~) Longman Group UK Ltd 1992
Midwifery
CONFERENCE REPORT
A world united against AIDS. Report on the Nursing Satellite Conference and the Eighth International Conference on AIDS, Amsterdam, The Netherlands, 19-24 July, 1992 Satellite conference report Since the inception of the first international conference on AIDS in 1985, nurses attending the conferences have noted an absence of nursing representatives on the conference scientific p r o g r a m m e committees. Efforts to increase the involvement of nurses in the planning of this annual conference internationally have failed. At the Florence, Italy, Conference last year, members of the European Association of Nurses in AIDS Care (EANAC), and the Association of Nurses in AIDS Care (ANAC, USA) collaborated on planning a satellite nursing conference entitled: ' H I V Nursing: Caring For T h e Future,' 19 July 1992 in Amsterdam. Over 140 nurses attended. Dr Sandra Anderson, a nurse from the World Health Organization's Global Prog r a m m e on AIDS, delivered the opening address entitled 'Nurses United Against AIDS.' As the pandemic intensifies, the need for organised, effective nursing action is critical. An open f o r u m identified six categories of major nursing issues. Small group discussions formulated a roster of priority H I V nursing issues and actions, which are listed below.
Education Curriculum development in schools of nursing must include HIV-related content. Interactive teaching methodology may assist students to explore their personal attitudes regarding sex, sexuality, addiction and HIV. Prevention H I V prevention is within the realm o f nursing. Nurses must consider the client's individuality when implementing prevention strategies.
Research Nurses are not identifiable at the International AIDS Conference, since no credentials are listed. Nurses are critical in recruiting, supervising and maintaining patients in clinical trials and should be co-authors on papers and publications. T h e vital role of nursing care can be validated by its positive affect on client outcome. Clinical practice T h e increased incidence of tuberculosis worldwide, related in a large part to H I V infection, means there is a need for nursing vigilance to identify cases, and prevent transmission. T h e risk to health care workers must be communicated. Approaches to protect health care workers should be evaluated and utilised. Policy Policy, based on tear and ignorance, regarding health care workers is being fl)rmulated. In the event of occupational H I V exposure, nurses are entitled to make their own decisions regarding personal care. International communication H I V nursing does not have an organised international network. T o o few nurses attend the International AIDS Conference. During this satellite conference, a representative from a pharmaceutical company authorised two $2500 scholarships for nurses in developing countries to travel to next year's conference in Berlin. Additional sources for funding will be tapped for future scholarships. This first satellite conference was a major step for international nursing and participants 195
196
MIDWIFERY
appreciated this unique opportunity to network with fellow professionals.
International conference report Epidemic trends Dr Michael Merson, Director of the World Health Organization's Global P r o g r a m m e on AIDS, predicts that one person contracts H I V every 15 to 20 seconds. T h e r e have been approximately 11 to 13 million people infected worldwide. T h e geography of H I V is changing and a dramatic increase in cases is now found in rural areas. More individuals are learning about AIDS on a firsthand basis. T h e H I V infection gap between the sexes has narrowed. T e n years ago, two-thirds of all cases were male. Presently, close to one-half of the one million newly H I V infected persons are female. By the year 2000, more than one-half of new H I V cases will be female. Women are the fastest growing sub-group of H I V infection in the USA. Heterosexual and perinatal transmission continue to rise. Thailand and other Asian countries are experiencing a dramatic increase in cases. In Africa, the impact of the projected potential years of productive life lost is devastating. A new AIDS-like illness During the conference, publicity focused on reports regarding a new syndrome, ICL (Idiopathic CD-4 T-lymphocytopenia). This syndrome severely depletes the h u m a n i m m u n e responses and causes symptoms similar to AIDS. Thirty cases have been identified in the USA since 1985. T h e r e is no convincing evidence that the H I V or any other virus is involved. In studying the patterns of ICL, epidemiologists have surmised that this disease is not contagious and cases are not increasing. Further studies of this situation are being conducted. These new reports should not be surprising, given the new and increasingly wide use of m o d e r n tests of i m m u n e function. These reports also should be placed in perspective compared to the millions of H I V infections and clinical AIDS cases which have already occurred.
Tuberculosis T h e incidence of tuberculosis (TB) has increased significantly, in both developed and developing countries, in large part due to H I V infection. T h e high rate of TB a m o n g H I V infected persons suggests the need for H I V screening a m o n g newly identified cases o f TB. TB is often the first clinical sign o f H I V infection. Many studies reported the dramatic increase of multiple d r u g resistant TB worldwide. Fischl suggests that crowded conditions, such as waiting rooms in H I V clinics, may facilitate nosocomial transmission of TB. Increased conditions of poverty, homelessness, and i m m u n e suppression have been listed as co-factors in this new epidemic of an old disease. A major factor in the development of d r u g resistance is the failure to complete initial courses o f antibiotic therapy. Health care workers must be warned of the increased risk of acquiring tuberculosis. In contrast to HIV, TB is casually transmitted. We may have become complacent in o u r infection control and we must become m o r e vigilant.
Sexually transmitted diseases In this decade 80% of H I V infection will be sexually transmitted. By the year 2000, 9 out of 10 new cases will be transmitted sexually. T h e scientific evidence continues to support the observation that the presence of Sexually Transmitted Diseases (STDs) increase the risk of H I V transmission. Studies suggest that H I V prolongs the infectious period o f STDs, thereby creating a dangerous infection cycle. Several African studies support the following H I V risk factors: multiple sexual partners, genital ulcer disease, STDs, cervical ectopy and uncircumcised males. It is strongly suggested that efforts to prevent the spread o f H I V must include an increased effort in STD prevention and treatment. Effective STD control strategies have been documented in two community-oriented programmes a m o n g sex workers in Nairobi, Kenya (Ngugi) and Kinshasa, Zaire (Laga). T h r o u g h comprehensive, community-based STD care, peer counselling, negotiating and role playing strategies, rates of condom use have increased and the incidence of H I V transmission have
MIDWIFERY 197
been reduced. T h e knowledge of the true sexual behaviour of the people and use of trained local workers are essential components of STD/AIDS education projects.
Perinatal transmission
New data suggest that the risk of H I V transmission to the newborn via breast milk is greatest during the first few weeks after birth. HIV-1 was identified m o r e frequently in breast milk during the first 14 days of birth than in later weeks (Buherys). It has been suggested that delaying breast feeding for several weeks may help to reduce transmission to the newborn baby. T h e World Health Organization recomm e n d e d that HIV-positive women should not breast feed unless they live in areas where infectious diseases are a primary cause of infant death. Data continues to suggest that perinatal transmission occurs in utero. A maternal CD4 count less than 260 and pneumocystis carinii pneumonia have been found to be maternal predictors of perinatal transmission (Thomas). However, the possibility of intrapartum transmission was also raised. Duliege noted in a 12 country study of 165 twin sets born to H I V positive women that the first-born twin was four times at risk of being H I V infected than the second born twin. Proximity to the birth canal is suggested as the possible cause of increased risk. T h e type of delivery was not a significant factor. Cleansing of the birth canal and suctioning the m o u t h and nose were r e c o m m e n d e d as preventive approaches for evaluation. I f intrapartum transfer is truly a factor, scientific evaluation of prevention measures at delivery is necessary. T h e data on the mechanism of perinatal transmission continues to be inconclusive. Most H I V infected babies do not test positive at birth. H I V spreads to the peripheral blood supply by four months of age. T h e polymerase chain reaction test and viral cultures have identified H I V positive children at age 1-2 months (De Rossi). This ability for early diagnosis of H I V positive babies has led to successful prophylactic administration of Bactrin and intravenous Pentamidine which was shown to improve baby survival.
Women
T h e r e continues to be many effects of H I V in women that are different then in men. An effort has been made to include women in scientific studies and more gender specific research is necessary (Klosen). At a major conference session, the following issues relating to women were identified: 1. T h e need for early H I V diagnosis. This can be the difference between long-time survival and early death. 2. T r e a t m e n t priorities. Utilise available d r u g therapy early in the disease. W o m e n show an increased incidence of esophageal disease. 3. Gynaecological considerations. An increase in cervical dysplasia, pelvic inflammatory disease and recurrent vaginal candidiasis is well documented with HIV. T h e need for aggressive treatment and frequent follow-up is evident. 4. Medication dose management. Drug information related to women is lacking, for example, the effect of drugs on female renal and endocrine function, and dose adjustment for physical weight. 5. Anaemia. T h r o u g h menstruation and other factors, such as sickle cell disease, specific treatment with iron and folic acid may be warranted. 6. Wasting Disease. Dietary enhancement and nutritional education is recommended. Genital and gastrointestinal evaluation may be necessary. 7. Pregnancy. Studies are needed to explore the effect of pregnancy on the health of the H I V infected woman. 8. Compliance. Community sources must be utilised to contact women in need of education and health care. Culturally, women may hesitate to seek treatment for themselves. T r e a t m e n t p r o g r a m m e s need to incorporate services that support and encourage female participation, such as, childcare facilities, clinic transportation costs, and neighbourhood-based projects. Socio-economic constraints severely impair the opportunity for sexual options for women.
198
MIDWIFERY . Safer Sex. W o m e n c a n n o t have safer sex if they c a n n o t negotiate options with their sexual partners. S u p p o r t is n e e d e d for e d u c a t i o n a l p r o g r a m m e s that stress roleplaying strategies for safer sex. T h e r e is a n e e d to focus o n g e n d e r equality as a variable in h u m a n sexuality. T e c h n o l o g y m u s t focus o n the d e v e l o p m e n t o f a costeffective, acceptable female c o n d o m . Cont i n u e d emphasis o n male e d u c a t i o n in sexual t r a n s m i s s i o n is r e c o m m e n d e d .
Summary T h e dramatic increase o f new H I V / A I D S cases i n w o m e n a n d their babies c o n t i n u e s to r e q u i r e midwives to be vigilant in their efforts to identify clients at risk for HIV. T h e role o f STDs in H I V t r a n s m i s s i o n a n d disease p r o g r e s s i o n is evident. Research is lacking o n the effect o f AIDS drugs, p r e g n a n c y a n d birth o n the H I V - i n f e c t e d woman. Prevention, t h r o u g h safer sex, is a critical e d u c a t i o n strategy to consider. Data suggesting i n t r a p a r t u m t r a n s m i s s i o n o f H I V is particularly i n t e r e s t i n g a n d w a r r a n t s f u r t h e r study. Developm e n t o f the i n t e r n a t i o n a l f r a m e w o r k for f u t u r e clinical vaccine trials is u n d e r w a y . Initial studies
o n the ability o f H I V vaccines to limit perinatal transmission may p r o v i d e some e n c o u r a g i n g f u t u r e results.
Selected Conference Papers Bulterys Marc et al Detection of HIV-1 in breast milk, multiple sexual partners, and mother-to-child transmission of HIV- 1: A cohort study. Johns Hopkins University, Baltimore, MD, USA, University of Rwanda, Butare, Rwanda DeRossi A et al Perinatal transmission of HIV- 1: Lack of detectable virus in peripheral blood cells at birth, and prognostic values of polymerase chain reaction results in infants. University of Padua, Padua, Italy Duliege A Met al High risk of HIV-1 infection for first born twin: The role of intra-partum transmission. Genetech, San Francisco, California, USA and the National Cancer Institute, Rockville, Maryland, USA Fischl Met al Outbreak of multiple drug resistant tuberculosis among patients with HIV infection. University of Miami, Miami, Florida, USA Kloser PC HIV disease in women. UMDNJ, New Jersey Medical School, Newark, New Jersey, USA Laga M Impact of STDs on HIV transmission. Institute for Tropical Medicine, Antwerp, Belgium Ngugi E Net al Development of an educational booklet for STD/AIDS control among commercial sex workers in Kenya. University of Nairobi, Nairobi, Kenya, University of Manitoba, Winnipeg, Canada Thomas P A et al Maternal predictors of perinatal HIV transmission. Perinatal HIV Transmission Collaborative Study Group, New York City Department of Health, New York, USA MARYANNE F LACHAT RN, PhD
Midwifery
CONFERENCE REPORT
A world united against AIDS. Report on the Nursing Satellite Conference and the Eighth International Conference on AIDS, Amsterdam, The Netherlands, 19-24 July, 1992 Satellite conference report Since the inception of the first international conference on AIDS in 1985, nurses attending the conferences have noted an absence of nursing representatives on the conference scientific p r o g r a m m e committees. Efforts to increase the involvement of nurses in the planning of this annual conference internationally have failed. At the Florence, Italy, Conference last year, members of the European Association of Nurses in AIDS Care (EANAC), and the Association of Nurses in AIDS Care (ANAC, USA) collaborated on planning a satellite nursing conference entitled: ' H I V Nursing: Caring For T h e Future,' 19 July 1992 in Amsterdam. Over 140 nurses attended. Dr Sandra Anderson, a nurse from the World Health Organization's Global Prog r a m m e on AIDS, delivered the opening address entitled 'Nurses United Against AIDS.' As the pandemic intensifies, the need for organised, effective nursing action is critical. An open f o r u m identified six categories of major nursing issues. Small group discussions formulated a roster of priority H I V nursing issues and actions, which are listed below.
Education Curriculum development in schools of nursing must include HIV-related content. Interactive teaching methodology may assist students to explore their personal attitudes regarding sex, sexuality, addiction and HIV. Prevention H I V prevention is within the realm o f nursing. Nurses must consider the client's individuality when implementing prevention strategies.
Research Nurses are not identifiable at the International AIDS Conference, since no credentials are listed. Nurses are critical in recruiting, supervising and maintaining patients in clinical trials and should be co-authors on papers and publications. T h e vital role of nursing care can be validated by its positive affect on client outcome. Clinical practice T h e increased incidence of tuberculosis worldwide, related in a large part to H I V infection, means there is a need for nursing vigilance to identify cases, and prevent transmission. T h e risk to health care workers must be communicated. Approaches to protect health care workers should be evaluated and utilised. Policy Policy, based on tear and ignorance, regarding health care workers is being fl)rmulated. In the event of occupational H I V exposure, nurses are entitled to make their own decisions regarding personal care. International communication H I V nursing does not have an organised international network. T o o few nurses attend the International AIDS Conference. During this satellite conference, a representative from a pharmaceutical company authorised two $2500 scholarships for nurses in developing countries to travel to next year's conference in Berlin. Additional sources for funding will be tapped for future scholarships. This first satellite conference was a major step for international nursing and participants 195
196
MIDWIFERY
appreciated this unique opportunity to network with fellow professionals.
International conference report Epidemic trends Dr Michael Merson, Director of the World Health Organization's Global P r o g r a m m e on AIDS, predicts that one person contracts H I V every 15 to 20 seconds. T h e r e have been approximately 11 to 13 million people infected worldwide. T h e geography of H I V is changing and a dramatic increase in cases is now found in rural areas. More individuals are learning about AIDS on a firsthand basis. T h e H I V infection gap between the sexes has narrowed. T e n years ago, two-thirds of all cases were male. Presently, close to one-half of the one million newly H I V infected persons are female. By the year 2000, more than one-half of new H I V cases will be female. Women are the fastest growing sub-group of H I V infection in the USA. Heterosexual and perinatal transmission continue to rise. Thailand and other Asian countries are experiencing a dramatic increase in cases. In Africa, the impact of the projected potential years of productive life lost is devastating. A new AIDS-like illness During the conference, publicity focused on reports regarding a new syndrome, ICL (Idiopathic CD-4 T-lymphocytopenia). This syndrome severely depletes the h u m a n i m m u n e responses and causes symptoms similar to AIDS. Thirty cases have been identified in the USA since 1985. T h e r e is no convincing evidence that the H I V or any other virus is involved. In studying the patterns of ICL, epidemiologists have surmised that this disease is not contagious and cases are not increasing. Further studies of this situation are being conducted. These new reports should not be surprising, given the new and increasingly wide use of m o d e r n tests of i m m u n e function. These reports also should be placed in perspective compared to the millions of H I V infections and clinical AIDS cases which have already occurred.
Tuberculosis T h e incidence of tuberculosis (TB) has increased significantly, in both developed and developing countries, in large part due to H I V infection. T h e high rate of TB a m o n g H I V infected persons suggests the need for H I V screening a m o n g newly identified cases o f TB. TB is often the first clinical sign o f H I V infection. Many studies reported the dramatic increase of multiple d r u g resistant TB worldwide. Fischl suggests that crowded conditions, such as waiting rooms in H I V clinics, may facilitate nosocomial transmission of TB. Increased conditions of poverty, homelessness, and i m m u n e suppression have been listed as co-factors in this new epidemic of an old disease. A major factor in the development of d r u g resistance is the failure to complete initial courses o f antibiotic therapy. Health care workers must be warned of the increased risk of acquiring tuberculosis. In contrast to HIV, TB is casually transmitted. We may have become complacent in o u r infection control and we must become m o r e vigilant.
Sexually transmitted diseases In this decade 80% of H I V infection will be sexually transmitted. By the year 2000, 9 out of 10 new cases will be transmitted sexually. T h e scientific evidence continues to support the observation that the presence of Sexually Transmitted Diseases (STDs) increase the risk of H I V transmission. Studies suggest that H I V prolongs the infectious period o f STDs, thereby creating a dangerous infection cycle. Several African studies support the following H I V risk factors: multiple sexual partners, genital ulcer disease, STDs, cervical ectopy and uncircumcised males. It is strongly suggested that efforts to prevent the spread o f H I V must include an increased effort in STD prevention and treatment. Effective STD control strategies have been documented in two community-oriented programmes a m o n g sex workers in Nairobi, Kenya (Ngugi) and Kinshasa, Zaire (Laga). T h r o u g h comprehensive, community-based STD care, peer counselling, negotiating and role playing strategies, rates of condom use have increased and the incidence of H I V transmission have
MIDWIFERY 197
been reduced. T h e knowledge of the true sexual behaviour of the people and use of trained local workers are essential components of STD/AIDS education projects.
Perinatal transmission
New data suggest that the risk of H I V transmission to the newborn via breast milk is greatest during the first few weeks after birth. HIV-1 was identified m o r e frequently in breast milk during the first 14 days of birth than in later weeks (Buherys). It has been suggested that delaying breast feeding for several weeks may help to reduce transmission to the newborn baby. T h e World Health Organization recomm e n d e d that HIV-positive women should not breast feed unless they live in areas where infectious diseases are a primary cause of infant death. Data continues to suggest that perinatal transmission occurs in utero. A maternal CD4 count less than 260 and pneumocystis carinii pneumonia have been found to be maternal predictors of perinatal transmission (Thomas). However, the possibility of intrapartum transmission was also raised. Duliege noted in a 12 country study of 165 twin sets born to H I V positive women that the first-born twin was four times at risk of being H I V infected than the second born twin. Proximity to the birth canal is suggested as the possible cause of increased risk. T h e type of delivery was not a significant factor. Cleansing of the birth canal and suctioning the m o u t h and nose were r e c o m m e n d e d as preventive approaches for evaluation. I f intrapartum transfer is truly a factor, scientific evaluation of prevention measures at delivery is necessary. T h e data on the mechanism of perinatal transmission continues to be inconclusive. Most H I V infected babies do not test positive at birth. H I V spreads to the peripheral blood supply by four months of age. T h e polymerase chain reaction test and viral cultures have identified H I V positive children at age 1-2 months (De Rossi). This ability for early diagnosis of H I V positive babies has led to successful prophylactic administration of Bactrin and intravenous Pentamidine which was shown to improve baby survival.
Women
T h e r e continues to be many effects of H I V in women that are different then in men. An effort has been made to include women in scientific studies and more gender specific research is necessary (Klosen). At a major conference session, the following issues relating to women were identified: 1. T h e need for early H I V diagnosis. This can be the difference between long-time survival and early death. 2. T r e a t m e n t priorities. Utilise available d r u g therapy early in the disease. W o m e n show an increased incidence of esophageal disease. 3. Gynaecological considerations. An increase in cervical dysplasia, pelvic inflammatory disease and recurrent vaginal candidiasis is well documented with HIV. T h e need for aggressive treatment and frequent follow-up is evident. 4. Medication dose management. Drug information related to women is lacking, for example, the effect of drugs on female renal and endocrine function, and dose adjustment for physical weight. 5. Anaemia. T h r o u g h menstruation and other factors, such as sickle cell disease, specific treatment with iron and folic acid may be warranted. 6. Wasting Disease. Dietary enhancement and nutritional education is recommended. Genital and gastrointestinal evaluation may be necessary. 7. Pregnancy. Studies are needed to explore the effect of pregnancy on the health of the H I V infected woman. 8. Compliance. Community sources must be utilised to contact women in need of education and health care. Culturally, women may hesitate to seek treatment for themselves. T r e a t m e n t p r o g r a m m e s need to incorporate services that support and encourage female participation, such as, childcare facilities, clinic transportation costs, and neighbourhood-based projects. Socio-economic constraints severely impair the opportunity for sexual options for women.
198
MIDWIFERY . Safer Sex. W o m e n c a n n o t have safer sex if they c a n n o t negotiate options with their sexual partners. S u p p o r t is n e e d e d for e d u c a t i o n a l p r o g r a m m e s that stress roleplaying strategies for safer sex. T h e r e is a n e e d to focus o n g e n d e r equality as a variable in h u m a n sexuality. T e c h n o l o g y m u s t focus o n the d e v e l o p m e n t o f a costeffective, acceptable female c o n d o m . Cont i n u e d emphasis o n male e d u c a t i o n in sexual t r a n s m i s s i o n is r e c o m m e n d e d .
Summary T h e dramatic increase o f new H I V / A I D S cases i n w o m e n a n d their babies c o n t i n u e s to r e q u i r e midwives to be vigilant in their efforts to identify clients at risk for HIV. T h e role o f STDs in H I V t r a n s m i s s i o n a n d disease p r o g r e s s i o n is evident. Research is lacking o n the effect o f AIDS drugs, p r e g n a n c y a n d birth o n the H I V - i n f e c t e d woman. Prevention, t h r o u g h safer sex, is a critical e d u c a t i o n strategy to consider. Data suggesting i n t r a p a r t u m t r a n s m i s s i o n o f H I V is particularly i n t e r e s t i n g a n d w a r r a n t s f u r t h e r study. Developm e n t o f the i n t e r n a t i o n a l f r a m e w o r k for f u t u r e clinical vaccine trials is u n d e r w a y . Initial studies
o n the ability o f H I V vaccines to limit perinatal transmission may p r o v i d e some e n c o u r a g i n g f u t u r e results.
Selected Conference Papers Bulterys Marc et al Detection of HIV-1 in breast milk, multiple sexual partners, and mother-to-child transmission of HIV- 1: A cohort study. Johns Hopkins University, Baltimore, MD, USA, University of Rwanda, Butare, Rwanda DeRossi A et al Perinatal transmission of HIV- 1: Lack of detectable virus in peripheral blood cells at birth, and prognostic values of polymerase chain reaction results in infants. University of Padua, Padua, Italy Duliege A Met al High risk of HIV-1 infection for first born twin: The role of intra-partum transmission. Genetech, San Francisco, California, USA and the National Cancer Institute, Rockville, Maryland, USA Fischl Met al Outbreak of multiple drug resistant tuberculosis among patients with HIV infection. University of Miami, Miami, Florida, USA Kloser PC HIV disease in women. UMDNJ, New Jersey Medical School, Newark, New Jersey, USA Laga M Impact of STDs on HIV transmission. Institute for Tropical Medicine, Antwerp, Belgium Ngugi E Net al Development of an educational booklet for STD/AIDS control among commercial sex workers in Kenya. University of Nairobi, Nairobi, Kenya, University of Manitoba, Winnipeg, Canada Thomas P A et al Maternal predictors of perinatal HIV transmission. Perinatal HIV Transmission Collaborative Study Group, New York City Department of Health, New York, USA MARYANNE F LACHAT RN, PhD
