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Questions and Answers

CD4 counts are sometimes difficult to get and are expensive. Is there anything else I can use to approximate it?
The total lymphocyte count can be used to approximate the CD4 count. The total lymphocyte count of <1250 approximates the CD4 count of <200 (the point at which one initiates bactrim prophylaxis with HIV positive patient. In addition, if there are symptoms or signs categorising a patient as World Health Organisation (WHO) Stage 3 or Stage 4, then prophylaxis is also warranted, even if the total lymphocyte count is not available. QJM. 1996. July 89(7) 505-8 Post, Wood, Maartens.

What are the possible causes of headaches in HIV positive patients?
Headaches are a common complaint of HIV infected patients. Possible etiologies include: 1) primary headache syndrome e.g. migraines and tension headaches 2) infections e.g. HIV itself, opportunistic cerebral infections (TB, cryptococcus and toxoplasmosis) and meningitis (bacterial, viral, aseptic).

What are the common skin manifestations that an HIV positive patient can present with?
Examples of common skin manifestations that HIV positive patients present with include: superficial fungal infections (e.g. tinea visicolor, candida, onychomycosis); and viral infections (e.g. herpes zoster, herpes simplex lesions that are extensive and non-healing). Other skin conditions to take note of include: recent onset of psoriasis, diffuse wart lesions, folliculitis, molluscum contagiosum, unusual pigmented lesions (query karposis) and varicella zoster virus in younger patients.

What is an accepted internationally understood classification of severity for HIV positive patients?
There are two main score in use: the Center for Disease Control classification and the World Health Organisation classification. The WHO classification has been adapted for Third World use where there is a high incidence of pulmonary TB. Pulmonary TB is defined as a Stage 3 disease in the WHO classification and not an AIDS defining classification (or Stage 4 disease) as in the Center for Disease Control classification. Both classifications are accepted internationally.

Should patients with HIV be given the influenza vaccination this year?
The evidence for efficacy of the influenza vaccine in the South African population is not available. There is some evidence to support the fact that, post vaccination, the viral load is elevated transiently due to immune activation. However, response to the vaccine depends on the level of cell mediated immunity and stage of HIV disease. Recommendation: if the vaccine is available, it may be given to the HIV-infected person. Effectiveness, however, is limited, especially in advanced disease.

Should antibiotics be given for aphthous ulcers in addition to topical steroids? Which antibiotic is the best choice?
Aphthous ulcers are a virally induced condition. Oral gingivitis is seen relatively frequently in HIV but should be diagnosed and treated in its own right. The approach to aphthous ulcers is: 1) good oral hygiene (a mouthwash with an antiseptic is not unwarranted); 2) symptomatic relief with topical anaesthetic; and 3) oral steroids.

Is a cocktail of multivitamins e.g. Vit BCo/Vit C/Vit E (in addition to other prophylactic drugs and curative medicines) necessary in stimulating the immune system and correcting micro-nutrient deficiencies in patients with HIV/AIDS?
Literature is thin and debatable for a definite positive benefit of giving HIV/AIDS patients a cocktail of multivitamins. There is evidence coming through at present, of giving patients high doses of Vitamin A to reduce vertical transmission, but there is also conflicting evidence. There is also evidence for giving HIV/AIDS patients the anti-oxidant vitamins and possibly selenium as a supplement. Recommendation: if the patient can afford the vitamins and is willing to take the vitamins, there is no risk to taking multivitamins, but the proven benefit has not yet been shown. It is more important that the patient takes prophylactic treatment.

What is the cheapest dual therapy combination available in South Africa?
The cheapest available dual therapy is the combination of didanosine (ddi) and hydroxyurea. The cost of this is: hydroxyurea at 500 mg twice daily (R120/month); and ddi at 200 mg twice daily (R680/month). Given financial constraints, this is an acceptable combination. However, one must keep in mind there is the risk of the therapy faltering and once a person has been on antiretroviral therapy he/she will probably not be able to qualify for a drug trial. It may be worth checking if the patient qualifies for a drug trial before initiating the above regime.

My patient has recurrent aphthous ulcers. What should I do?
After taking care of oral hygiene and prescribing a basic mouth wash, as well as topical anaesthetic such as Teejel, consider topical steroids. We use belomethasone topical sprays (beconase/becotide) applied directly to the affected oral mucosa 2 Ė 3 times a day. Short course systemic steroids can also be considered preferably after confirmation on biopsy and histology. Finally permission to use thalidomide can be obtained from the Medicine Control Council on a named patient basis.

What is oral hairy leukoplakia?
This is a lesion that occurs on the lateral border of the tongue and is specifically associated with HIV. It has the same prognostic implications as the onset of oral candidiasis in HIV. It puts the patient into Stage III category. It is though to be due to epidermal changes induced by Ebstein-Barr virus.

Should I inform colleagues about a mutual patientís HIV status?
This information is confidential and should be kept between care-giver and patient. Whenever possible the need to pass on information should be discussed with the patient and should be given out if it is considered to be in the best interests of the patient.

Is lymphadenopathy always present in HIV infection?
Lymphadenopathy is usually due to HIV, tuberculosis, lymphoma or Kaposiís sarcoma. Moderately small lymph nodes (less than 2cm) will occur in early HIV and are not significant. Nodes that are asymmetrical and increasing in size need intervention i.e a FNAB with a large bore needle and staining for TB after airdrying are used.

My patient complains of odynophagia. What should I do?
In most cases this will probably be due to oesophageal candidiasis especially if looking into the mouth you see evidence of orapharyngeal candidiasis. Because the azoles are so effective it is worth giving an empiric trial of fluconazole 100mg daily for two weeks. If symptoms do not improve an endoscope can be arranged to exclude other possible causes of ulceration such as CMV, HIV or other.

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