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- Volume 10, Issue 4, 2009
Southern African Journal of HIV Medicine - Volume 10, Issue 4, 2009
Volumes & issues
Volume 10, Issue 4, 2009
Source: Southern African Journal of HIV Medicine 10, pp 5 –6 (2009)More Less
This edition sees the publication of the fourth SA HIV Clinicians Society paediatric antiretroviral therapy (ART) guidelines. Previously it has not been possible to have one guideline for the whole country because of wide discordance between the government and private sectors. This year, for the first time, our guideline is applicable to both the private and public sectors. Inevitably some differences remain and are addressed in the document. They include choice of first-line regimen and genotyping recommendations. The national Department of Health (NDoH) is still updating its guidelines, hopefully for publication in early 2010. We hope you will find the Society's guidelines pragmatic and helpful. We have the potential to save and improve many young lives.
Author Francois VenterSource: Southern African Journal of HIV Medicine 10, pp 6 –7 (2009)More Less
The global recession has thrown the problem of funding for AIDS programmes to the fore, with Botswana's president saying his country's programme is unsustainable, and donors sounding warnings that rationing may need to be implemented. This is very alarming - we have made big strides in terms of antiretroviral access in the last few years, and these are suddenly looking very fragile.
Author Leon LevinSource: Southern African Journal of HIV Medicine 10 (2009)More Less
The Southern African HIV Clinicians Society Paediatric Discussion Group (PDG) began in December 2001. The concept was born after Dr (now adjunct Professor) Ashraf Coovadia of the Rahima Moosa Mother and Child Hospital, Coronationville, Johannesburg, sent an e-mail to 5 or 6 local HIV 'experts' and Professor Mark Kline of the Baylor College of Medicine, Houston, Texas, seeking advice on how to manage a child with severe disfiguring parotomegaly but who had a normal CD4 count, so antiretroviral therapy (ART) was not indicated. The answer came back that there was no indication for ART for a purely cosmetic condition!
Source: Southern African Journal of HIV Medicine 10, pp 9 –11 (2009)More Less
Before the widespread introduction of antiretroviral therapy (ART), most perinatally infected children did not survive beyond the first 2 years of life. With treatment, HIV-positive children are living longer. In the developed world, where HAART has been widely available since 1996, survival of perinatally infected children into adolescence is now the norm. Of a French cohort of perinatally infected children born before 1993, 58% were still alive and receiving HIV care 13 years later. In the UK the proportion of HIV-infected children in care aged 10 - 19 years increased from 11% to 44% between 1996 and 2005. As HAART becomes increasingly available in South Africa, we can expect similar trends.
Source: Southern African Journal of HIV Medicine 10, pp 12 –15 (2009)More Less
The prevention of mother-to-child transmission of HIV (PMTCT) programme is a critical intervention to reduce the incidence of paediatric HIV infections. It is also a key intervention to decrease infant, child and maternal mortality. The optimal implementation of a sound, evidence-based PMTCT programme is essential to meet both the HIV reduction targets in the National Strategic Plan and to achieve Millennium Development Goals (MDGs) 4 (reducing infant and child mortality) and 5 (reducing maternal mortality). Since 2001, South Africa has been implementing a programme to prevent mother-to-child transmission (MTCT) of HIV. Since 2007, national PMTCT policy has evolved into a strong, enabling framework that should reduce vertical transmission significantly. This paper reviews the milestone studies that have contributed to our knowledge about drug regimens to reduce MTCT, and reviews the latest South African PMTCT guidelines and the possible future changes. Strengthened/revised drug regimens for PMTCT are essential but insufficient for measureable decreases in HIV transmission and improvements in maternal and child health. The main challenge is implementation. Until the enhanced PMTCT policy is effectively operationalised, measurable achievements will remain elusive.
A window into a public programme for prevention of mother-to-child transmission of HIV : evidence from a prospective clinical trial : original articleSource: Southern African Journal of HIV Medicine 10, pp 16 –19 (2009)More Less
Objectives. To evaluate efficacy of the antenatal, intrapartum and postnatal antiretroviral components of a public service prevention of mother-to-child (PMTCT) programme in infants.
Design. Analysis of prospectively collected screening data of demographic and MTCT-related interventions and HIV infection status of infants identified through HIV-specific DNA polymerase chain reaction.
Setting. Tygerberg Children's Hospital, Western Cape, South Africa.
Subjects. HIV-infected women and their infants identified through participation in a public service PMTCT programme were referred for possible participation in a prospective study of isoniazid prophylaxis.
Interventions. Key components of the programme include voluntary counselling and testing, administration of zidovudine to the mother from between 28 and 34 weeks' gestation and to the newborn infant for the first week, single-dose nevirapine to the mother in labour and to the newborn shortly after birth, and free formula for 6 months.
Main outcome measures. Number and percentage of HIV-infected infants and extent of exposure to antenatal, intrapartum and postnatal antiretrovirals.
Results. Of 656 infants with a median age of 12.6 weeks, screened between 1 April 2005 through May 2006, 39 were HIV-infected, giving a transmission rate of 5.9% (95% confidence interval (CI) 4.4 - 8.0%). Antenatal prophylaxis was significantly associated with reduced transmission (odds ratio (OR) 0.43 (95% CI 0.21 - 0.94)) as opposed to intrapartum and postpartum components (p=0.85 and p=0.84, respectively). In multivariable analysis the antenatal component remained significant (OR=0.40 (95% CI 0.19 - 0.90)).
Author Ameena Ebrahim GogaSource: Southern African Journal of HIV Medicine 10, pp 20 –30 (2009)More Less
Recent studies on antiretroviral prophylaxis during breastfeeding show that maternal highly active antiretroviral therapy (HAART) (alone or with 1, 4 or 24 weeks' infant prophylaxis) or infant prophylaxis alone for 6, 14 or 24 weeks (with limited maternal prophylaxis) reduces HIV transmission through breastmilk (postnatal transmission). Maternal postnatal regimens appear to be as efficacious as infant postnatal regimens, although one study shows a trend favouring infant nevirapine over maternal HAART (both used from 1 week to 6 months after delivery). These new findings necessitate a review of existing interventions to prevent mother-to-child transmission of HIV (PMTCT) , and the immediate implementation of regimens that reduce postnatal transmission - where this is feasible - to save children's lives.
Source: Southern African Journal of HIV Medicine 10, pp 32 –49 (2009)More Less
These guidelines are intended to provide paediatric HIV antiretroviral treatment (ART) recommendations for both the public and private sectors.
ART in children follows the same principles as in adults, and treaters should not be daunted by some of the differences, which include more frequent dose adjustments, liquid formulations occasionally being poorly palatable, and the dependence of children on adult caregivers for receiving medication. These should not be viewed as obstacles, and everything should be done to assist the process of treating children.
Since the last publication of these guidelines there have been pivotal paediatric studies that have necessitated the updating of paediatric guidelines in South Africa.
Source: Southern African Journal of HIV Medicine 10, pp 50 –53 (2009)More Less
We review the background and key studies that inform decisions on when to initiate antiretroviral therapy (ART) in infants and children. The World Health Organization staging system from 2006 was based on conditions commonly seen in Africa and provided an impetus for advancing ART in children. Because of poor predictive value of CD4 counts in infancy and inability to predict risk of death or disease progression, we recommend initiating ART in all infants under a year of age. CD4 thresholds for initiating therapy decline as children become older.
Source: Southern African Journal of HIV Medicine 10, pp 54 –61 (2009)More Less
Dosing in infancy is complicated by inadequate characterisation of pharmacokinetics, unpredictable drug concentrations and a lack of suitable dosage forms. Additional challenges are presented by the concomitant administration of interacting drugs (e.g. rifampicin in antituberculosis treatment) and disease conditions that may alter drug disposition. The extent and implications of breastmilk transfer of drugs to the infant are poorly understood. New technologies facilitate pharmacokinetic studies in infants and will improve access to therapeutic drug monitoring.
Author James J.C. NuttallSource: Southern African Journal of HIV Medicine 10, pp 62 –69 (2009)More Less
One of the obstacles to scaling up paediatric antiretroviral therapy (ART) coverage in resource-limited settings is the relative complexity of paediatric dosing. There is a need to simplify ART in order to facilitate treatment initiation and ongoing management of infants and children by health care providers, as well as to support adherence in the home. This article reviews the development of weight-band dosing tables as a strategy for simplifying the delivery of paediatric ART.
Source: Southern African Journal of HIV Medicine 10, pp 70 –75 (2009)More Less
Paradoxical deterioration due to immune reconstitution inflammatory syndrome (IRIS) occurs in up to 21% of children initiating antiretroviral therapy. Mycobacterial diseases are the most common, with BCG-vaccine adenitis predominating in infants and Mycobacterium tuberculosis (TB) in older children. The difficulty of diagnosing TB in HIV-infected children and the increasing risk of drug-resistant TB complicate the diagnosis and management of both paradoxical IRIS and post-antiretroviral therapy TB. History and clinical assessment remain key strategies in the management of these infants and children. There are no prospective studies investigating diagnostic criteria and therapeutic strategies in children.
Source: Southern African Journal of HIV Medicine 10, pp 76 –80 (2009)More Less
Lipodystrophy syndrome (LD) is common in HIV-infected children, particularly those taking didanosine, stavudine or zidovudine. Lipo-atrophy in particular causes major stigmatisation and interferes with adherence. In addition, LD may have significant long-term health consequences, particularly cardiovascular. Since the stigmatising fat distribution changes of LD are largely permanent, the focus of management remains on early detection and arresting progression. Practical guidelines for surveillance and avoidance of LD in routine clinical practice are presented. The diagnosis of LD is described and therapeutic options are reviewed. The most important therapeutic intervention is to switch the most likely offending antiretroviral to a non-LD-inducing agent as soon as LD is recognised. Typically, when lipo-atrophy or lipohypertrophy is diagnosed the thymidine nucleoside reverse transcriptase inhibitor (NRTI) is switched to a non-thymidine agent such as abacavir (or tenofovir in adults). Where dyslipidaemia is predominant, a dietician review is helpful, and the clinician may consider switching to a protease inhibitor-sparing regimen or to atazanavir.
Source: Southern African Journal of HIV Medicine 10, pp 81 –84 (2009)More Less
Abacavir, a nucleoside reverse transcriptase inhibitor, is useful in first- and second-line HIV therapy and as a substitute for stavudine and zidovudine when toxicity is a problem. Although it is safe and well tolerated, a life threatening hypersensitivity reaction can occur. The risk for developing this reaction relates to the presence of specific genotypes, especially HLA-B*5701.
Author Leon J. LevinSource: Southern African Journal of HIV Medicine 10, pp 85 –90 (2009)More Less
This article is an update of a similar article published in the November 2005 edition of this journal. The rapid pace of changes in this field necessitates this update. Alarming numbers of children are failing both first- and secondline antiretroviral therapy regimens in a very short space of time, underscoring the importance of adhering to the basic guiding principles of changing therapy outlined below.
Author Polly ClaydenSource: Southern African Journal of HIV Medicine 10, pp 91 –96 (2009)More Less
A wealth of paediatric data was presented at IAS 2009. Also preceding the conference was the 1st International Workshop on HIV Pediatrics, which looks as if it will become an annual fixture on the conference calendar and gave an additional opportunity to present and discuss the state of the art in the field.
Overall, far too much was presented to review here. Abstracts, some slides and, for IAS 2009, webcasts can be viewed on the respective conference websites. We have also covered some paediatric cohorts and a few studies in more detail in our review of programme data in HTB South, distributed with the Journal.
Several themes occurred over and over again at both meetings.
National capacity for early infant diagnosis, which not only enables early initiation of treatment but also gives a clearer picture of how well prevention of mother-to-child transmission (PMTCT) programmes are performing, with the goal of vastly reducing cases of paediatric HIV, is not yet nearly sufficient in most places.
Where infants are diagnosed in time, early initiation of treatment is not without its difficulties. It can, however, be extremely beneficial in young children.
Treatment of children who are HIV-infected despite exposure to single-dose nevirapine through PMTCT is another challenge, as is what to do in the longer term with exposed children initiated on a protease inhibitor-containing HAART to overcome the risks of NNRTI resistance.
Strategies to simplify regimens, including paediatric fixed-dose combinations and once-a-day dosing, are essential for successful management of children with HIV, as are strategies to enable co-treatment of tuberculosis in this population.
The research summarised below addresses these issues.