HIV and TB in Practice for nurses

ARVs as prevention

This is the second monthly edition of HATiP targeted to nurses and other health care workers involved in task-shifting in sub-Saharan Africa, kindly supported by the Stop TB department of the World Health Organization.

These special editions of HATIP are intended to support the capacity development of nurses and other health care staff as they take on new roles and tasks in the scale-up of HIV counseling and testing, antiretroviral treatment, HIV/TB activities, TB case finding, diagnosis, treatment and cure.

One of our goals with these editions is to draw out key messages and issues addressed in HATIP, the HATIP Blog, and www.aidsmap.com news coverage relevant to nurses, and others providing counselling, medical care and support services; and then to link these to related job aids, training materials, posters and training manuals that may be useful.

If you have validated materials targeting nurses and others involved in task shifting that you would like to share, or are a nurse or health care provider and want to see particular issues addressed, or would like to share your personal experience in task shifting, please contact us at info@nam.org.uk.

ART IS Prevention

The biggest HIV news at the big HIV conference in Rome last year, and indeed the biggest HIV news of the past few years, are the results of a big clinical trial showing that the antiretroviral medications used as HIV treatment can also prevent the SEXUAL transmission of HIV.

It is amazing how easily the words 'sexual' or 'sex' get left out of reports and discussions about these things. Sex is something people like to do, but not necessarily talk about.

But ultimately, that is a big part of the 'ART is Prevention' news, and what most of this issue is about: people, some of whom have HIV – some of whom may be your patients – are having sex; and sometimes wanting to have children. It is good health practice to help clients with HIV and their partners live their lives as safely as possible – their need for non-judgmental services and information on family planning and sexual and reproductive health was also news in Rome. Fortunately, the treatment as prevention news should make sex and having children safer.

Fortunately, the treatment as prevention news should make sex and having children safer.

How can ARVs be used as prevention?

There are several ways ARVs are being used as HIV prevention:

Prevention of vertical transmission to keep babies HIV-free As we described in last month's edition, there are comprehensive guidelines on how to use antiretrovirals to minimise the risk of HIV transmission during pregnancy, delivery and breastfeeding.

Post-exposure prophylaxis (PEP) This means taking a course of ART as soon as possible after HIV exposure, definitely before 48-72 hours have passed, and for 4 weeks afterwards to prevent becoming infected with the virus. If you wait too long, PEP won’t work. It is best to take PEP within a few hours after exposure.

There are a number of situations when IMMEDIATE ACCESS to PEP (ART as PREVENTION) is ESSENTIAL.

• PEP for occupational HIV exposure: Nurses and other healthcare staff may be at risk of occupational exposure, especially if they accidentally puncture themselves with a used needle or other sharp instruments (see box on universal precautions). Other healthcare workers and health facility staff such as maids and janitors need to know this too. Taking a four-week preventive course of ART (the exact regimen varies by country) started as soon as possible after occupational HIV exposure (such as needlestick injuries) can protect healthcare staff from HIV.

• PEP as part of sexual assault care: The provision of PEP after rape is part of the package of post-sexual assault care in many countries, and also need to be made available for children who have been assaulted. It should also be available for victims of sexual assault in prisons. Many programmes have developed kits containing a few days worth of PEP so that treatment can begin immediately, and not be delayed by HIV counselling and testing, or risk assessment. HIV counselling and testing of the perpetrator IS NOT REQUIRED.

• PEP after other high-risk exposures: PEP could also help prevent HIV infection among people who have other high-risk exposures, such as men who have sex with men, people who have shared needles, or women who have had sex with a man known to be, or who has a high risk of being, HIV infected. Policies regarding PEP for these non-occupational exposures vary by setting.

ARV-containing microbicides These are experimental products containing ARV drugs that women can apply themselves to reduce the risk of getting infected with HIV during sex. The best-known example of this is the tenofovir-containing gel that a major study in South Africa suggested offered some protection to women who used it regularly before sex. Another recent study did not find that it worked as well, so time will tell whether this will become a product women can use to protect themselves from HIV.

Pre-exposure prophylaxis (PrEP) PrEP is an experimental prevention tool, that involves taking ARVs before and, after sexual activity (in the studies performed to date). Studies have been in:

• Men who have sex with men, with one study suggesting that regularly taking daily Truvada (tenofovir/emtricitabine) reduced the risk of HIV infection.
• Women: For reasons that are yet unclear several large studies in women have failed to demonstrate any protective benefit, with the exception of the studies described below.
• Men and women with HIV-positive partners: Two large studies of PrEP presented at the AIDS conference in Rome showed it might have benefit for both uninfected men and women who are in serodiscordant relationships (in relationships with an HIV-infected partner) – possibly because their partner helped them to adhere regularly to taking their PrEP.
• Infants: Infants who are given ARVs to prevent their infection due to exposure to HIV through their HIV-positive mother’s breastmilk are, in essence, taking PrEP.

Treatment as prevention This refers to the discovery that HIV-positive people whose HIV is suppressed as the result of taking effective ART are generally not infectious, as long as they don’t have other untreated sexually transmitted diseases that could increase HIV levels in their genital fluids. Results last year showed that taking ART may be the most effective way of all for people living with HIV to protect their sexual partners from infection, and also suggested that increasing reliable access to effective ART may be the best way to prevent the continuing spread of HIV.

ART as prevention news

ART as Prevention

HPTN 052 was a large study that recruited couples where one partner had HIV, and the other did not, 1763 couples in total from Malawi, Zimbabwe, Botswana, Kenya, South Africa, Brazil, Thailand, the US and India.

The study looked at whether starting ART soon after the parter with HIV was diagnosed (in this study when their CD4 cell counts were between 350 and 550) reduced the chances of their partner becoming HIV infected, compared to waiting until their CD4 cell count dropped to < 250 to start ART. Reported condom use was high at the start of the study and remained high during the study – so any effect was due to ART.

The good news?

Starting ART early reduces HIV transmission in a BIG way – by 96%. The only transmission that occurred from a person on treatment is believed to have occurred within the first few weeks on ART, before HIV was fully suppressed.

What does this mean for nurses?

Nurses prescribing ART and other healthcare staff scaling up and improving the quality of ART services should know that they are also helping to reduce new HIV infections. Early diagnosis, prompt referral for ART if eligible, retention in care, and adherence to treatment are all essential for treatment as prevention to show its full potential. Tip: Partnering with trained community health workers and expert patients helps achieve the best retention in care and treatment adherence.

Other possible implications

The ART as Prevention news makes a good case for starting ART earlier in people living with HIV. Policy changes have happened in some countries, for example:

• Malawi: Even before the results came out, Malawi announced that it would provide universal lifelong ART to any HIV-positive woman entering their PMTCT programme 1) for her health – studies show ART reduces maternal mortality, 2) to prevent the spread of HIV to the infant she is currently pregnant with, 3) to better prevent the infection of any subsequent children she might have by providing protection from conception on, and 4) to help her keep her partner uninfected, if he doesn’t already have HIV. Unfortunately, this programme is jeopardised by recent HIV funding cuts.

• Rwanda and Zambia are now offering ART to any person in a serodiscordant relationship, should they and their partner want it. This follows naturally from their policies on couples HIV counselling and testing.

WHO and other countries are considering policy in light of these results. Many programmes are busy expanding to put people who immediately need ART to stay alive, and need to plan carefully to find the money to sustain current programmes first, before widening eligibility criteria for ART. But it is hoped that the ART as Prevention news increases support for the HIV programmes and importantly, the health system that provides it, both from the national government and international donors.

PrEP news 

Although the results do not nearly seem as profound, two studies also showed that PrEP may be an alternative or supplemental option to protect HIV-negative people who may have a partner, or sexual partner with HIV. (Read the news report here).

The Partners PrEP study compared tenofovir and tenofovir/emtricitabine (Truvada) versus placebo as PrEP in serodiscordant couples in Kenya and Uganda, while the TDF2 study compared Truvada versus placebo in heterosexual men and women in Botswana.

In brief, the Partners study found that tenofovir reduced the HIV infection rate by 62%. Truvada reduced the infection rate by 73%; there was no statistical difference between the efficacy of Truvada and tenofovir.

In the TDF2 study, Truvada reduced the infection rate by 63%, but by 78% in patients who had picked up their study drugs within the previous month and who therefore had pills available.

PrEP to prevent sexual transmission of HIV is still considered an experimental approach, and in particular, further study is needed in women to understand why it seems to work in some studies but not others.

When resources for ART as treatment and prevention are limited, PrEP may seem less of a priority but it may be an important option for some people. For instance, it may offer increased protection for the seronegative partner over and above ART as Prevention, such as when a couple is trying to conceive but cannot afford access to safer but high tech fertilisation methods (see below). More research is needed.

ARV for breastfeeding HIV-exposed infants

PrEP in breastfeeding infants is NOT an experimental approach however, and in Rome, an analysis of data from several major studies showed that extending the use of nevirapine or zidovudine and nevirapine in infants can reduce the risks of HIV transmission through breastmilk by over 70%. (Read the news report here).

Results from these studies showed that giving HIV-exposed infants daily nevirapine could help protect them from HIV transmission through breastmilk and led the World Health Organization (WHO) to change its guidelines in 2010.

Essentially, the analysis found that the longer you give nevirapine prophylaxis to infants who continue to be exposed to HIV through breastfeeding the more HIV transmission is reduced, and it should probably continue as long as the HIV-exposed infant is breastfeeding.

Currently WHO recommends exclusive breastfeeding for six months with the introduction of complementary foods for the next six months. Breastfeeding should stop at the end of 12 months, if feasible. Rapid weaning is no longer advised.

This is not the national policy in every country, so healthcare staff are advised to consult with their local guidelines.

Other prevention news: Circumcision

The World Health Organization has recommended that services offering access to voluntary male circumcision, to reduce one’s risk of HIV infection, should be widely available in high-HIV-burden settings — but demand for the procedure often outstrips the supply in some sub-Saharan African settings.

In Kenya, procedures and policy have been adapted to empower nurses to safely perform male circumcision. After two campaigns, the programme has delivered 268,000 male circumcisions within 2.5 years.

Even so, there may not be enough nurses given their role in providing treatment in care — so one researcher at the conference recommended bringing retired or unemployed nurses back into service to provide these services.

Do you know any sisters who are bored with retirement, and good with their hands?

Meeting the needs of people living with HIV for sexual health and reproductive services and family planning

Underlying all of the talk about ART as prevention advances for serodiscordant couples is one simple truth.

People living with HIV, like anyone else, still have sexual needs and sometimes want to have families, just like everyone else. They need information and services to help them do this safely — the trouble is, they just ain’t getting it.

At the conference in Rome, there were reports from Kenya, Tanzania and Namibia, just 46% of HIV-positive women and 28% of HIV-positive men have discussed family planning with a healthcare provider, and there is low awareness of strategies which allow a serodiscordant couple to conceive while limiting the risk of sexual HIV transmission. Meanwhile, a study conducted by people living with HIV in Zambia has found that there are a large number of adolescents living with HIV who are becoming sexually active, but there are no services for them and, in that country, it is even illegal to give them condoms!

How can nurses, counsellors and other healthcare workers keep people in their community, in particularly people living with HIV, and sometimes even young men and women growing up with HIV, healthy, happy and capable of having families?

The truth is that many HIV programmes simply have not prepared healthcare staff to respond to these needs.

But there are some excellent tools that some international NGO’s have made available that we think should be highlighted in order to kick start the process.

Talking about sex is really the first hurdle

Studies have shown that trained and supervised peer educators and community health workers can provide high quality family planning services. Tools listed below may prove useful to help staff become more comfortable assessing and talking about sexual and reproductive health and family planning with people living with HIV.

Ensuring that your team are comfortable and competent in talking about sex and contraception is one of the first steps towards delivering good quality sexual and reproductive health services. The training module reproduced below is an example of the sort of exercise that may be helpful.

It comes from Chapter 16 of ICAP’s Comprehensive Peer Educator Training Curriculum: Trainer Manual. 

The manual describes interactive training sessions; the methodology for the training and advice on how to adapt it for local settings is given in the introduction.

The following is excerpted from Module 16, Sexuality, Childbearing and Family Planning Basics:

As the manual points out:

“Sex is a normal part of life. It is very important… to be comfortable talking about sex and reproduction with… clients and in the community. If [you] do not talk about sex and sexual behaviors with clients, they may not get the information, skills and supplies they need to protect themselves and their partners and reduce risks of HIV, STIs, sexual violence, discrimination and unwanted pregnancy. “

Serodiscordant couples

Serodiscordant couples have specific needs that many healthcare workers who aren’t HIV-positive may not have considered. One of the best resources addressing this topic comes from a set of cards which is one of the supporting materials in ICAP’s “Improving Retention, Adherence and Psychosocial Support within PMTCT Services: A Toolkit for Health Workers.” The toolkit contains materials intended to improve the knowledge, skills, and confidence of a range of professional and lay health workers within PMTCT programmes, and can be downloaded in whole here.

The counselling cards can be downloaded as a PDF here or as Word documents here. A document containing many of the Toolkit's materials is also available in French for download here. 

As examples, we have included counselling cue card 10 on “Being part of a serodiscordant couple. PLHIV also have a right to have children, and counselling cue card 18 addresses this issue. See pages 7-8 of this edition.

Meeting other family planning needs

The table above summarises current contraceptive recommendations for women with HIV, and is reproduced from the FHI 360 counselling tool Reproductive health choices for clients with HIV, which can be downloaded here.

Note that WHO has recently posted updated advice on hormonal contraception and HIV which emphasises that women with HIV can continue to use hormonal contraception, but that women should be counselled to use dual protection - oral contraception and condoms - to prevent HIV transmission. 

Similarly, we would like to highlight some excellent materials materials by FHI 360 to support provision of family planning services for people living with HIV.  We’ve included some examples of curriculum materials for FHI 360's "Increasing Access to Contraception for Clients with HIV: A Toolkit. 

One family planning basic is that one should be reasonably certain your patient is not pregnant, and FHI 360 has developed a simple checklist, which is reproduced on page 10 of this edition.

Task shifting aspects of laboratory developments

One issue that has been noted by people living with HIV and nurses working at remote primary health clinics is that they do not have the same easy access to laboratory tests, such as CD4 cell count monitoring, as at larger ART sites.

But that may be changing soon. Researchers are putting more effort into creating easy to use lab tests that can be done by trained nurses in a clinic setting without a real lab. For instance, new point-of-care CD4 cell counting machines are starting to come out.

Several were described at the meeting that don’t require a laboratory technician but can be performed onsite by a trained nurse, providing results in less than an hour – while the patient waits). According to one scientist these should start rolling out out in the next 6 to 18 months, along with several other basic lab tests the can be done at the PHC level. These could make a difference in patient retention… and better outcomes because you can start treating the patient on the basis of the results you have the same day, in your hands.

Of course, funding will need to be found to make these tests widely available.

But some governments, such as the government of South Africa, have shown they are willing to invest in new laboratory infrastructure. For instance, South Africa is making remarkable progress scaling up the GeneXpert Rif/TB test.

They say that GeneXpert will result in 39% more people on TB treatment in South Africa by 2013, and that it could cut the time to starting TB treatment from over 50 days to around 5 days — that should reduce the time that people with TB are infectious, and could have a real impact on South Africa’s TB burden.

GeneXpert is still too expensive and needs a steady power supply (and an air conditioner in the room to keep the machine cool) to produce reliable results, so it isn’t going into every clinic. But the protocol for handling specimens will change — specimens won’t just go off for smear microscopy anymore, they will  also need to be processed and placed in GeneXpert cartridges (see figure on page 6).

An upcoming issue of HATIP will describe how GeneXpert will change the work-flow and processes for managing people who are TB suspects…. Stay tuned…