NANASI urticaria

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No. 15                   June 2003

In this issue of NANASI:
      Opportunistic infections: Itch
      Q and A: Generics from MEDS
      Peripheral nervous system complications of AIDS
      Counseling Sheet K: Memory books

                             -- opportunistic infections –

                                    ITCH (PRURITIS)
        Itch or pruritis is a common symptom of persons with AIDS. Although itch usually is
not life threatening, it diminishes the quality of life and can make the patient miserable. Itch
either can be caused by HIV infection itself or can arise from conditions and infections
opportunistic to HIV/AIDS. While it often is difficult to know the cause of the itch, this
knowledge is important because different types of itches require different types of
treatments. There are four types of itch, any or all of which can be at work in AIDS patients.

Psychogenic itch is due to overwhelming psychological trauma and delusions.
Psychogenic itch is treated best with drugs such as amitriptyline and largactil.

Neurogenic itch is due to substances in the body which provoke generalized pruritis.
Examples are: excess bile salts seen in cholestasis, hepatitis C infection, and uremia from
kidney disease. There is no good treatment for this type of itch except to address the
source of the disease. Some consultants also use amitriptyline.

Neuropathic itch originates in damaged nerves leading to the brain. For AIDS patients,
this is the itch which persists after a bout of shingles (Varicella zoster). There is no
satisfactory treatment for this type of itch and its associated pain, except to interrupt the
nerve transmission by surgery or by the injection of substances to destroy the offending
nerve. Amitriptyline sometimes can help.

Pruritoceptive itch is due to damage of the skin by infection, inflammation or dryness.
Most itch suffered by AIDS patients is the pruritoceptive type. Commonly occurring
examples are:

       Eczema—patients with AIDS suffer more eczema and eczematoid conditions (e.g. Psoriasis)
            than other people. These conditions usually respond to hydrocortisone cream 1%.
            Sometimes a stronger steroid cream is required (e.g. Dermavite cream).

        Pruritoceptive itch (continued)

        Seborrheic dermatitis—this condition in AIDS patients frequently is caused by a fungus,
               Malassezia furfur, (also called Pityrosporum orgiculare). This fungus can be treated
               with topical ketoconazole cream, clotrimazole cream or Whitfields ointment. Difficult
               cases respond to oral ketoconazole, 200 mg daily for 10 to 30 days. Some
               consultants have good results by giving one large dose of ketoconazole (400 mg.)
               one time only. Occasionally an associated bacterial infection may require topical
               antibiotics and steroids for itch.

        Scabies –this infestation frequently causes itch in AIDS patients, although it may not look
              like typical scabies. Sometimes it is crusted and secondarily infected. Scabies
              responds to benzyl benzoate solution applied once a day or to lindane 1% ointment
              or lotion. Crotamiton (Eurax cream or lotion) and Malathion also are effective. One
              oral ivermectin tablet given once will cure scabies. Note: after scabies has been
              effectively treated, the itch may persist for as long as a week.

        Drug eruptions—these are the result of the body’s reaction to drugs commonly used to treat
               AIDS patients (e.g. Cotrimoxazole, anti-tuberculosis medications and ARVs). They
               can cause local skin damage and itching. Often the manifestation is urticaria (hives)
               which responds to antihistamines and local steroid creams. Extreme drug reactions
               may require systemic steroids such as prednisone. The offending drug may have to
               be discontinued.

        Pruritis ani—this pesky ailment can be caused by monilia infection and will respond to
                 clotrimazole cream and ketoconazole cream. Sometimes it simply is secondary to
                 dry or irritated skin which can be treated with oily lotions or a mild steroid ointment.

        Folliculitis or pruriginous papular eruption (PPE)—probably is an autoimmune reaction to
                 skin sebum. It occurs as a discrete, very itchy papule usually on the upper part of the
                 body. Treatment is unsatisfactory although some consultants have reported results
                 with metronidazole 250 mg. tid for 3-4 weeks. Long-term (>8 weeks) erythromycin or
                 doxycycline treatment success also has been reported.

Non-specific measures: because itch is so subjective and so non-specific it is difficult to
treat. For some people, the measures below will relieve itch. Generally, they can do no
harm if used in moderation.

       Sodium bicarbonate washes. Dissolve one tablespoon of powder in one liter of water.
        Apply to the affected areas as often as required.
       Very hot water applied to the affected area will relieve itch temporarily.
       Benzyl benzoate and crotamiton have anti-itch properties even if there is no scabies. Apply
       Farm liniment, which contains menthol and methyl salicylate, is effective. A 12.5% farm
        liniment preparation is available from MEDS at KSh 417 for 5 litres
       Carbolic acid solution (phenol) 1-3 %, applied q4h. is helpful.

NOTE: Antihistamines usually are not effective in reducing itch unless it is due to an allergic reaction.

                        Q and A: Generics from MEDS

Question from the administrator at a large church hospital in Nairobi:
       We generally do not purchase generic Anti-Retroviral (ARV) drugs from MEDS
because we cannot be certain of their safety or efficacy. Does MEDS verify that their
generics are safe and effective?

Answer:         Experience shows that it is good to be alert to the safety and efficacy of any
generic drugs purchased in Kenya. For this reason, MEDS has in place a strict mechanism
for certifying the generic drugs that it sells.

Dr. Jane Masiga, chief pharmacist at MEDS explains:

      The MEDS Pharmaceutical Technical Committee continuously reviews quality
standards and screens products during tendering and at delivery to MEDS.

      MEDS does regular site visits to manufacturers to review production procedures and
does not hesitate to ban drugs from suppliers which do not meet specifications.

       Ninety percent of all drugs sold by MEDS are generic drugs. MEDS has a quality
control laboratory to conduct quality analyses on new drugs and drugs from new-purchase
manufacturers. MEDS analyzes drugs which have been questioned by users and does
random spot checks on drugs from its general stocks.

       ARV drugs present a special situation. Even though MEDS sells twice as many
generic ARVs than branded ARVs, MEDS does not have the capacity to analyze them all.
MEDS relies on the World Health Organization pre-qualification and certification of
manufacturers before it purchases any of their ARVs. MEDS does not purchase or sell any
ARV without the WHO recommendation. This strict adherence to WHO quality control is
why so few generic ARVs presently are on the MEDS list.

      Distal symmetrical sensory polyneuropathy (DSP) is the most common peripheral nervous system
complication of AIDS. Usually there are no visible signs of this condition, only symptoms: burning pain,
tingling and numbness of the toes and feet. Later, the patient might suffer painful involvement of the
ankles, calves and fingertips and eventually, diminished Deep Tendon Reflexes (DTRs).

      This neuropathy occurs as a result of HIV involvement of sensory nerves, or as an adverse side -effect
of drugs used to treat AIDS, most commonly didanosine, zalcitabine and stavudine.

      When a patient presents with symmetric pain and numbness of toes and feet, first obtain an HIV rapid
test in order know if the probable cause is AIDS. Other possible causes of polyneuropathy, which should
be addressed, are: diabetes, alcoholism, metronidazole toxicity, and pyridoxine (Vitamin B -6) deficiency
provoked by taking isoniazid (INH) for tuberculosis.

      If the patient already is taking ARV drugs, these drugs may have t o be reduced or changed
depending upon the severity of DSP symptoms. The patient should move his feet and walk around as
much as possible. For relief of pain, one should give pain medications in a stepwise fashion in accordance
with the WHO analgesic ladder until relief is obtained. The following drugs are recommended:

       BEGIN WITH:
            Paracetamol 500 mg q4h.
            Ibuprofen 200-400 mg. q6h.

                     THEN ADD:
                           Amitriptyline 25-150 mg. nocte.
                           Phenytoin 100-200 mg bid.
                           Carbamazepine (Tegretol) 200 mg. bid.

                                      LATER FOR S EV ERE OR REFRACTORY PAI N ADD:
                                            Morphine 5-10 mg. q3-4h.

                                COUNSELLlNG SHEET “K”
                           Memories are made of this

               All around Kenya nowadays, parents are dying, leaving their children with
                         unanswered questions and an uncertain future.

                                       An idea that spread
       Memory projects first originated in the United Kingdom as a tool to help children of
cancer patients cope with a parent’s death. The idea has since been adopted in the HIV and
                                       AIDS sector.

       SWAK (the Society for Women and AIDS in Kenya) has become the first organization in the
country to initiate a Memory Project, borrowing experiences from neighboring Uganda.

                                   What kind of memories?
      The overall aim of the Memory Project is to enable parents living with HIV to develop
supportive strategies for their children.

         Children often find out during or after the funeral that their parent died from AIDS. They are
left traumatized. The Memory Project prepares the parent to disclose their status and support the
children in coping with it, while the parents are still strong and active.

       The project enables parents to understand
           -   child growth and development,
           -   parenting, and
           -   effective ways of communication.

       Memory books and memory boxes help parents break the news of their HIV status to the
            children, and it helps them prepare themselves and their children for permanent

                                                                             >> >>>

Writing --- a will, a book, and a box
        The parents learn how to make a valid will, to protect the family house and land for the
children’s future.

         They can then go ahead to write a Memory Book to pass over significant memories to their
children about themselves, friends and relatives. Different pages of the book may be titled, ―My
favorite memories of you‖ or ―My hopes for your future‖. Children orphaned by AIDS can thus
live with positive memories of their parents.

       The Memory Book equips the children with information and knowledge they can fall back on.
The book can include family history and culture, which might later help them seek assistance
from relatives and friends. It could also help them appeal to the law in case of abuse or
disinheritance of their property.

        Some parents prepare a Memory Box of photos (with names and dates marked on the
backs), birth certificates, school records, and some special things to help the children remember
their parents and their own childhood.

       A Memory Project helps the family to cope with illness and approaching death, and it helps
            them plan a dignified future for their children.

                                        Training and a manual

        SWAK (Society for Women and AIDS in Kenya) has conducted one-week training sessions
on the Memory Project in all provinces of Kenya. A Memory Project Training Manual is also
available. Contact SWAK to inquire about the cost (to cover copying, binding and posting the

               SWAK National Office
               Kamburu Drive off Ngong Road (opposite Caltex)
               (020) 574044, 561624

        Compiled by NANASI, PO Bo x 208, Karuri 00219, Kenya. E-mail, Jan 2005

 NANASI is produced by Chri stians Concerned about AIDS in Kenya and is distributed by Action Aid.
       Send comments and questions to NANASI, P.O. Box 1968, City Square 00200, Kenya

               P.O. Box 1968
               City Square 00200

               No. 15 – June 2003

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