Wednesday, September 30, 1998

Condoms with coffee
By Andrew Perrin
It used to be a "social evil" the Government preferred to ignore. But with Vietnam’s HIV rate becoming the fastest growing in the region, Hanoi has been forced to put aside old objections and tackle the problem.

Cluster and migraine
By Prof K.C. Kanwar; MSc, Ph.D
These headaches are severe but rare and affect only one to two per cent of the total population. Further, unlike migraine, these do not run in families.

Care for AIDS-affected
By Ajay Wanchu; MD, DM

SINCE the early 1980’s more than 40 million individuals worldwide have been infected by HIV (human immunodeficiency virus) and nearly 12 million have died so far. In 1997 about six million people, nearly 16,000 a day, acquired the infection. These figures provided by UNAIDS, a programme sponsored by the United Nations, reflects some unpalatable facts. India dominates the epidemic in South-East Asia and between three and five million individuals are believed to have been infected.

Given the high figures of affected individuals in our country it is possible that a friend or a relative may have acquired the disease. Hence, it may be worthwhile to know some basic facts about the infection and how to look after someone infected by the virus.

AIDS (acquired immunodeficiency syndrome) is the last stage of the infection with HIV. Most people who have acquired the virus are still healthy and can live for several years with either no symptoms or only minor ailments. With the passage of time HIV attacks the body’s natural defences leaving the individual unprotected against infections. Only when serious infections or cancers occur in someone infected with HIV is the person diagnosed as having AIDS.

If you have to care for someone with HIV infection it is important to know how it is and how it is not spread. The commonest modes of the spread of HIV are by having unprotected vaginal, anal or oral sex with someone infected by HIV, by getting transfused with blood from an infected individual, by sharing needles or syringes with someone infected and from mothers to their babies before the baby is born, during birth or by breast-feeding. HIV does not spread from air, food, water, animals, insects, spoons, sharing the toilet or bathroom with an infected individual or anything else that does not involve blood, semen, vaginal fluid or breast milk. Likewise, one cannot get infection from saliva, sweat, farces, urine, tears or vomit unless these have been mixed or contaminated with blood.

So long as there is no serious infection, the best place for persons infected with HIV is at home surrounded by the loved ones. They should be allowed to take care of themselves and feel as independent as possible. They should continue to carry out their jobs as long as their strength permits. If they have to spend most to their time in bed it helps to change their posture at least every four hours to prevent bed sores.

Guarding against infections in one of the most important aspects of looking after people with HIV infection they can get very sick from common infections. The best way to kill germs causing infection is to wash your hands often enough with warm soapy water for at least 15 seconds.

Remember to clean the spaces between the fingers and under the fingernails. Wash them after going to the bathroom, when you cough and sneeze, touch the mouth or genitals, handle garbage or if you touch anyone’s blood, urine or faeces (like those of children). This may be a tall order but it helps! If you are or someone else is ill, avoid coming to the infected individual until you are well. If there is no one else to look after the person, wear a well-fitting mask to cover your mouth and nose. The person infected with HIV should not share his toothbrush, razor or nail cutter or any other object that may have blood on it.

There is no restriction on food for these individuals. A well-balanced diet is recommended. Avoid using raw milk or raw eggs. If meat has to be eaten, it should be well cooked. Wash fresh fruits and vegetables thoroughly. No separate dishes or spoons are needed. The utensils can be washed together with soap or detergent in hot water. Anyone who had diarrhoea should not cook food till he is well.

While you are looking after someone with HIV infection it is important to protect yourself from blood or other body fluids like bloody faeces that could infect you. Wear gloves if you have to touch any material that contains blood or if you have to change diapers or to empty bedpans. It is preferable to use disposable gloves and throw them off after single use. When taking them off, take them off by turning them inside out.

If you have sexual relations with a person with HIV infection, use a latex condom the right way each time you have sex. Condoms were initially designed to prevent the passage of sperms through them. Since the virus is much smaller in size as compared to sperms there are apprehensions that it may pass through the condom. This is an area of some debate and controversy. However, condoms could go to a great extent in protecting you from acquiring the infection.

Individuals with HIV infection can be lonely, scared or depressed. It is important to realise that you have to care not only for the body but also for the feelings. Just listening to them can help immensely. They need encouragement and not indifference or pity.

What about treating the virus itself? It makes sense to try to rid the body of the virus so that the damage caused by it to the immune system is repaired and the body regains its capacity to fight infections. In a short period of time since the virus has been discovered scientists have been able to make over one dozen drugs that work against the virus. Alone they are not very effective and, hence, they are used in combination of two or three.

Currently, the recommendations are to use at least three drugs together (belonging to more than one group). There are at least two problems associated with this. First, the cost of this sort of combination, excluding the cost of tests for monitoring therapy, is more than Rs 20,000 per month. This is in spite of tax relief given to these the drugs in the last Budget. Second, once the drugs are discontinued the virus, that may have been undetectable by routine tests, rebounds to pre-treatment levels within a matter of weeks.

Based on complex mathematical calculations it had been suggested that if the virus could remain undetectable for a period varying for 2.3 to 3.1 years, it might be possible to rid the body of the virus altogether. More recent studies have suggested a time frame of eight years after taking into account the fact that a small number of cells may continue to harbour the virus for a long period of time.

Clearly that is not an immediate possibility. The treatment of individuals for the time being depends to a great extent on treating infections as and when they develop. Considerable progress has been made against infections linked to AIDS and treating them would help people stay healthy longer. Surely, sooner than later scientists would be able to find curative therapy for HIV infection too.

When to consult your doctor? Initially when the individual is healthy, every six months. Later on more frequent visits may be necessary depending on the nature and frequency of infections that might occur. Also, consult the doctor if there are fever, cough, persisting headache, persistent diarrhoea, feeling of tiredness all the time, weight loss, blurring of vision, burning, itching or discharge from the vagina, persistent abdominal pain or for that matter anything that makes the person unwell. If the problem is not significant, reassurance alone may be enough.

Caring for someone with HIV infection can be a challenging task. More often than not, company of the loved ones in more familiar surroundings can lead to a better quality of life for the infected individual.

The author is a clinical immunologist and an Assistant Professor in the Department of Internal Medicine at the PGI, Chandigarh.

Condoms with coffee
By Andrew Perrin

It used to be a "social evil" the Government preferred to ignore. But with Vietnam’s HIV rate becoming the fastest growing in the region, Hanoi has been forced to put aside old objections and tackle the problem.

Ho Chi Minh City, Vietnam: It could have been a mother’s meeting anywhere in the world. A group of seven women, accompanied by their young children, sitting around a table discussing work.

But what is different is these woman are all prostitutes talking about AIDS and HIV, one of the dangers of their profession.

They are from the notorious Thu-Doc district in Ho Chi Minh City, and nearly all have been in jail during the past 10 years for soliciting and carrying condoms. In the Communist world of Vietnam that was as illegal as selling sex.

Times have changed.

The fortnightly HIV awareness meeting the women now attend has the support of the authorities that once imprisoned them. The distribution of condoms that occurs at the end of each session is encouraged.

"We are still scared of arrest for selling flower (sex)," says one of the women. "But not scared of having condoms in house".

Support of condom use is evidence of a government trying to come to terms with a disease that for so long it preferred to ignore.

Although the first documented cases were not recorded until 1990 — several years later than the rest of Asia — World Health Organisation (WHO) figures show Vietnam to have the fastest growing HIV and AIDS epidemics in the region.

About 75,000 people are now believed to be infected with HIV in Vietnam —a figure expected to top 300,000 by the year 2000.

The infection rate is spreading beyond the high risk groups of drug addicts and sex workers and into the wider community. Promiscuity is rampant in a country where more than half of the country’s 64 million people are under 30 years old.

In an attempt to slow the epidemic and increase awareness, the government has increased the budget for its AIDS awareness campaign from $50,000 in 1992 to $5 million this year.

It has also allowed international aid organisations to set up needle-exchange programmes for drug users, condom distribution centres for prostitutes, and even trendy cafes in the youth-dominated cities of Hanoi and Ho Chi Minh city.

Coffee to served with a condom and a safe sex booklet.

"Vietnam knows it is facing a crisis," said Dr Laurent Zessler, country programme adviser for UNAIDS.

"The government has seen what happened in Thailand and is aware that the cost of an AIDS epidemic will run into billions of dollars each year and so they have had to admit to problems, or social evils as they call them, that previously they refused to acknowledge existed."

This year, a 32-part soap opera series was screened on national television. The plot revolved around a Vietnamese family which had one member infected by HIV.

The changes in sexual practice have also been dramatic.

In 1993, DKT International, a social marketing company and the largest condom suppliers in Vietnam, sold 3.5 million packets of condoms. In 1995, they sold 21 million. They expect the figure to reach 42 million this year, providing the makers of its two best selling brands can keep up with demand.

There is still a long way to go.

Despite the social upheavals of the past few years, Vietnam remains fiercely protective of its patriarchal society. A recent survey of rural women found that 100 per cent admitted their husbands made all decisions on when to have sex and what protection, if any, to use.

The accepted practice of Vietnamese men having more than one sexual partner is also proving a stubborn thorn in the side of AIDS educators, making the world’s oldest profession even more risky.

"Many men come to me and ask to have sex without condom," said one Thu-Doc prostitute. "They say they will pay more for flower without condom. I’m very poor. I cannot say no." —GEMINI

Cluster and migraine

By Prof K.C. Kanwar; MSc, Ph.D

These headaches are severe but rare and affect only one to two per cent of the total population. Further, unlike migraine, these do not run in families. Interestingly, cluster headaches are nocturnal and bother one in sleep. These are four to five times more common in men than in women and occur as daily bouts of severe piercing pain lasting about 30-120 minutes and involve invariably only one side of the head.

The ipsilateral eye becomes red, waters profusely and suffers intense pain. The nostril of the side affected may also be blocked. In cluster headaches, the pain is continuous, non-throbbing and invariably intense and unbearable.

Initially, even though cluster headaches are restricted to one orbit, in due course the pain radiates to the forehead, temple or cheek and may even involve the jaw. These last from half an hour to two hours but once the cycle is started, they occur regularly once within 24 hours and thereafter continue to bother for weeks or even months.

Even after complete remission, cluster headaches can recur after a lapse of months — or even years — retaining the characteristics of the earlier episodes. Such relapses become likely when the sufferers are under severe stress or prolonged strain or subjected to overwork and emotional disturbances. Cluster headaches require medical attention.

The etiology of cluster headaches is largely unknown. Elevated blood histamine levels during attacks are not considered significant any more. Autoimmune involvement, though suspected, is not firmly proved. Many workers believe that cluster headaches can be attributed to insufficient production of serotonin and norepinephrine, both of which regulate perception of pain by the brain. As to why cluster headaches afflict predominantly men or also as to why these are limited to only one side of the head is not understood, nor even convincingly theorised, yet.

It is surprisingly uncommon for a patient to both migraine and cluster headaches simultaneously.

The essence of the treatment is prevention. To ward off the attacks which overwhelmingly are nocturnal, the drugs, mostly ergot-based, are advised to be administered an hour or so in anticipation of the attack, i.e., just before getting into bed. In many intractable cases of cluster headaches, steroids seemingly work with dramatic results.

MIGRAINE, the most common affliction of the nervous system, is a severe periodic recurrent headache. It occurs as intense incapacitating throbbing pain in the head, often accompanied by nausea, vomiting, frightening visual hallucinations and may rarely even cause partial transient paralysis. Migraine as well as the accompanying symptoms usually last for days together incapacitating the sufferers.

Migraine has the prevalence rate of 20-30 per cent in populations and 60-80 per cent sufferers are women who are particularly prone to it during menstrual days. It usually begins in childhood or early adolescence (rarely after 10-12 years) and recurs in diminishing numbers and intensity with advanced age.

Lucky are those sufferers who experience only a few migraine attacks in their lifetime. Most of the migraine victims are subjected to repeated attacks. Migraine is more common among energetic, ambitious and perfectionist people who are impatient to perform and achieve fast.

Migraine generally is classified as (i) of common type and (ii) of classic type. The common migraine, less serious but more predominant of the two, erupts suddenly as a simple headache without warning. The classic type, which afflicts only 20 per cent of all the migraine sufferers, is a paroxysmal disorder marked by a severe headache accompanied almost invariably by nausea, anorexia and even vomiting. The associated symptoms at times are as troublesome as migraine itself.

(To be concluded)