seen on the palate, gingiva, tongue and buccal mucosa. 19.2.1 Management Treatment needs to be individualized and will depend on the number, size and location of lesions. Good oral hygiene should be practiced by the patient and radiotherapy, cytotoxic chemotherapy and surgical excision may be necessary. See CANCER CHAPTER 19.3 Oral ulceration Oral ulcers are commonly encountered in persons with HIV infection. There are a number of different causes of such ulcers. Ulcers may vary in size from 1mm to more than 2cm in diameter. Usually oral ulcers are painful and if extensive may affect chewing and deglutition. The ulcers are similar to

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apthous ulcers and usually have a red base that is covered in purulent material. 19.3.1 Management The following principles should be followed when managing oral ulcers in persons with HIV infection: Pain reduction through appropriate use of analgesics Reduction of ulcer duration Increasing disease-free intervals Performing a biopsy to exclude malignancy in large suspicious ulcers

Patients with oral ulcers should be treated as follows 0,2 % chlorhexidine digluconate mouth rinse 2-4 times daily, and 1% topical povidone iodine applications, and Topical applications of triamcinolone acetonide in orabase 00.1% 8

hourly, and Topical antibiotic application as mouthwash using doxcycline 100mg

three times daily for 3 days 19.4 Periodontal (gum) diseases Gum disease occurs commonly in persons who do not practice good oral hygiene. Many different forms of gum disease have been reported in persons with HIV infection. These are described below: 19.4.1 Necrotizing ulcerative gingivitis This is usually of sudden onset when the patient notices spontaneous bleeding from the gums. The gingival tissue becomes red, inflamed and oedematous. There is rapid loss of soft tissue and ulcers appear at the tips of the interdental papilla and gingival margins. The condition is associated with severe pain. Ulcers heal with crater formation.

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Management Oral hygiene is necessary with tooth brushing, flossing and rinsing

with 0.2% chlorhexidine gluconate 2-4 times daily, Plus Scaling and local debridement, Plus Topical 1% povidine-iodine irrigation Mobile teeth may need to be splinted or extracted

19.4.2 Necrotizing ulcerative periodontitis (NUP) There is rapid loss of supporting bone and soft tissue in isolated areas with loosening and loss of teeth and there is severe pain and spontaneous bleeding with sequestration of bone and halitosis. Management Oral hygiene (as above), Plus Plaque removal, Plus Local debridement, Plus Irrigation with povidone iodine, Plus Scaling and polishing, Plus Metronidazole 200mg three times daily for 5 days, Plus Amoxycillin 500mg three times daily for 5 days

19.4.3 Necrotizing Stomatitis This condition extends from the gingival and involves the buccal mucosa. Management Oral hygiene, Plus Local debridement, Plus Removal of tooth and sequestra, Plus Metronidazole 200mg three times daily for 5 days, Plus

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Amoxycillin 500mg three times daily for 5 days 19.4.4 Linear gingival erythema This appears as a fiery red gingival line 2-3mm broad along the teeth margins and is often associated with petechiae-like lesions and diffuse red lesions on the attached gingiva or oral mucosa. Plaque may be present Management Oral hygiene is necessary with tooth brushing, flossing and rinsing

with 0.2% chlorhexidine gluconate 2-4 times daily. 19.4.5 Cancrum Oris This is an extension of necrotizing stomatitis and is associated with necrosis and sequestration of bone. Teeth become loose and may exfoliate. There is usually loss of soft tissue and bone. Management Oral hygiene, Plus Debridement, Plus Sequestrectomy, Plus Metronidazole 200mg three times daily for 5 days, Plus Amoxycillin 500mg three times daily for 5 days, Plus Fluid and electrolyte replacement, Plus Improvement of general nutrition, Plus Surgical reconstruction later

19.5 Non-Hodgkin’s lymphoma This may occur anywhere in the oral cavity. The condition presents as firm, painless swelling son the mucous membrane of the mouth. Lesions may be ulcerated or fungating and there may be bone destruction.

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Management A biopsy should be performed to confirm the diagnosis and surgical

remove should be carried out. Patients with lymphoma will require chemotherapy or radiotherapy.

19.6 Salivary gland disease 19.6.1 Parotid gland enlargement Painless, diffuse soft swelling of one or both parotid glands is a fairly common manifestation of HIV infection especially in children. Patients usually complain of noticing swelling of the face and a feeling of dry mouth. Management For dry mouth give: salivary substitutes, moisturizing or lubricating

solutions or artificial saliva. Glycerin may be useful in alleviating symptoms. Stimulation of salivary flow with sugarless chewing gum may also be useful.

Topical fluoride applications to teeth should be practiced daily to prevent tooth decay.

Thorough oral hygiene and dietary control should be practiced to avoid caries

If there is parotitis appropriate antibiotics and analgesics may be used.

19.6.2 Lymphoepithelial cyst This appears as a painless swelling in the parotid gland or submandibular gland area. It comprises of an accumulation of cysts and is unsightly. Management Surgical excision for cosmetic purposes.

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19.7 Caries There is multiple decay on tooth surfaces and necks of teeth Management Thorough oral hygiene is necessary: tooth brushing with a

toothpaste with fluoride, flossing of teeth and use of topical varnish, gels or rinses.

Dietary control is essential - Limit sugar and sugary foods. Note that due to high sugar content of some medications, topical fluoride gels or rinses should be used daily, if frequently prescribed.

Regular dental check-ups are essential to maintain healthy teeth and gums.

19.8 Hairy leukoplakia Oral hairy leukoplakia occurs in HIV-infected patients as well as in some immunosuppressed transplant recipients. It presents as raised, white, corrugated lesions of the oral mucosa, especially on the lateral aspect of the tongue. It is a non-malignant lesion of epithelial cells. It is commonly mistaken for oral candidiasis with which it is commonly found. Management No specific treatment is available for the condition. Good oral hygiene Anti-retroviral therapy may clear the lesion

19.8 Herpes zoster The herpes virus, varicella zoster, often causes disseminated infection after initial exposure. In children initial infection results in the development of chicken pox, though most persons that become infected develop no symptoms and signs of infection. Skin and oral lesions may occur. On the face, zoster lesions are unilateral and follow the distribution of the maxillary mandibular branches of the trigeminal nerve.

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Management Acyclovir 800 mg oral 5 times daily to 14days; or Valacyclovir 1000 mg oral 8 hourly for 7 days; or Famciclovir 250 mg 8 hourly for 7 days Post-herpetic neuralgia is a common and serious debilitating

problem. It causes severe pain in a dermatomal distribution usually at the site of the lesions. Pain control is often necessary and be achieved with mild analgesics such as paracetamol. If pain control is not achieved with this then non-steroidal anti-inflammatory drugs may be used or failing this amitryptiline, cabamazepine or phenytoin may be tried.

19.9 Herpes simplex Lesions of herpes simplex may be found on gums, hard palate and lips. Lesions appear as vesicles that rupture to produce painful irregular ulcers. Often the patient has fever and malaise. Oral lesions are often associated with cervical lymphadenitis. Management Usually no specific treatment is necessary. If lesions are extensive,

recurrent and persistent antiviral therapy should be commenced. Antibiotics may be necessary if there is secondary bacterial infection.

Patient should be rehydrated if dehydrated and advised on good nutrition.

The patient may need analgesics and the application of 2% viscous lidocaine gel every 3-4 hours is useful.

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20. HIV-RELATED MALIGNANCIES 20.1 Kaposi’s sarcoma Kaposi’s sarcoma is the most common tumour that occurs in HIV positive patients. Four clinical variants are described: Classical/Sporadic/Mediterranean Endemic African Organ transplant associated immunosuppression Epidemic (AIDS-related)

All varieties are associated with infection with Kaposi’s sarcoma-related herpes virus (KSHV) or human herpes virus type 8 (HHV-8) 20.1.1 Diagnosis Diagnosis is clinical with recognition of typical mucocutaneous lesions. A biopsy is necessary to confirm the presence of disease histologically. Lesions occur on the limbs (lower more often than upper), face (often on the nose), trunk and genitalia. Lymph nodes may be enlarged. The palate and oropharyngeal mucosa are often affected. Lesions are not usually painful or itchy. They range from hyperpigmented (reddish purple) macules to papules (several millimeters to several centimeters diameter) and may be plaque like or nodular/exophytic. Lymphoedema occurs as a result of lymphatic obstruction. 20.1.2 Staging It is useful to stage patients. Most patients in Zimbabwe present with advanced (Clinical stage 3 or 4) disease. Kaposi’s sarcoma is classified clinically as follows: Stage 1 – localized indolent cutaneous lesion Stage 2 – localized aggressive cutaneous lesion with regional lymph

nodes

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Stage 3 – multiple generalised cutaneous lesions or generalized lymph node involvement

Stage 4 – palatal or visceral disease A = without systemic symptoms B = with systemic symptoms of weight loss>10% body mass, drenching night sweats, intermittent fevers 20.1.3 Investigations Prior to commencing treatment for Kaposi’s sarcoma the diagnosis should be established by histological examination of tissue biopsies. In addition it is necessary to perform a chest x-ray and to determine the HIV status of the patient. A full blood count, blood urea and electrolyte levels and liver function tests should be measured. If possible the peripheral blood CD4+ lymphocyte counts and the HIV plasma viral load should also be measured. Depending on the extent of disease and symptoms a bronchoscopy or endoscopy may be indicated. 20.1.4 Treatment There is no known cure for KS. The goals of treatment are to: Alleviate symptoms Reduce the tumour mass Reduce oedema Prevent disease progression

Non-drug related treatment The following may be useful for lymphoedema: Elevation of the limb Multilayer bandaging Compression stockings Manual lymphatic drainage (massage)

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Exercise Radiation therapy Radiotherapy is used to palliate for pain, fungating disease and for cosmesis. KS lesions are very radiosensitive and 90% or more of the lesions will respond to treatment. Most of the lesions are superficial hence superficial X-rays and electron beams are suitable for these lesions. Where there is severe oedema or visceral disease mega voltage treatment is used with parallel opposing portal employed. Most lesions will respond to 800cGy as a single fraction. Lesions on more sensitive areas eg. the mouth will require more protracted fractionation regimes to minimize side effects. Total doses of 20 Gy in 10 fractions are employed to areas such as hands, genitalia and the conjunctiva. Alternative dose schedules are 14 Gy in 4 fractions on alternate days and 30 Gy in 10 fractions in 2 weeks. There is a dose-response relationship for these tumours with better control if higher doses are used. The choice of dose will depend on the length of survival expected. In extensive disease lower hemi-body RT (800 cGy single fraction) and/or upper hemi-body RT (600 cGy single fraction) can be used. Other field arrangements are determined by the extent of the disease. Drug related treatment Antiretroviral therapy Highly active antiretroviral therapy should also be used to treat patients with KS. Chemotherapy The tumour usually responds to cytotoxic chemotherapy. However this form of treatment further suppresses the immunity in persons with AIDS. It is important to individualise treatment in each case and monitor treatment benefits and side effects. The following cytotoxic agents have been used with beneficial effects in persons with Kaposi’s sarcoma:

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Combination of bleomycin and vincristine: Bleomycin 15mg/m2 and vincristine 1.4mg/m2 (maximum of 2mg) given every 4 weeks as an IV pulse for 4 to 6 months

Actinomycin D is sometimes added to the above regime or used alone in children 15µgm/kg IV given daily for 5 days (maximum 500µgm per day) given for 5 days each month for 4 to 6 months

Etoposide 150 to 200mg orally daily for five days, given as monthly 5-day pulses for 4 to 6 months

Liposomal daunorubicin is first line chemotherapy where it is affordable; paclitaxel is used as second line chemotherapy.

Topical (intralesional) chemotherapy Topical treatment with intralesional vinblastine or 9 cis-retinoic acid is used for scanty lesions. Dose of vinblastine is 0.2 to 0.3mg/ml solution, use 0.1ml per 0.5cm2 of lesion. Topical cryotherapy and laser therapy Ablation of localized lesions by cryotherapy and laser therapy has been successful in endemic disease and depending on the extent of the disease may be useful in persons with epidemic disease as well. NOTE: most patients present with multifocal lesions and a large tumour burden, thus local therapy of individual lesions is impractical except in extremely rare situations Other modalities of treatment Angiotensin inhibitors e.g. thalidomide have been used. There is

little evidence to support their routine use. Biological response modifiers e.g. interferon-α may be used HCG and Vitamin D have been used but the evidence for their

efficacy is poor Future routes – targeted treatment of the KSHV (HHV8) infection

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20.1.5 Symptom control / nursing care Symptoms of pain, cough and dyspnoea are frequent and require treatment. Fungating lesions may require additional nursing and antibiotic usage. Opportunistic infections must be treated. 20.1.6 Counseling Counseling is required with regard to the HIV infection as well as the cancer. Palliative care should begin with diagnosis and issues relating to the end of life should be discussed with the patient and his/her family before the patient is terminally ill. 20.1.7 Social services support The vast majority of patients with KS present with advanced disease and are no longer able to work. It should be policy that all patients with AIDS-KS receive support from the AIDS levy as well as free treatment. 20.2 Cervical cancer Cervical cancer may be the first indication of HIV infection. Pre-malignant lesions also known as squamous intraepithelial lesions (SILs) are frequently found in association with HIV infection. They may also be associated with a higher incidence of invasive lesions. Both pre-malignant and invasive lesions are associated with the human papilloma virus (HPV) of subtypes such as 16, 18, 31, 33 and 35. 20.2.1 Screening and diagnosis Due to the asymptomatic nature of the early pre-invasive and early invasive lesions, screening of women at risk for HIV infection must be undertaken. HIV-positive women must have pelvic examination and cytological screening every six months. Those women found to have SIL will need close monitoring through repeat colposcopy. The diagnosis of pre-invasive lesions is made from cervical cytology. Invasive lesions are usually symptomatic and clinically palpable on digital

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vaginal examination. Examination under anesthesia, biopsy and histological confirmation is necessary wherever possible. 20.2.2 Staging A number of staging systems exist, including the FIGO and the TNM systems. 20.2.3 Investigations Women with invasive cervical cancer need complete staging and the following should be done: Pelvic examination Full blood count Urea and electrolytes Liver function tests CD4 lymphocyte count and viral load Chest X-ray IVU Lymphangiography may be useful to outline nodal disease CT abdomen and pelvis

20.2.4 Treatment Non-drug related In pre-invasive disease the following can be used: Cryotherapy Laser therapy Cone biopsy Loop electrosurgical excision procedure (LEEP)

Recurrence rates of 40-60% have been seen.

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For invasive disease surgery can be performed for the same indications as in the HIV-negative individual as follows: Stage 1A1 – Simple hysterectomy, cone biopsy Stage 1A2, 1B1 and non-bulky 11A – Radical hysterectomy Stage 1B2 and bulky 11A –may consider adjuvant extrafascial

hysterectomy where available following chemo radiation. Radiation therapy Most patients with invasive disease will need radiotherapy as treatment due to the advanced nature of the lesions. This treatment is now mostly given concurrently with cisplatin-based chemotherapy (chemo radiation) and response rates are similar to the non-HIV infected. Intracavitary brachytherapy treatment and external beam radiotherapy are both used except in the very ill patient or very advanced disease (stage 1V) when only external beam treatment is used. Radical doses for external beam therapy are typically 40 - 50 Gy in 20 -25 fractions in 4 to 5 weeks. Intracavitary therapy is also given and doses of 21 – 25 Gy to point A in 3 –5 fractions of high dose rate brachytherapy are employed. Palliative RT can be given to pelvic disease, bone and soft-tissue metastases, para-aortic and other nodal metastases. Typical doses would be 30 Gy in 10 fractions in 2 weeks or 45 Gy in 25 fractions in 5 weeks in the case of para-aortic lymph node RT. 20.2.5 Drug related treatment Antiretroviral therapy Antiretroviral drugs should be used as well as any other drugs needed to treat other co-existing HIV related illnesses. Chemotherapy Cisplatin has been used with varying degrees of success in persons with invasive cancer of the cervix. This is usually given together with radiotherapy

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(chemo-radiation). Response rates to chemo-radiation are similar in HIV-infected and in non-HIV-infected persons. Chemotherapy is used as part of chemo-radiation or on its own for palliation of symptoms in recurrent or metastatic disease. Cisplatin is the drug of choice and can be used as a single agent or in combination with other drugs such as bleomycin, 5-fluorouracil and vincristine. The usual dose of cisplatin is 50 mg/m2. Where renal impairment is present, carboplatin can be used instead. 20.2.6 Nursing care Meticulous management of the side effects of these treatments should be carried out. Symptomatic management of pain, nausea, diarrhoea and vomiting should be given. Special nursing care may be needed for the patient with incontinence from fistulae. 20.2.7 Counseling Pre and post-test counseling for HIV testing is necessary. Death and dying issues must be discussed at family level. Preparation for events such as loss of hair during treatment should

be made. The possibility of sexual dysfunction and reproductive failure following treatment must be explained.

Counseling is required with regard to the HIV infection as well as the cancer. Palliative care should begin with diagnosis and issues relating to the end of life should be discussed with the patient and his/her family before the patient is terminally ill.

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20.2.8 Post Admission care Care for the skin following protracted radiotherapy should be well explained to avoid moist desquamation. 20.2.9 Social Services Support Most of the patients with cervical cancer have young families whom they support whilst the husbands work in town. Provision for family support during the time that they are attending treatment and in the event of disability and bereavement should be given. 20.3 Non-Hodgkins lymphoma (NHL) The incidence of NHL is 60 times higher in individuals with HIV infection than in the general population. HIV related NHL is a result of continuous stimulation of B-cell proliferation by HIV, Epstein-Barr virus (EBV) and other infections. Over 95% of HIV related NHL tumours are of B-cell origin. They are usually of the high-grade type. NHL occurs in 10 to 15% of HIV infected patients. NHL is a more aggressive and a more malignant tumour in HIV-infected persons. The nodal form is mainly found in the neck region. Extranodal sites include the oral cavity, the sinonasal regions and the pharynx and larynx. Clinically, presentation is usually with a nodal mass or masses. Extra-nodal presentation is also common and symptoms will vary according to the site of disease. B symptoms (fever, weight loss, night sweats) are also common but other opportunistic infections must be excluded before labeling these as such. The Ann Arbor classification system of staging is used. 20.3.1 Diagnosis The diagnosis is made by histological examination of biopsied tissue and fine needle aspiration. CT scan and MRI scans of other regions like the brain, head, neck, mediastinum or abdomen because need to be performed

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in order to assess the extent of the tumour as management and prognosis depend on the extent of the disease. Bone scan and bone marrow biopsy are useful for staging purposes. An examination of the cerebrospinal fluid is necessary to exclude asymptomatic leptomeningeal lymphoma, which occurs in as many as 60% of cases. 20.3.2 Investigations Full blood count Urea and electrolytes Liver function tests/LDH CD4 lymphocyte count and viral load. CT neck/chest/abdomen/pelvis. Other sites e.g. brain if indicated Bone marrow aspiration and trephine Spinal fluid analysis

20.3.3 Management Non-drug related treatment Counseling and education is important There is no specific role of surgery in the treatment of NHL other than biopsy for confirmation of the diagnosis. Radiation therapy In systemic lymphoma radiotherapy is limited to the consolidation of the effects of chemotherapy. The principles remain similar to those used for the non-HIV infected patient and involved fields or extended fields are used as appropriate. Radiotherapy is the main treatment for primary CNS lymphomas. Fractionated doses of 40 to45 Gy in 20-25 fractions in 4-5 weeks are commonly used to control deposits at various sites. An additional boost to residual disease of 5-10 Gy in 3-5 fractions may be given to patients with a high performance status.

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If the prognosis is poor e.g. in lymphomatous meningitis, 30 Gy in 10 fractions in 2 weeks would be best to shorten the treatments whilst giving sufficient palliation. Radiotherapy can be used as CNS prophylaxis in cases with marrow involvement and 24Gy is given in 12 fractions in two and a half weeks. If there is known CNS involvement then a minimum of 40Gy is given at conventional fractionation. Drug related treatment Antiretroviral therapy Antiretroviral drugs should be used as well as any other drugs needed to treat other co-existing HIV related illnesses. Chemotherapy Chemotherapy is the mainstay of treatment since dissemination of disease in the NHL patient with HIV infection is more likely and should be assumed. It is best to use low dose or standard dose regimens in these patients. Performance status and a CD4 count cut-off point of 100 cells /mm3 should be a guideline on whether low or standard doses should be used. In the absence of B symptoms standard doses are indicated if the CD4 count is above 100/mm3 and the disease stage is I or II. The total number of cycles given is usually determined by the side effect profile in these patients. The CHOP regime is commonly used at standard or reduced dosage and 4-6 cycles can be given. The standard dose regime is as follows: Cyclophosphamide 750mg/m2 IV day 1, doxorubicin 50mg/m2 IV day 1, Vincristine 1.4mg/m2 (max. 2mg) IV day 1 and prednisolone 60mg orally day 1-5 in divided doses. The m-BACOD regime has also been shown to be effective in these patients and the low dose regimen is as follows: Bleomycin 4mg/m2 IV day 1, doxorubicin 25mg/m2 IV day 1, cyclophosphamide 300mg/m2 Iv day 1, vincristine 1.4mg/m2 (max. 2mg) IV day 1, dexamethasone 3mg/m2 orally days 1-5, methotrexate 200mg/m2 IV day 15 with folinic acid rescue of 25mg every 6hours for 4days orally, beginning 6hours after completion of methotrexate. The CEOP regimen is a modification of CHOP where doxorubicin is replaced with epirubicin whilst achieving the same results. CDE is also nearly as effective as the above regimens and is given as follows:

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Cyclophosphamide 800mg/m2 IV/96 hrs, doxorubicin 50mg/m2 IV/96 hrs and etoposide 240mg/m2 IV/96 hrs. Growth factor support to reduce the myelosupppression that inevitably results is essential. Patient tolerance is greatly enhanced with the use of a myeloid hematopoietic growth factor. Salvage chemotherapy usually has no usefulness. For intracranial lymphoma, cranial radiation together with cytotoxic chemotherapy and steroids are advised. Nursing care requirements Vigorous management of nausea and vomiting is necessary to avoid nutritional deterioration. Moist desquamation is more likely to occur as a side effect of radiotherapy in these patients. Clear instructions on skin care are to be given. Other opportunistic infections must be appropriately treated. Counseling Pre and post-test counseling for HIV testing is necessary. Death and dying issues must be discussed at family level. Preparation for events such as loss of hair during treatment should be made. Social services support With the high cost of chemotherapy drugs, financial support from organizations such as the National AIDS Council is recommended. 20.4 Ocular Surface Squamous Neoplasias SEE CHAPTER ON OCULAR MANIFESTATIONS A strong association has been noted between HIV infection and ocular surface squamous neoplasia. There has been a marked increase in the incidence of this cancer over the last 10 years in Zimbabwe. The exact aetiology is not known but it has been suggested that the cancer may be associated with human papilloma virus infection.

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20.4.1 Diagnosis Ocular surface squamous neoplasia appear as persistent, progressively enlarging tumours on the conjunctiva that lead to the eventual erosion of the cornea. Lesions are highly vascular, painful and irritating. The diagnosis should be confirmed by histologic examination of tumour tissue. Conjunctival cytology may be useful in identifying malignant cells. 20.4.2 Management Counseling All patients undergoing HIV testing should receive pre- and post-test counseling. Non-drug related treatment All patients need supportive therapy including advice on good nutrition and preventing transmission of infection to household contacts. Visually impaired persons may require additional support and care. Localised lesions may be surgically excised or removed by cryotherapy The tumour responds to radiotherapy Drug related treatment Neodexone / sofradex eye drops/ ointment should be used initially to treat inflammatory lesions like phylectenulosis Systemic cytotoxic chemotherapy is usually necessary once the diagnosis has been confirmed or in the presence of metastasis. Analgesics should be given for pain and discomfort. Nursing Care Requirements Supportive role and ensuring treatment compliance and regular follow up attendance. General nursing care and support for patient with cancer. Post Admission Care and Discharge Plan Long term follow-up by ophthalmologist / oncologist to monitor progress. Early detection and treatment of other opportunistic infections. Patient should be commenced on long-term prophylactic treatment with cotrimoxazole.

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Social Services Support Patients should be encouraged to join AIDS support organisations as they may require long-term social, educational and financial assistance.

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21. SKIN CONDITIONS

21.1 Introduction Certain dermatologic diagnoses are strongly suggested by the characteristic morphology and pattern of arrangement of skin lesions. Location of lesions on the body and presence or absence of associated symptoms, e.g., itchiness, should also be considered when making a diagnosis. There are four distinct patterns of lesions: Linear lesions (include contact dermatitis, lesions that exhibit

Koebner phenomenon, i.e., appear in sites of previous trauma, e.g., psoriasis, lichen planus, warts)

Annular lesions (include urticaria, erythema multiforme, erythema annulare, tinea, psoriasis, pityriasis rosea, discoid lupus)

Grouped lesions (include urticaria, herpes simplex, herpes zoster, warts, molluscum contagiosum, dermatitis herpetiformis)

Reticular (net-like) lesions (include vascular lesions, livedo reticularis)

The morphology of skin lesions varies tremendously and numerous types of primary and secondary lesions may occur.

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Some of these are described in Tables 21.1 and 21.2. Table 21.1: Morphological definitions of primary skin lesions Vesicle Lesion containing visible fluid in or under the

epidermis, usually less than 5mm in diameter

Bulla Lesion containing visible fluid in or under the epidermis, usually more than 5mm in diameter

Pustule Circumscribed collection of pus

Cyst Closed cavity or sac containing fluid

Wheal Transient area of dermal oedema, pale and compressible and may be papular or plaque-like

Erythema Redness of skin due to vascular congestion or increased vascular flow

Petechiae Pinpoint, non-raised, round, purplish spots caused by intradermal or submucous haemorrhage

Purpura Bleeding into the skin

Telangiectasis Tiny visible blood vessels in dermis

Macule Flat lesion on skin, alteration of colour or texture of skin

Papule Solid lesion, elevation in skin, less than 5mm in diameter

Plaque Solid lesion, elevation in skin, more than 5mm in diameter

Nodule Elevated, palpable, solid mass in skin more than 5mm in diameter

Papilloma Finger-like projection above surface of skin

Prurigo Group of discrete iriitable papular or nodular lesions

Discoid Disc shaped lesion, also known as nummular

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lesion

Poikiloderma Lesion comprising collection of telangiectasia, hypopigmentation or hyperpigmentation and skin atrophy

Comedo Papule due to plug of keratin and sebum in the opening and the duct of pilosebaceous gland

Milium Tiny white cyst containing keratin produced by occlusion of pilosebaceous unit

Table 21.2: Morphological definitions of secondary skin lesions Atrophy Loss of tissue from epidermis, dermis, subcutis with fine

wrinkling and increased translucency of skin

Sclerosis Localised area of diffuse induration of dermal and/or subcutaneous tissues

Erosion Loss of epidermis that heals without scarring

Excoriation Loss of epidermis and sometimes dermis due to scratching

Fissure Linear split in the skin

Scar Fibrosis that replaces normal skin collagen that has been destroyed by injury or disease

Ulcer Loss of epidermis, dermis and sometimes subcutaneous tissue

Callus Localised hypertrophy of stratum corneum

Crust Dried exudates of necrotic cells, serum, fibrin (also called “scab”)

Hyperkeratosis Cornefied cells visible on the skin surface (also called “scale”)

Keratoderma Thickening of skin especially stratum corneum

Lichenification Papular or plaque-like thickening of skin with increased skin markings, hyperkeratosis and hyperpigmentation

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21.2 HIV-Related Skin Conditions The range of skin conditions that occur in persons with HIV infection is very broad and includes all the skin conditions encountered in persons who do not have HIV infection plus those that are related to HIV infection and to immunosuppression. Skin involvement in persons with HIV infection may be the result of: The direct effect of the virus on the skin The effect of body's immune mechanisms directed against HIV Skin infection (opportunistic and non-opportunistic infections) Other dermatoses

21.2.1 Possible direct effect of HIV on skin A number of skin rashes may occur as a result of the direct effect of HIV on the skin. In many of these skin conditions the exact pathogenesis is not clear. The following skin conditions probably occur as a result of the direct effect of HIV on the skin: i. Papular pruritic dermatosis - This is a common clinical problem.

Adults with papular pruritic dermatosis usually complain of severe pruritus associated with a generalised follicular or papular rash.

ii. Eosinophilic folliculitis - Folliculitis commonly occurs in HIV infected individuals. It is commonly of bacterial origin but in some cases an eosinophilic infiltrate is found. Lesions are small (less than 5mm in diameter), multiple, erythematous follicles that may have a centre of pus. Lesions are itchy and are often found in clusters.

iii. Generalised erythroderma - This is an erythrosquamous generalised eruption which affects adults mainly. The skin is reddish in appearance and looks hyperpigmented and scaly. The rash is similar in appearance to the rash of eczema.

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21.2.2 Immune mediated rashes Some rashes develop as a result of the body's immune mechanisms being directed against HIV. i. Urticaria - Early in the course of HIV infection, usually at the time of development of antibodies against HIV, some patients develop urticaria. This probably occurs as a result of the antibody reacting against the viral antigen forming antibody-antigen complexes (immune complexes) that are deposited in the dermis. The deposition of the immune complexes releases histamine which causes the typical flat, itchy wheals and papules of urticaria to appear. ii. Pruritic maculopapular rash - A generalised itchy maculopapular rash may appear during the acute illness phase of HIV infection. The rash, the cause of which is unclear, may be seen all over the body including the face. Like all the other manifestations of the acute illness syndrome, this rash often disappears on its own. It is different from the rash of papular pruritic dermatosis in that the latter often remains for a long period of time. 21.2.3 Skin infections With the onset of immunosuppression, a number of opportunistic skin infections may occur. Opportunistic infections may be viral, bacterial, fungal or parasitic and may affect adults and children equally. They are listed below: i. Viruses - infections with herpes simplex virus (HSV), varicella

zoster virus (VZV), molluscum contagiosum virus (MCV), human papilloma virus (HPV) and Epstein-Barr virus (EBV) often occur in immunosuppressed persons. HSV causes oral and genital herpes, VZV causes shingles and chickenpox, MCV causes molluscum contagiosum, HPV causes warts, and EBV causes oral hairy leukoplakia. The skin lesions of Kaposi's sarcoma are purple papules that may be found anywhere on the body including on the mucosal surfaces. Kaposi's sarcoma occurs uncommonly in children. Kaposi’s sarcoma is now believed to be caused by the Human Herpes virus Type 8 (known as HHV8 or KSHV).

ii. Bacteria - Any pyogenic bacteria may infect the skin. In persons with immunosuppression infection with Staphylococcus aureus and

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Streptococcus pyogenes may result in impetigo, furuncles and boils. Bacterial infection of the apocrine glands is fairly commonly encountered in persons with HIV infection; the condition which is known as hidradenitis suppurativa is a chronic one and usually proves very difficult to treat. Tuberculosis of the skin should also be kept in mind in persons with HIV infection.

iii. Fungi - cutaneous fungal infections occur more commonly amongst immunosuppressed persons. Fungal infections include candidiasis, seborrhoeic dermatitis, dermatomycosis and histoplasmosis.

iv. Parasites - In persons who are immunosuppressed, scabies follows an atypical course. Lesions are more numerous, more widespread and larger than those found in non-immunosuppressed individuals.

21.2.4 Other dermatoses Conditions such as acne, boils, eczema and psoriasis are affected adversely in persons who have HIV infection. All these conditions are common in the general adult population, however, they occur with increasing frequency and are more difficult to treat in immunosuppressed individuals. Boils, skin sepsis and eczema occur frequently in children. Adverse drug reactions occur more frequently in persons with HIV infection: fixed drug reaction, erythema multiforme, Stevens Johnson syndrome and toxic epidermal necrolysis. The latter two are serious conditions and may cause the death of the patient. Vesicular skin eruptions Herpes simplex virus and varicella zoster virus produce vesicles. The former produces oral, labial and genital lesions, while the latter produces a vesicular rash in a dermatomal distribution (shingles or zoster) and generalised vesicular rash (chicken pox or varicella). Vesicular eruptions may also occur as result of drug allergy. Papular skin eruptions Papules may be found in the skin anywhere in the body and they may be found on the mucous membranes as well. Common causes include secondary syphilis, molluscum contagiosum virus, scabies and pruritic

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papular dermatosis. The lesion of Kaposi's sarcoma is also a papule. The lesion is purplish in colour and is not painful and feels firm to touch. Warty skin lesions Warty lesions (also known as papillomatous lesions) are caused by the human papilloma virus. The virus causes the common skin warts (verruca vulgaris) and genital warts (condylomata acuminata). Pustular skin eruptions A pustule is any superficial skin lesion that contains pus. Vesicles may become infected and then become pustules. Any of the following conditions may lead to the development of pustules: acne, boils, furuncles, pyoderma and impetigo. The lesions of chicken pox start off as vesicles but soon become pustules. Squamous skin eruptions Squamous lesions are scaly, dry lesions. In squamous rashes the skin overlying the lesions becomes loose and is shed. Squamous eruptions are found in eczema, seborrhoeic dermatitis, pruritic papular dermatosis, fungal skin infections, late secondary syphilis and in drug reactions. Oral manifestations of HIV infection These are described in the chapter on oral manifestations of HIV.

21.3 Principles of management of skin conditions Persons presenting with skin conditions should be assessed carefully because The skin condition may be an indication of serious underlying illness Some skin conditions lead to psychological problems because of the

unsightly nature of lesions Many skin conditions cannot be cured but simply controlled with

available medications

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A thorough history should be taken from all patients presenting for care of skin conditions. The history should include a family and drug history. All patients should be examined carefully in a well-lit room in private. The skin condition should be accurately described noting specifically the type of lesions, the pattern of distribution of the lesions and whether or not lesions appear on the mucous surfaces in the mouth and on the genitals. It may be necessary to perform a skin biopsy and histological examination of tissue before an accurate diagnosis can be made. The general principles of managing patients with skin conditions are summarised in Table 21.3:

Table 21.3: Principles of management of skin conditions Diagnosis of the skin condition

Diagnosis based on history and clinical examination and results of laboratory tests and skin biopsy

Non-drug related treatment All patients should be educated in general principles of good personal hygiene including hand washing and washing of the body parts that are affected by the skin condition. Simple use of soap and water to keep the affected area clean should be advocated. Open sores and lesions that are oozing blood or pus should be kept covered with gauze bandages that are replaced frequently.

Special requirements Room where patient can be interviewed and examined in private; examination couch; light source; disposable gloves

Provide education All patients should be provided with education regarding the nature of the condition and good personal hygiene

Counseling Counseling should be provided on how to live with a chronic skin condition and on treatment compliance and side effects of medications. If there are factors that lead to exacerbation of the condition, then patients should be counselled on how they may avoid trigger factors.

Treatment compliance All patients should be counselled on treatment compliance and adherence to treatment

Nursing requirements No special nursing is required for most skin conditions. However in the situation where the patient has chronic, indolent, necrotic, fungating lesions that tend to become

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infected, regular dressings may be necessary and a patient’s individual needs should be worked out.

Follow-up plan Arrange to review patient regularly Social services support Drugs for terminally ill patients and those with fungating

malignancies may not be affordable by all patients and should be provided

First line treatment Is the recommended treatment given when the patient makes first contact with the health facility

Second line treatment Is the recommended when the patient returns with symptoms and signs after having been given first line treatment

Third line treatment Is given after consultation with a specialist 21.4 Differential diagnosis of skin conditions Most skin conditions produce easily recognizable lesions. It is therefore important to describe the lesions and their distribution accurately. This will assist in making a specific diagnosis. Table 21.4 summarises the commoner skin conditions and their causes.

Table 21.4: Differential diagnosis of skin conditions Type of skin lesion Causes of condition Vesicular lesions Herpes simplex, varicella, herpes zoster, drug

reactions, insect bites, dermatitis herpetiformis, pompholyx

Macular lesions Secondary syphilis, measles, drug reactions, leprosy

Papular lesions Secondary syphilis, HIV infection, scabies, drug reactions, acne, folliculitis

Erythematous Eczema, atopic dermatitis, seborrhoeic dermatitis, contact dermatitis, lupus erythematosus, fixed drug eruption

Erythrosquamous Seborrhoeic dermatitis, eczema, psoriasis, contact dermatitis, discoid lupus erythematosus, tinea capitis, tinea corporis, tinea cruris, pityriasis versicolor, mycosis fungoides, intertrigo, acanthosis nigricans, lichen planus

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Pustular Acne vulgaris, acne rosacea, staphylococcal folliculitis, varicella, zoster

Bullous lesions Bullous impetigo, staphylococcal scalded skin syndrome, bullous erythema multiforme, toxic epidermal necrolysis, burns, contact dermatitis, drug eruptions, dermatitis herpetiformis, bullous pemphigoid, porphyria cutanea tarda, pemphigus, epidermolysis bullosa, linear IgA disease, renal failure, diabetes

21.5 Bacterial infections 21.5.1 Impetigo A superficial bacterial infection causing rapidly spreading blisters and pustules. It occurs commonly in children, usually starting on the face, especially around the mouth or nose. Often due to Staphylococcus aureus, but may also be the result of infection with Group A streptococci. Impetigo is contagious and measures should be implemented to prevent transmission to household and school contacts, and to other patients and carers. Keep infected areas clean and prevent spread to others (care with towels, clothes, bedding; change frequently and wash clothes separately). Streptococcal infection of the skin with nephritogenic streptococci of the Lancefield group A may lead to glomerulonephritis. Mild or localized disease First line treatment of mild or localized disease is to soak off the crusts with frequent soap and water washes or by soaking lesions with potassium permanganate:

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Severe disease If disease is extensive and severe, or if there are systemic symptoms, systemic antibiotic treatment will be necessary in addition to soaking: First line treatment for severe impetigo Drug Codes Adult dose Route Frequency Duration Erythromycin C V 500mg PO QID 7 to 10

days OR

Cloxacillin B V 500mg PO QID 7 to 10 days

Paediatric doses: Erythromycin 25mg/kg/day in 2 divided doses orally Cloxacillin 50mg/kg/day in 4 divided doses orally

Second line treatment for severe impetigo Drug Codes Adult dose Route Frequency Duration Cephalexin S N 250mg PO QID 10 days Paediatric dose: Cephalexin 25mg/kg (maximum 250mg) PO QID for 10 days

NOTE: If the recommended first line and alternative drugs are not available refer the patient to the next level; If the patient fails to respond to treatment, refer him/her to a level where microbiology services are available.

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21.5.2 Folliculitis This is a common condition and patients present with mildly itchy pustules on an erythematous base. It is a superficial infection causing small pustules, each localised around a hair. It is usually caused by Staphylococcus aureus. Pseudomonas aeruginosa, Pityrosporum species, dermatophytes, and herpes simplex virus may also cause folliculitis. A variant known as eosinophilic folliculitis occurs in HIV infected persons. Deep follicular inflammation often occurs in hairy areas. Staphyloccocal folliculitis often occurs in nasal and perineal carriers of the organisms and in recurrences it may be necessary to clear the carrier state. Mild or localized disease First line treatment of mild or localized disease is to bathe and remove crusts and clean the skin with frequent soap and water washes or by soaking lesions with potassium permanganate: First line treatment for mild folliculitis Drug Codes Adult dose Route Frequency Duration Soap and water washes C V Local

wash 2 times daily

Till healed

OR Potassium permanganate 1:4000 (0.025%) solution

B N Local soak

Once daily Till healed

Severe disease If the disease is extensive and severe, or if there are systemic symptoms, systemic antibiotic treatment will be necessary in addition to soaking: First line treatment for severe folliculitis Drug Codes Adult dose Route Frequency Duration Erythromycin C V 500mg PO QID 7 to 10

days OR

Cloxacillin B V 500mg PO QID 7 to 10 days

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Paediatric doses: Erythromycin 25mg/kg/day in 2 divided doses orally Cloxacillin 50mg/kg/day in 4 divided doses orally

Second line treatment for severe folliculitis Drug Codes Adult dose Route Frequency Duration Cephalexin S N 250mg PO QID 10 days Paediatric dose: Cephalexin 25mg/kg (maximum 250mg) PO QID for 10 days

NOTE: If the recommended first line and alternative drugs are not available refer the patient to the next level If the patient fails to respond to treatment refer him/her to a level where microbiology services are available 21.5.3 Furunculosis, boils and carbuncles These conditions are deep forms of folliculitis and are usually painful and tender. They are in fact abscesses and often require incision and drainage, depending on their size and location. They are most frequently caused by Staphylococcus aureus. Furunculosis usually resolves by itself, but may be improved by placing frequent hot compresses until the small abscess localizes and ruptures. Review the patient after 2 days and if not improving, consider surgical incision and drainage. If the boil causes swollen lymph nodes and fever, consider systemic antibiotics: First line treatment Drug Codes Adult dose Route Frequency Duration Cloxacillin B V 500mg PO QID 7 to 10

days

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Paediatric doses: Cloxacillin 50mg/kg/day in 4 divided doses orally

Second line treatment Drug Codes Adult dose Route Frequency Duration Cephalexin S N 250mg PO QID 10 days Paediatric dose: Cephalexin 25mg/kg (maximum 250mg) PO QID for 10 days

NOTE: If the recommended first line and alternative drugs are not available refer the patient to the next level; If the patient fails to respond to treatment refer him/her to a level where specialist services are available 21.5.4 Paronychia Paronychia is infection of the nail fold. It may be acute or chronic. Acute paronychia is painful and is caused by bacterial (usually staphylococcal) or viral (usually herpes simplex virus) infection. Chronic paronychia is painless and is the result of trauma followed by secondary infection by Candida albicans. Patients with acute paronychia present with painful red swellings of the nail fold. Acute paronychia is commoner in persons who have the habit of biting their nails. Acute Paronychia Tenderness and presence of visible pus requires incision and drainage and systemic treatment with antibiotics: First line treatment of acute paronychia Drug Codes Adult dose Route Frequency Duration Phenoxymethyl-penicillin

C E 500mg PO QID 5-7 days

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Paediatric doses: Phenoxymethylpenicillin 10mg/kg (maximum 500mg) PO QID for 5-7

days Second line treatment of acute paronychia Drug Codes Adult dose Route Frequency Duration Cloxacillin B V 500mg PO QID 10 days Paediatric doses: Cloxacillin 50mg/kg/day in 4 divided doses orally for 10 days Persons with acute paronychia caused by herpes simplex virus infection need to be treated with acyclovir once the diagnosis has been confirmed. In adults acyclovir is given in a dose of 200mg PO five times a day for 7 to 10 days and in children acyclovir is given in a dose of 5mg/kg (maximum 200mg) 5 times a day PO for 7 to 10 days. Chronic Paronychia This is usually caused by trauma followed by infection with Candida albicans. It is commoner in persons engaged in wet work, e.g., washing clothes and dishes, bar workers and food handlers. Infected persons with chronic paronychia should avoid prolonged and excessive contact with water, detergents and soaps and should protect the area from trauma. Treatment is with applications of topical imidazoles and if there is secondary bacterial infection then systemic antibiotics may be used as described for acute paronychia: Treatment of chronic paronychia Drug Codes Adult dose Route Frequency Duration Griseofulvin B N 500mg PO OD 6 weeks

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1.6 Fungal Infections 21.6.1 Tinea Tinea (“ring worm”) is caused by the dermatophyte species of fungi. Any part of the skin, hair and nails can be affected. Typically lesions are itchy, scaly, and erythematous, and have an annular or geographic shape that tends to clear in the centre. Lesions expand gradually and may sometimes be pustular. Body Ringworm (Tinea Corporis) Round, expanding lesions with white, dust-like scales and distinct borders, found on the body, face or limbs. Treat as follows: First line treatment of tinea corporis Drug Codes Adult dose Route Frequency Duration Benzoic acid compound ointment

C E Apply Local 2 – 3 times a day 4 weeks

OR Imidazole cream (miconazole 2%)

B N Apply Local 2-3 times a day For 7 days after resolved

Second line treatment of tinea corporis Drug Codes Adult dose Route Frequency Duration Imidazole cream (miconazole 2%)

B N Apply Local 2-3 times a day For 7 days after resolved

Tinea Pedis (Fungal / Athlete's Foot) This is a very common fungal infection and is often the source of infection at other sites. Keep the feet as dry as possible, and as far as possible avoid

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wearing socks / closed-in shoes. Treat any bacterial superinfection first, then treat the fungal infection as follows: First line treatment of tinea pedis Drug Codes Adult dose Route Frequency Duration Imidazole cream (miconazole 2%)

B N Apply Local 2-3 times a day For 7 days after resolved

Second line treatment of tinea pedis Drug Codes Adult dose Route Frequency Duration Griseofulvin B N 500mg PO OD 4 weeks Tinea Capitis (Scalp Ringworm) In tinea capitis the fungus has usually grown down into the hair follicle and hence topical treatment is unlikely to be effective. Treat as follows: First line treatment of tinea capitis Drug Codes Adult dose Route Frequency Duration Griseofulvin B N 500mg PO OD 4 weeks 21.7 Parasitic infections of the skin 21.7.1 Scabies Scabies is a parasitic infection of the skin caused by the mite Sarcoptes scabei. Infection is transmitted by skin-to-skin contact, including sexual intercourse. Household contacts of infected persons may become infected through close body contact. If untreated it spreads to all members of the household. The main symptoms of infection are itchiness and a rash. The itch becomes worse at night and after a hot bath. Usually there is an itchy,

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excoriated, non-specific rash on the trunk, associated with scaly burrows in the web spaces of the fingers, on the wrists and on the ulnar margins of the forearms and on the buttocks, periumbilcal and genital areas, axillae and inner aspects of the feet. All close contacts in the same household, especially children and the elderly should be treated at the same time. Sexual contacts of persons with scabies should also be treated. Clothing and bedding should be washed pressed and left to dry in the sun. The following treatment should be given: 1. Treatment of scabies in adults After normal bathing, apply: First line treatment of scabies - adults Drug Codes Adult dose Route Frequency Duration Gammabenzene hexachloride lotion (1%)

C V Apply from neck down to toes

Local Apply once and wash off after 24 hours

Single application

2. Treatment of scabies in children After normal bathing, apply: First line treatment of scabies – children Drug Codes Adult dose Route Frequency Duration Gammabenzene hexachloride lotion (1%)

C V Apply from neck down to toes

Local Apply once and wash off after 12 hours

Single application

CAUTIONS: Hot baths and scrubbing should be avoided to prevent systemic absorption.

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3. Treatment of scabies in pregnant women, in lactating women and in children less than 6 months of age Treatment of scabies in pregnant women, lactating women, and children < 6 months of age Drug Codes Adult dose Route Frequency Duration Benzyl benzoate emulsion (25%)*

B N Apply from neck down to toes

Local Apply nightly for and wash off after 12 hours

3 nights and repeat in 10 days if necessary

OR Sulphur ointment 5-10% (for infants)

B N Apply from neck down to toes

Local Twice daily 10-14 days

For children dilute benzyl benzoate with one part water 1:1 For infants dilute benzyl benzoate with 3 parts water 1:3 If there is secondary bacterial infection (“septic sores”), treat as

for impetigo for 4-5 days. Only apply scabicide once lesions are closed.

Advise that the itch may continue for several weeks. This can be relieved by applying:

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Treatment of itch in scabies Drug Codes Adult dose Route Frequency Duration Calamine lotion C N Apply Local As needed As required

OR Chlorpheniramine maleate

C E 4mg PO TID 3 days

Paediatric doses: Chlorpheniramine maleate 0.1mg/kg PO TID for 3 days Alternative treatments include, lindane, 1% lotion or cream, rubbed gently but thoroughly into the

infested area and adjacent hairy areas and washed off after 8 hours. Lindane must not be used during pregnancy or lactation

Permethrin 1%, applied as above Crotamiton 10%, lotion, applied to the entire body from the neck

down, nightly for 2 nights and washed off thoroughly 24 hours after the second application; an extension (crotamiton has the advantage of an antipruritic action).

Sulphur 6%, in petrolatum applied to the entire body from the neck down, nightly for 3 nights; patients may bathe before reapplying the product and should bathe 24 hours after the final application.

21.8 Viral infections 21.8.1 Herpes Simplex Virus Herpes simplex virus infections are extremely common. The virus causes vesicles, usually around the lips or around the mouth and also on the genitals. The first attack is usually extensive and may last up to 2 to 3 weeks. Recurrences occur in more than half of the patients who have had a primary attack and are usually localized and last 4 to 7 days. Recurrences are often associated during times of decreased well-being (incubation time

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of infectious diseases, menses, mental stress, febrile illnesses). No specific medication; keep the lesions dry. Immunosuppressed persons with HIV infection, tend to develop frequent, extensive and persistent recurrent attacks of herpes simplex virus infections. Treatment of mild attack of herpes simplex infection Drug Codes Adult dose Route Frequency Duration

Wash well and frequently with soap and water OR

Povidone iodine C V Apply Local 3 times a day

Till resolved

Treatment of severe primary or recurrent attack of herpes simplex virus infection Drug Codes Adult dose Route Frequency Duration Acyclovir B E 400mg PO TID 7 days

OR Famiciclovir S N 125mg PO BID 7 days 21.8.2 Varicella (chickenpox) and Zoster (shingles) Varicella and zoster are caused by the herpes virus varicella-zoster. Persons exposed to the virus for the first time often develop no symptoms or signs of the infection. Children, and adults, may develop disseminated infection known as chickenpox or varicella after the initial exposure. This will resolve though the virus remains in the body indefinitely. With immunosuppression and other aggravating stress factors, viral replication may occur and then patients develop symptoms limited to the cutaneous distribution of dermatomal nerves resulting in an attack of zoster or shingles.

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Chickenpox The incubation period for chickenpox is 12-21 days after exposure. Macules appear first on the trunk, then spread to the face and scalp. Within a few days these develop into papules, vesicles and crusts. Lesions in all stages of maturity are seen in persons with chickenpox. Specific treatment is not indicated. Patients should be advised to keep the lesions dry with frequent washes with soap and water or saline and by applying zinc oxide preparation. For itching patients may be given: Treatment of zoster Drug Codes Adult dose Route Frequency Duration Acyclovir B E 800mg PO 5 times a day 7 days

OR Famiciclovir S N 250mg PO TID 7 days Paediatric doses: Acyclovir 20mg/kg (maximum 800mg) PO 5 times a day for 7 days Famiciclovir 6mg/kg (maximum 250mg) PO TID for 7 days Treatment of post-herpetic neuralgia For post-herpetic neuralgia amitryptiline, carbamazepine or phenytoin may be used: Treatment of post-herpetic neuralgia Drug Codes Adult dose Route Frequency Duration Amitriptyline B E 75mg PO Once nightly As required

OR Carbamazepine B E 200mg PO Once nightly As required

OR Phenytoin B V 100-200mg PO Once nightly As required

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21.8.3 Warts Warts are caused by the Human papilloma virus. They are seen in all ages but most commonly in children. 1. Common skin warts (verruca vulgaris) and plantar warts Common warts (verruca vulgaris) occur mostly on the hands, feet and extensor surfaces. Common skin warts often resolve spontaneously and in most cases, especially in children, should not be treated. There is no reliable specific treatment for warts if treatment is necessary then chemical or physical removal may be attempted. Common skin warts and plantar warts should not be treated with podophyllin and if extensive patients should be referred for excision, cryotherapy or cauterization. 2. Genital warts (Condylomata acuminata) Genital warts are caused by the human papilloma virus (HPV). A large number of different strains of the virus are known to cause disease in humans. Some HPV strains are associated with cervical cancer and anogenital cancers. Treatment of genital warts Treatment of external genital and perianal warts First line treatment for external genital and perianal warts Drug Codes Adult dose Route Frequency Duration Podophyllin paint 20%

B N Apply to warts and wash off after 4 hours

Apply to warts

Once weekly 3 weeks

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CAUTIONS: For external use only. Do NOT use podophyllin in pregnancy. Do not apply to the cervix, urethra or anal mucosa. Treatment of cervical, urethral and vaginal warts: These should not be treated with podophyllin. Patients should be referred for electrocautery, cryotherapy or surgical excision 21.8.4 Molluscum Contagiosum Molluscum contagiosum is caused by the molluscum contagiosum virus. The infection is not always acquired sexually, commonly being transmitted through contaminated towels. The lesions of molluscum contagiosum may occur on any part of the body. The condition presents as papules with a central umbilication. The contents of the papules when expressed are seen as a white cheesy material. Treatment of molluscum contagiosum The lesions of molluscum contagiosum may resolve spontaneously. If not, then each lesion should be pricked with a sharpened “orange-stick” or needle and the contents of the lesion expressed. This alone may be sufficient, or each lesion can then be touched carefully with liquefied phenol. Lesions of molluscum contagiosum may become extensive and large in immunosuppressed persons with HIV infection. If the lesions are very extensive and are very large then the patient should be referred for specialist attention. REFER TO THE CHAPTER ON SEXUALLY TRANSMITTED DISEASES 21.9 Urticaria Allergic urticaria may be caused by: drugs (e.g. penicillin) infection, contact with plants, pollen, insect bites, or foodstuffs (e.g. fish, eggs, citrus fruits, nuts, strawberries, tomatoes.) Physical urticaria may be caused by mechanical irritation, cold, heat, sweating.

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Exclude drug reaction (e.g. penicillin), or infection (bacterial, viral or fungal). Give antihistamine by mouth [never use topical antihistamines]: Treatment of itching in eczema Drug Codes Adult dose Route Frequency Duration Chlorpheniramine

C E 4mg PO TID 3 days

OR Promethazine B N 25-50mg PO Once at night As required Paediatric dose: Chlorpheniramine 0.1mg/kg PO TID for 3 days Promethazine DO NOT USE IN CHILDREN LESS THAN 2 YEARS OF AGE If no improvement after 1 month or chronic problem, refer. 21.10 Management of skin conditions in persons with HIV infection The flowchart on the next page gives guidance on the management of skin conditions in persons with HIV infection.

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21.10.1 Flowchart for the management of skin conditions in adults and children with HIV infection

1. Patient complains of skin condition?

13. Refer for specialist opinion [y]

3. Vesicular eruption found?

Yes

No

5. Papular eruption found?

No

4. Differentiate between: * varicella/zoster * herpes simplex * drug reaction and treat appropriately

6. Differentiate between: * secondary syphilis * molluscum contagiosum * scabies * papular dermatosis * Kaposi’s sarcoma and treat appropriately

8. Treat for warts 7. Warty lesions found?

9. Pustular eruption found?

11. Pruritic squamous eruption found?

10. Differentiate between: * varicella/zoster * acne * impetigo * boils [and treat appropriately

Yes

Yes

No

Review in 14 days

No

15. Continue treatment

2. Take history and examine patient

14. Patient is improved?

Yes

Yes

Review in 14 days

Yes

16. Refer

12. Differentiate between:* eczema * seborroeic dermatitis * pruritic dermatosis * dermatomycosis * drug reaction * secondary syphilis and treat appropriately

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Recurrent chest pains that are often poorly defined. Contact with a tuberculous adult Unresponsive failure to thrive Isolated or generalised lymphadenopathy Recurrent subacute intestinal obstruction Persistent lobar consolidation/collapse shadows on chest x-ray Straw coloured high protein non-purulent pleural, pericardial or

ascitic fluid Monoarthritis Erythema nodosum

Diagnosis Every effort must be made to get microbiological or pathological confirmation. Acid fast bacilli (AFB) should be looked for in induced sputum, and gastric aspirates may also show AFBs. A reactive Mantoux test greater than 5mm is suggestive of TB. Histologic examination of lymph node and liver biopsies and pleural, pericardial, synovial and peritoneal biopsies may be diagnostic. Lymph node aspirates should be examined for AFBs. Bone marrow aspirates should also be examined for AFBs. All material should be sent for microscopy, culture and sensitivity in order to monitor for multi-drug resistant TB. If TB is strongly suspected and laboratory tests do not confirm the diagnosis there is room for a trial of TB therapy provided this is carried out in controlled circumstances and for a period not exceeding two months and after consultation with a specialist. Treatment Follow the National TB Guidelines. Identify and treat the adult from whom the child got TB and other family members who are at risk.

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25.3.5 Suppurative lung disease and bronchiectasis in children aged 2 to 16 years This may be suspected clinically in children with a productive cough that is worse in the mornings and on going to bed. There may be persistent rales in one or more lobes of the lung, and there may be lung fibrosis with tracheal traction to one side of the chest. Chest x-ray may show the lesions but it is best diagnosed on CT scan of the chest with or without contrast. Sputum examination and culture may reveal organisms such as Pseudomonas, Klebsiella or Staphylococcus. Treatment is with chest physiotherapy for drainage and crystalline penicillin, ampicillin, chloramphenicol or gentamicin are given for 10 days or more. The child should be referred for specialist opinion and management. 25.3.6 Tuberculosis Both acute and chronic tuberculosis occur commonly in children with HIV infection. Tuberculosis has always been a difficult diagnosis to make in children and the problem is more complex in children with HIV infection as a number of conditions that occur in HIV infected children mimic TB. These include HIV related failure to thrive, unexplained fever and chronic cough. In addition immunosuppressed persons may have an unreactive Mantoux test. Tuberculosis accelerates the progress to AIDS and HIV makes Tuberculosis worse. A high index of suspicion for TB needs to be maintained at all times . The diagnosis and case finding would be greatly facilitated if contact tracing for TB was efficient. In children under 5 years treatment for latent tuberculosis is recommended as the risk of progression of the primary complex is higher than in adults. Suspect TB in the presence of the following: Persistent pyrexia despite treatment with antibiotics and

cotrimoxazole Persistent cough of more than three weeks, Unexplained loss of appetite and weight Abnormal episodes of sweating,

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such as, missed meningitis and empyema and investigate for tuberculosis.

If not totally better by 10 days consider commencing antituberculous treatment and refer the child for specialist opinion

Check the HIV status and if positive send home on PCP prophylaxis. 25.3.3 Children 2-16 years of age with severe pneumonia Treat with crystalline penicillin or ampicillin or amoxycillin If not responding add gentamicin and high dose cotrimoxazole Look for TB and other infections If not improving after 10 days refer the child for specialist opinion

Steroid use The use of steroids in children with pneumonia remains a controversial topic as it is possible that CMV infection and TB may be disseminated and worsened in children with these infections. Studies are currently underway to determine whether steroids have a beneficial effect and until such a time that the results of such studies are known it is recommended that steroids in the form of hydrocortisone or prednisolone be used only in desperately ill children: Prednisolone 2mg/kg/day in two divided doses orally. 25.3.4 Pulmonary lymphoid hyperplasia This is a slowly progressive lung disease whose aetiology is unknown. It is an AIDS-defining illness and is usually seen after the first year of life. It is often associated with parotid enlargement, generalised lymphadenopathy, hepatosplenomegally and digital clubbing. Children are usually well though in severe cases they may have chronic cough, progressive breathlessness and getting fatigue with exercise. Chest X-ray may look like miliary tuberculosis and the X-ray features do not change with TB treated. Corpulmonale may complicate its course. Such children should be referred for specialist opinion.

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previously) and consider changing the crystalline penicillin/ampicillin to chloramphenicol or cephalosporin,

If the child is still not better and is spiking temperatures after 10 days, consider the addition of anti-tuberculous treatment

Always give supportive therapy described in the box below: Supportive therapy is always critical

If the child is improving continue to treat with high-dose

cotrimoxazole for a minimum of 21 days and send home on cotrimoxazole prophylaxis for PCP in those whose HIV status is positive or unknown. Start tapering off steroid dose after 7 days.

25.3.2 Children 12-24 months with severe pneumonia Treat with crystalline penicillin/ampicillin and gentamycin Review after 48 hours If the child is improving, continue treatment for a total of 10 days If the child is not improving, add steroids as above and high-dose

cotrimoxazole to the regimen and look for other causes of problems,

Supportive therapy

Oxygen by headbox, nasal prongs, mask. If very cyanosed and able to monitor IV fluids give 75mls per kg per 24 hours

of 1/2 dextrose darrows, Maintelyte or neonatolyte. If unable to monitor fluids pass a nasogastric tube and give Expressed breast

milk at 80-100ml per kilogram per day 3 hourly. Feed by cup once improvement has occurred after 48 hours. If frothing with acute pulmonary oedema give stat dose of frusemide

0.5mg/kg IV or IM followed by 1mg/kg PO.

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25.2.6 Dermatologic manifestations Severe seborrhoeic dermatitis Zoster Generalised fungal dermatitis Kaposi’s Sarcoma Extensive perineal or skin warts

25.2.7 General Infections Children with HIV have a tendency to recurrent bacterial infections

which may need treatment with antibacterials for longer period than for non-HIV children.

Daily Cotrimoxazole prophylaxis in symptomatic HIV children may reduce morbidity and hospital admissions and prolong life.

25.3 The respiratory system in children with HIV In the first year of life respiratory infections are the commonest cause of morbidity and mortality. PCP and CMV dominate the picture in the first 6 months while bacterial infections and PCP in that order dominate the picture from the second 6 months of life. After the first year of life recurrent bacterial infections are the common causes of morbidity and mortality. Both acute and chronic tuberculosis are found in children of all age groups. Mixed infections occur commonly. 25.3.1 Management of severe and very severe pneumonia in high (10% or more) HIV prevalence areas Admit the child. Treat with crystalline penicillin/ ampicillin and gentamycin given IV

and high dose cotrimoxazole given orally. Give steroids 2mg/kg/day once daily If there is no improvement after 5 days think of other conditions,

do a lumbar puncture, arrange for a chest x-ray (if not done

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25.2.2 Respiratory system Severe /very severe pneumonia in a child 2-12 months of age. LIP/PLH as diagnosed on chest x-ray - persistent generalised miliary

like nodular pattern in a well child Chronic suppurative lung disease

25.2.3 Cardiovascular system Cor pulmonale Cardiomyopathy

25.2.4 Gastrointestinal system Persistent or recurrent diarrhoea: at least two loose stools a day

for >30 days Persistent hepatomegaly/splenomegaly in the absence of any other

condition other than HIV Acquired rectovaginal fistula

25.2.5 Central nervous system Failure to attain, or loss of, developmental milestones or loss of

intellectual ability Acquired microcephaly demonstrated by head circumference

measurements or brain atrophy as seen on CT scan Acquired symmetric motor deficit manifested by two or more of the

following, paresis, pathological reflexes, ataxia, or gait disturbance, increased muscle tone

Recurrent bacterial meningitis in the absence of a predisposing factor

Cryptococcal meningitis,

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In children HIV infection may be suspected if: The child's mother is known to be HIV positive, One or both parents have had tuberculosis or are known to be

chronically ill One or both parents are dead One or more siblings are known to be chronically ill or have died Child has one or more of the symptoms listed below:

25.2.1 General clinical features The following symptoms and signs are suggestive of HIV if they occur in the absence any known concurrent illness: Growth failure in a child less than six months who is fully breastfed. Growth failure lasting three months or more. Severe stunting in a child less that 12 years. Child falls below the 5th percentile on the weight for height chart

on 2 consecutive measurements taken 30 days or more apart Fever lasting more than one month, recurrent or continuous. Serious recurrent bacterial conditions, septicaemia, pneumonia, bone

or joint infection, abscess of an internal organ or body cavity. Generalised lymphadenopathy - lymph nodes at two or more sites

measuring at least 0.5cm and present for more than 1 month Parotid enlargement lasting more than one month Severe dental caries in an African child Oral and oral pharyngeal candidiasis in a breastfed child older than

one month Oesophageal candidiasis. Finger clubbing in the absence of congenital heart disease

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25. PAEDIATRIC HIV INFECTION 25.1 Introduction 30-40% of pregnant women in Zimbabwe carry HIV and 30-40% of them will pass on the infection to their child during pregnancy or breastfeeding. 50-60% of childhood admissions to Hospital are HIV related. 25.2 Diagnosis of HIV infection in children Under the age of 18 months it is difficult to distinguish the child

who is actually infected with the virus from the one who is just carrying maternal antibody using the HIV tests available in Zimbabwe. No totally satisfactory clinical diagnostic criteria have been established except in the presence of recognizable AIDS defining illnesses.

It is important to take a good history and carry out a thorough examination.

If HIV is suspected then precounseling is important before an HIV test is done.

After 18 months of age a positive HIV test is diagnostic of HIV disease in a child. Clinical suspicion of HIV disease should always be confirmed by an HIV anti body test at or after 18 months of age.

Many conditions in a developing country context are common in both the HIV infected and the non infected :- malnutrition, Tuberculosis, persistent diarrhoea, generalised lymphadenopathy.

The presence of any 2 of the conditions listed below and positive HIV serology should lead to a suspicion of HIV infection till proved otherwise at 18 months till proved otherwise.

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24.5 Summary of long term follow up & care

Schedule of visits for mother/infant follow up:

• 10 – 14 days • 6 weeks • Monthly up to 18 months

INFANT: Counselling on infant feeding and

address any problems. Encourage exclusive breast feeding

for 6 months followed by rapid weaning For non-breastfeeding, ensure

hygienic preparation and adequacy of feeds including micro nutrient supplementation

Monitor growth Monitor development Follow routine immunisation schedule Give cotrimoxazole prophylaxis and

increase dose according to age* Monitor signs and symptoms of HIV

infection and refer appropriately

Check HIV status at 18 months

MOTHER: Monitor mother’s weight

and give nutritional advice Cotrimoxazole

prophylaxis if indicated* Refer appropriately if ill Discuss and provide

family planning, emphasis on dual protection

Referral for psychosocial support

Positive Negative

Discharge from PMTCT follow up

Continue cotrimoxazole prophylaxis *

Continue nutrition and growth monitoring

*MOTHER COTRIMOXAZOLE PROPHYLAXIS DOSES 2 tablets OD

*INFANT COTRIMOXAZOLE PROPHYLAXIS DOSES 6 wks – 5 months: 2.5ml OD 6 – 18 months: 5ml OD 18 months – 3 yrs: 7.5ml OD 3 yrs onwards: 10ml OD (10ml = 1 tablet)

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24.4 Summary of post natal practices

Woman has delivered her baby

Educate/counsel mother on the following issues: • Good hygiene/cord care • Signs and symptoms of infection in both herself and her

baby. • Importance of good nutrition • Family planning (dual protection) • Importance of follow up visits • Encouragement to seek health care promptly if problems

arise in herself or baby • Encourage safe sex • Encourage VCT for partner

Establish HIV Status

Positive Negative Support chosen infant feeding method If unwell, refer Give Nevirapine to baby at 48 – 72 hrs Complete Child Health Card including

PPTCT code

Support breast feeding

DISCHARGE mother and infant Give date of first follow up visit (ten to

fourteen days post delivery)

275

24.3 Summary of practices during labour and delivery

Woman presents to labour ward in “labour”

Carry out labour and delivery using SAFE OBSTETRIC PRACTICES:

• Use of the partogram • Avoid ARM where possible Avoid unnecessary episiotomy Minimise trauma from instrumental

delivery and routine suctioning of baby’s mouth/nostrils

Clamp cord immediately after birth and do not “milk”

Dry baby and keep warm immediately after birth

Apply baby friendly practices

YES

Give baby 0.6ml NVP syrup immediately after birth AND repeat at 72 hours age

NO

Establish that it’s true labour

If false labour replace

Nevirapine and

discharge Ensure Nevirapine has been taken

POSITIVE HIV status

NEGATIVE OR UNKNOWN

HIV exposed baby

Mother did not take NVP OR took NVP less than 2 hours

before delivery

Routine postnatal

care of infant

274

24.2 Summary of antenatal care practices

All pregnant women offered VCT

Continue routine ANC Offer VCT at subsequent visits Carry out individual

pretest counselling

Proceed to HIV rapid testing

Post Test

Counselling NEGATIVE

POSITIVE

Continue routine

ANC and reinforce messages at each

visit

NO

YES Informed consent for HIV testing?

Group information

• Give Nevirapine • Counselling on infant feeding • Offer partner counselling • Discuss “safer sex” and offer

condoms • Look for signs and

symptoms • Discuss positive living

Discuss window period, offer further HIV test in 3 months if “high risk”

Offer partner VCT and encourage involvement

Discuss safer sex and give condoms

Encourage breastfeeding

273

24. PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV INTERVENTION 24.1 Overview of PMTCT interventions Prevention of mother-to-child transmission (PMTCT) of HIV is one of the key HIV prevention strategies in Zimbabwe’s national response to the HIV/AIDS epidemic. Mother-to-child transmission (PMTCT) of HIV is the most significant source of HIV infection in children below the age of 15 years. Over 90% of HIV infection in infants and children is due to PMTCT. About 30 to 35% of pregnant women are HIV positive. Without any PMTCT intervention, about a third of the HIV infected women will pass the virus to their babies. It is estimated that about 20% of the infected babies become infected during pregnancy, 60% during labour and delivery, and 20% after birth through breast-feeding. Most infections therefore occur during labour and delivery. The goal of Zimbabwe PMTCT is to reduce PMTCT of HIV infection, thereby leading to reduction of infant morbidity and mortality. The Four Main Strategies for PMTCT in Zimbabwe are: Primary prevention of HIV infection in Women of childbearing age

and their partners. Prevention of transmission of HIV to the infant during pregnancy

and breastfeeding Prevention of unwanted pregnancies in HIV infected women. Care and Psychosocial support to HIV infected women and their

families PMTCT practices need to be carried out during the antenatal period, labour and delivery and post-natal period including after hospital / clinic discharge.

272

related to disease process

management and complications, and referring to tangible psychosocial support. Self-care strategies including use of condoms

Anxiety and distress related to stigma

Find out the source of anxiety. Counsel according to the client’s needs

Vaginal discharge due to STI, bleeding,

Perineal care, relevant antibacterial creams, use of antiperspirant deodorants

Pruritis related to vaginal discharge, herpes, or unhygienic practices

General hygiene, antimicrobial vaginal pessaries, perineal care

Fluid volume deficit related to vomiting, diarrhoea or excessive sweating

Encourage to drink at least 8 glasses of water per day. If she cannot tolerate this amount of water, other drinks or fluids may be taken according to preference.

Fluid volume excess related to generalised oedema

Administer prescribed diuretics. Encourage exercise especially of the lower limbs. Elevate limbs when sitting down

Altered self concept

Counseling

Altered role concept as mother and wife

Counseling

Self-care deficit Counseling, assistance with activities of daily living

271

23.8.4 Bacterial Vaginosis About 50% of HIV-infected women will present with vaginal fishy smelling discharge due to this condition. The organisms commonly associated with bacterial vaginosis are anaerobic bacteria such as Gardnella vaginalis, Bacteroides spp, Mobiluncus and Mycoplasma hominis. Diagnosis is made clinically using Amsel criteria: vaginal pH>4.5, release of fishy smell on addition of 10% potassium hydroxide, characteristic discharge on examination and presence of “clue cells” on microscopy. The treatment is Metronidazole 400mg orally twice a day for five days or 2g as a single oral dose. 23.9 Prevention of Malaria during Pregnancy HIV-infected women are more likely to develop malaria during pregnancy if they are at risk of this infection. Therefore they should be advised to use malaria prophylaxis. 23.10 Nursing care requirements The nursing care requirements for women with HIV infection are summarised in Table 23.1.

Table 23.1 Nursing care requirements for women with HIV infection Condition Nursing Intervention Pain and discomfort related to genital lesions, PID, dysmenorrhoea, dyspareunia

Administer prescribed analgesia. Advise on fowler’s position for PID. Use hot or cold compresses for dysmenorrhoea, vaginal jellies to relive dyspareunia

Altered nutrition related to disease condition as evidenced by loss of weight

Give information on well balanced diet. Increase caloric intake to provide energy. Encourage diet with increased fat and carbohydrate in diet and also use fruit and vegetables, and natural unrefined foods.

Risk for infection related to reduced immunity

Encourage long term antibiotics like Cotrimoxazole to prevent Pneumocystis pneumonia (PCP). Hand washing Proper disposal of sanitary pads and good perineal care

Knowledge deficit Client education regarding diagnosis, signs and symptoms, and

270

intraepithelial neoplasia and Bowen´s disease. Approximately 20% of HIV-infected women have severe cervical intraepithelial neoplasia (CIN). Because of this cervical screening should be performed annually and persistent vulval lesions should be biopsied in women with HIV infection. For women with AIDS, 6 monthly cervical screening is appropriate. Approximately 30 types of HPV can infect the genital mucosa but only 17 are carcinogenic with types 16, 33 and 18 being the commonest in our population. Treatment of HPV infection may not be effective until the immune anti-HPV response controls viral replication. This can be achieved if antiretroviral treatment is given. 23.8.2 Herpes simplex virus (HSV) infection HSV is the commonest cause of genital ulcers in immunosuppressed individuals. A herpetic genital ulcer that persists for more than one month is indicative of immunosuppression. Herpetic ulcers are often multiple, deep, recurrent and painful. HSV has been implicated in postpartum endometritis in HIV-infected women. Diagnosis is made on clinical findings. Treatment is effective in reducing the severity of the symptoms and controlling the extent of lesions and to prevent the recurrence of lesions. Acyclovir 200mg PO given five times a day for five days is an effective treatment. In persons with persistent and protracted ulcers it is appropriate to prescribe a long-term treatment with acyclovir 400mg PO BID. 23.8.3 Genital candidiasis Vaginal candidiasis can be severe and recurrent in women with HIV infection. Patients present with itching and soreness of the vulva and vagina, and complain of a white discharge. The pH of the vagina is usually normal and microscopy or culture of the discharge confirms diagnosis. Topical treatment is preferable. A variety of pessaries and creams containing imidazole or nystatin are available. In severe cases systemic treatment with a single dose 150mg of Fluconazole is effective if the pathogen is Candida albicans only. In recurrent infection once or twice monthly treatments can be offered.

269

Management Women found to have an abnormal Pap should be referred for colposcopy and biopsy. Early lesions can be treated with loop excision or cryo-therapy. Early stages of cervical cancer are treated with surgery. In late stages for example stages 2b and above, radiotherapy is indicated. 23.7 Cervical intraepithelial neoplasia (CIN) Cervical intraepithelial neoplasia presents as dysplasia of the surface layers of the cervical cells. CIN is classified according to degrees of severity. There are 3 grades of CIN: grades I, II or III. Patients with CIN usually have no symptoms, the diagnosis being made on cytologic examination of Pap smears and on colposcopy and biopsy. It is therefore important that all women with abnormal Pap smears, i.e., smears showing any atypical cellular activity (including persistent inflammation), be referred for expert opinion. Management CIN-I: No therapy needed, but patient should be monitored closely and regular Pap smears should be performed CIN-II-III: Any of the following modalities of treatment may be used: laser vaporization treatment, loop electric excision procedure (LEEP), excision biopsy, cryotherapy - this option may be the least desirable as it may mask

future problems 23.8 Sexually transmitted infections SEE CHAPTER ON STIs 23.8.1 Human papillomavirus (HPV) infection HPV infection can be severe and persistent in immunosuppressed women. Chronic HPV infection can result in cervical pre-cancer or cancer, vulval

268

23.4 Pregnancy Women presenting with amenorrhoea should be investigated for pregnancy. Management Offer option to terminate or keep the baby. If she wants to keep the baby, plan for a caesarean section and no breast-feeding. Prepare for provision of nevirapine 200mg to the mother during labour and nevirapine to the neonate in order to prevent the mother-to-child transmission of HIV. See also counseling under nursing care requirements. 23.5 Vertical transmission Vertical transmission occurs in 25-40% of pregnancies if no interventions are given. A combination of antiretroviral therapy, Caesarean Section and avoidance of breastfeeding can reduce the risk to less than 3%. Antiretroviral therapy that have been used include: Zidovudine 100mg five times a day starting from preferably the

second trimester, followed by zidovudine 2mg/kg loading dose, then 1mg/kg/hr during labour and to the baby zidovudine syrup 2mg/kg/6hrly beginning at 8-12 hours after birth for 6 weeks.

Combination therapy A single dose of Nevirapine 200mg at the onset of labour followed

by a single dose to the infant at 48-72 hrs of life 4mg/kg 23.6 Abnormal Pap smear HIV positive women should have a gynaecological examination annually. This should include a visual inspection of the cervix after application of acetic acid and a Pap smear. Women with symptomatic HIV infection and those with HIV infection and a CD4 lymphocyte count of 200/mm3 or less should have a Pap smear performed every 6 months.

267

Hypogonadotrophic amenorrhoea Severe weight loss (15-20%) can be associated with hypothalamic disorder and functional hypogonadotrophic hypogonadism. This can result in menstrual disturbance or amenorrhoea similar to that seen in anorexia nervosa. History and specific investigations such as LH/FSH levels will point to the diagnosis. Improvement of body weight will usually result in resumption of menstruation. Emotionally stressful events, which are not uncommon in HIV-infected individuals may result similarly in amenorrhoea. Some women can present with severe menopausal symptoms, in which case, HRT may be used. Menorrhagia In cases with thrombocytopenia, menorrhagia can present due to delayed clotting of the blood. History of other bleeding events as well as simple platelet count will help make a diagnosis. Treatment of thrombocytopenia will reduce menstrual blood flow. Other treatment options include: Tranexamic Acid 500 mg twice or three times a day for the time of the period or suppression of menstruation by Depo Provera injection, which may require higher than contraceptive doses. Management of menstrual disorders Current standards of care for HIV-positive women neither approve nor forbid the use of hormonal therapies or birth control for menstrual regulation. Stress management and nutrition may relieve symptoms. Dilatation and curettage (D&C) may be necessary to exclude endometrial polyps or endometritis. If D&C reveals no pathology give the patient low estrogen combined pill (30 days cycle), or if this is contraindicated give progestogen only pill. Alternatively give the patient Norethisterone 5 mg BID for 15 days. 23.3 Contraception HIV-infected women should be advised to use reliable forms of contraception such as Norplant or injectable Medroxyprogesterone (Depo Provera) together with condoms. It should be noted that antiretroviral drugs might interact with the metabolism of synthetic oestrogens. Preferably in appropriate cases female or male sterilisation should be performed.

266

23. WOMEN WITH HIV/AIDS 23.1 Introduction HIV disease can be devastating because of the stigma of sexual transmission and the risk of vertical transmission to children. It requires continued counseling and multidisciplinary support. Genital infections are risk factors for HIV transmission and acquisition. These include genital ulcer disease, chlamydial and gonococcal infection. In addition bacterial vaginosis appears to be very common in some women and may also constitute a risk factor. HIV infected women should be urged to use condoms to prevent transmission of infection as well as becoming re-infected with HIV or other STIs. This section will focus on the gynaecological and obstetric aspects of HIV infection. 23.2 Menstrual disorders Up to 40% of HIV-infected women experience menstrual disorders. Disorders experienced by women with HIV infection may be exacerbated by weight loss, anaemia, drugs and medications and psychological problems such as depression. Menstrual disorders in women with HIV infection include: Absence or suppression of menstruation (amenorrhea), Irregular periods Menorrhagia Oligomenorrhoea Intermenstrual bleeding Worsening of symptoms associated with premenstrual syndrome

In women with menstrual disorders it is important to carry out some investigations, such as, detailed history and careful clinical examination, pregnancy test, full blood count, haemoglobin and platelet levels, visual inspection of the cervix, bimanual pelvic examination and Pap smear.

265

hyperplasia" or "follicular hyperplasia". A lymph node biopsy is necessary to establish a cause (See Box below).

Cervical Disease Cervical disease is clinically evident in 12% to 45% of patients. The neck is the third most common site of PGL. In decreasing order sites involved are: posterior triangle, pre and post auricular regions, submandibular triangle and occipital regions. Patients may have associated pharyngeal follicular hyperplasia and enlarged tonsils leading to otitis media with effusion secondary to eustachian tube obstruction. It is important to exclude TB, Kaposi’s Sarcoma, Lymphoma and metastatic carcinoma. And therefore it may be necessary to to carry out biopsies of lymph nodes or fine needle aspiration.

Criteria for performing a lymph node biopsy A patient with PGL should be referred for a lymph node biopsy if he/she has any of the following: • Lymph nodes are asymmetrically enlarged • There is massive enlargement of lymph nodes, i.e., at least one lymph

node measures more than 3 cm in diameter • Lymph nodes are getting bigger over a period of observation • There is evidence of TB on chest x-ray • There is evidence of enlargement of hilar lymph nodes on chest x-ray • There is evidence of Kaposi's sarcoma elsewhere in the body

266

23. WOMEN WITH HIV/AIDS 23.1 Introduction HIV disease can be devastating because of the stigma of sexual transmission and the risk of vertical transmission to children. It requires continued counseling and multidisciplinary support. Genital infections are risk factors for HIV transmission and acquisition. These include genital ulcer disease, chlamydial and gonococcal infection. In addition bacterial vaginosis appears to be very common in some women and may also constitute a risk factor. HIV infected women should be urged to use condoms to prevent transmission of infection as well as becoming re-infected with HIV or other STIs. This section will focus on the gynaecological and obstetric aspects of HIV infection. 23.2 Menstrual disorders Up to 40% of HIV-infected women experience menstrual disorders. Disorders experienced by women with HIV infection may be exacerbated by weight loss, anaemia, drugs and medications and psychological problems such as depression. Menstrual disorders in women with HIV infection include: Absence or suppression of menstruation (amenorrhea), Irregular periods Menorrhagia Oligomenorrhoea Intermenstrual bleeding Worsening of symptoms associated with premenstrual syndrome

In women with menstrual disorders it is important to carry out some investigations, such as, detailed history and careful clinical examination, pregnancy test, full blood count, haemoglobin and platelet levels, visual inspection of the cervix, bimanual pelvic examination and Pap smear.

267

Hypogonadotrophic amenorrhoea Severe weight loss (15-20%) can be associated with hypothalamic disorder and functional hypogonadotrophic hypogonadism. This can result in menstrual disturbance or amenorrhoea similar to that seen in anorexia nervosa. History and specific investigations such as LH/FSH levels will point to the diagnosis. Improvement of body weight will usually result in resumption of menstruation. Emotionally stressful events, which are not uncommon in HIV-infected individuals may result similarly in amenorrhoea. Some women can present with severe menopausal symptoms, in which case, HRT may be used. Menorrhagia In cases with thrombocytopenia, menorrhagia can present due to delayed clotting of the blood. History of other bleeding events as well as simple platelet count will help make a diagnosis. Treatment of thrombocytopenia will reduce menstrual blood flow. Other treatment options include: Tranexamic Acid 500 mg twice or three times a day for the time of the period or suppression of menstruation by Depo Provera injection, which may require higher than contraceptive doses. Management of menstrual disorders Current standards of care for HIV-positive women neither approve nor forbid the use of hormonal therapies or birth control for menstrual regulation. Stress management and nutrition may relieve symptoms. Dilatation and curettage (D&C) may be necessary to exclude endometrial polyps or endometritis. If D&C reveals no pathology give the patient low estrogen combined pill (30 days cycle), or if this is contraindicated give progestogen only pill. Alternatively give the patient Norethisterone 5 mg BID for 15 days. 23.3 Contraception HIV-infected women should be advised to use reliable forms of contraception such as Norplant or injectable Medroxyprogesterone (Depo Provera) together with condoms. It should be noted that antiretroviral drugs might interact with the metabolism of synthetic oestrogens. Preferably in appropriate cases female or male sterilisation should be performed.

268

23.4 Pregnancy Women presenting with amenorrhoea should be investigated for pregnancy. Management Offer option to terminate or keep the baby. If she wants to keep the baby, plan for a caesarean section and no breast-feeding. Prepare for provision of nevirapine 200mg to the mother during labour and nevirapine to the neonate in order to prevent the mother-to-child transmission of HIV. See also counseling under nursing care requirements. 23.5 Vertical transmission Vertical transmission occurs in 25-40% of pregnancies if no interventions are given. A combination of antiretroviral therapy, Caesarean Section and avoidance of breastfeeding can reduce the risk to less than 3%. Antiretroviral therapy that have been used include: Zidovudine 100mg five times a day starting from preferably the

second trimester, followed by zidovudine 2mg/kg loading dose, then 1mg/kg/hr during labour and to the baby zidovudine syrup 2mg/kg/6hrly beginning at 8-12 hours after birth for 6 weeks.

Combination therapy A single dose of Nevirapine 200mg at the onset of labour followed

by a single dose to the infant at 48-72 hrs of life 4mg/kg 23.6 Abnormal Pap smear HIV positive women should have a gynaecological examination annually. This should include a visual inspection of the cervix after application of acetic acid and a Pap smear. Women with symptomatic HIV infection and those with HIV infection and a CD4 lymphocyte count of 200/mm3 or less should have a Pap smear performed every 6 months.

269

Management Women found to have an abnormal Pap should be referred for colposcopy and biopsy. Early lesions can be treated with loop excision or cryo-therapy. Early stages of cervical cancer are treated with surgery. In late stages for example stages 2b and above, radiotherapy is indicated. 23.7 Cervical intraepithelial neoplasia (CIN) Cervical intraepithelial neoplasia presents as dysplasia of the surface layers of the cervical cells. CIN is classified according to degrees of severity. There are 3 grades of CIN: grades I, II or III. Patients with CIN usually have no symptoms, the diagnosis being made on cytologic examination of Pap smears and on colposcopy and biopsy. It is therefore important that all women with abnormal Pap smears, i.e., smears showing any atypical cellular activity (including persistent inflammation), be referred for expert opinion. Management CIN-I: No therapy needed, but patient should be monitored closely and regular Pap smears should be performed CIN-II-III: Any of the following modalities of treatment may be used: laser vaporization treatment, loop electric excision procedure (LEEP), excision biopsy, cryotherapy - this option may be the least desirable as it may mask

future problems 23.8 Sexually transmitted infections SEE CHAPTER ON STIs 23.8.1 Human papillomavirus (HPV) infection HPV infection can be severe and persistent in immunosuppressed women. Chronic HPV infection can result in cervical pre-cancer or cancer, vulval

270

intraepithelial neoplasia and Bowen´s disease. Approximately 20% of HIV-infected women have severe cervical intraepithelial neoplasia (CIN). Because of this cervical screening should be performed annually and persistent vulval lesions should be biopsied in women with HIV infection. For women with AIDS, 6 monthly cervical screening is appropriate. Approximately 30 types of HPV can infect the genital mucosa but only 17 are carcinogenic with types 16, 33 and 18 being the commonest in our population. Treatment of HPV infection may not be effective until the immune anti-HPV response controls viral replication. This can be achieved if antiretroviral treatment is given. 23.8.2 Herpes simplex virus (HSV) infection HSV is the commonest cause of genital ulcers in immunosuppressed individuals. A herpetic genital ulcer that persists for more than one month is indicative of immunosuppression. Herpetic ulcers are often multiple, deep, recurrent and painful. HSV has been implicated in postpartum endometritis in HIV-infected women. Diagnosis is made on clinical findings. Treatment is effective in reducing the severity of the symptoms and controlling the extent of lesions and to prevent the recurrence of lesions. Acyclovir 200mg PO given five times a day for five days is an effective treatment. In persons with persistent and protracted ulcers it is appropriate to prescribe a long-term treatment with acyclovir 400mg PO BID. 23.8.3 Genital candidiasis Vaginal candidiasis can be severe and recurrent in women with HIV infection. Patients present with itching and soreness of the vulva and vagina, and complain of a white discharge. The pH of the vagina is usually normal and microscopy or culture of the discharge confirms diagnosis. Topical treatment is preferable. A variety of pessaries and creams containing imidazole or nystatin are available. In severe cases systemic treatment with a single dose 150mg of Fluconazole is effective if the pathogen is Candida albicans only. In recurrent infection once or twice monthly treatments can be offered.

271

23.8.4 Bacterial Vaginosis About 50% of HIV-infected women will present with vaginal fishy smelling discharge due to this condition. The organisms commonly associated with bacterial vaginosis are anaerobic bacteria such as Gardnella vaginalis, Bacteroides spp, Mobiluncus and Mycoplasma hominis. Diagnosis is made clinically using Amsel criteria: vaginal pH>4.5, release of fishy smell on addition of 10% potassium hydroxide, characteristic discharge on examination and presence of “clue cells” on microscopy. The treatment is Metronidazole 400mg orally twice a day for five days or 2g as a single oral dose. 23.9 Prevention of Malaria during Pregnancy HIV-infected women are more likely to develop malaria during pregnancy if they are at risk of this infection. Therefore they should be advised to use malaria prophylaxis. 23.10 Nursing care requirements The nursing care requirements for women with HIV infection are summarised in Table 23.1.

Table 23.1 Nursing care requirements for women with HIV infection Condition Nursing Intervention Pain and discomfort related to genital lesions, PID, dysmenorrhoea, dyspareunia

Administer prescribed analgesia. Advise on fowler’s position for PID. Use hot or cold compresses for dysmenorrhoea, vaginal jellies to relive dyspareunia

Altered nutrition related to disease condition as evidenced by loss of weight

Give information on well balanced diet. Increase caloric intake to provide energy. Encourage diet with increased fat and carbohydrate in diet and also use fruit and vegetables, and natural unrefined foods.

Risk for infection related to reduced immunity

Encourage long term antibiotics like Cotrimoxazole to prevent Pneumocystis pneumonia (PCP). Hand washing Proper disposal of sanitary pads and good perineal care

Knowledge deficit Client education regarding diagnosis, signs and symptoms, and

272

related to disease process

management and complications, and referring to tangible psychosocial support. Self-care strategies including use of condoms

Anxiety and distress related to stigma

Find out the source of anxiety. Counsel according to the client’s needs

Vaginal discharge due to STI, bleeding,

Perineal care, relevant antibacterial creams, use of antiperspirant deodorants

Pruritis related to vaginal discharge, herpes, or unhygienic practices

General hygiene, antimicrobial vaginal pessaries, perineal care

Fluid volume deficit related to vomiting, diarrhoea or excessive sweating

Encourage to drink at least 8 glasses of water per day. If she cannot tolerate this amount of water, other drinks or fluids may be taken according to preference.

Fluid volume excess related to generalised oedema

Administer prescribed diuretics. Encourage exercise especially of the lower limbs. Elevate limbs when sitting down

Altered self concept

Counseling

Altered role concept as mother and wife

Counseling

Self-care deficit Counseling, assistance with activities of daily living

273

24. PREVENTION OF MOTHER-TO-CHILD TRANSMISSION OF HIV INTERVENTION 24.1 Overview of PMTCT interventions Prevention of mother-to-child transmission (PMTCT) of HIV is one of the key HIV prevention strategies in Zimbabwe’s national response to the HIV/AIDS epidemic. Mother-to-child transmission (PMTCT) of HIV is the most significant source of HIV infection in children below the age of 15 years. Over 90% of HIV infection in infants and children is due to PMTCT. About 30 to 35% of pregnant women are HIV positive. Without any PMTCT intervention, about a third of the HIV infected women will pass the virus to their babies. It is estimated that about 20% of the infected babies become infected during pregnancy, 60% during labour and delivery, and 20% after birth through breast-feeding. Most infections therefore occur during labour and delivery. The goal of Zimbabwe PMTCT is to reduce PMTCT of HIV infection, thereby leading to reduction of infant morbidity and mortality. The Four Main Strategies for PMTCT in Zimbabwe are: Primary prevention of HIV infection in Women of childbearing age

and their partners. Prevention of transmission of HIV to the infant during pregnancy

and breastfeeding Prevention of unwanted pregnancies in HIV infected women. Care and Psychosocial support to HIV infected women and their

families PMTCT practices need to be carried out during the antenatal period, labour and delivery and post-natal period including after hospital / clinic discharge.

274

24.2 Summary of antenatal care practices

All pregnant women offered VCT

Continue routine ANC Offer VCT at subsequent visits Carry out individual

pretest counselling

Proceed to HIV rapid testing

Post Test

Counselling NEGATIVE

POSITIVE

Continue routine

ANC and reinforce messages at each

visit

NO

YES Informed consent for HIV testing?

Group information

• Give Nevirapine • Counselling on infant feeding • Offer partner counselling • Discuss “safer sex” and offer

condoms • Look for signs and

symptoms • Discuss positive living

Discuss window period, offer further HIV test in 3 months if “high risk”

Offer partner VCT and encourage involvement

Discuss safer sex and give condoms

Encourage breastfeeding

275

24.3 Summary of practices during labour and delivery

Woman presents to labour ward in “labour”

Carry out labour and delivery using SAFE OBSTETRIC PRACTICES:

• Use of the partogram • Avoid ARM where possible Avoid unnecessary episiotomy Minimise trauma from instrumental

delivery and routine suctioning of baby’s mouth/nostrils

Clamp cord immediately after birth and do not “milk”

Dry baby and keep warm immediately after birth

Apply baby friendly practices

YES

Give baby 0.6ml NVP syrup immediately after birth AND repeat at 72 hours age

NO

Establish that it’s true labour

If false labour replace

Nevirapine and

discharge Ensure Nevirapine has been taken

POSITIVE HIV status

NEGATIVE OR UNKNOWN

HIV exposed baby

Mother did not take NVP OR took NVP less than 2 hours

before delivery

Routine postnatal

care of infant

276

24.4 Summary of post natal practices

Woman has delivered her baby

Educate/counsel mother on the following issues: • Good hygiene/cord care • Signs and symptoms of infection in both herself and her

baby. • Importance of good nutrition • Family planning (dual protection) • Importance of follow up visits • Encouragement to seek health care promptly if problems

arise in herself or baby • Encourage safe sex • Encourage VCT for partner

Establish HIV Status

Positive Negative Support chosen infant feeding method If unwell, refer Give Nevirapine to baby at 48 – 72 hrs Complete Child Health Card including

PPTCT code

Support breast feeding

DISCHARGE mother and infant Give date of first follow up visit (ten to

fourteen days post delivery)

277

24.5 Summary of long term follow up & care

Schedule of visits for mother/infant follow up:

• 10 – 14 days • 6 weeks • Monthly up to 18 months

INFANT: Counselling on infant feeding and

address any problems. Encourage exclusive breast feeding

for 6 months followed by rapid weaning For non-breastfeeding, ensure

hygienic preparation and adequacy of feeds including micro nutrient supplementation

Monitor growth Monitor development Follow routine immunisation schedule Give cotrimoxazole prophylaxis and

increase dose according to age* Monitor signs and symptoms of HIV

infection and refer appropriately

Check HIV status at 18 months

MOTHER: Monitor mother’s weight

and give nutritional advice Cotrimoxazole

prophylaxis if indicated* Refer appropriately if ill Discuss and provide

family planning, emphasis on dual protection

Referral for psychosocial support

Positive Negative

Discharge from PMTCT follow up

Continue cotrimoxazole prophylaxis *

Continue nutrition and growth monitoring

*MOTHER COTRIMOXAZOLE PROPHYLAXIS DOSES 2 tablets OD

*INFANT COTRIMOXAZOLE PROPHYLAXIS DOSES 6 wks – 5 months: 2.5ml OD 6 – 18 months: 5ml OD 18 months – 3 yrs: 7.5ml OD 3 yrs onwards: 10ml OD (10ml = 1 tablet)

278

25. PAEDIATRIC HIV INFECTION 25.1 Introduction 30-40% of pregnant women in Zimbabwe carry HIV and 30-40% of them will pass on the infection to their child during pregnancy or breastfeeding. 50-60% of childhood admissions to Hospital are HIV related. 25.2 Diagnosis of HIV infection in children Under the age of 18 months it is difficult to distinguish the child

who is actually infected with the virus from the one who is just carrying maternal antibody using the HIV tests available in Zimbabwe. No totally satisfactory clinical diagnostic criteria have been established except in the presence of recognizable AIDS defining illnesses.

It is important to take a good history and carry out a thorough examination.

If HIV is suspected then precounseling is important before an HIV test is done.

After 18 months of age a positive HIV test is diagnostic of HIV disease in a child. Clinical suspicion of HIV disease should always be confirmed by an HIV anti body test at or after 18 months of age.

Many conditions in a developing country context are common in both the HIV infected and the non infected :- malnutrition, Tuberculosis, persistent diarrhoea, generalised lymphadenopathy.

The presence of any 2 of the conditions listed below and positive HIV serology should lead to a suspicion of HIV infection till proved otherwise at 18 months till proved otherwise.

279

In children HIV infection may be suspected if: The child's mother is known to be HIV positive, One or both parents have had tuberculosis or are known to be

chronically ill One or both parents are dead One or more siblings are known to be chronically ill or have died Child has one or more of the symptoms listed below:

25.2.1 General clinical features The following symptoms and signs are suggestive of HIV if they occur in the absence any known concurrent illness: Growth failure in a child less than six months who is fully breastfed. Growth failure lasting three months or more. Severe stunting in a child less that 12 years. Child falls below the 5th percentile on the weight for height chart

on 2 consecutive measurements taken 30 days or more apart Fever lasting more than one month, recurrent or continuous. Serious recurrent bacterial conditions, septicaemia, pneumonia, bone

or joint infection, abscess of an internal organ or body cavity. Generalised lymphadenopathy - lymph nodes at two or more sites

measuring at least 0.5cm and present for more than 1 month Parotid enlargement lasting more than one month Severe dental caries in an African child Oral and oral pharyngeal candidiasis in a breastfed child older than

one month Oesophageal candidiasis. Finger clubbing in the absence of congenital heart disease

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25.2.2 Respiratory system Severe /very severe pneumonia in a child 2-12 months of age. LIP/PLH as diagnosed on chest x-ray - persistent generalised miliary

like nodular pattern in a well child Chronic suppurative lung disease

25.2.3 Cardiovascular system Cor pulmonale Cardiomyopathy

25.2.4 Gastrointestinal system Persistent or recurrent diarrhoea: at least two loose stools a day

for >30 days Persistent hepatomegaly/splenomegaly in the absence of any other

condition other than HIV Acquired rectovaginal fistula

25.2.5 Central nervous system Failure to attain, or loss of, developmental milestones or loss of

intellectual ability Acquired microcephaly demonstrated by head circumference

measurements or brain atrophy as seen on CT scan Acquired symmetric motor deficit manifested by two or more of the

following, paresis, pathological reflexes, ataxia, or gait disturbance, increased muscle tone

Recurrent bacterial meningitis in the absence of a predisposing factor

Cryptococcal meningitis,

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25.2.6 Dermatologic manifestations Severe seborrhoeic dermatitis Zoster Generalised fungal dermatitis Kaposi’s Sarcoma Extensive perineal or skin warts

25.2.7 General Infections Children with HIV have a tendency to recurrent bacterial infections

which may need treatment with antibacterials for longer period than for non-HIV children.

Daily Cotrimoxazole prophylaxis in symptomatic HIV children may reduce morbidity and hospital admissions and prolong life.

25.3 The respiratory system in children with HIV In the first year of life respiratory infections are the commonest cause of morbidity and mortality. PCP and CMV dominate the picture in the first 6 months while bacterial infections and PCP in that order dominate the picture from the second 6 months of life. After the first year of life recurrent bacterial infections are the common causes of morbidity and mortality. Both acute and chronic tuberculosis are found in children of all age groups. Mixed infections occur commonly. 25.3.1 Management of severe and very severe pneumonia in high (10% or more) HIV prevalence areas Admit the child. Treat with crystalline penicillin/ ampicillin and gentamycin given IV

and high dose cotrimoxazole given orally. Give steroids 2mg/kg/day once daily If there is no improvement after 5 days think of other conditions,

do a lumbar puncture, arrange for a chest x-ray (if not done

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previously) and consider changing the crystalline penicillin/ampicillin to chloramphenicol or cephalosporin,

If the child is still not better and is spiking temperatures after 10 days, consider the addition of anti-tuberculous treatment

Always give supportive therapy described in the box below: Supportive therapy is always critical

If the child is improving continue to treat with high-dose

cotrimoxazole for a minimum of 21 days and send home on cotrimoxazole prophylaxis for PCP in those whose HIV status is positive or unknown. Start tapering off steroid dose after 7 days.

25.3.2 Children 12-24 months with severe pneumonia Treat with crystalline penicillin/ampicillin and gentamycin Review after 48 hours If the child is improving, continue treatment for a total of 10 days If the child is not improving, add steroids as above and high-dose

cotrimoxazole to the regimen and look for other causes of problems,

Supportive therapy

Oxygen by headbox, nasal prongs, mask. If very cyanosed and able to monitor IV fluids give 75mls per kg per 24 hours

of 1/2 dextrose darrows, Maintelyte or neonatolyte. If unable to monitor fluids pass a nasogastric tube and give Expressed breast

milk at 80-100ml per kilogram per day 3 hourly. Feed by cup once improvement has occurred after 48 hours. If frothing with acute pulmonary oedema give stat dose of frusemide

0.5mg/kg IV or IM followed by 1mg/kg PO.

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such as, missed meningitis and empyema and investigate for tuberculosis.

If not totally better by 10 days consider commencing antituberculous treatment and refer the child for specialist opinion

Check the HIV status and if positive send home on PCP prophylaxis. 25.3.3 Children 2-16 years of age with severe pneumonia Treat with crystalline penicillin or ampicillin or amoxycillin If not responding add gentamicin and high dose cotrimoxazole Look for TB and other infections If not improving after 10 days refer the child for specialist opinion

Steroid use The use of steroids in children with pneumonia remains a controversial topic as it is possible that CMV infection and TB may be disseminated and worsened in children with these infections. Studies are currently underway to determine whether steroids have a beneficial effect and until such a time that the results of such studies are known it is recommended that steroids in the form of hydrocortisone or prednisolone be used only in desperately ill children: Prednisolone 2mg/kg/day in two divided doses orally. 25.3.4 Pulmonary lymphoid hyperplasia This is a slowly progressive lung disease whose aetiology is unknown. It is an AIDS-defining illness and is usually seen after the first year of life. It is often associated with parotid enlargement, generalised lymphadenopathy, hepatosplenomegally and digital clubbing. Children are usually well though in severe cases they may have chronic cough, progressive breathlessness and getting fatigue with exercise. Chest X-ray may look like miliary tuberculosis and the X-ray features do not change with TB treated. Corpulmonale may complicate its course. Such children should be referred for specialist opinion.

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25.3.5 Suppurative lung disease and bronchiectasis in children aged 2 to 16 years This may be suspected clinically in children with a productive cough that is worse in the mornings and on going to bed. There may be persistent rales in one or more lobes of the lung, and there may be lung fibrosis with tracheal traction to one side of the chest. Chest x-ray may show the lesions but it is best diagnosed on CT scan of the chest with or without contrast. Sputum examination and culture may reveal organisms such as Pseudomonas, Klebsiella or Staphylococcus. Treatment is with chest physiotherapy for drainage and crystalline penicillin, ampicillin, chloramphenicol or gentamicin are given for 10 days or more. The child should be referred for specialist opinion and management. 25.3.6 Tuberculosis Both acute and chronic tuberculosis occur commonly in children with HIV infection. Tuberculosis has always been a difficult diagnosis to make in children and the problem is more complex in children with HIV infection as a number of conditions that occur in HIV infected children mimic TB. These include HIV related failure to thrive, unexplained fever and chronic cough. In addition immunosuppressed persons may have an unreactive Mantoux test. Tuberculosis accelerates the progress to AIDS and HIV makes Tuberculosis worse. A high index of suspicion for TB needs to be maintained at all times . The diagnosis and case finding would be greatly facilitated if contact tracing for TB was efficient. In children under 5 years treatment for latent tuberculosis is recommended as the risk of progression of the primary complex is higher than in adults. Suspect TB in the presence of the following: Persistent pyrexia despite treatment with antibiotics and

cotrimoxazole Persistent cough of more than three weeks, Unexplained loss of appetite and weight Abnormal episodes of sweating,

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Recurrent chest pains that are often poorly defined. Contact with a tuberculous adult Unresponsive failure to thrive Isolated or generalised lymphadenopathy Recurrent subacute intestinal obstruction Persistent lobar consolidation/collapse shadows on chest x-ray Straw coloured high protein non-purulent pleural, pericardial or

ascitic fluid Monoarthritis Erythema nodosum

Diagnosis Every effort must be made to get microbiological or pathological confirmation. Acid fast bacilli (AFB) should be looked for in induced sputum, and gastric aspirates may also show AFBs. A reactive Mantoux test greater than 5mm is suggestive of TB. Histologic examination of lymph node and liver biopsies and pleural, pericardial, synovial and peritoneal biopsies may be diagnostic. Lymph node aspirates should be examined for AFBs. Bone marrow aspirates should also be examined for AFBs. All material should be sent for microscopy, culture and sensitivity in order to monitor for multi-drug resistant TB. If TB is strongly suspected and laboratory tests do not confirm the diagnosis there is room for a trial of TB therapy provided this is carried out in controlled circumstances and for a period not exceeding two months and after consultation with a specialist. Treatment Follow the National TB Guidelines. Identify and treat the adult from whom the child got TB and other family members who are at risk.

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25.4 ENT conditions Recurrent, chronic suppurative otitis media is common in HIV infected children and may contribute to social isolation in the older child because of the foul smelling ear. It is difficult to treat. Microscopy and culture of the discharge may grow pseudomonas, s.aureus, anaerobic organisms, or multiple drug resistant organisms. It may be complicated by mastoiditis and facial nerve palsy, brain abscess, partial deafness. For acute episodes of less than 2 weeks duration should be treated with Amoxycillin. Acute on chronic episodes should also be treated with Amoxycillin. Mainstay of treatment for chronic otitis media is dry mopping of the ear as often as is necessary to keep the ear dry. If still discharging for more than 2 months refer. Mothers must be discouraged from plugging ears or instilling any form of eardrops into the ears. Acute Sinusitis: Acute sinusitis is a common cause of headache in the older HIV positive child. It usually occurs 3 to 5 days after a bout of an acute cold. The cold may be more severe than usual often associated with a high fever of >390 C, periorbital oedema and facial pain and tenderness. Nasal blockage may be present or there may be an upper respiratory tract infection that is not getting better after 10 days. Postnasal discharge is often present. The diagnosis is by examining x-rays of the facial sinuses. It is important to exclude other causes of headache. Children should be treated with Amoxycillin, for 14-21 days. 25.5 Gastrointestinal system 25.5.1 Mouth Several conditions affect the mouth of the child with HIV and are critical to the nutrition of the child. SEE CHAPTER ON ORAL MANIFESTATIONS OF HIV INFECTION.

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Oral candidiasis This is a major cause of morbidity and malnutrition in children. Children may present with the following symptoms: Refusal to eat or to suck Alteration in taste Burning taste in mouth Odynophagia, painful swallowing Dysphagia Sores in the mouth Often discovered on routine exam

The diagnosis is usually made on clinical examination. The child may have white plaques on an erythematous base. Other presentations of oral candidiasis include erythematous and pseudomembranous candidiasis and angular cheilitis. Refer to Oral chapter for treatment Herpetic gingival stomatitis This condition usually appears as small painful white ulcers on the tongue, tonsils or gingival margin associated with erythema and bleeding from the gums with or without some herpetic vesicles around the mouth area. If the condition is severe, persistent, extensive or recurrent, the child should be referred for specialist opinion. REFER TO ORAL CHAPTER FOR MANAGEMENT 25.5.2 Oesophagus Oesophageal Candidiasis The diagnosis of candidial oesophagitis should always be considered in severely immunosuppressed children and in children with oral candidiasis. The child may be unable to suck or to eat or swallow and may cry on

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feeding, swallowing and vomiting. The older child may complain of retrosternal pain and heartburn. REFER TO CHAPTER ON FUNGAL OPPORTUNISTIC INFECTIONS 25.5.3 Gastroenteritis It is important to note that acute, recurrent, and especially persistent diarrhoea is more common, and up to 10 times more deadly in HIV positive infants compared to HIV negative infants. Risk factors for gastroenteritis include: Early introduction of other foods other than breastmilk, Mother is ill or has died Malnutrition

The importance of exclusive breastfeeding in the first six months of life for those mothers who are HIV negative or whose status is unknown or who are HIV positive but have not got the capacity to use breast milk substitutes cannot be over-emphasised.

Hand washing with soap or ash is the most effective proven method of prevention. The most important considerations in managing children with diarrhoea are the prevention and management of dehydration and the prevention and management of malnutrition. All children should be managed according to the Guidelines set out in EDLIZ and in the IMCI manuals. Persistent diarrhoea Persistent diarrhoea is defined as diarrhoea lasting more than 2 weeks. This is much more frequent in HIV infected children and is often the cause of malnutrition and death. The more frequent the episodes of recurrent diarrhoea are in an infant, the greater the risk for development of persistent diarrhoea and malnutrition. Rehydration and the maintenance of nutritional status of the HIV child thus becomes the most important strategy for survival in diarrhoeal episodes. Always consider the possibility of lactose intolerance and hence test the stool for reducing

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substances if possible. The possibility of systemic illness like urinary tract infection should always be considered. Pathogens associated with persistent diarrhoea Children with HIV infection and immunosuppression are prone to infection with a number of enteric pathogens. Whenever such an infection is suspected attempts should be made to identify these through laboratory tests. Table 25.1 summarises the features associated with some of these pathogens.

Table 25.1 Clinical features and management of enteric pathogens associated with persistent diarrhoea Organism Clinical signs Diagnosis Treatment Cryptosporidiosis

Frequent non-bloody diarrhoea, abdominal cramps, fever, vomiting, anorexia, weight loss

Stool microscopy, for C. parvum. 3 stool samples on separate days

None consistently effective. Paramomycin, Spiramicin Azithromycin and Bovine colostrum has been tried

Campylobacter

Fever, abdominal pain, malaise, visible or occult blood in stool

Darkfield microscopy or culture with special isolation techniques

Erythromycin 40-60mg /kg /day in 3-4 doses Tetracycline for children>8 years Aminoglycosides for septicaemia

Isospora belli

Protracted, foul smelling watery diarrhoea, abdominal pain, anorexia, weight loss, fever, vomiting, headache

Oocysts in stool and duodenal aspirates

Cotrimoxazole for 2 to 4 weeks, or if allergic, Pyrimethamine 50-75mg/kg per day for 1 month, then 25mg / kg / day plus folinic acid 5mg daily

Microsporidium

Watery, non-bloody diarrhoea, weight loss

Formalin fixed specimen of stool for spores or duodenal aspirates

Albendazole for 3 weeks, or Metronindazole, or Atavoquone, and Nutritional supplements Diarrhoea may recur after therapy

NOTE: Milk feeds should be mixed with porridge to reduce lactose

concentration, Sour milk or yoghurt are better tolerated Foods rich in vitamin A, folic acid and Zinc include liver, kidney,

green vegetables, fish, beans should be encouraged Vitamin supplements should be given

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Bloody diarrhoea If a child presents with diarrhoea with blood and mucus in stools he/she should be managed as for dysentery. It is important to try and identify the cause of the dysentery by sending fresh stool specimens to the laboratory for microscopy culture and sensitivity. Children are usually managed initially with Nalidixic acid and rehydration together with nutritional advice. If the patient fails to respond to initial treatment consider other organisms, such as, Salmonella spp., Campylobacter, Escherichia coli as causes. Alternative treatments are Ciprofloxacin 7.5 - 15mg/kg/day or Ceftriaxone 20 to 80mg/kg/day for 3 to 5 days. 25.6 Central nervous system 80% of HIV-infected children develop nervous system involvement. Direct effects of HIV infection in children are seen on the brain, spinal cord and the peripheral nerves. In addition the nervous system may be affected by the development of opportunistic infections and cancers. Children also suffer from illnesses of the nervous system not related to HIV infection and immunouppression and need to be treated for these if they occur. 25.6.1 AIDS dementia complex AIDS dementia complex results from HIV infection of the brain resulting in progressive cerebral atrophy with decline in cognitive, behavioural and motor function. It carries a poor prognosis and invariably has a fatal outcome. Clinical manifestations Affected children usually fail to attain expected milestones, have evidence of regression of milestones already acquired. Microcephaly may be evident and there may be symmetrically increased or decreased muscle tone and pathological reflexes. The onset may be abrupt or insidious and progression is relentless, with chronic or relapsing features. Nervous deficits may however remain static for some time. Seizures do not usually occur and

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when they do occur other causes should be sought. Older children may have features similar to those seen in adults. SEE CHAPTER ON NEUROLOGIC MANIFESTATIONS 25.6.2 Focal encephalitis Focal encephalitis may occur in HIV infected children and is usually the result of opportunistic infection such as toxoplasmosis, herpes simplex vuris infection and cytomegalovirus infection. Diagnosis The diagnosis of focal encephalitis is made on clinical suspicion confirmed by brain imaging and serology. The treatment of toxoplasma encephalitis is with: Cotrimoxazole 60mg/kg 12 hourly for 2 weeks, Or Pyrimethamine 2mg/kg/day for 3 days then 1mg/kg /day (maximum

25mg) given for 4weeks, Plus Sulfadiazine100-200mg/kg/day for 3 to 4 weeks, Plus Folinic acid 5mg PO OD, Plus Lifelong prophylaxis with Pyrimethamine 1mg/kg /day (maximum

25mg) PLUS Sulfadiazine 85 to 120mg/kg/day given with Folinic acid 5mg given every 3 days.

SEE CHAPTER ON NEUROLOGIC MANIFESTATIONS 25.6.3 Diffuse encephalitis Diffuse encephalitis may be caused by meningitis or malaria. SEE CHAPTER ON NEUROLOGIC MANIFESTATIONS

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25.6.4 Spinal cord HIV infection can lead to vacuolar myelopathy. This causes gait dysfunction. The lower extremities are affected more than the upper extremities. There may also be mild sensory loss and cognitive decline. Diagnosis Spinal cord imaging may reveal atrophy of the cord with vacuolation. Cerebrospinal fluid examination should be carried out to exclude tuberculous and cryptococcal meningitis. SEE CHAPTER ON NEUROLOGIC MANIFESTATIONS 25.7 Nutrition HIV infection itself leads to weight loss in the advanced stages. The problem is compounded by the lack of macro- and micro-nutrient supplementation. Malnutrition alone can lead to immunosuppression, and is a major determinant of outcome of common afflictions in the HIV infected child. It is important to carry out nutritional assessments in all children and simple measures may be used for this. Children who are malnourished may require admission and hospitalized care. The following criteria may be used for admitting children: Weight for height less than 70% Presence of bilateral pedal pitting oedema Mid upper arm circumference less than 12cm in a child in child more

than 6 months old Marasmus (Weight less than 60% of expected weight for age with

no oedema) if no height available. Visible severe wasting – if no measurements are available

25.6.1 Treatment of malnutrition All children aged less than 6 months who have not gained weight for more than two months should be referred.

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For the management of severe acute malnutrition therapeutic feeding is usually carried out with two formulae F75 which has 100 Kcals per 130 mls and F100 which is equivalent to 100 Kcals per 100mls. These formulae are easily prepared from local ingredients ( see appendix 3). In severe malnutrition, the oral rehydration solution (Resomal ) is different (see appendix 3. In children aged 6 months or more malnutrition is treated in 3 phases: Phase 1: Return to normal homeostasis and treatment of complications. Treat immediate complications like infections, heart failure,

anaemia, hypoglycaemia, hypothermia, septic shock, dehydration. Severe infections are difficult to detect in children with severe

malnutrition. It is therefore advisable to treat all treat with crystalline penicillin and gentamycin for 7 days.

Give F75 at 130 ml/kg/day in 8 meals – (F75 - 130mls =100 calories). If very severe oedema or child very sick reduce this by 20% till child can better tolerate full dose.

Continue F75 until child has a good appetite and has evidence of loosing oedema and has no diarrhoea or other severe illness. Transition phase give F100 at the same dose for at least 2 days or until the oedema has completely subsided. Phase 2: Promote rapid weight gain. Give 160-220 calories/kg/day - (F100 - 160-220 mls /kg/day) - To

be started when child has good appetite, all oedema has gone, and no more complications.

Can be given in 6-8 meals Can be given as outpatient in day care units Start introducing normal diet slowly making sure child takes all

prescribed F100

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Any time complications arise go back to phase 1. Vitamins and minerals should be given as well as folate 5 mg once

then 5mg twice weekly, vitamin A on days 1, 2, and 14, and ferrous sulphate after 2days in phase 2.

Vitamin A dose: 0-6 months 50,000 IU 7-11months 100,000 IU, 12 months and above 200,000 IU Mebendazole 200 mg on discharge where indicated.

NOTE: If not possible to carry out this feeding programme as prescribed

treat as in EDLIZ. Only non-complicated cases of severe malnutrition should be treated in District.

If very severe oedema present or no response to F75 in 7 days, refer

Malnutrition in HIV child not qualifying for therapeutic feeding manage as in EDLIZ

25.8 Haematological disorders Anaemia Anaemia is common in children with HIV infection and can independently worsen the outcome of infection. Anaemia is defined as a haemoglobin or haematocrit level of less than that shown for the age groups below: 6 months to 4 years - Haemoglobin: 11g/dl Haematocrit: 33% 5 to 11 years - Haemoglobin: 11.5g/dl Haematocrit: 34% 12 to 14 years - Haemoglobin: 12g/dl Haematocrit: 36% Symptoms of anaemia do not usually develop until the haemoglobin level drops to less than 8g/dl.

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Causes of anaemia in HIV-infected children include: Anaemia of chronic infections or infiltrations Malabsorption of folate Iron deficiency from chronic bleeding, low birth weight, dietary

deficiency and causes such as malaria and hookworm infestations. Iron deficiency is very common in non-breastfed infants and should be looked for. Diagnosis The diagnosis of anaemia is usually made on clinical findings and confirmed by laboratory tests. In all children with anaemia blood should be sent to the laboratory for a full blood count (FBC), peripheral blood film examination and comment, reticulocyte count, malaria parasites, and unconjugated bilirubin levels, and stool should be examined for parasites. Treatment Treat the underlying cause, such as, underlying infection, TB, worm

infestation and malaria Give Iron and Folate as in EDLIZ. If not responding after one month refer.

Transfusion may be indicated If, Anaemia is severe, i.e., haemoglobin level less than 4g/dl There is overt or impending congestive cardiac failure and the

haemoglobin level is less than 6g/dl There is malaria and a haemoglobin level of less than 6g/dl There is respiratory distress in a child with malaria

Thrombocytopenia Usually cause by auto-immune reactions.

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Need to rule out other serious underlying conditions such as sepsis. Treat with steroids is level below 10,000 or actively bleeding. Pancytopaenia Need to rule out other serious underlying conditions such as sepsis. Treat with steroids. 25.9 Skin conditions REFER TO SECTION ON SKIN CONDITIONS

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26. HAEMATOLOGIC DISORDERS Haematological disorders are frequently encountered in PLWHA. In addition to the haematological problems caused by opportunistic infections and the toxic effects of drugs, including antibiotics and antiretrovirals, HIV affects the haematologic system by invading stem cells. 26.1 Anaemia Anaemia is defined as a haemoglobin level less than 13.8g/dl for men and less than 11.7g/dl for women. Anaemia of chronic disease is very common in the HIV-infected persons. Treatment of anaemia leads to an improved quality of life. However, very rarely is there a need for intervention when the haemoglobin level is above 10g/dL and thorough investigation at these levels is not necessary in persons with HIV infection. Patients with haemoglobin levels less than 6g/dL are invariably symptomatic and need investigations. 26.1.1 Clinical features Patients who have gradual declines in haemoglobin may be asymptomatic even at very low haemoglobin levels. Patients may complain of weakness, palpitations, and dyspnoea on exertion, dizziness, headache and malaise. It is important to check for fever, weight loss, pain and other symptoms suggestive of infectious or neoplastic aetiology. Always review the list of drugs that the patient is taking. Examine the patient and note any abnormal findings such as lymphadenopathy, hepatosplenomegaly, tumours, tachycardia and pallor. Confirm anaemia with a full blood count; check the reticulocyte count, the MCV and peripheral blood smear. Table 26.1 gives guidance on the approach to the investigation of anaemia based on the reticulocyte count and the MCV. 26.1.2 Investigation of anaemia A full blood count and haematologic indices together with haematinic assays, i.e., serum iron, folate and vitamin B12 levels should be performed in anaemic patients. Depending on the results of such tests, further tests may need to be carried out to establish the cause of anaemia.

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Bone marrow aspirates and trephine biopsies should be examined for morphology and cellularity and should be stained by the Ziel Nielsen method and examined for tuberculosis. An examination of the buffy coat may reveal parasites. In persons with HIV infection and AIDS the bone marrow is hypercellular and dysplastic in 80%, and hypoplastic in 20%. Table 12.1 summarises the investigations that need to be carried out in anaemic persons with HIV infection.

Table 26.1 Investigating anaemia in persons with HIV infection Low reticulocytes and low MCV

Low reticulocytes and normal MCV

Low reticulocytes and high MCV

High reticulocytes

Iron deficiency from blood loss from neoplasm, GI infection, e.g., CMV, or from menorrhagia. Reduced intake in very ill patients.

Cause may be drugs (atovaquone, dapsone, primaquine, pyrimethamine, ganciclovir, amphotericin, flucytosine, others); neoplasm; infections; renal failure; anaemia of chronic disease. Marrow aplasia. Combined haematinic deficiencies.

May be due to B12 or folic acid deficiency; malabsorption; liver disease; ARTand other drugs; autoimmune process. Marrow aplasia.

Consider hemolysis due to oxidant drugs; if the RBCs are fragmented and thrombocytopenia is present, DIC or TTP may be causing the problem

Further tests: Stool for

occult blood x 3; if positive may need endoscopy to determine cause of bleeding

Iron studies, including, ferritin, transferrin, TIBC. Ferritin often elevated in anaemia of chronic disease, but low level will confirm iron deficiency.

Haemoglobin electrophoresis (for patients with

Further tests: AFB and fungal blood

cultures Look for OIs Fever work up Biopsy or fine needle

aspiration of lymph node to exclude neoplasm, mycobacteria

Refer for bone marrow test for suspected lymphoma, neoplasm, B-19 parvovirus

Further tests: B12 level RBC folate Direct Coombs test

Further tests: Peripheral blood smear, Platelet count Direct Coombs test

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normal iron studies)

Bone marrow studies

NOTES: Additionally, for symptomatic patients, or those with declining

haemoglobin levels < 7, arrange for urgent transfusion. Discontinue offending drugs, if appropriate substitutes available,

and monitor FBC. Treat appropriately if infectious pathogen identified (see applicable

treatment guidelines), or if neoplasm detected. With B-19 parvovirus infection, the patient is likely have a

reticulocyte count of <0.2%, and a profound isolated anaemia, compared to fungal, parasitic, or mycobacterial infections, in which the patient usually has pancytopenia

An elevated LDH, low haptoglobin, or increased indirect bilirubin would support the diagnosis of haemolysis

Patients with HIV-related anaemia usually respond to control of viral replication using ART.

Refer for treatment of neoplasm or bleeding. 26.1.3 Management of anaemia The mainstay in the management of anaemia is correcting the cause where possible. Blood transfusion may be used as a temporary measure. It is important to withdraw drugs that may be implicated in causing anaemia. It is also important to search for infections. Androgenic steroids and erythropoietin are also used in treating anaemia. NOTE: All antiretroviral may be used in patients with pre-existing anaemia

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Declining haemoglobin levels indicate need to review drugs prescribed and possible withdrawal of certain drugs such as zidovudine

In patients in whom no treatable pathology is identified, manage as follows: If normocytic and isolated anaemia (haemoglobin more than 10 g/dL), and patient with no unexplained constitutional symptoms, the most likely diagnosis is anaemia of chronic disease. Close follow-up and avoidance of haematotoxic medications is indicated. Note: Patients with symptomatic anaemia and erythropoeitin levels less than or equal to 500 IU/L may benefit from erythropoeitin 100-200 U/kg given 3 times a week till RBC count normalizes. RBC must be checked weekly, as polycythaemia can occur. Injections are then given weekly. Patients who do not respond to erythropoeitin may have occult iron, folate, or B12 deficiency, which must be corrected for response to occur. 26.2 Leucopenia White cell abnormalities occur commonly in HIV-infected persons; leucopenia is found in 11%, neutropenia in 30%, lymphopenia in 32% and eosinophilia in 25% of cases. In persons with severe neutropenia the management is with broad spectrum antibiotics when fever is also present. The use of colony stimulating factors, e.g., G-CSF “Neupogen”, provides a transient rise in neutrophils and therefore should not be used in persons with neutropenia with septicaemia. Intravenous immunoglobulin has a role in limiting infections and stimulating an increase in white cells. 26.3 Thrombocytopenia Thrombocytopenia occurs in 25% of patients with HIV infection. It is not an indication of disease severity on its own but is more severe in advanced AIDS. Thrombocytopenia occurs as a result of the effects of HIV infection on the bone marrow and also as a result of autoimmune processes suggestive of idiopathic thrombocytopenia (ITP). Thrombotic thrombocytopaenic purpura (TTP) should be considered in cases where renal impairment and red cell fragmentation are present.

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26.3.1 Management Prednisolone 1mg/kg body weight is given daily for 10 to 12 weeks. Persons who do not respond to this should be treated with azathioprine. Failing this splenectomy should be considered together with the usual vaccines and antibiotic prophylaxis pre- and post-splenectomy should be given. There is little evidence that short-term immunosuppressive therapy and even splenectomy have an adverse effect on the outcome of the HIV. 26.4 Coagulation and thrombophilia Lupus anticoagulant and phospholipid antibodies have been demonstrated in over 20% of HIV/AIDS patients. The presence of lupus anticoagulant results in a prolongation of the activated partial thromboplastin time (APTT). However lupus anticoagulant is clinically associated with thrombosis rather than haemorrhage and both arterial and venous thrombosis have been reported in persons with HIV infection. 26.4.1 Management Thrombosis should be managed by anticoagulation, initially with heparin and then with warfarin, maintaining an INR around 2 to 4. Anticoagulation should be continued for 3 months. It is important to monitor the patients’ platelet count as well. Management of haemorrhage that may occur as a result of a coagulopathy due to the presence of other antibodies, is with transfusions of fresh frozen plasma and platelets. This management is reactive to, rather than elective, as there are no laboratory tests that predict bleeders. 26.5 Hypergammaglobulinaemia Most patients with HIV/AIDS are hypergammaglobulinaemic until the very advanced stage of AIDS when they may become hypogammaglobulinaemic. The increase in gammaglobulin can lead to the hyperviscosity syndrome which is diagnosed by measuring the viscosity of plasma.

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27. HIV-ASSOCIATED CARDIOMYOPATHY 27.1 Introduction Cardiac disease has been reported in patients with AIDS based on clinical, echocardiographic and autopsy findings. While abnormalities are often clinically silent, patients have developed pericarditis, congestive heart failure, cardiomyopathy, focal myocarditis, abnormal wall motion, pericardial effusions and cardiac tamponade. Cardiac abnormalities may be caused by primary HIV infection of the myocardium, by superinfections or by the sequelae of drug therapy, substance abuse, renal impairment, or pulmonary disease. Pathogens such as CMV, toxoplasmosis, candida, EBV, and coccidiodes have been discovered to affect the myocardium. HIV-related cardiomyopathy is characterized by left ventricular dilatation and hypocontractility, which may result in heart failure and pulmonary congestion. Clinical cardiomyopathy is seen in 1-4% of AIDS patients. 27.2 Clinical aspects The patient complains of difficulty breathing, swelling of the legs, or chest pain at mid-sternum. Frequently patients are asymptomatic. In the history, note the presence of previous cardiovascular disease, hypertension and medications that the patient is taking. Note also that some nucleoside reverse transcriptase inhibitors cause mitochondrial toxicity that can lead to myocardial failure. Substance abuse, especially cocaine, injecting drug use or alcoholism can lead to myocardial disease. Other cardiotoxic medications are adriamycin and foscarnet. On physical examination check for pulsus paradoxus as well as signs compatible with congestive heart failure such as raised jugular venous pressure, displaced apex, palpable pulsatile liver, crepitations in the chest and leg oedema. Poor quality heart sounds, loss or displacement of apex beat, tricuspid or mitral valve murmurs (related to valvular insufficiency), are early signs. Late signs include: signs of pulmonary congestion; peripheral oedema. In the differential diagnosis, always consider pericardial effusion (most common aetiology is TB or MAC), pericardial lymphoma or KS, other viral

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myocarditis and hypertensive cardiomyopathy. If there is evidence of cardiac tamponade, the patient will need a pericardial tap. Refer the patient for expert opinion. Investigations that need to be performed include: Chest x-ray PA and lateral CXR – this may show a globular, enlarged

heart, evidence of pericardial effusion or pulmonary oedema. ECG which may show non-specific T wave and ST segment changes Echocardiography is useful in determining the cause and type of

heart failure, the ejection fraction and to rule out pericardial effusion.

Pericardiocentesis is necessary for large effusions or tamponade (or for any effusion accompanying clinical pericarditis with pain and fever). Fluid should be sent for chemistry, microscopy and culture and stained and cultured for microbiologic entities, including AFB. Fluid should also be examined for neoplastic cells. 27.3 Management The patient should rest in bed and should be nursed in the cardiac

position. Diuretics should be given e.g frusemide 40 – 80mg daily. You need to

get a diuresis and hence may need to keep increasing the doses of the Frusemide.

Afterload reduction with ACE inhibitors should be commenced for clinical congestive cardiac failure and reduced systolic blood pressure (Note: if there is good left ventricular function with diastolic dysfunction, avoid ACE inhibitors and afterload reducers and instead use nitrates, diuretics, beta blockers or calcium channel blockers.

If patient is not on ART, this should be commenced as it may be helpful to the patient's condition.

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Low salt diet: schedule with dietician for instruction. Consider discontinuation of all unnecessary drugs, especially

nucleosides (ddI or ZDV) for 4 weeks; and repeat ECHO in 2 weeks - if these drugs are the cause, the condition is usually improved.

Consider digitalis if ejection fraction is very low (< 25%). Commence anticoagulants prophylactically Monitor electrolytes biweekly for 2 months after starting diuretics;

then monthly after stabilization. Give the patient the following advice: Reduce stress, take appropriate rest, and maintain adequate

nutritional intake. The diuretics prescribed to you will make you urinate more often.

Keep legs elevated and wear elastic pantyhose to decrease swelling in the legs and feet.

Avoid alcohol, cocaine, and other drugs, which can greatly worsen your heart's function.

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28. HIV-ASSOCIATED NEPHROPATHY 28.1 Introduction Renal disease in HIV infected people can be caused by the same aetiologies as in non-infected people. Therefore, it is important that the same approach i.e that of excluding pre-renal causes initially be adopted in this group of patients. Exclude simple and potentially reversible causes such as hypovolaemia as a result of vomiting and diarrhoea; hypotension e.g. in septicaemic syndromes, malaria; drug toxicities e.g. with use of high dose cotrimoxazole, amphotericin B infusions. HIV infection can complicate existing renal disease and cause two types of pathologically distinct diseases, namely, HIV-associated immune-mediated renal disease, and HIV-associated nephropathy (HIVAN). One type of HIV-associated immune-mediated renal disease is thought to be caused by immune complexes with HIV itself; another is precipitated by Hepatitis C, which is very common in injection drug users and others with HIV. The HCV-related variety can present more like HIVAN, with nephrotic syndrome, hypertension, and rapid progressive renal insufficiency. 28.1.1 HIV-associated immune mediated renal disease HIV-associated immune-mediated renal disease presents with low-grade proteinuria, haematuria, and mild or no renal insufficiency, and rarely progresses to end-stage renal disease. Immune complexes are deposited in the glomeruli, leading to proliferative glomerulonephritis and renal insufficiency. In contrast, HCV-related immune-mediated disease can produce cryoglobulinemic glomerulonephritis and progresses to end-stage disease quickly. The diagnosis can only be made on histologic and electron microscopic examination of renal tissue obtained by biopsy. 28.1.2 HIV-associated nephropathy(HIVAN) HIVAN has a poor prognosis, usually progressing from a focal glomerulosclerosis to end-stage renal disease over the course of weeks or months. It produces a high-grade proteinuria and normal or large kidneys

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with increased echodensity on ultrasound. HIVAN was once thought to be related to intravenous drug use, but is now thought to be a direct effect of HIV gene expression in the kidneys. Treatment with ACE inhibitors and HAART has been shown to be beneficial if instituted early. Dialysis(preferably Haemodialysis) is the only treatment in end-stage renal disease. 28.2 Clinical aspects Renal failure should always be anticipated in those who are unwell for any reason. Thus, urinalysis and blood urea and electrolytes should be ordered as soon as possible. In HIVAN, the patient complains of easy fatigue, swelling of limbs and face, or generalized swelling. Examination may reveal peripheral oedema. The blood pressure is usually normal. With renal failure due to other causes, the history and clinical examination may suggest the underlying cause. 28.2.1 Differential diagnosis: Table 26.2 Classification of renal diseases in persons with HIV infection Prerenal Renal Postrenal Dehydration Vomiting, diarrhoea Sepsis NSAIDs Hypotension

Acute tubular necrosis Drugs, e.g., amphotericin B, aminoglycoside therapy, acyclovir, radiocontrast Hypotension Acute interstitial nephritis caused by sulphamethoxazole, dapsone, NSAIDs, rifampin, UTI Glomerular diseases HIVAN, HCV-related renal disease Microangiopathic haemolytic anaemia

Exclude the usual potential causes such as; schistosomiasis, renal stones, cervical cancer, prostatic hypertrophy. Consider obstruction due to drugs, e.g., sulfadiazine, indinavir, acyclovir

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NOTE: Rule out diabetes; obstruction (stones, neoplasia); hypertension;

drug toxicity (IV pentamidine, NSAIDs, indinavir, foscarnet, amphotericin B, or aminoglycoside therapy); syphilis; extrapulmonary/renal TB, hypotension due to dehydration.

28.3 Investigations Anticipate renal dysfunction whenever the patient is unwell. Assess the urinary volume and the patient’s volume status. Is the patient dry, fluid over loaded or normovolaemic? Remember that a normal serum creatinine does not exclude renal failure. 1. Document renal insufficiency with blood urea and creatinine. 2. Arrange kidney ultrasound - increased echodensity is a common finding in HIVAN. Large-stone obstructions will also be visible, facilitating emergency referral. 3. Do a urinalysis to exclude haematuria and proteinuria. An MSU is needed to check for infection. 4. Obstruction may be in the tubules, not visible on ultrasound. In these cases, vigorous re-hydration usually restores renal function. 5. Sediment showing brown or granular casts suggests acute tubular necrosis. Acute nephritis usually shows white cells, cellular casts, proteinuria and /or haematuria. White but cloudy urine usually suggests a severe urinary tract infection. 6. If there is sterile pyuria, consider TB, malignancy and stones. If tuberculosis is suspected, send urine for AFB staining and culture each morning for 3 days. Renal TB may be concurrent with pulmonary disease. 7. Always quantify both the 24-hour urinary proteinuria as well as the creatinine clearance. In nephrotic syndrome, serum albumin is decreased, with increased serum cholesterol and peripheral edema; 24 hour urine usually will show >3 g protein. 8. Measure calcium, phosphate and albumin levels. Elevated serum phosphate requires phosphate binders(e.g Calcium Carbonate given with meals) plus dietary control of phosphate intake.

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9. Renal biopsy gives the most accurate histological diagnosis whenever the cause of the renal failure is not clear. It is not necessary for the diagnosis of HIVAN. 28.4 Management 1. Institute fluid/volume status management and appropriate dietary restrictions such as low potassium diet (usually means no bananas and no oranges). 2. Discontinue nephrotoxic medications. 3. Use of steroids in patients with HIVAN can be beneficial; using prednisolone 1mg/kg e.g. 60 mg/day for up to 12 weeks decreased protein excretion and serum creatinine. The steroid dose should start to be reduced after one month. 4. Especially for HIVAN, ACE inhibitors, if used before significant decline in renal function, can decrease protein losses by decreasing glomerular filtration rate. Most patients progress rapidly to end-stage renal disease within 6-8 months, although earlier diagnosis of renal disease, more aggressive treatment, including haemodialysis and HAART are changing the prognosis. 5. Highly active antiretroviral therapy may improve prognosis for HIV-associated nephropathy. 6. If renal tuberculosis or untreated syphilis is discovered, begin appropriate treatment for the underlying condition immediately. 7. Refer to specialist early in the course of disease so plans may be made for dialysis where it is appropriate and deemed to be life saving. Dialysis in HIV infected people Acute peritoneal or haemodialysis dialysis can be offered for acute renal failure just like in any other non-HIV infected people. The goals of dialysis therapy in end-stage renal failure due to HIVAN are essentially palliative unless there is going to be the use of HAART. These goals need to be discussed and made clear to the patient and the caregivers. Use of CAPD in advanced AIDS is not to be recommended as the person is at risk of recurrent peritonitis and hence a poor quality of life. Transplantation is not an option in our setting and this should be emphasised. Pre-Dialysis Counseling – Extensive counseling forms an important aspect of the management of those who require dialysis especially if it is going to

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be needed chronically. The doctor cannot offer this on their own. Hence it is recommended that all potential dialysis patients be referred to the Renal Coordinator or Nurses for counseling as soon as possible. The Renal Coordinator will help the non- nephrologists with making rational decisions regarding dialysis availability and suitability for the mode of dialysis proposed. The Renal Coordinator is also able to liaise with the family/Dialysis Centres regarding the various logistical issues involved in preparing and starting a patient on dialysis. Pre-Dialysis Patient Education 1. End-stage renal disease(ESRD) from what ever cause in HIV is a serious illness. It is important to discuss issues of disability and death with the patient at this point. It may be helpful to learn how the patient might feel about peritoneal dialysis or Haemodialysis well in advance of this treatment being needed, if dialysis is a possibility for the patient. Pre-dialysis familiariastion with the Dialysis Centres and what they can provide is crucial for success on dialysis. 2. Special diets such as low protein/phosphate, low potassium diet and medications such as captopril can prolong kidney function and life. 3. Discuss antiretroviral therapy, if appropriate. 4. Consult with dietician to learn about renal diet and fluid restrictions.

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29. GUIDELINES ON DISCHARGE PLANNING 29.1 Definition of discharge planning Discharge planning is the process of moving the patient from one level of care to another. The process should start on admission of the patient by assessing the patient’s needs and identifying resources available. The process should incorporate the multidisciplinary approach and involve all the appropriate health team professionals and offer holistic patient care. 29.1.1 Vision of the planners The vision of discharge planners is to ensure continuity of quality of patient care by preparing the family and / or refer the patient to a relevant community based care program. 29.2 Objectives of discharge planning The objectives of discharge planning are to: Identify the patient’s needs Identify the resources and support available to the patient Identify the level of involvement of the patient and his/her family

in the preparation of continued care Educate the patient, family and caregiver on the patient’s condition,

management, potential environmental changes and lifestyle, e.g. wheelchairs, catheters and nasogastric tube

Strengthen the coordination and communication within the family and between the various carers

Identify the discharge team members Develop a framework for the support of the health care worker and

other service providers in the discharge process. Monitor and evaluate the discharge process.

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29.3 Stages in discharge planning The following areas should be considered when planning the discharge of any patient: Health assessment Planning Implementation Evaluation and monitoring Discharge and handover of the patient

The activities that need to be conducted in order to address these areas may be grouped into a number of stages that are described further: 29.3.1 Stage 1 - Health Assessment These activities start on admission or at first contact with the patient and are on-going and sometimes overlapping History taking: demographic data collection, (including bio-social and

medical). Physical examination Data analysis Medical diagnosis/ nursing diagnosis.

29.3.2 Stage 2 - Support systems assessment An assessment of support systems should include: Home assessment Assessment of availability of community resources Assessment of caregivers’ needs Accurate and comprehensive documentation of information

Communication of findings to relevant multidisciplinary team members should be undertaken.

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29.3.3 Stage 3 - Setting short and long term objectives The short- and long-term objectives of care should be clear and should be based on the health assessment carried out. Important components are: Prioritization of the needs of the patient and family Use of the multidisciplinary approach to plan for interventions Consideration of available human, financial and material resources. Drawing up of the schedule for implementing interventions such as

counseling, physical home adjustments etc. 29.3.4 Stage 4 - Implementation Care needs of the patient will need to be individualized for each patient: Identification and provision of services required by the patient Information giving and counseling about services offered on the

community home based care program Assessment of the patient on an ongoing basis and adjustment of

care plan. Mobilization of resources e.g. drugs, bandages Record keeping of care plan Liaison and coordination of patient care with other team members

i.e. pharmacy, TB coordinators, physiotherapist, social workers, counselors etc.

29.3.5 Stage 5 - Evaluation The efficacy and feasibility of the care plan should be monitored and evaluated periodically. This may be carried out by: Using a checklist to assess progress of implementation. Review of records Re-planning where necessary.

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29.3.6 Stage 6 - Discharge and hand over of the patient When a patient is moved from one care level to another or from one care provider to another sufficient details should be passed on: The results of the final assessment should be documented Filling in of discharge and referral forms (see Section 29.5) Remind clients and relatives of follow up system and the need to

attend for review on specified dates and for replenishing drug supplies

Advise patient and relatives of the need to seek hospital assistance when worried

Make transport arrangements if applicable Collaboration with relevant disciplines for the referral and further

management at the next level Liaise closely with the Discharge Plan Coordinator who will plan,

coordinate and link closely with the appropriate receiving institution, such as, Island Hospice, community home based care teams, health institutions, homes and others

Discharge and hand over of patients

Identified Resources and Support Systems

Relevant community home based care programs Immediate family caregiver Health care provider Social services Physiotherapy/rehabilitation NGOs and churches for spiritual and material support Community – mobilize people and provide resources, transport etc Nutritionist Basic care items in the homes (gloves, disinfectant, dressings etc).

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29.4 Discharge plan checklist 1. On admission

Health assessment History and Physical examination Laboratory results

2. During hospital stay

Identify the patient’s needs Involvement of the client and family in preparation for continued care Education of the patient and family or caregiver Home and community resources assessment

3. Discharge and handover of the patient

Final Health assessment Fill in the discharge and referral forms Facilitate or supply or prescribe the patient with the relevant drugs Educate the patient and caregiver about their drugs Coordination with the relevant community support groups Facilitate transport needs Hand over the patient

29.5 Discharge form The following is an example of a Patient Discharge Summary (To be completed in triplicate)

Copy to the patient Copy for the receiving institution Copy to the discharging institution

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Section 1 Demographic Data Name of Facility From: ……………………………………………………………… Name of Facility To: ……………………………………………………………… Name of Patient: ……………………………………………………………………… Hospital Number:…………………. ID Number:……………………… Age: ………………..Sex:……………… Marital status: ..……. Number of dependants:……………… Home Physical address: ……………………………………………………………………………………… ……………………………………………………………………………………… Home Telephone Number: ……………………………… Address of nearest School/ Kraal Head or Chief: ……………………………………………………………………………………… Occupation: ………………………………………………………………………………. Name And address of Employer: ……………………………………………………………………………………… Telephone Number of Employer: ……………………………………………………… Name of Caregiver / Next of Kin: ……………………………………………………… Attending Doctor: ……………………………………………. Date of Admission: ………………… Date of Discharge: …………………… Date of next appointment: ………………

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Section 2 Discharge Considerations Attending Doctor: ……………………… Date of admission: …………………Date of discharge: …………………….. List Problems/Complaints: ……………………………………………………………………………………… Key clinical findings: ……………………………………………………………………………………… Key results: ……………………………………………………………………………………… Doctors /Final Diagnosis: …………………………………………………….. Discharge to:

Home Nursing home Other

Condition on discharge: Able to walk Able to eat Passing urine well Passing stool well In pain Wounds

Key concerns on discharge: ……………………………………………………………………………… Condition on discharge: …………………………………………………………………………………. Activities of daily living: Bathing…………………………………………………………………… Feeding…………………………………………………………………………… Dressing…………………………………………………………………………… Mobility…………………………………………………………………………… Communication…………………………………………………………………… Ability to cope at home: ……………………………………………………………………………………… Specific Instructions ……………………………………………………………………………………… List Drugs Prescribed: Supplied Prescription given

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………………… Yes /No Yes / No

……………….. Yes / No Yes / No

……………….. Yes / No Yes / No

……………….. Yes / No Yes / No

Relevant Dietary advice (specify): ……………………………………………………………………………………… Other special instructions: Wound Care…………………………………………………………………………. Infection control (universal precautions)……………………………………………. Prophylactic drugs………………………………………………………………….. The condition has been explained adequately and counseling given. Signature of Patient / Significant Other ………………………….. Signature of Discharging Doctor/Nurse ………………………… Follow up Instructions: Review Date: …………… Review Person ………… 29.6 Basic Essential Hospice Drugs Antiemetics: Metoclopromide, Prochloperazine Analgesic: Paracetamol, Aspirin, Codeine, Morphine Laxatives: Bisacodyl, Glycerine suppositories, Liquid paraffin Antibiotics/Antifungals: Cotrimoxazole, Metronidazole, Miconazole oral gel, Miconazole topical cream, Cotrimazole paint Dressings: Crepe bandages, Plaster/ Micropore – gauze, packs, Betadine solution, Betadine scrub, Gloves Miscellaneous: GV paint, Soda Bicarbonate, Mercurochrome, Zinc and Castor oil, Methylated spirits, Indomethacin, Ibuprofen, Diclofenac, Haloperidol, Atropine, Infusion sets for the syringe driver, Water for injection, Dexamethasone, Prednisolone, Catheters: Foley catheter – Sizes 12, 14, 18, 20, 22, 24, 26, Silicon Catheter – Sizes as above, Urine Drainage Bags – Bottom drain / Leg Bags, Peniflows- Sizes Small, medium, Large, Syringes- Sizes 2ml, 5mls, 10ml, 20ml, Needles – Sizes 21g, 23g, 25g.

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APPENDIX 1: RAPID COTRIMOXAZOLE DESENSITIZATION REGIMEN (Suitable for prophylactic dose Cotrimoxazole or high dose Cotrimoxazole for treatment of PCP). Do not desensitize anyone who has had an anaphylactic reaction to cotrimoxazole or a severe skin rash such as a Stevens-Johnson syndrome. Desensitization is usually about 60% effective. Rapid desensitization ideally should be performed during the day in a setting where emergency resuscitation can be provided and adrenaline can be given. Observations during rapid desensitization should be done every 30 minutes before each dose is given and include temperature, pulse and BP. If mild rash or pruritus only occur, administer antihistamine (e.g. chlorpheniramine or promethazine) and continue. If more serious side effects occur such as severe wheeze, severe or symptomatic hypotension, severe rash etc, discontinue desensitisation, manage appropriately and do not try to restart desensitisation. Once cotrimoxazole has been started it can be continued indefinitely as long as no reactions are noted, but if the drug is stopped at any time, there may be a risk of reaction when it is restarted. Using a 1ml syringe put 0.5ml of paediatric Cotrimoxazole 240mg/5ml syrup in 1000ml of 5% Dextrose and mix well.

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Give as follows:

Minutes Quantity of above mixture given orally 0 1ml (use 10ml syringe) 30 10ml (use 10ml syringe) 60 100ml (use 10ml syringe)

Then switch to paediatric cotrimoxazole 240mg/5ml syrup. Minutes Quantity 90 0.5ml 120 5ml 150 480mg tablet 180 Start full prophylactic or therapeutic dose.

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APPENDIX 2: LABORATORY DIAGNOSIS NOTE: Any suspicious skin lesion that is not responding to the recommended treatment should be biopsied and sent for histologic examination in formalin and a portion of the biopsy should be sent in a sterile universal bottle for microscopy and culture. In addition a sample of clotted blood should be submitted. A full description of the lesion and illness as well as treatment given should be provided.

1. Laboratory diagnosis of fungal infections

Pathogen Specimen Transport Laboratory tests Dermatomycoses Skin scrapes,

clippings of hair, skin biopsies

In sterile universal tubes

Microscopy, KOH preparation, culture

Candida albicans Vaginal, oral, genital, oesophageal swabs

Amies transport medium

Gram stain microscopy Culture

Cryptococcus neoformans

CSF, aspirate of pleural fluid, other aspirates, tissue, blood

In sterile universal tubes

Microscopy of fluid and aspirates using India Ink stain, Culture, Cryptococcal antigen test on CSF and serum

Histoplasma capsulatum

Tissue biopsy, sputum, bronchoalveolar lavage, blood

In sterile tube Tissue in formalin

Histologic examination, Culture Complement fixing antibody test (CFT)

Coccidioidces immitis

Tissue biopsy, CSF, bronchoalveolar lavage, blood

In sterile tube Tissue in formalin

Microscopy, culture, CFT

Pneumocystis jiroveci

Bronchoalveolar lavage, induced sputum, transbronchial biopsy

In sterile tube Microscopy after appropriate staining with Romanosky, toluidine, silver methanamine stains, PCR

Pathogen Specimen Transport Laboratory tests

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Herpes virus varicella-zoster (HHV3)

Fluid from lesions, blood

In sterile tubes PCR or IFA on Fluid Serolgy on blood

Herpes simplex virus (HHV 1 and 2)

Fluid from lesions, ulcers, urethra, cervix, conjunctiva, oral mucosa, pharynx, CSF, biopsy tissue, blood

In sterile universal tubes

Cell culture, IFA ELISA and RIBA

Cytomegalovirus Tissue biopsy (lung and liver), prostatic secretions, cervical secretions, CSF, urine, blood

In sterile tube Histologic examination Viral culture Serum antibody

Kaposi’s sarcoma Herpes Virus (HHV8)

Tissue biopsy, blood In sterile tube Tissue in formalin

Histology of tissue PCR for HHV8, HHV8 antibody

Human papilloma virus Tissue biopsy, Pap smear

In sterile tube Cytology, IFA, DNA hybridization, PCR, Electron microscopy

Molluscum contagiosum virus

Tissue biopsy Formalin Histology, cytology, microscopy

Hepatitis B virus Blood, liver biopsy Sterile tube Biopsy in formalin

Antibody and antigen (HbsAg, HbeAg, HBCAb, HbsAb) Histology of tissue

Hepatitis C virus Blood, liver biopsy Sterile tube Biopsy in formalin

PCR for HCV-RNA Histology of tissue

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3. Laboratory diagnosis of bacterial infections Pathogen/diagnosis Specimen Transport Laboratory tests Syphilis Ulcer exudates,

CSF, blood Wet prep for immediate dark field examination

Dark field microscopy for motile treponemes Culture and sensitivity for bacteria Blood and CSF for syphilis serology

Mycobacterium tuberculosis

Sputum, biopsy of tissue, lymph node biopsy, urine, bone marrow, CSF, pleural aspirate

In sterile tubes Ziel Neilsen stain for acid fast bacilli, Special stains, e.g., rhodamine auramine Histology, PCR TB culture and sensitivity: all body fluids and bone marrow

Septicaemia Blood, Always state diagnosis and site of type of specimen

In blood culture bottles

Culture and sensitivity

Pulmonary bacterial infections (pneumonia, lung abscess)

Sputum, blood, State diagnosis and site of type of specimen

In sterile tubes and blood culture bottles

Culture and sensitivity

Salmonelloses Stool, blood, urine, Always state diagnosis and site of type of specimen

In sterile tubes and blood culture bottles

Culture and sensitivity Blood serology (Widal test)

Shigellosis Stool In sterile tubes Culture and sensitivity Campylobacter Stool, blood In sterile tubes Culture and sensitivity,

Serology Clostridium difficile Stool In sterile tubes Culture and sensitivity

Identification of toxin in stool

Bartonella henselii Tissue biopsy, blood

In sterile tube Histologic examination, Microscopy after silver staining, Serologyy

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5. Laboratory diagnosis of parasitic infections Pathogen Specimen Transport Laboratory tests Toxoplasma gondii

Tissue biopsy, blood

In sterile tubes

Microscopy, histology Blood serology (IgG antibody)

Cryptosporidia parvum

Stool, tissue biopsy In sterile tubes

Microscopy for ova and oocysts Modified Ziel Nielsen stain for oocysts Cryptosporidia detected by IFA on stool

Strongyloides stercoralis

Stool, blood In sterile tube Microscopy of stool concentrate for ova Culture stool for larvae Blood serology

Isospora belli Stool In sterile tube Microscopy of stool concentrate Formol ether concentrate

Enterocytozoon bieneusi (Microsporidiosis)

Stool In sterile tube Stool microscopy after staining by Chromotrope 2R method IFA on stool

Sarcoptes scabei Scrapes obtained from typical skin burrows

In sterile tube Microscopic examination for mites

5. Laboratory diagnosis for sexually transmitted infections It is recommended that all patients with STI are treated syndromically in the first instance. The following table shows the organisms that can cause the various STI syndromes and what specimens may be collected and tests performed to confirm the aetiologic diagnosis of STIs.

STI syndrome

Aetiologic agents

Specimens to be collected

Laboratory tests

Urethral discharge

Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis,

Urethral wet prep, Urethral smear, Urethral swab, Urine

Wet prep for T. vaginalis Gram stain for organisms Culture and sensitivity Ligase chain reaction

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Ureaplasma urealyticum

and PCR (on urine and secretions)

Vaginal discharge

N. gonorrhoeae, C. trachomatis, T. vaginalis, Candida albicans, bacterial vaginosis

Vaginal wet prep, Vaginal smear, Vaginal swab, Cervical smear, Cervical swab, Urine

Wet prep for T. vaginalis and yeasts and clue cells Gram stain for organisms Culture and sensitivity Ligase chain reaction and PCR (on urine and secretions)

Genital ulcer

Treponema pallidum, Haemophilus ducreyi, Chlamydia trachomatis (Types L1, L2, L3), Herpes simplex virus, Calymmatobacterium granulomatis

Ulcer wet prep, Ulcer smear and swab, Deep ulcer scrape (when indicated), Fluid from vesicles Blood

Darkfield microscopy Gram stain for organisms Giemsa stain for Donovan bodies Monoclonal antibody test, IFA Culture and sensitivity Blood for syphilis serology and for RIBA and ELISA (herpes)

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STI syndrome Aetiologic agents Specimens to be collected

Laboratory tests

Lower abdominal tenderness

N. gonorrhoeae, C. trachomatis, group B streptococci, anaerobic bacteria

Vaginal wet prep, Vaginal smear, Vaginal swab, Cervical smear, Cervical swab, Urine

Wet prep for T. vaginalis and yeasts and clue cells Gram stain for organisms Culture and sensitivity Ligase chain reaction and PCR (on urine and secretions)

Sexually transmitted inguinal lymphadenitis

Haemophilus ducreyi (chancroid), Chlamydia trachomatis (Types L1, L2, L3) (lymphogranuloma venereum)

Bubo aspirates Gram stain microscopy Culture and sensitivity LCR

Acute scrotal swelling

N. gonorrhoeae, C. trachomatis, mumps virus, other bacteria

Endourethral swab and smear

Wet prep Gram stain for organisms Culture and sensitivity Ligase chain reaction and PCR (on urine and secretions)

Neonatal conjunctivitis

N. gonorrhoeae, C. trachomatis, other bacteria

Conjunctival smear and swab

Wet prep Gram stain for organisms Culture and sensitivity Ligase chain reaction and PCR (on urine and secretions)

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Appendix 3: To calculate and prepare the amount of therapeutic products needed Food needs depend on the type of food used, recipes and ration sizes. Essential food commodities might be obtained from donors (WFP /UNHCR/UNICEF) or be purchased locally and therapeutic products should be purchased through suppliers. The following calculations are based on the requirements of a patient with an average weight of 10 kg and on the assumption that a therapeutic treatment fasts on average 1 month. 1- Therapeutic milk phase 1 -F75. Composition Kcalories (750), protein (9 g), fats (20 g), carbohydrates (133.50 g). TABLE 19: COMPOSITION OF F75 Vitamins: Vit A (1500mcg), vit D (30mcg), Minerals: Calcium (320mg), Vit E (22mg), vit B1 (0.7mg), vit B2 (2mg), phoshorus (240mg), potassium Vit B6 (0,7mg), vit B12 (1 mcg), Vit C (1570mg), magnesium (105mg) (100mg), folic acid (350mcg), niacin zinc (20.5 mg), copper (2.8mg), (10mg), vit K (40mcg), biotin (100mcg), iron(<0.3 mg), iodine (77mcg), pantothenic acid (3 mg) sodium (<130 mg), selenium (47mcg).

Osmolality = 280 mOsm / Kg H2O

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How to prepare F75 Dry skimmed milk, vegetable fat, sugar, malto – dextrin, vitamin and mineral complex. 1 sachet = 410g (net weight) Preparation Dilute 1 sachet in 2litres boiled water to make 2.4litres of reconstituted F75 Alternative way of preparing F75

Type of Milk(g) Eggs(g) Sugar (g) Oil (g) Cereal water Milk powder(g) (ml) DSM 25 0 70 27 35 up to 1000 DWM 35 0 70 20 35 up to 1000 Fresh cow milk 280 0 65 20 35 up to 1000 Fresh goat milk 280 0 65 20 40 up to 1000 Whole eggs 0 80 70 20 40 up to 1000 Egg yolks 0 50 70 15 40 up to 1000

Needs A child needs 130 ml/kg/day of F-75 and stays in phase1 for an of average 3 days, the total requirement of F- 75 per month is: 130 ml/kg/day x 10 kg x 3 days = 4.05 litres per child A sachet (410 g) makes up 2.4 litres of F75, therefore the need for the whole treatment in phase 1 is: 410 g x 4.05 Lt /2.4 Lt = 690 g per child Each carton of F-75 contains 20 sachets of 410 9 (8.2 kg net) and will cover the needs of 12 patients (1.7 sachets per patient). 2- Therapeutic milk for the rest of the treatment -F 100. Composition Osmolarity: < 320 mOsm/L

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TABLE 20: COMPOSITION OF F100

Elements /100g of powder

/1litre of Therapeutic milk

Elements /100g of powder

/1litre of therapeutic milk

Energy 520Kcal 988Kcal Vit B12 1.8 µg 3.4 µg Proteins 13.8g 26.2 g Biotin 65 µg 123.5 µg Lipids 29.2 55.5 g Pantothenic

acid 3.1 mg 5.9 mg

Humidity 2.5g max

-

Vit K 21 µg 40 µg

Vit A 900µg 1710 µg Sidoum 240mg 456 mg Vit D 16µg 30.4 µg Calcium 480 mg 912 mg Vit E 20mg 38 mg Phosphorus 400 mg 760 mg Vit C 53mg 100 mg Magnesium 80 mg 152 mg Vit B1 0.6mg 1.1 mg Zinc 11.8 mg 22.4 mg Vit B2 1.7mg 3.2 mg Iodine 80 µg 152 µg Niacin 5.3mg 10 mg Potassium 1100mg 2090mg Vit B6 Folic acid

0.6mg 210 µg

1.1 mg 399 µg

Copper Selenium

Iron

1.4 mg 25 µg 0.3mg max

2.6 mg 47 µg 0.6 mg max

How to prepare F100 Skimmed milk powder; vegetable fat, lactoserum, dextrin – maltose, sugar, mineral and vitamin complex. 1 sachet = 456g (net weight) Preparation Dilute 1 sachet in 2litres boiled water to make 2.4litres of the reconstituted F100.

• F100 diluted 1 sachet (F100) dilute in 2.7liters boiled water.

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Alternative method of preparing F100

Type of Milk(g) Eggs(g) Sugar (g) Oil (g) water Milk (ml) DSM 80 0 50 60 up to 1000 DWM 110 0 50 30 up to 1000 Fresh cow milk 900 0 50 25 up to 1000 Fresh goat milk 900 0 50 30 up to 1000 Whole eggs 0 220 90 35 up to 1000 Egg yolks 0 170 90 10 up to 1000 One red scoop (6g) of CMV should be added for 2000ml of F75 or F100 reconstituted.

Needs - A child needs to be offered 200 ml/kg/day of F-100 and stays for an average 27 days, the total requirement of F-100 per month is:

200 ml/kg/day x 10 kg x 27 days = 54 litres per chi1d - A sachet (456g) makes up 2. 41itres of milk, therefore the need for the who1e treatment is: 456g x 54 Lt /2.4 Lt = 10kg 260g per child - Each carton of F-I00 contains 30 sachets of 456g. (each patient will consume about 22 sachets). 3- ReSoMal ReSoMal is a special re-hydration solution for the severely malnourished ready to use. Composition Composition: Glucose 55mmol, Sucrose 73mmol, potassium 40mmol, sodium 45mmol, chloride 70mmol, citrate 7mmol, magnesium 3mmol, zinc 300O µmol, copper 45µmol. Its osmofarity is 294mEq/litre A sachet of 84 g has to be diluted in 2 litres of drinking water. Many patients will not require any ReSoMal. There should be provision for 2 sachets per

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treatment for half the patients giving an average of one sachet per patient. However, to have provision for an epidemic of diarrhoea an initial stock provision of 2 packets per anticipated patient should be ordered. How to prepare ReSomal Standard WHO – ORS - 1litre Combined mineral and vitamin mix - 6g (1red scoop) Sucrose (sugar) - 50g Water - up to 2 000ml Alternative method of preparing ReSomal

Ingredient Amount Standard WHO – ORS CMV (Mineral & Vitamin mix) Sucrose (sugar) Water

One 1-litre packet 1 red scoop (6gr.) 50g 200ml

4- Ready- to-use- therapeutic- food (plumpy-nut)

• It is consumed as it is, without prior dilution in water, which eliminates the risk of bacterial contamination, associated with using polluted water.

• It is easy to distribute with a nutritional value of 500 Kcal / sachet. • It can be distributed to the beneficiary with prior knowledge of

quantity distributed and therefore food value (1 sachet = 500Kcal). • A child on its own without help can consume it. • It allows use at home with follow up from the medical centre. • It offers logistics facilities with an optimized ratio weight/volume.

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This form of diet can be distributed allows with a smaller number of staff than required for the preparation and distribution of other foods. . It Is Recommend - that water must always be available to the child who eats Plumpy'nut, - plumpy'nut is only given to children who can express their thirst, - plumpy'nut is only given to children who are not allergic to peanuts (exceptionally uncommon in the areas where most operations are conducted). Composition Vegetable fat, peanut butter, skimmed milk powder, lactoserum, maltodextrin, sugar, mineral and vitamin complex. Composition per 100g: Kcalories (545), of which 10% protein calories and 59% lipid calories. Vitamins: Vit A (910 µg ), vit D (16 µg), vit E (20 mg), vit C (53 mg), vit B1 (0,6 mg), Vit B2 (1,8 mg), vit B6 (0,6 mg), Vit 12 (0,53 µg), vit K (21µg), Biotin (65 µg), Folic acid (210 µg), pantothenic acid (3,1 mg), niacin 5,3 mg). Minerals: Calcium (320 mg), phosphorus (394 mg), potassium (1111 mg), magnesium (92 mg), zinc (14 mg), iron (11,53 mg), iodine (110 µg), sodium (189 mg), selenium (30 µg).

332

Recipes of refeeding formulas F-75 and F-100 F-75a,b F-75c F-100d Dried skimmed milk (g) 25 25 80 Sugar (g) 100 70 50 Cereal flour (g) - 35 - Vegetable oil (g) 27 27 60 Electrolyte/minerals (ml) 20 20 20 Water: make up to (ml) 1000 1000 1000

Contents per 100ml Energy (kcal) 75 75 100 Protein (g) 0.9 1.1 2.9 Lactose (g) 1.3 1.3 4.2 Potassium (mmol) 4.0 4.2 6.3 Sodium (mmol) 0.6 0.6 1.9 Magnesium (mmol) 0.43 0.46 0.73 Zinc (mg) 2.0 2.0 2.3 Cooper(mg) 0.25 0.25 0.25 %energy from protein 5 6 12 % energy from fat 32 32 53 Osmolality (mOsm/l) 413 334 419 a. A comparable starter formula can be made from 35 g whole dried milk,100 g sugar, 20 g oil, 20 ml electrolyte/mineral solution, and water to make 1000 ml. If using fresh cow's milk, take 300 ml milk, 100 g sugar, 20 ml oil, 20 ml electrolyte/mineral solution, and water to make 1000 ml. b. Isotonic versions of F- 75 (280 mOsmol/l) are available commercially, in which maltodextrins replace some of the sugar, and in which all the extra nutrients (K, Mg and micronutrients) are incorporated. c. Cook for 4 minutes. This may be helpful for children with dysentery or persistent diarrhoea. d. A comparable catch-up formula can be made from 110 g whole dried milk, 50 g sugar, 30 g oil, 20 ml electrolyte/mineral solution, and water to make 1000 ml. If using fresh cow's milk, take 880 ml milk, 75 g sugar, 20 ml oil, 20 ml electrolyte/mineral solution, and water to make 1000 mI.

333

Mix the milk, sugar, oil and electrolyte/mineral solution to a paste, and then slowly add the warm boiled water. Make up to 1000 mI. If available, use an electric blender or hand whisk.

334

Appendix 4: Antiretroviral drugs doses LOPINAVIR WITH RITONAVIR Capsules: Lopinavir (133.3mg), Ritonavir (33.3mg) capsules, Dose: For adults and adolescent with body surface area of 1.3m2 or

greater take 3 capsules daily with food. Oral solution: Lopinavir (400mg) with ritonavir (100mg/5ml) Dose: Adults and adolescent with body surface area of 1.3m2 or greater,

5mL twice daily with food. Child over 2 years 2.9mL/m2 twice daily with food, max. 5mL twice

daily; CHILD UNDER 2 YEARS, SAFETY AND EFFICACY NOT ESTABLISHED.

Note: 5mls oral solution = 3capsules EFAVIRENZ Capsules: efavirenz 50mg (yellow/white) Dose: Adult and Child over 3yeras, body-weight 13 – 14kg, 200mg once

daily: body-weight 20 – 24kg, 300mg once daily; body-weight 32.5-39kg, 400mg once daily; body-weight 40kg and over, 600mg once daily.

Oral solution: suager-free strawberry and mint flavour efavirenz 30mg/mL. Dose: Adult and Child over 5years, 13 – 14 kg = 270mg once daily, 15 – 19 kg = 300mg once daily, 20 – 24 kg = 360mg once daily, 32.5 – 39kg = 510 mg once daily, 40kg & over = 720 mg once daily.

Child 3 –4 years, 13 – 14 kg = 360mg once daily, 15 – 19 kg = 390mg once daily, 20 – 24 kg = 450mg once daily, 25 – 32.4kg = 510mg once daily.

335

NEVIRAPINE Dose: 200mg once daily for first 14days then (if no rash present) 200mg twice

daily; Child 2months – 8years, 4mg/kg once daily for first 14 days then (if no rash present) 7mg/kg twice daily (max. 400mg daily); 8-16 years (but under 50kg), 4mg/kg once daily for first 14 days the (if no rash present) 4mg’kg twice daily (max. 400mg daily); over 50kg, adult dose.

Tablets: Nevirapine 200mg Suspension, nevirapine: 50mg/5mL DIDANOSINE Dose: Adult under 60kg 250mg daily in 1-2 divided doses, 60kg and over

400mg daily in 1-3 divided doses. Child over 3months (under 6 years Videx tablets only), 240mg/m2

daily (180mg/m2 daily in combination with zidovudine) in 1-2 divided doses.

STAVUDINE Capsules: Stavudine 15mg (yellow/red) Dose: Adult under 60kg, 30mg every 12 hours preferably at least

1 hour before food; 60kg and over, 40mg every 12 hours; Child over 3 months, under 30kg, 1mg/kg every 12 hours; 30kg and over, adult dose

Oral Solution: cherry-flavoured, stavudine for reconstitution with water, 1mg/mL. ZIDOVUDINE Capsules: Zidovudine 100mg (white/blue band) Tablets: Zidovudine 300mg Syrup: Sugar-free, strawberry-flavoured, zidovudine 50mg/5mL Injection: Zidovudine 10mg/mL. For dilution and use as an

intravenous infusion. Dose: By mouth, 500-600mg daily in 2-3 divided doses;

336

Child over 3 months 360-480mg/m2 daily in 3-4 divided doses; max. 200mg every 6 hours.

Patients temporarily unable to take zidovudine by mouth, by intravenous infusion over 1 hour, 1-2mg/kg every 4 hours(approximating to 1.5-3mg/kg every 4 hours by mouth) usually for not more than 2 weeks.

Child 80 – 160mg/m2 every 6 hours (120mg/m2 every 6 hours approximates to 180mg/m2 every 6 hours by mouth).

INDINAVIR Capsules: Indinivar (as sulphate) 100mg Counselling: Administer 1 hour before or 2 hours after a meal; may be

administered with a low-fat, light meal; in combination with didanisone tablets, allow 1 hour between each drug (antacids in didanosine tablets reduce absorption of indinavir)

Dose: 800mg every 8 hours; Child and Adolescent 4-17 years, 500mg/m2 every 8 hours (max. 800mg every 8 hours); Child under 4 years, safety and efficacy not established.

LAMIVUDINE Tablets: Lamivudine 150mg Oral solution: Banana and strawbery flavoured lamivudine 50mg/5mL. Dose: HIV infection in combination with other antiretrovirals drugs,

150mg every 12 hours or 300mg onc daily; Child 3 months – 12 years, 4mg/kg every 12 hours; max.

300mg daily. Tablets: Lamividine100mg Oral sulution: Banana and strawberry flavoured lamivudine 25mg/5mL Dose: Chronic hepatitis B infection(with evidence of viral

replication and either decompensated liver disease or histologically documented active liver inflammation or fibrosis), adults over 16 years, 100mg daily; patients receiving lamivudine for concomitant HIV infection should continue to receive lamivudine in a dose appropriate for HIV infection.

337

RITONIVAR Capsules: Ritonavir 100mg Oral Solution: Sugar-free ritonavir 400mg/5mL. Oral solution contains 43%

alcohol; bitter taste can be masked by mixing with chocolate milk; do not mix with water, measuring cup must be dry.

Dose: 600mg every 12 hours;Child over 2 years initially 250mg/m2

every 12 hours, increased by 50mg/m2 at intervals of 2-3 days to 350mg/m2 every 12 hours (max. 600mg every 12 hours)

Low-dose booster to increase effect of other protease inhibitors, 100mg evry 12 hours. SAQUINAVIR Capsules: Fortovase (gel-filled) beige saquinavir 200mg. Dose: Adult over 16 years, 1.2g every 8 hours (within 2 hours

after a meal).With low-dose ritonavir, Adult over 16 years, 1g every 12 hours (within 2 hours after a meal).

Capsules: Invirase, brown/green saquinavir (as mesilate) Dose: With low-dose ritonavir, Adult over 16 years, 1 g every 12

hours (within 2 hours after meal). GANCICLOVIR Capsules: Ganciclovir 250mg (green) Dose: By intravenous infusion, initial (induction) treatment, 5mg/kg every

12 hours for 14-21 days for treatment or for 7-14 days for prevention; maintenance (for patients at risk of relapse of retinitis) 6mg/kg daily on 5 days per week or 5mg/kg daily every day until adequate recovery of immunity; if retinitis progresses initial inductin treatment may be repeated.

Maintenance treatment in AIDS patients where retinitis stable (following at least 3 weeks of intravenous ganciclovir), by mouth, 1g 3 times daily with food or 500mg 6 times daily with food or 500mg 6 times daily with food, prevention of cytomegalovirus disease in liver and kidney transplant patients, by mouth, 1g 3 times daily with food.

338

ZALCITABINE Tablets: Zalcitabine 375 micrograms (beige), & 50micrograms (grey) Dose: 750 micrograms every 8 hours; Child under 13 years safety

and efficacy not established. AMPRENAVIR Capsules: Both ivory amprenavir 50mg Dose: Adult over 12 years, body-weight over 50kg, 1.2g every 12 hours;

Adult over 12 years, body-weight under 50kg and Child over 4 years 20gm/kg every 12 hours(max. 2.4g daily), Child under 4 years saftey and efficacy not established. With low-dose ritonavir, Adult over 12 years, body-weight over 50kg amprenavir 600mg every 12 hours with ritonavir 100-200mg every 12 hours.

Oral solution: Grape-bubblegum and peppermint flavoured amprenavir

15mg/mL Dose: Adult and Child over 4 years, 17mg/kg every 8 hours (max.

2.8g daily); Child under 4 years not recommended.

339

INDEX TO HIV/AIDS STANDARD TREATMENT GUIDELINES

340

INDEX

Abdominal pain 159 Anaemia 298 Antiretroviral drugs 40, 335 Antiretroviral therapy 40 ART in adults 49, 66 ART in children 53, 68 ART in pregnancy 52, 67 Clinical monitoring 62

WHO staging sytem 48,55 Bacterial cerebral abscess 178 Candidiasis 210 Cardiomyopathy 303 Cervical cancer 223 Cervical disease 266 Chicken pox 249 Confusion 169, 196 Counseling 14 Bereavement counseling 25 Post-test counseling 19 Pre-test counseling 17 Psychological support 21 Cranial nerve lesions 260 Cryptococcal meningitis 76 Cryptosporidiosis 93 Cyclosporiasis 96 Cytomegalovirus retinitis 146 Diarrhoea 159, 193 Discharge planning 311 Epstein Barr Virus 103 Folliculitis 239 Genital candidiasis 271 Giardiasis 93 Gingivitis 213 Headache 167 Herpes Simplex Virus 99, 218, 247 Herpes Zoster 100, 153, 217 Cytomegalovirus 103

341

INDEX Histoplasmosis 78 HIV infection in children 279 Bloody Diarrhoea 291 Clinical features 280

ENT conditions 287 Oral candidiasis 288

Oesophageal candidiasis 288 Malnutrition 293 HIV infection 10

Primary prevention 11 HIV Testing 35 ELISA tests 35 Interpreting results 37 Rapid tests 35 Home-based care 188

Anorexia 191 Constipation 194 Coughing 188 Gastrointestinal system 191 Haemoptysis 190 Hiccups 191 Nausea 192 Stridor 191 Urinary retention 195 Vaginal infections 195 Vomiting 192

Hospice drugs 318 Human Papilona Virus 270 Impetigo 242 Involuntary movements 174 Isosporiasis 95 Kaposi’s sarcoma 155, 212, 219 Laryngitis 264 Leg cramps 196 Meningitis 176 Menorrhagia 268 Microsporidiosis 94

342

INDEX Molluscum contagiosum 251 Nephropathy 306 Non-Hodgkin’s lymphoma 215, 227 Nutrition in HIV/AIDS 27 Food handling 29 Food Safety 29 Dietary management 31 Oesophageal candidiasis 74 Opportunistic Infections 69 Otitis externa 259 Otitis media 260 Palliative care 200 Pain in AIDS 201

Pain management 202 Analgesics 204

Pap Smear 269 Paronychia 246 Peripheral paraesthesia 172 Pneumococcal meningitis 80 Pneumococcal pneumonia 79 Pneumococcal septicaemia 82 Pneumocystis pneumonia 80 PMTCT in Zimbabwe 274 Post exposure propyhlaxis 74 Post natal care 277 Rashes 237 Rhinitis 262 Salmonellosis 87 Sexually Transmitted Infections 104

Acute Scrotal swelling 131 Genital Ulcers 112 Genital warts 136 Inguinal Buboo 128 Lower Abdominal pain 123 Molluscum Contagiosum 137, 157 Pelvic inflammatory disease 124 Pubic lice 138 Scabies 139, 249

343

INDEX STIs in children 146

STIs during pregnancy 143 Syphillis 140 Urethral discharge 108 Vaginal Discharge 115

Sinusitis 261 Skin conditions 236

In HIV children 253 HIV related 231 Skin infections 237

Stomatitis 214 Streptococcus Pneumoniae 84 Tinea 248 Tonsillitis 258 Toxoplasmosis 177 Tuberculosis 92 Transverse myelitis 179 Urticaria 256 Varicella 253 Warts 255 Weakness 170

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