Infectious Diseases

The Infectious Diseases Service in Donostia Hospital is integrated by:

The Service is focused on two ways of attention: in and out patient hospital care.

One of the main activities in the Infectious Diseases Unit is the following of patients infected by the virus HIV. As well as the co-infection (HIV-HCV) in coordination with the Gastroenterology Service. Apart from that, and in collaboration with other Services at Donostia Hospital we participate in:

Serious infections treatment

Bone infections and articular prosthesis

Infections in immunodeficients

Tropical infections

Sexual transmission diseases

Nosocomial infections

Out patient care telephone contact : 943 007220 (Day Hospital) and 943 007006 (14 Consulting Room).

HIV in Haemophilia

People affected with haemophilia have been constantly exposed to infectious agents transmitted through sanguineous products needed for its treatment. In Haemophilia, Human Immunodeficiency Virus (HIV) has caused the more severe infection having the most devastating consequences. In October 1981 a haemophiliac patient was described for the first time as having AIDS.

The Atlanta Disease Control Centre, in United States of America, reported it in July 1982. In this date the Atlanta Disease Control Centre published three cases diagnosed by Pneumocistis Carinii in haemophiliacs, who were not neither homosexual nor drug addicts but they had in common the use of factor VIII concentrates.

The study of the natural history of HIV infection in haemophilia was confusing at the beginning. But the publication by Mr. Montagnier in April 1984 about T-linfotropic retrovirus in a T-lymphocyte culture from two brothers affected by haemophilia B, made possible to develop an antibody specific test.

During those years the specialists dedicated to the haemophiliacs attention begun to look for this alteration in their own patients. During the International Congress of the World Federation of Haemophilia, celebrated in 1983 in Stockholm, were presented 21 cases of HIV infections appeared in the States till this date.

The World Health Organization advised to treat factor concentrates with heat, and since 1985 it is compulsory to use the anti-HIV test to select blood donors. In a study done by the Atlanta Disease Control Centre in 1986 to determine the heated concentrate treatment efficiency, 2370 patients with haemophilia A were studied and 434 with haemophilia B, being the HIV rate 53%.

According to the World Federation of Haemophilia the percentage in Spain is about 45%. The high repercussion of HIV infection in the haemophilia community it could be due to:

The frequency of treatment

Contagion way (the intra-venous way is the way of infection with a high load of virus in concentrates)

Viral co-infectious (hepatitis, citomegalovirus, parvovirus…)

Immunological disorders due to be constantly exposed to high amount of strange proteins, which is a challenge to the Immune-competent System.

All that explains the HIV infection impact in the haemophilia community. In the same way, the lack of new viral inoculations, the application of prophylaxis programs and treatment give to the haemophilia community different characteristics related to other groups infected by HIV.

Nowadays, fear of transmission of HIV through factor concentrates has completely disappeared.

General care in a person infected with HIV (Recommendations by the Spanish Ministry of Health)

The following of people infected by HIV is getting more like other chronic patients with long term, slow evolution diseases and without a final treatment. It is important to learn living with the infection and to understand how important it is the following of treatment as well as medical recommendations. To obtain that it is important to be able to have a good communication with doctors based in honesty.

It is important to ask questions or share difficulties or necessities in an open and clear way. Since we know we are infected by HIV, it begins a long way of collaboration between the different healthcare professionals.

We inform you that once the first diagnosis and evaluation is done, following visits will be adjusted to the needs of the patient. But normally they will be periodical visits within 3-6 months, leaving the chance open to have medical visits when needed by the patient.

Support of preventive behaviour

Within the framework of healthcare education we will remind how essential it is to maintain preventive and self care behaviour.

1. Recommendations about safe sex Related to preventive behaviour in safe sex we should remember the following: • The most important is to use always condom in the right way each time you have penetration, because:

You avoid transmitting HIV to your partner

You protect yourself from new infections with HIV (re-infections), which can deteriorate more your immunitary system.

You avoid other sexual transmission infections

Practice sex as safe as possible, letting you give and receive pleasure without penetration: fantasies, erotic games, mutual masturbation…

Diminish the number of sexual partners. The exposing to the virus and the risk of infection transmission will be less.

Remember that none of these things will protect you from catching HIV: contraceptives, vaginal shower, diaphragm, spermatozoid killers, etc.

If you want to avoid pregnancy, to use condoms is a good way but not the only one. However, condoms are the best way to avoid HIV transmission.

2. Serodiscordant couples

We understand as serodiscordant couples the ones formed by a seropositive and seronegative person (regardless the sexual condition). It is a common situation that requires a special approach, because it is a high-risk situation for the more vulnerable: the seronegative. In this situation is where we have to focus our maximum preventive effort, working simultaneously with the two components of the couple. The degree of HIV transmissibility by an infected person to one who is not infected depends on many factors, which are going to determine the risk magnitude: Factors depending on the infected person:

Immunological situation: viral load (any situation that increases the VL will increase infectiousness: vaccines, others infections…)

Infection moment

Treatment or not with “Antiretroviral treatment”

Factors depending on the virus itself (HIV-2 is more transmissible in a sexual way).

Factors depending on the person in risk:

Immunological status (other diseases, stress)

Presence of Sexual Transmission Disease lesions

Gender: there is a higher vulnerability in women in heterosexual transmission

Sexual practice: It necessary to remember some important questions related to the kind of couple. Anyway it is always important to remember:

After some time, the non-infected serodiscordant couples tend to relax their preventive behaviour exposing themselves to a high risk of contagion. It has been seen patients that have been infected after many years living with the same seropositive partner (they end up having an false feeling of invulnerability).

Each day this situation is more frequent, because of the higher percentage of survival in people with HIV, as well as the improvement of the quality of life.

It is important to undo false concepts like: “to show you how much I love you I will run the risk (avoiding to use condoms)...” and try to make them think: “just because I love you, in order to take care of you, it is more important for me not to run the risk”.

Females are in a more vulnerable situation inside the relationship (apart from the biological factor we have already talked about) due to cultural factors, less capacity to negotiate safe sex, etc… All that we will have to take into account and consider when we offer a preventive project.

The best way to avoid the transmission will be using the condom in the right way in each and every sexual meetings with penetration.

Do not forget what we have said before when sexual meetings without a regular partner.

3. Foetal maternal transmission

HIV’s infection vertical transmission has experimented a big change during the last years, since the application of preventive treatment with antiretroviral in pregnancy’s last perinatal period and the first weeks of the newborn. Several studies find a significative decrease in newborn children infections from seropositive mothers. With the new preventive guide for pregnant women it is likely to find even a bigger reduction. But there is no doubt that the best way to avoid the foetal maternal infection is to avoid pregnancy. However, our responsibility is to give all the necessary information to help to take a responsible decision.

4. Other transmission ways:

It is important to clarify all doubts and avoid leaving anxieties about the possible contagion. Those doubts are more frequent in families with children and immobilized patients. We should not forget that there are many irrational doubts but understandable if there is a lack of a complete information. In spite of being so unusual to be infected when living or taking care of a person infected with HIV, it is important to recall the “universal precaution measures” in the same way we should do it with any other patient.

Use gloves in contact with blood, any other fluid with blood, vaginal secretions or semen.

Wash your hands often, and each time you take out your gloves, with water and soap .

You could use regular gloves at home when there is a contact with blood or other corporal fluids. Afterwards you can clean them, disinfect and use them again.

Use a mixture of water and bleach (10%) twenty minutes to wash utensils, containers and any surface touched by blood or corporal fluids.

If you are exposed to blood or vomit splashes, protect your mouth and nose with a face mask and your eyes with glasses. If blood or other fluids touch your skin clean it with water and soap and your eyes with plenty of water.

Cloths and sheets could be washed as usual with the rest of the families’ just in case they have not blood or corporal fluids.

Dishes and cutlery can be used for everyone living in the same place and it is not necessary to have a special way of cleaning except when the mouth is wounded.

Do not share any personal hygiene objects such as toothbrush, razor blade, etc… that could be with blood.

When using needles or syringes to take care a HIV infected patient do not touch or manipulate the needle. Through it away to a special container.

The elimination of contaminated residues (such as paper towels, sanitary towels, bandages, and other objects dirty with blood, semen, or vaginal fluids that can not thrown into the toilet), will be done in a double plastic bag throwing it with the rest of the rubbish.

If you happen to inject with a used needle, it is recommended to wash with water and soap go to the doctor to do post exposition prophylaxis.

5. Opportunistic infections prevention

Actually, one of the most effective preventive measures in the development of opportunistic infections is the use of antiretroviral treatment, which helps to recover the inmunological system. There are general measures and simple precautions that helps to diminish the exposition to fungus, bacteria, mycobacteria, virus, parasites that we can have at home. (It will be convenient to adapt those measures to the personal inmunological situation of the patient)

Avoid to eat raw or half done meat, fish or seafood. Food must be well cooked to destroy toxoplasma.

Do not drink milk or dairy products without sanitary control. You will avoid, among others, brucella. Respect expire dates.

Consume raw fruits and vegetables previously washed with some drops of bleach. You will diminish the risk to take toxoplasma.

Use gloves to touch raw meat, fish or vegetables.

Wash all kitchen utensils before cooking another food.

Do not mix raw food juices with other products.

Wash up your inside refrigerator with water and soap regularly and check temperature (oº - 5º) and freezer (-18º).

Healthy habits

1. Physical Care

To do exercise have relaxing and stimulating effects (increases appetite) and also it helps to improve the quality of life. The kind of physical exercise will depend on the general health situation. In general, sports and aerobic activities will be more suitable (walking, jogging, swimming, etc…). It is convenient a dairy walking (form 30 to 60 minutes). It is recommended to maintain the usual sport activity as much as possible. It is important to respect the night rest (8 hours approximately) in order to maintain the right level of activity.

Cooked food should not be at ambient temperature for more than two hours.

Avoid mayonnaise, fresh cream, and other food which easily spoils, except when there are recently prepared.

You should wash hands each and every time you touch an animal. It is important someone else to take care of animal excrements. If it is not possible use gloves and wash your hands afterwards.

Clean and empty your dustbin regularly.

When touching soil or doing gardening it is convenient to use gloves

Do not throw dirty water in the sink where food is prepared

If someone living with the person infected by HIV have varicella or herpes zoster should avoid having contact with the infected person and go to the doctor to be treated.

2. Body Hygiene

It is important to maintain a good body hygiene and keep the skin hydrated in order to avoid infections (skin, scalp, genital system).

3. Buccal Hygiene A good dental care prevents buccal infections, helps chewing, stimulates appetite and improves nutrition

Brush your teeth after meals

Brush frequently your tongue and palate to clean saliva.

Use a soft toothbrush to avoid hurting

Do not ever share your toothbrush.

Visit your dentist every time you have problems or at least once a year. Many people infected with HIV, frequently have a bad dental health for many reasons: intravenous use of drugs, bad hygiene, lack of care, bad alimentary habits (sweets…) When you visit your dentist you should inform him about your infection and make sure that he uses protection: gloves, face mask, glasses if splashing, and sterilizing instrumental.

4. Other toxic habits

To encourage a healthy way of life it is necessary to approach the use of alcohol and tobacco. The most common reasons to avoid the use of alcohol in people infected with HIV are the following:

Alcohol could be incompatible with antiretroviral treatments

Most of antiretroviral medicines are metabolised by the liver. So to drink too much alcohol can damage it, making difficult the infectious treatments.

It is frequent to find virus coexistence (HBV,HCV) with hepatic disease.

And also it can diminish the capacity to be in one’s right mind and the following of preventive measures. In case of abuse it must be considered an adequate treatment.

In general, it is recommended not to take over 40 grams per day or 280 grams per week of alcohol in men and 25 grams per day or 175 grams per week of alcohol in women. Abstention is indicated when taking pharmacological treatment. To smoke, apart from being a risk factor for several pathologies, decreases appetite, lungs resistance and damages buccal hygiene.

It is recommended to stop smoking. But we will have into account the using of other substances (heroine, cocaine, etc.), which will be a priority to stop using. Take care of yourself and count with all the help you have to leave consuming all these substances (therapeutic groups, etc).

Bibliography

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8. Vernazza P, Eron JJ, Fiscus M y Cohen MS. Sexual transmission of HIV: infectiousness and prevention. AIDS 1999; 13:155-166.

9. Quinn TC, Wawer MJ, Sewankambo N, Serwadda D, Li Ch, Wabwire-Mangen F et al. Viral load and heterosexual transmission of human inmunodeficiency virus type 1. N Engl J Med 2000; 342:921-9.

10. Dillon B, Hecht FM, Swanson M, Goupil-Sormany I, Grant RM, Chesney MA y Kahn JO. Primary HIV infection associated with oral transmission. www.retroconference.org/2000/abstracts/473.htm

If you need more information go to:

www.msc.es/sida