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Issue 8 September 1989 |
The following story is based on one of the daily activities of the AIDS home care team at Chikankata Hospital, Zambia.
Doris is working in the maize fields, in rural Zambia, when a yellow van belonging to the AIDS home care team arrives at the farm. Two health workers, Zebron and Christine, are bringing the result of a blood test carried out on Doris' 18-month-old baby daughter.
Doris comes in from the fields, but insists on her mother being present before talking to Zebron and Christine. Gently, Christine tells Doris that the baby is infected with HIV, the virus that causes AIDS, and will need a lot of care because she will often be ill. She may not live long enough to go to school. Zebron explains how this virus is transmitted, and that Doris is probably infected. He suggests she and the child's father should have a blood test for HIV.
The problem is that Doris is not married to the child's father, a worker on the farm who already has one wife. He has promised to marry Doris as well, and has already paid the dowry. Doris says she will try to persuade him to come to the hospital, but she does not seem hopeful. Zebron will return next month and try to speak with the child's father - but only if Doris agrees. Zebron and Christine are members of a mobile hospital team which is providing HIV infected individuals with the medical and psychological support they need. One of the other major successes of the programme (described on pages 2-3) lies in the educational and counselling effect that home based care can have on the wider community. For example, if other villagers become frightened of catching AIDS from Doris' baby and begin to spread false rumours, Doris could ask the hospital team to help, by organising educational meetings with villagers in co-operation with the village Headman. The schools educator in the team could also speak to local schoolchildren and encourage positive educational activities, such as those organised by Zambia's anti-AIDS schools clubs (see page 5).
Community care programmes, like the one at Chikankata, are based on two fundamental primary health care (PHC) principles. Firstly, co-operation between health and non-health services (for example, a local clinic and school). Secondly, community participation. This does not simply mean getting people to build their own pit latrines. It means the development of ideas and action arising from popular and/or traditional forms of organisation. In the case of Chikankata, the participation of village Headmen like Mr. Handa Bile (pictured here) is vital to the promotion of AIDS awareness in the local community. In any AIDS programme, all relevant forms of community based organisation, such as women's groups, should be encouraged. The Society of Women against AIDS in Africa (see page 4), formed to address the social and economic problems which prevent effective behavioral change among women, is an example. The Society aims to find ways of helping women like Doris, who are frightened of telling their partner 'Your child is dying of AIDS,' or women who, as yet uninfected by HI\/; cannot persuade their unfaithful lover to use a condom, or cannot risk leaving his home, quite simply because there is nowhere else to go.
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Mr. Handa Bile, pictured here with his
youngest children, is Headman of
Chikankata village, Zambia, and a keen
AIDS educator. |
In this issue
Home based care a case study from rural Zambia
Oral signs of AIDS prevention, treatment and diagnosis
Clubbing together organising anti-AIDS clubs in schools
Opinion from Rabbi Nilton Bonder in Brazil
WHO Report biomedical update on HIV and drug research
The international newsletter for information exchange on AIDS prevention and control
AIDS action Issue
8
1 Page 2
3 
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Counselling |
Taking counselling and care into the community
How does a hospital cope with the increasing demands of AIDS care and prevention without sacrificing work in other vital areas? Chikankata Hospital, in rural Zambia, may have found an answer.
The Salvation Army Hospital at Chikankata is 130 kilometres from the capital city, Lusaka, serving a mainly rural population of 100,000. It has 240 beds, with special units including leprosy, tuberculosis (TB), ophthalmology and nutrition. By 1987, the hospital was treating increasing numbers of AIDS patients. As the scale of the problem became more apparent, a British funding agency suggested converting buildings formerly used for leprosy patients into a small AIDS hospice. After careful consideration it was agreed that this approach would not be appropriate, particularly because the numbers of AIDS patients expected would far exceed the capacity of the hospice.
Staff at the hospital eventually decided to try a new concept in the management of AIDS patients - home based care. The family network, not the hospital, would be the main means of caring for people with AIDS. But this would not mean leaving patients and their families to cope alone. The hospital would decentralise its services and visit patients in their own homes, providing medical, psychological and pastoral care through a small, mobile team.
The decision was based on the following assumptions:
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in rural Zambia, the family is the most effective means of supporting patients and assisting the hospital in providing clinical care and psychological support |
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as the incidence of HIV infection/AIDS increases, the decentralisation of case management is the most economic and effective way of providing patient care |
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taking care into the community has an educational and counselling effect that extends beyond family members |
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terminally ill patients prefer to die at home. |
Setting up a team
A small team of health personnel was
organised to give the home based
care idea a try. The team began by
making weekly visits to patients within
20-30 kilometres of the hospital,
reaching five to eight patients a day.
Soon the team realised that home visits
offered an ideal opportunity for
'contact tracing' - that is, asking
about the patient's sexual partners
(past and present) and trying to contact
them for counselling and the
possibility of blood testing. In addition,
home based care presented new
opportunities for educating family
members about AIDS, and helping to
dispel the many fears and false rumours spreading in communities.
The pilot project was so successful
that, two months later, the funding
agency agreed to provide funds for a
vehicle and its running costs, blood
testing kits, medical supplies and
other expenses.
The home care team now consists of
four people, including a clinical officer, a nurse, a schools educator and a
driver. They are often joined by a
social worker, a health educator or the
project manager. The team travels
through rural areas in a yellow van.
Activities include:
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visiting people with HIV infection/AIDS in their homes to assess their physical, psychological and social needs, and to provide for these needs wherever possible |
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counselling and education within families and communities, providing personal support and promoting changes in sexual behaviour |
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contact-tracing |
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evaluating the educational impact of their work on patients, families and communities. |
It may be thought that Patients would
prefer not to attract local attention to
their illness by having regular visits
from the hospital team. So far, this has
not been the case and the team is
almost always made welcome by
patients and their families. From the
start of the programme in March 1987;
up until the end of 1988, a total of 267
people with HIV infection, from 176
families, were visited in their homes.
The team traced 105 contacts of HIV
infected patients and took samples of
their blood for testing.
Among the difficulties faced by the
team are the poor state of the roads
and the remoteness of villages.
Patients are often difficult to find;
addresses are vague, and patients
may be out working or travelling when
the team arrives. In the future it may be
possible to work more closely with
rural health centres and community
health workers and to give patients
advance warning of team visits.
AIDS action Issue
8
2 Page 3 4
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Counselling |
Counselling
Counselling is an essential part of the Chikankata approach to AIDS management. All individuals diagnosed HIV positive by a blood test are informed of the result as soon as possible. With the patient's permission, a close relative responsible for looking after the patient is also informed. The counsellor explains the various stages of HIV infection and the ways in which the virus is transmitted, encouraging the patient and other members of the family (if present) to ask questions.
Wherever possible, patents are counselled before having a blood test. Usually, however, counselling takes place only after the results of the test have been received, because pre-test counselling is often not possible in a busy hospital where staff already have a very heavy workload. The counsellor also starts the process of contact-tracing; although sexual partners and family members are not told of the patient's diagnosis without the patient's consent. The patient may also ask the counsellor for advice or direct help in dealing with employers, workmates, or neighbors, which opens up the possibility of education and counselling within the wider community: a process which the Chikankata team describe as 'community counselling'.
The experience of Sinadambe community, situated on the northern shores of lake Kariba, is an example of how caring for patients within a family can lead to greater community awareness of AIDS. In December 1987; the Chief of Sinadambe called a meeting of all village Heads in his area to discuss the problem of AIDS. For several months the team had been visiting three AIDS patients in the area. One of them, the son of a village Headman, had died only a few weeks earlier. Surprisingly few people, however, were aware of the seriousness of the AIDS threat to themselves and their families. Some had not even heard about the disease, despite frequent radio broadcasts.
The meeting was held in the local primary school and attended by about 20 village Headmen. The discussion demonstrated how little these community leaders knew about AIDS: most wrongly believed that it was spread by shaking hands, sharing eating utensils, or standing in the shadow of someone with the disease. Few could accept that there was no cure, and felt that the traditional healers probably had a remedy. Finally the father of the young man who had received home based care up until his death, stood up and passionately spoke out, 'You all saw how my son suffered before he died. You all saw how he was. Have you ever seen anything like that before? There is no cure for this disease. It's something completely new. We have to do something now to stop it spreading further.' This meeting marked the start of a gradual process of raising people's awareness of the seriousness of AIDS and for the urgent need for changes in sexual behaviour to reduce further transmission.
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As in the counselling of individuals or families, the home care team spend a great deal of time listening and learning about people's attitudes before giving information or trying to guide discussions at public meetings. The emphasis is on helping people develop a sense of collective responsibility for dealing with the threat of AIDS. The team is now involved in community counselling in four different types of communities: traditional villages, commercial farms, periurban farming settlements and one urban area. One common problem is stigmatisation of people suspected of having AIDS. |
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Gilbert's story
Gilbert, for example, worked as a
labourer on a commercial farm about
20 kilometres from Chikankata. He
had been unwell for several weeks
and had sought treatment for a persistent
genital ulcer; his workmates suspected
he had AIDS and were
frightened of catching AIDS from him
at work. They insisted that he took an
HIV antibody test so they could know
the result. The hospital stated that a
test could be done but that the result
would not be given to anyone without
Gilbert's permission. Gilbert was
found to be HIV positive.
At this point the home care team
offered to visit the farm and discuss the
problem. The meeting created enormous
interest, and was attended by
over 50 workers and their families. Initially,
everybody was very tense, as
speaker after speaker got up and
expressed fears of catching AIDS from
someone at work. Without referring to
Gilbert in particular, the team
explained that it was impossible to
catch AIDS during normal social contact
with an infected workmate; the
only risk was through having sex with
that person or with that person's sexual
partners. The most effective way of
avoiding exposure to the virus was to
have one faithful partner for life. The
meeting reduced tension in the community,
at least temporarily. Gilbert
continued working at the farm for several
months before returning to his
home village for terminal care. He left
behind a farming community better
able to discuss and confront the problem
of AIDS. As Thebisa Chaava,
social worker and head of the counselling
team points out: '...the only
long term hope for prevention is for
communities themselves to feel a
sense of responsibility for dealing with
AIDS. They are the only ones who can
change their behaviour and stop the
spread of the virus.'
This article is based on two booklets due
to be published in November 1989:
'AIDS Management - an integrated
approach' by Dr Ian Campbell and Glen
Williams. A case study aimed at health
practitioners and planners. Includes hospital and home care treatment protocols.
'From Fear to Hope; AIDS care and prevention
at Chikankata hospital, Zambia'
by Glen Williams. Describes a home care
programme for people with HIV infection/AIDS in a rural area. Aimed at policy makers,
health professionals, field workers and
community leaders.
These publications are part of 'Strategies
for Hope', a new series of printed and
audiovisual materials on AIDS control in
developing countries, published by Action
Aid, AMREF and World in Need. Both
booklets are available from: Action Aid,
Hamlyn House, Archway, London N19 5PG, UK. Price £1.50 each (includes
package
and postage worldwide). SPECIAL
OFFER Organisations in sub-Saharan
Africa may order up to 25 copies of each
booklet free of charge, while stocks of the
first edition last.
Chikankata Hospital offers free training
courses for those working on AIDS prevention and control in Africa. For further information
please write to:
Captain (Dr.) Ian
Campbell, The Salvation Army Hospital, Chikankata, Private Bag 52, Mazabuka,
Zambia.
AIDS action Issue
8 3 Page 4
5
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Opinion / News |
Not just a Rabbi's responsibility
From Rabbi Nilton Bandel;
in Brazil
'Within the Jewish community, AIDS was first seen as the 'Rabbi's problem' - that is, it was the Rabbi who was expected to provide pastoral care when called upon. I am one such Rabbi. While living in the United States in the early 1980s, I found myself working with AIDS patients in a New York hospital, with almost no guidance from state or religious leaders on e building a communal response to the growing crisis.
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Since then, things have changed considerably in the United States. AIDS slowly forced religious and lay communities to face particularly controversial issues, such as sexuality and homophobia (hatred or fear of homosexuality), and theological questions, such as the belief that AIDS is a 'punishment' of the 'guilty'. Many religious movements have set up special AIDS committees. One of the most effective is the National Committee on AIDS, formed by the Union of American Hebrew Congregations, which provides practical and emotional support to those who suffer from AIDS, has developed health education materials and participates in the AIDS Pastoral Care Network. |
Being a disease that does not stop
at religious or geographical boundaries, AIDS has exposed the need for an
institutional framework to provide support
to Third World prevention and
control programmes. This is how the World Jewish Service and the Hessed
Institute were started, with the aim of supporting community based health and development
programmes.
However, when I returned to my
native country, Brazil, I found a very different
situation. Although many
Jews are involved individually in fighting AIDS, the community itself has not been active collectively or institutionally. The response has been restricted
to pastoral care, carried out by a few Rabbis
like myself. My work within the
group Religious Action Against AIDS (ARCA) - part of the Religious Studies Institute
(ISER) in Rio de Janeiro -
forms the beginning of efforts to inform and organise the Jewish community as a whole.
We are developing a curriculum on AIDS for our Bar and Bat Mitzvah celebrations with young adults. AIDS is now an issue for our sermons. I
have also written articles for Jewish-magazines on AIDS and have been interviewed on television. At first, the
community was shocked to learn that some of its own members could be, or were, HIV positive; shocked that AIDS is also a 'Jewish' question. A Jewish
question which could provide an important link between the Jewish
community in Brazil (one of the largest in the Third World) and a wider Brazilian reality. Jews are only now
under standing that AIDS must be responded to collectively by working together with other members of the national and
international community. In this sense, AIDS has one positive side effect
- to open up new areas for human understanding, interreligious and political debates, and for
developing solidarity between religious and lay communities alike.'
Rabbi Bonder was ordained by the Jewish Theological Seminary and is the Rabbi
of the Jewish Congregation of Brazil.
Readers are invited to write in with their contributions to AIDS action
'Opinion' page.
A group of African professional women
has formed a regional organisation to
carry out research, education and
development activities aimed at helping
women protect themselves and their
families from AIDS.
The Society for
Women and AIDS in Africa (SWAA) was
formed in June 1988 during the Fourth International
Conference on AIDS in Stockholm,
Sweden. SWAA's first major event
was a four-day international workshop,
held in Harare, May 1989. The workshop
provided a forum to discuss a range of
women's health problems, including prostitution,
reproductive health, and hetero-sexual
transmission of HIV The event was
officially opened by the Zimbabwean
Deputy Minister of Health, Dr Swithun Mombeshora, and was the first meeting of
its kind, attracting 90 participants from 14
English and French-speaking African
countries.
Speaking about AIDS prevention
activities among female prostitutes, the
President of SWAA, Dr Fathia Mahmoud, a
Sudanese obstetrician and gynecologist,
said: 'It's not just a matter of giving out condoms to prostitutes and their clients
- we are concerned that the social and
health problems of female prostitutes
should be addressed.' This message was
also stressed in a speech given by the First
Lady of Zimbabwe, Sally Mugabe, when
she introduced the conference delegates
to a group of women who, five years ago,
were working as prostitutes. In an attempt
to make a better life for themselves, some
of the women got together to seek assistance to start an income-generating
cooperative.
The First Lady donated an initial Z$300, and with additional financial support
from other sources, it was possible for
the women to rear and sell chickens, and
to set up a food bar and nursery school.
In preventing heterosexual HIV transmission
by changing their own and their
partners' sexual behaviour, women face a
number of problems, including: lack of
decision-making power over sexual
behaviour or traditional practices such as
polygamy and widow inheritance; cultural
and religious taboos which prevent discussion of sexual practices, AIDS and
STDs.
Workshop recommendations considered cultural, social and economic
realities affecting the role of African
women in HIV prevention and control, and
were aimed at finding practical solutions.
Both women and men are welcome to
join SWAA. For further information, and
membership, please write to: Dr N. P. Luo,
Treasurer, SWAA, UTH, Dept. of Pathology and Microbiology, PO Box 50110,
Lusaka, Zambia.
AIDS action Issue
8
4 Page 5 6
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Working in schools |
Join the Club!
In 1987, Dr Kristina Baker visited a secondary school in Lusaka, Zambia, to talk to students about AIDS. They were obviously interested and wanted to do something to help. Dr Baker suggested starting an anti-AIDS club. Students took up the idea, and with Dr Baker's help, they worked out activities and club promises for members. There are now nearly 200 similar clubs in Zambia and more are forming in neighboring countries. Dr Baker explains about their activities and gives advice on setting one up.
There are three main aims to anti-AIDS clubs, reflected in the club promises each member has to make (in other countries, different promises may be considered more suitable)
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I will avoid HIV infection/AIDS by avoiding sex before marriage, and outside marriage |
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I will help my friends and relatives to protect themselves by telling them about HIV infection and AIDS |
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I will help people with HIV infection/AIDS as much as possible. |
Each school club has an adult 'patron'
usually a teacher at the school, who
helps students run the club.
What do the clubs do?
Each club develops its own organisation,
rules and activities, so each is
slightly different. Some clubs are very
active; others less so. After getting permission
from the head teacher or community
leader, a committee of
interested members can be formed to
plan future activities and to write the
membership rules.
Firstly, all committee members
should carefully read and discuss
information on AIDS with an adult who is well informed (for example, a nurse
or doctor from the local hospital or clinic).
Why not order back issues of 'AIDS action' and select articles for
discussion?
Club activities could include:
doing a local survey to find out what
school students and members of the
public believe, or know, about AIDS.
Use the results of this to plan information
campaigns.
making and circulating membership cards, which members can sign and keep, and which have club promises
written clearly on them.
offering help to people with AIDS such
as doing the gardening, carrying
water, helping with the children, taking
messages, and to act as an example
to others in the community.
organising fundraising activities for
printing educational materials, a club magazine (see below) and posters,
providing support to patients and their families. It is also worth approaching
the parent-teacher association, local
health workers and the Notional AIDS
Committees for club funds.
organising educational activities for
example, using the subject of AIDS
and other sexually transmitted diseases
(STD) as the base for school
projects in science or English; organising
school quizzes and debates; inviting outside speakers from the local
hospital or clinic where AIDS patients
are being treated; writing and
rehearsing plays or songs about HIV
infection; organising a 'design a
poster' competition with prizes for
winning posters; practising writing and giving talks on AIDS. Talks must
be short, accurate and interesting. If
you have access to a slide projector,
low-cost, colour slide sets on AIDS/HIV infection are now available (see page
8).
Try producing a short, local club
magazine in duplicated form. The
magazine could include: poems,
stories, cartoons, and a section for
readers' letters and questions (these
should be answered anonymously
where requested). Why not provide a
special club mail box in school for people to put their written questions
about AIDS and other STDs? Correct
answers should be published in the
club magazine.
How are the Zambian clubs organised and funded?
After the first few school talks were
given, the project was offered financial support from NORAD (the
Norwegian Agency for International
Development) to help run an AIDS
education campaign and expand and
co-ordinate clubs nationwide. The
anti-AIDS club project now has an
office and a widely publicised postal
address.
People write to us for information
about AIDS and also for educational
materials - such as booklets, posters,
a club Resource Pack including samples of club badges and membership
cards - which we were able to
develop and print with NORAD funds.
We send out a leaflet called 'Information
about anti-AIDS clubs' with ideas
about starting up clubs, and the office
keeps a record of established clubs
and their addresses. This regular contact
is important, to keep clubs active
and interested. However, clubs do not
need external funding to be effective,
nor do they need a central office. It
costs nothing for a school student to
talk to his friends about AIDS!
How successful are the clubs?
When lots of students are members of
anti-AIDS clubs, it is tempting to feel
satisfied that many young people are
hearing about AIDS. But will the sexual
behaviour of these students actually
change? We cannot tell the success of the project by looking to see if
numbers of AIDS patients are going
down, since people who become ill
now were often infected years ago.
Perhaps the best way to measure sexual
activity in schools is to look at the
number of schoolgirl pregnancies and
STD rates among students.
Schoolchildren are an essential
target group for AIDS education, and
everyone involved in health education
should try their best to reach this
group. The anti-AIDS clubs are one
idea among many others.
For further information, and addressees of existing school clubs, write to:
The anti-AIDS project, P/Bag RW
75X, Lusaka, Zambia, Central Africa.
AIDS action Issue
8
5 Page 6 7
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Oral signs of AIDS |
Oral signs of AIDS
Diseases of the mouth can often be the first indication of HIV infection. Dr Jens Pindborg, from the WHO Collaborating Centre on Oral Manifestations of HIV, describes the most common symptoms.
Oral diseases are found in people infected with HIV both during the early and final stages of infection, as well as in sick and/or malnourished individuals not infected with HIV. Many of the oral signs of AIDS are the same common diseases which occur in people without HIV infection/AIDS, for example, oral candidiasis (thrush) which commonly affects malnourished babies, and the elderly. A diagnosis of AIDS, therefore, cannot be made on oral signs alone.
However, people with HIV infection often develop diseases of the mouth before any other visible sign develops. Because of this, dentists are likely to be the first health workers to recognise these symptoms and are best placed to provide treatment and to refer patients where necessary for full medical examination and counselling. For this reason, dentists should be encouraged to participate more fully in the diagnosis and management of AIDS patients.
In 1986, the European Economic Community classified over 40 different oral diseases associated with HIV infection (1). This classification is used to help dentists, dental hygienists and physicians to diagnose infections associated with HIV infection/AIDS. The most common of these are out-lined below.
Fungal infections
The most common oral infection associated with HIV infection is candidiasis (thrush), a pseudomembranous type which looks like large white patches on the palate (roof of the mouth and the buccal mucosa (inside cheeks) and which can be scraped off (see photo). The majority of epidemiological surveys in the developed world indicate over 40 per cent of HIV infected individuals develop candidiasis. There are fewer surveys available from developing countries. Another less common type of candidiasis, erythematous, has also been associated with HIV infection, where the palate and upper surface of the tongue look very red. Several patients have been observed where the erythematous type developed into the pseudomembranous type, indicating a progression from early HIV infection to AIDS. Oral candidiasis can be effectively treated (see page 7).
Bacterial infections
So-called gum disease is caused by a variety of bacterial infections. Gum disease is very common in developing countries, and people with HIV infection are at particularly high risk of developing common bacterial infections.
The early signs of gum disease are swollen areas of the gingiva (gums) and an increased tendency to bleed when pressed, or when food is scraped from under them. Gums look red instead of pink, and are loose instead of tight against the tooth. The patient has bad breath, and a bad taste inside the mouth.
Necrotising gingivitis, now a rare condition in Europe, has reappeared over recent years in some HIV positive patients. The condition (also known as trench mouth) is where the gum tissue dies, becomes grey, and pus and old blood collect around the teeth. In the developing world, Necrotising gingivitis is more common, particularly in malnourished children recovering from measles; however, in Zaire and Zambia, an even more serious form of Necrotising stomatitis (cancrum oris) has been reported amongst infants of HIV positive mothers. In its worst form, this disease can eat a hole through the cheek of a weak child. Fortunately, effective treatment is available for gum disease. However, prevention is very important, especially in HIV positive patients (see page 7).
Viral infections
Many HIV positive people are at increased risk from all common viral infections. Of interest to the dentist is herpetic stomatitis (which affects about ten per cent of AIDS patients) and hairy leukoplakia. The signs of herpetic stomatitis are bright red blisters which develop either on the gums (but not between the teeth) or outside the mouth on the lips, painful swelling under the jaw, fever and sore throat. (See treatment guidelines).
Hairy leukoplakia is more commonly found among AIDS patients in Europe/North America than in developing countries. It is characterised by a white lesion with vertical folds situated on the edges of the tongue. The folds look like corrugated lines of hairs. Since hairy leukoplakia can mimic a number of white lesions, a biopsy (where tissue and/or surface cells are removed for laboratory examination) is necessary for its diagnosis. There is no successful treatment.
Professor J J Pindborg, The Royal Dental College, Copenhagen, Department of Oral Pathology, 20 Norre Aile, DK-2200 Copenhagen, Denmark.
References/further reading
(1) Pindborg J J. Classification of oral lesions associated with HIV infection. Oral Surg 1989; 67: 292-5. This is a revised edition of the 1986 EEC classification. Copies are available from AHRTAG.
A more detailed discussion of the less frequent oral manifestations of AIDS can be found in 'AIDS and the Dental Team' Greenspan et al., Copenhagen, Munksgaard, 1986.
Guidelines on cross-infection control in the dental surgery will be published in the December issue of AIDS action.
AIDS action Issue
8
6 Page 7 8
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Oral signs of AIDS |
Oral manifestations: prevention and treatment guidelines
Prevention
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Show the patient how to clean teeth better near the gums. Teeth should be cleaned after every meal, either with a tooth brush, or local chewing stick. Advise the patient to visit a dentist more often to have tartar removed. |
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Tell the patient to rinse his/her mouth regularly with water - preferably warm, salt water. |
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Advise the patient to eat fresh vegetables and fruit daily to improve nutritional status. |
Treatment
Thrush
Thrush
can often appear in babies, in
people who are weak, poorly nourished and sick, taking antibiotic medicines, or
in adults wearing dentures. Thrush can also be indicative of HIV infection/AIDS.
Treat as follows:
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Check to see if there is some other, underlying cause of thrush which is not HIV infection. For example, treat malnutrition where possible. Stop antibiotic treatment of other infections if possible (antibiotics can make thrush worse). |
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Wipe nystatin cream on the white patches with a bit of cotton (adults four times a day, children three times a day, children under five years twice a day.) If there is no nystatin, gentian violet should be painted on the white areas twice a day. Local application of a number of other fungicidal drugs gives good results within one or two weeks, but these may not be available in many developing countries e.g. miconazole, amphotericin B, clotrimazole and chlorhexidine. In general, drugs in tablet form should be sucked three times a day, or gel should be applied three times a day. |
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If no improvement is noted after three or four weeks, the patient should be referred to a local doctor for a fuller medical examination. |
Gum disease
Refer to prevention guidelines above, but note that for treatment, salt water mouth washes should be given four times a day until the bleeding stops and then once a day. Rinse regularly with chlorhexidine where this is available.
Necrotising stomatitis (cancrum oris) This is a very serious form of gum disease. You should refer the patient to the nearest hospital/medical centre. However, begin treatment straight away. Give penicillin for three days, according to the dosage in figure one.
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Tell the patient to rinse his/her mouth with water. Wipe the gums with cotton soaked in five per cent solution of hydrogen peroxide. Rinse with warm water. For a child, use a weaker solution of one part hydrogen peroxide with five parts water. |
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Dry the gums with cotton and apply topical anaesthetic if you have some. Remove some of the tartar. |
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Give vitamin C (ascorbic acid), two tablets a day for seven days, where one tablet = 500mg. |
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Teach the patient (or parents if it is a child) how to care for the gums at home. Rinse at home for three days, every hour, with a weak solution of hydrogen peroxide. The patient should try to keep the solution in the mouth for several minutes: the longer the better. For a child, gums should be wiped with the solution four times a day. After three days change to salt water, four cups a day. If you have no hydrogen peroxide, rinse with salt water from the beginning. Teeth should be cleaned regularly with a soft brush even if the gums bleed. |
Herpetic stomatitis (fever
blisters/mouth sores)
Medicine cannot kill the herpes virus.
The blisters will go away by themselves
in about ten days. Treat as follows:
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Give aspirin or acetaminophen for fever. |
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Advise the patient to wipe milk or yoghurt over the sores to protect them before eating. |
|
Paint sores on the lips with gentian violet, tincture of benzoin or petroleum jelly to prevent them becoming infected. |
Adapted from Where there is no dentist
by Murray Dickson, published by the
Hesperian Foundation, Mexico
AIDS action Issue
8
7 Page 8 9
|
Letters / Resources |
Letters
Quality and proper use of condoms
In response to a short article that appeared in issue five, under 'Counselling Hints: Using Condoms' I would like to add a few guidelines an this important subject:
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Always check the 'sell by' date on the condom packet. Store condoms in a cool, dry place. |
|
After you open the packet, check for the following: a strong rubbery smell, condom sticky to the touch and tiny bits of loose rubber which separate out. If you find any of the above, the condom is old and damaged - IT IS NOT SAFE TO USE. Ask the distributors (e. g. your local clinic or store) to investigate their supplies. |
After use, the condom should be
tied in a knot at the open end (making
sure that no air is trapped) so that the
semen does not leak out after disposal.
Remember that condoms are
the only method of contraception that
provides protection against HIV and
the germs that cause other sexually
transmitted diseases.
Dr Chandra Mouli, Copperbelt
Health Education Project, Zambia.
I am a Medical Assistant at the
Kuhalanga Medical Centre. I totally
agree that condoms used in a proper
way are really helpful, but from my
own experience, condoms, if not used
in the right way, are another problem
area in the transmission of sexually
transmitted diseases like gonorrhoea
and syphilis. On this issue a pertinent
question is, 'Is it safe to use one condom
with two partners if it is washed?'
Name withheld, Kuhalanga Medical
Centre, Magoche, Malawi.
Editor: No it is not safe! Washing condoms
weakens the condom rubber.
Condoms are very fragile and should
not be used more than once.
Education in School
An excellent pack for use in schools has
been developed by the AIDS Control
Programme in Uganda, and is now available for wider distribution, suitable for all
English and French speaking African
countries. The pack contains: seven colour
posters printed' on indestructable, water-resistant 'paper' (with titles including: How
is AIDS spread? What does a person with
AIDS look like? etc.,); flip-charts which tell the
story of four friends (two of whom become
infected with HIV); definition cards to explain
the meaning of AIDS; teachers' guide
to using the materials, as well as a
teachers' booklet on human reproduction
and sexual responsibility. Packs available
in English and French free of charge from:
the Medical Missions Institute, Salvator Str.
7, Postfach D-8700 Wurzurg, West
Germany.
A Colour Atlas of AIDS in the
Tropics
Describes diseases associated with AIDS,
including colour illustrations of the many
clinical manifestations observed among
patients in the tropics. Written by four
Zambian doctors, it will be of value to a
wide range of health practitioners.
M A Ansary et al, A Colour Atlas of AIDS
in the Tropics, 126 pp, price £8.00, Available
from: Tropical Health Technology, 14
Bevills Close, Doddington, March, Cambridge shire PE15 0TT, UK.
AIDS-Wise, No Lies
Suitable for use with adolescents. Made in
the United States of America with fast-moving
visuals and popular music. Consists
of a series of emotionally powerful
interviews with a variety of young people
(not actors), some of whom are suffering
from AIDS. The interviews successfully
convince the audience that AIDS can
affect anyone, but that each one of us has the power to avoid it. The audience should
be aware of the facts about AIDS/HIV
infection before seeing the video. Comes
with an excellent viewers' guide, which
includes ideas for discussion., Produced by
Rutledge Ltd. 22 minutes. US$250 per
copy, plus $10 postage and packing. Discounts
available for non-profit organisations.
Available from: New Day Films,
853 Broadway, Suite 1210, New York
NY 10003, USA. Indicate format required
(VHS, Beta, 3/4").
'Three sets of 24 colour slides are available
from Teaching Aids at Low Cost (TALC).
Suitable for a range of health workers/educators in Africa. Each set includes
teaching notes and subjects for discussion.
The first in the series, Virology and Transmission,
should be used before the other
two sets, Clinical Manifestations and Prevention
and Counselling.
PLEASE NOTE price of sets is £2.75
EACH for self-mount sets with instructions.
Seamail to developing countries or £0.60
extra for airmail. From: TALC, PO Box 49, St
Albans, Hertfordshire, AL1 4AX, UK
AIDS action Issue
8
8 Page 9 10
|
WHO Report - Global Programme on AIDS |
WHO Report - Special Programme on AIDSThe role of non-governmental organisations (NGOs) in National AIDS Programme
The Ugandan AIDS Control Programme (ACP) provides a leading example in the development of effective working relations with non-government organisations and community groups. Bob Grose, External Relations Officer for NGOs at the Global Programme on AIDS, interviews Dr Samuel Okware, Director of the Ugandan ACP.
What are the major areas for government and NGO co-operation in the ACP?
Nearly thirty hospitals and about 100 large health centres (a major part of the existing health structure in Uganda) are run by two coalition Christian organisations, the Catholic Medical Bureau and the Protestant Medical Bureau. These religious groups also run AIDS health promotion in their churches and schools, alongside the government education programmes, especially in the rural areas.
Much of the care and counselling activities, including training and home visiting, have been carried out by these, and other, NGOs, such as The AIDS Support Organisation (TASO - see AIDS Action issue 7), the Ugandan Red Cross Society and the Moslem Supreme Council. The Federation of Ugandan Employers has been running a project on worker education. Another NGO has produced over two million leaflets in more than 20 local languages.
How does NGO/government co-operation really work?
We have now asked all NGOs interested in working on AIDS to register with the ACP, which makes it much easier to review their proposals and approve activities.
When an NGO brings a proposal to the ACP we approve it or we suggest small changes. Once agreement has been reached, NGOs usually carry out their project independently. Our approval simply indicates that it is a useful part of the medium term plan. By coordinating in this way, we are able to share available resources in the most effective way and avoid needless duplication of work. For NGO training activities, we ask for the participation of a member of the ACP, in this way, both the national programme and the NGO can contribute and benefit.
What is the financial relationship between NGOs and the national programme?
Many NGOs have their own source of funding, sometimes raised through other NGOs or government agencies. However, for NGOs who do not have resources available for their programmes, the ACP can provide grants through the WHO Trust Fund. These funds are normally used for individual events such as seminars, training sessions, or contracts for specific services, though it can also be used for activities in the medium term plan. When funding is granted to an NGO, a contract is set up through the exchange of letters.
We are now trying a new mechanism to ensure that money is available for practical, community-based NGO projects within the framework of the medium term plan (see also article on back page WHO Report). First the NGO drafts a proposal for its activities, setting out objectives, work plan and budget. After approval from the ACP, the NGO requests funds from WHO's Global Programme on AIDS (GPA) to cover the total budget or to contribute to joint funding. If both the ACP and GPA agree, funds can be transferred from Geneva through NGO headquarters or through the ACP in Uganda, whichever is preferred.
What do you see as the main direction for ACP/NGO co-operation in the future?
About half of all AIDS patients in our country are treated through NGO facilities. We are now finding that NGOs, as well as the government programme, need drugs and medical supplies. Information on AIDS care and prevention needs to be adequately distributed and care-givers need to be trained in both government and non-government sectors. Supporting regional meetings between NGOs and ACPs may be a way forward: we have found that work-shops are useful for exchanging information and ideas.
Consultation between the ACP and NGOs is improving. NGO involvement is vital to the success of the programme, especially since their existing structures allow for effective out-reach in counselling and home care.
AIDS action Issue
8
9 Page 10 11
|
WHO Report - Biomedical update |
HIV infection and drug
Dr Jose Esparza, from the Biomedical Research Unit, Global Programme on AIDS, describes current scientific knowledge about HIV (the virus that causes AIDS) and the development of drugs for the treatment of HIV infection
The Acquired Immune Deficiency Syndrome (AIDS) is a disease characterised by progressive damage to the body's immune system(1) which results in the development of a number of 'opportunistic infections' which are eventually fatal.
AIDS is caused by the Human Immunodeficiency Virus (HIV), which is a member of the retrovirus family. Viruses are intracellular parasites (very small organisms that exist and multiply inside living cells). Different viruses are attracted to different types of cells, and the destruction of these cells (caused by the multiplication of the viruses inside the cell) results in different types of disease. For example, polioviruses multiply in cells in the spinal cord, causing paralysis and muscle wasting, whereas hepatitis viruses multiply in, and damage, liver cells.
When a person is infected with HIV there is an initial period when the virus multiplies rapidly (reproducing or replicating itself). The body's immune system then produces antibodies specific to the virus (known as seroconversion) - often within the first three months of infection. This initial period is usually without symptoms of illness although some people may develop mild symptoms for a few days or weeks, such as a fever, or a rash.
|
After infection, individuals generally remain fit and
healthy for a number of years. During this period, HIV
keeps a low level of multiplication, with a slow, but progressive,
destruction of certain cells in the immune system. |
HIV-1 and HIV-2
Most cases of AIDS worldwide are produced by a type of
virus currently known as HIV-1. A second virus that causes
AIDS has also been identified, called HIV-2, which is notably
more prevalent in certain areas in West Africa. Like HIV-1, HIV-2 is also a retrovirus, but it more closely
resembles
the structure of some simian (monkey) immunodeficiency viruses (SIV) than HIV-1. Most scientists believe that
HIV-2 causes AIDS in the same way as HIV-1, but possibly
with a lower pathogenicity (smaller capacity to cause disease)
and a longer period between initial infection and
the onset of AIDS.
Drugs which slow down or block the
multiplication of HIV
The more the virus multiplies, the more cells become
infected and damaged, eventually leading to the destruction of the immune system and the onset of AIDS. Drugs
which slow down, or block, the multiplication of the virus
are currently being researched and developed. There has
been extraordinary progress in scientific understanding of
the molecular biology of the virus, enabling drugs to be
designed which interfere with one or more steps essential
for the multiplication of the virus. These drugs include
zidovudine (AZT - see below) and soluble CD4. At present,
AZT is the only licensed anti-retroviral drug.
Soluble CD4
The first step in viral multiplication is the attachment of the
virus to the surface of the target cells. In the case of HIV the
targets are specialised cells of the immune system known as helper T (T4 or CD4+) lymphocytes and
macrophages. The infection and destruction of these key elements
of the immune system is the underlying cause of
AIDS. In general, HIV can only infect CD4+ lymphocytes
and macrophages because they carry the appropriate
'receptor' for the virus on their surface. This receptor is the
CD4 protein, onto which the surface proteins of the virus
attach themselves. This knowledge has allowed the
development of large quantities of genetically engineered (made in the laboratory) CD4 molecules
- known
as 'soluble' CD4 - which can be used to link onto
viruses just like the CD4 molecules attached to cells of the immune system. It has been shown that soluble CD4
molecules can block viral receptors and in theory could
make the virus less capable of linking or binding with a
human cell. In this way, the capacity of HIV to infect
increasing numbers of human cells (and thus progressively
to destroy the immune system) may be reduced.
However, the therapeutic effects of soluble CD4 have yet
to be evaluated. Other drugs which act by interfering with
the attachment of the virus to target cells are also being
tested.
AIDS action Issue
8
10 Page 11 12
|
WHO Report - AIDS: a worldwide effort will stop it |
AZT
Another way of interfering with the multiplication of the virus is to stop the virus reproducing itself after it has got inside the target cell. One such drug is zidovudine or AIDS. This is the only drug which has been shown to have a beneficial effect on AIDS patients. It works in the following way:
Once the virus has entered the target cell, it uses the cell to reproduce itself. Retroviruses, such as HIV; carry an enzyme called 'reverse transcriptase' which copies the viral RNA (genetic information) to make viral DNA, which is then integrated into the host cell genetic material. The viral DNA (now part of the human cell) instructs the cell to make multiple copies of viral RNA. A new generation of viruses then emerges from the cell (see figure one). AZT acts by interfering with this process of reverse transcription.
There are a large number of similar drugs being tested as new products, such as DDC (dideoxycytidine) and DDI (dideoxyinosine), but well controlled clinical trials are needed to assess their effectiveness against the virus, and to look at any negative side-effects on the patient. DDI is a more recent development and, so far, seems to be more potent against the virus and may be less toxic than AZT.
 |
None of the drugs mentioned above are cures for
AIDS/HIV infection. This is because the drugs do not rid
the body completely of the virus, but may only inhibit or
slow down its multiplication. After initial infection, when
the virus has entered a human cell, it is very difficult to
eliminate it, because it becomes part of the cell's genetic
material and is passed on to new cells which are formed.
Once a patient is infected, they are infected for life, and
need life-long therapeutic management. This is one of the
major problems we have to confront in the development of anti-retroviral drugs. |
The next edition of WHO Report will include on update on vaccine development.
(1) Terms in bold are explained further in the below box.
|
Explanation of scientific terms |
AIDS action Issue
8
11 Page 12
| WHO Report - AIDS: a worldwide effort will stop it |
Our lives, our world
World AIDS Day, 1 December 1989
AIDS and Youth will be focus of events for the forthcoming World AIDS Day - the biggest single annual day of information and action against AIDS worldwide.
Preparations for the event, to be held on 1 December 1989, are being made at WHO Headquarters in Geneva, six regional WHO offices (Africa, the Americas, the Eastern Mediterranean, Europe, SE Asia and the Western Pacific) as well as thousands of government and non-government organisations and community groups worldwide.
|
World AIDS Day 1989 aims to increase awareness of the risk of HIV infection/AIDS; strengthen AIDS prevention activities and programmes; promote respect and care for those with
HIV infection/AIDS and provide a
foundation for continuing activities
into the 1990s. The theme 'Our Lives,
Our World - let's take care of each
other' has been chosen to stress the
need for compassion, respect and
care in meeting the challenge AIDS
poses to us all. |
|
Write in for your Action Kit
Information about World AIDS Day is
being circulated through a central
World AIDS Day mailing list, which
already includes over 1,700 individuals,
organisations and other interested groups. Two newsletters on
the event have already been distributed and a poster entitled 'Ten points
on AIDS' and a brochure are also available.
Further newsletters will be
mailed out nearer the time, as well as
a twenty-page Action Kit with 101
ideas for activities and a guide to
organising events and working with the media (including press kits).
William Mwanza, field officer of the
Planned Parenthood Association in Chadiza,
Zambia, is one of many who has written to WHO for educational
materials to support activities planned
for 1 December: 'I work in a remote
rural area where facilities to mount a
meaningful campaign against AIDS do not exist. I am therefore appealing
to you to send me as much support
material as possible...'
Thomas W Netter, Public Information
Unit/GPA
Are you involved?
If you or your Organisation are not already on the
WHO World AIDS Day Mailing list,
please write to: Global Programme on AIDS, WHO, 1211 Geneva 27,
Switzerland, for further information and ideas for action.
For a trial period, the Global Programme
on AIDS will consider providing funds to a wider range of AIDS
projects initiated by non-government
organisations.
There are a number of ways that non-government organisations (NGOs) fund their activities in support of the
national AIDS programmes:
|
In some instances, NGOs have contributed their own funds to national programmes. |
|
NGOs can obtain funds for specific projects from external donors, including other larger, international NGOs or government development agencies. |
|
NGOs can submit proposals to their national AIDS Programmes which may agree to provide funding on a contract basis, through the exchange of letters. Funds are provided from the WHO Trust Fund (i.e. the national programme budget). The contract is agreed between the NGO and the in-country representative of the WHO/Global Programme on AIDS, who is authorised to disburse Programme funds if national programme approval has been given. |
|
A further funding system is now
being developed. For a trial period,
GPA is able to provide funds for a wide
range of NGO in-country projects
designed to strengthen the national
AIDS programmes. This system allows
NGOs to apply for funds outside the
country in which they are working, so
long as they have national approval
for the activities which they plan. For
example, if an NGO in a particular
country seeks funds for a project,
WHO will now consider contributing
all or part of the budget, administered
through the NGO headquarters (if
these are outside the country) or
through a supporting international
NGO. The proposal would be assessed
according to the usual criteria:
including clear objectives, practical
activities, availability of key resources
such as personnel, management
skills, and equipment. The project
would also be evaluated according to
the same criteria, such as ability to
reach targets and effectiveness. |
The programme is in a trial phase. NGOs seeking further information are invited to contact
Mr. Bob Grose
at WHO/GPA (address below).
Any questions about the content of the WHO Report should be sent to WHO/GPA/HPR, 20 Avenue Appia,
1211 Geneva 27; Switzerland.
Managing editor: Kathy Attawell
Executive editor: Hilary Hughes
Production: Katherine Miles
Editorial advisory group: Professor E M Essien (Nigeria), Dr K Fleischer (FRG), J Hayman (WHO), Dr P Kataaha (Uganda), Professor K McAdam (UK), Professor L Mata (Costa Rica), Dr D Nabarro (Kenya), Dr P Nunn (Kenya), Dr A Pinching (UK), Dr P Poore (UK), Dr W Almeida (Brazil), Dr T K Sinyangwe (Zambia), Dr M Wolff (FRG).
Produced and distributed (free of charge to developing countries)
With support from Misereor, ODA, Oxfam, Save the Children Fund, SIDA and WHO/GPA.
The International Newsletter on AIDS Prevention and Care
This English edition of AIDS action was produced and distributed by Healthlink Worldwide.
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