Grandir

Malaria and HIV: an interaction to consider!

The way that Malaria and HIV interact is now well documented. In adults the more suppressed the immune system the greater the number of malarial fever episodes. In addition, a person's viral load temporarily climbs while he/she is experiencing a malarial fever. A recent Ugandan study clearly showed the beneficial effects of two types of interventions: 1. cotrimoxazole used as prophylaxis (CTX) significantly reduces the numbers of malarial fevers (CTX is in the same medicinal category as Fansidar) ; 2. when ART is being administered simultaneously to CTX prophylaxis, the number of fevers is reduced even further in HIV+ adults by increasing immunity (CTX+ART>CTX alone).

Both infections also result in anemia, one potentially aggravating the other. Children are particularly vulnerable to this. Anemia during malarial fevers is more severe in HIV+ children. Finally, malaria aggravates a nutritional state already often weakened in the HIV+ child (higher caloric needs, poor nutrition, loss of weight) and consequently contributes to the progression of HIV.

In practice: for children infected with HIV, current knowledge suggests rapid and appropriate treatment of malarial fevers, and routine use of cotrimoxazole prophylaxis, as well as using insecticide-impregnated mosquito nets. Finally, because young children are particularly at risk of severe malarial fevers, the initiation of ART before 18 months of age in an infant with presumptive HIV infection (WHO 2006) should be contemplated (even without PCR virological diagnosis).

To find out more
Whitworth J et al: Lancet
2000 Sep 23; 356(9235):
1051-6

Froebel K et al:
Parasite Immunol.
2004 May; 26(5):213-7

Mermin J et al: Lancet
2006 367:1256-61

Otieno RO et al: AIDS
2006 Jan 9; 20(2):275-80

Comics about malaria
("Impact Malaria" programme)
www.impact-malaria.com/
en/gp/la_bibliotheque_des_
outils_educatifs/diaporamas/
thecomicsaboutmalaria.asp

Malaria infection during pregnancy in the HIV+ woman has potentially harmful effects. Growing Up Info will address this topic in an upcoming issue.

UNITAID: another opportunity to finance pediatric ARVs?

Starting July 1st, 2006, a solidary levy amounting to 1 euro or more will be set aside from every airplane ticket bought in France totaling more than 200 million euros per year in order to sustainably finance the International Drug Purchase Facility (IDPF) to treat HIV, Malaria and Tuberculosis. Similar initiatives have started up in Brazil, Chile, Norway, Gabon as well as in numerous other states under the name of "UNITAID: together to heal". What impact will UNITAID have on access to pediatric ARVs? Prof. Michel Kazatchkine, Ambassador of France on HIV/AIDS and transmissible diseases, offers some answers:

"Pediatric ARVs, 2nd line ARVs, 2nd generation anti-malaria drugs and medicines to treat multidrug resistant tuberculosis were deemed a priority by UNITAID/FIAM. IDPF needs to negotiate lower prices for drugs already on the market and to diversify what's available by encouraging a larger number of companies and particularly generic drug manufacturers to be present. The experience of 1st line ARVs demonstrates that competition brings down prices."

"Currently the market for pediatric ARVs is insufficiently developed because the overall demand is weak and fragmented. Ivory Coast will order 400 boxes of a given product, Burkina Faso 200, South Africa 2300, etc. The producers lack long-term visibility. UNITAID can create predictability by guaranteeing purchases over the course of several years and bringing companies into the market to diversify the supply and bring down prices."

To find out more
UNITAID's website
www.unitaid.eu
 
NGO position paper on UNITAID-IDPF www.sidaction.org/pro/
international/actualites/
fiamjuillet06

A possible answer to last month's case

Last month Growing Up Info published an exercise on HIV disclosure. Here is a possible strategy to use when faced with this situation:

Cecilia's questions should be seen as an opportunity to have a conversation with her about the illness. Cecilia expects answers to her questions and we need to help her out. An interview beforehand with her grandmother is indispensable: 1. to ask her what she has already told Cecilia about her illness and her brother's illness and about the fact that her father is no longer there, 2. to get her agreement on disclosing to Cecilia and, 3. to involve her.

If the grandmother hasn't said anything yet to Cecilia, we should help her find the right words so that she herself can answer her granddaughter's questions. There is no therapeutic urgency for Cecilia. It is therefore recommended to take some time with the grandmother so she can overcome whatever reluctance she may feel so that she feels ready to answer Cecilia's questions. We should advise the grandmother to use simple, age-appropriate words and metaphors (Cecilia is 8 years old), for example, terms like "a bug in the blood."

In practice, once the grandmother feels ready, we could tell Cecilia to ask these same questions to her grandmother. Alone with Cecilia a few days after her conversation with her grandmother started, we could ask Cecilia to talk about fears she may have regarding her own health and the health of members of her family (her brother and father).

Here is a multiple choice questionnaire on cotrimoxazole

This month Growing Up Info invites you to review your knowledge on this important subject. Everyone can have a go, not just those of you who are medical doctors!

I. Cotrimoxazole (CTX) is an anti-infectious agent which is mainly prescribed to prevent:
A Toxoplasmosis - B Tuberculosis - C Mycobacterium avium -
D Pneumocystis carinii (PCP)
II. It is strongly recommended NOT to prescribe CTX to children less than 18 months old whose HIV status is unconfirmed:
A True - B False
III. The recommended dosage in primary prophylaxis in the HIV+ child is:
A 6-8 mg/kg/day - B 15-20 mg/kg/day - C 50 mg/kg/day
IV. Primary prophylaxis of CTX can be interrupted at the commencement of antiretroviral therapy:
A True - B False

Hats off to Dr Sabrina Kitaka (Uganda) for her brillant answer. Her thoughts inspired our answer. Our answer isn't the only one possible. Do not hesitate to let us know your thoughts.

Thanks to MTCT-Plus/ICAP.
One of their case-studies inspired us to conceive this exercise.

Growing Up and Serment Merveil (a Congolese NGO) will organize a skills-building workshop on disclosure at the AIDS Conference in Toronto (in French-only): on August 17, 2006, 10.45 -12.45, in room KC5. Come one come all (if you understand French)!
























Be the fastest at giving us the right answers and you will win a reference book on HIV /AIDS! Please send us your answers and explanations at grandir@sidaction.org

Procurement of pediatric ARVs: a model for estimating quantities

Procurement of pediatric ARVs on the national level is a real puzzle: liquid ARVs have a very short shelf life; the amounts that need to be ordered vary tremendously depending on the weight of the children; the prescription by health practitioners of liquids as opposed to pills is hard to estimate, etc. In their support of developing countries, which includes 16 countries and 10,000 children on ARVs (drug donations and negotiated prices), the Clinton Foundation has developed a Pediatric Forecasting Model which makes it possible to evaluate precisely, on the national level, the necessary quantities of each pediatric ARV for scaling up.

This detailed estimate was done after taking into account several variables:
- number of children who need to be on ART in the country?
- gradual or full scale-up: will all the children who need to be on ART benefit from the program as soon as it begins or will the number of children to benefit from this program grow gradually?
- weight: what is the distribution by weight of children who need to be on ART?
- drug selection: what is the percentage of the usage of each ARV regimen? Ex: AZT vs. d4T in first line regimen.
- switching regimens: what are the probabilities of changing combinations because of toxicity or treatment failure?
- suspensions vs. solids: what is the percentage of liquid formulations vs. caps/tabs? (depending on the weight).

To find out more
The Clinton Foundation website
www.clintonfoundation.org/
index.htm

Presentation of the model during the conference on Childhood and AIDS (Paris, June 2006)
http://colloque.colloque-enfance-sida.org/
mediastore/9/2066-4.ppt