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- Volume 13, Issue 2, 2012
Southern African Journal of HIV Medicine - Volume 13, Issue 2, 2012
Volumes & issues
Volume 13, Issue 2, 2012
Author Francesca ConradieSource: Southern African Journal of HIV Medicine 13, pp 38 –39 (2012)More Less
In late March 2012, all the elected members of the Board of the Southern African HIV Clinicians Society met for the first time under my leadership to discuss the way forward. We decided that our objectives would now include partnering with governments to implement optimal HIV programmes and policies. For South Africa, this means doing all we can to assist the government to achieve the goals of National Strategic Plan 2012 - 2016.
Author Landon MyerSource: Southern African Journal of HIV Medicine 13 (2012)More Less
SAJHIVMED has undergone a bit of a facelift since the previous issue. For more than a decade, the layout and formatting had been essentially unchanged, and a revamp was in order to provide a more contemporary profile suitable to a research-driven publication. The new look was shaped by the talented team at the Health & Medical Publishing Group (who produce the SAMJ and several other prominent journals, as well as the South African Medicines Formulary), particularly Siobhan Tillemans and Melissa Raemaekers. Thanks to both, and the entire HMPG team, for their assistance!
Southern African guidelines for the safe use of pre-exposure prophylaxis in men who have sex with men who are at risk for HIV infection : guidelinesSource: Southern African Journal of HIV Medicine 13, pp 40 –55 (2012)More Less
Background. The use of oral antiretrovirals to prevent HIV infection among HIV-negative men who have sex with men (MSM) has been shown to be safe and efficacious. A large, randomised, placebo-controlled trial showed a 44% reduction in the incidence of HIV infection among MSM receiving a daily oral fixed-dose combination of tenofovir disoproxil fumarate and emtricitabine (Truvada) in combination with an HIV prevention package. Improved protection was seen with higher levels of adherence.
Aim. The purpose of this guideline is to: (i) explain what pre-exposure prophylaxis (PrEP) is; (ii) outline current indications for its use; (iii) outline steps for appropriate client selection; and (iv) provide guidance for monitoring and maintaining clients on PrEP.
Method. PrEP is indicated for HIV-negative MSM who are assessed to be at high risk for HIV acquisition and who are willing and motivated to use PrEP as part of a package of HIV prevention services (including condoms, lubrication, sexually transmitted infection (STI) management and risk reduction counselling).
Recommendations. HIV testing, estimation of creatinine clearance and STI and hepatitis B screening are recommended as baseline investigations. Daily oral Truvada, along with adherence support, can then be prescribed for eligible MSM. PrEP should not be given to MSM with abnormal renal function, nor to clients who are unmotivated to use PrEP as part of an HIV prevention package; nor should it be commenced during an acute viral illness. Three-monthly follow-up visits to assess tolerance, renal function, adherence and ongoing eligibility is recommended. Six-monthly STI screens and annual creatinine levels to estimate creatinine clearance are recommended. Hepatitis B vaccination should be provided to susceptible clients. Gastro-intestinal symptoms and weight loss are common side-effects, mostly experienced for the first 4 - 8 weeks after initiating PrEP. There is a risk of the development of antiretroviral resistance among those with undiagnosed acute HIV infection during PrEP initiation and among those with sub-optimal adherence who become HIV infected while on PrEP. Risk compensation (increasing sexual behaviours that can result in exposure to HIV) while on PrEP may become a concern, and clinicians should continue to support MSM clients to continue to use condoms, condom-compatible lubrication and practice safer sex. Research is ongoing to assess optimum dosing regimens, potential long-term effects and alternative PrEP medications. Recommendations for the use of PrEP among other at-risk individuals, and the components of these recommendations, will be informed by future evidence.
Approaches to tenofovir and abacavir drug shortages in South Africa : a guide for clinicians : forumSource: Southern African Journal of HIV Medicine 13, pp 56 –57 (2012)More Less
Shortages of the nucleoside reverse transcriptase inhibitors (NRTI) abacavir and tenofovir have been reported recently at health facilities across South Africa. The Society issued the following clinical advice to healthcare providers experiencing shortages on 29 March 2012. These recommendations are intended only as a guide to clinical therapy, based on expert consensus and best available evidence. Treatment decisions for patients should be made by their responsible clinicians, with due consideration for individual circumstances.
Author Regina OsihSource: Southern African Journal of HIV Medicine 13 (2012)More Less
The Southern African HIV Clinicians Society's online clinical cases are geared at providing excellent continuing medical education for members of the Society. This activity has been created to offer clinicians working in the HIV area access to online education. Cases are written by experienced HIV specialists and can range from general adult HIV/TB through specialist paediatric cases to other related infectious diseases encountered when managing patients with HIV.
Source: Southern African Journal of HIV Medicine 13, pp 59 –63 (2012)More Less
Background. Analytical variability in CD4 enumeration is well known, but few studies from southern Africa have quantified the inter- and intra-laboratory variability in CD4 count measurements. In addition, the possible impact of time lapse after sample collection on CD4 reliability is not well understood.
Methods. A cross-sectional study was conducted at Royal Swaziland Sugar Corporation Hospital and three laboratories, Lab A (comparator), Lab B (national reference) and Lab C (rural hospital). Blood from HIV-infected individuals was collected using routine venepuncture into separate specimens for each of the three laboratories. The samples were further subdivided at each laboratory: one was run at 12 hours and the second at 24 hours after venepuncture. The results of absolute CD4 count and CD4 percentage testing were compared within (intra-laboratory) and between (inter-laboratory) laboratories.
Results. Among 53 participants, the mean CD4 count at 12 hours was 373 cells/µl, 396 cells/µl and 439 cells/µl, and at 24 hours 359 cells/µl, 389 cells/µl and 431 cells/µl, for laboratories A, B and C, respectively. The coefficient of intra-laboratory variation was 4%, 8% and 20% for CD4 count for laboratories A, B and C, respectively. Comparing 12- and 24-hour measurements, the mean difference (bias) within the laboratories between the two time points (and limits of agreement, LOAs) was 14 (-46 to 73), 8 (-161 to 177) and 7 (20 to 33) cells/µl for labs A, B and C, respectively. Comparing Lab A versus Lab B, lab A versus Lab C and Lab B versus Lab C, the inter-laboratory bias for the CD4 count at 12 hours was -32, -64 and -38 cells/µl, respectively. The corresponding LOAs were -213 to 150, -183 to 55, and -300 to 224, respectively. At 24 hours, the biases and LOAs were similar to those at 12 hours.
Conclusions. CD4 counts appeared reliable at all three laboratories. Lab B and Lab C were clinically interchangeable with the comparator laboratory, Lab A, but not between themselves. Time to measurement does not affect the inter-laboratory agreement within 12 and 24 hours.
Source: Southern African Journal of HIV Medicine 13, pp 64 –67 (2012)More Less
Background. Pneumocystis pneumonia (PcP) is one of the most common opportunistic infections found in patients with HIV. The prognosis if ventilation is required is poor, with mortality of 36 - 80%. Although more recent studies have shown improved survival, our experience has been that close to 100% of such patients die, and we therefore decided to investigate further.
Methods. All patients with confirmed or suspected PcP who died owing to respiratory failure were eligible for the study. Where consent was obtained, trucut lung biopsies were performed post mortem, stored in formalin and sent for histopathological assessment.
Results. Twelve adequate lung biopsies were obtained from 1 July 2008 to 28 February 2011 - 3 from men and 9 from women. The mean age was 34.7 years (range 24 - 46), and the mean admission CD4 count was 20.8 (range 1 - 68) cells/µl and median 18.5 cells/µl. All specimens demonstrated typical PcP histopathology; in addition, 9 showed significant interstitial fibrosis. Three had co-infection with cytomegalovirus (CMV), two of which had fibrosis present. There was no evidence of TB or other fungal infections.
Conclusion. The high mortality seen in this cohort of PcP patients was due to intractable respiratory failure from interstitial lung fibrosis. Whereas the differential includes ventilator induced lung injury, drug resistance or co-infections, we suggest that this is part of the disease progression in certain individuals. Further studies are required to identify interventions that could modify this process and improve outcomes in patients with PcP who require mechanical ventilation.
Localised treatment and 6-month outcomes in patients with cytomegalovirus retinitis at a tertiary ophthalmology service in Ga-Rankuwa : original articleSource: Southern African Journal of HIV Medicine 13, pp 68 –71 (2012)More Less
Objective. There are few data from before the antiretroviral therapy (ART) era for cytomegalovirus retinitis (CMV-R) from settings where cost limits use of systemic treatment. This study examines CMV-R treatment and survival outcomes in a public hospital ophthalmology service in Ga-Rankuwa, South Africa.
Methods. From October 2009 to October 2010, voluntarily consenting participants over the age of 15 years with incident clinically diagnosed CMV-R seen at the Dr George Mukhari Hospital ophthalmology clinic were prospectively enrolled in an observational study. Treatment was per clinic protocols and patients were followed up with structured data collection for up to 6 months.
Results. Eight individuals, all HIV infected and 50% female, were identified and enrolled. At enrolment, median age was 38 years (interquartile range (IQR) 32 - 39 years), median CD4 count 20 cells/µl (IQR 13 - 46.5 cells/µl), and 50% were currently receiving ART (mean duration of ART use 18 days, standard deviation (SD) 2.99 days). No participant received systemic ganciclovir, but 6 reported symptom combinations suggesting systemic CMV: shortness of breath (n=3), diarrhoea (n=3) and/or central nervous system complaints (n=3). Ten eyes had visual impairment less than counting fingers at enrolment. Treatment combinations were: ART plus intravitreal ganciclovir (n=5), intravitreal ganciclovir alone (n=2), and ART alone (n=1). Six-month outcomes were: death (n=1), survival (n=6), loss to follow-up (n=3), untraceable (n=1), systemic symptom resolution (4/4), visual acuity deterioration (0/5), and persisting uveitis (2/3).
Conclusion. In the ART era, incident CMV-R appears to be uncommon in this setting. CMV-R may occur within the first 3 weeks after ART initiation. Even in CMV-R patients with suggestive systemic symptoms, 6-month survival is good despite no systemic CMV therapy.
Association of -308 TNF-alpha promoter polymorphism with viral load and CD4 T-helper cell apoptosis in HIV-1 infected black South Africans : original articleSource: Southern African Journal of HIV Medicine 13, pp 72 –77 (2012)More Less
Objective. To determine whether the -308 TNF-α promoter polymorphism is associated with markers of HIV progression in the South African population.
Methods. Polymerase chain reaction-restriction fragment length polymorphism was used to detect the -308 TNF-α polymorphism in 75 patients and 76 healthy controls. Serum TNF-α concentrations were measured using ELISA in each cohort. CD4+ T cell apoptosis and HIV-1 RNA viral load were determined using Annexin-V-FITC assay and Nuclisens Easy Q HIV-1 assay respectively. CD4+ T cell counts were measured flow cytometrically.
Results. The frequency of -308 G allele was similar in the HIV-1 and control cohorts. The -308GG genotype was associated with lower TNF-α concentrations and markers of increased HIV progression indicated by higher TH lymphocyte apoptosis, lower TH lymphocyte count and higher plasma viral load, irrespective of treatment.
Conclusion. The presence of the TNF-α -308 G allele in HIV-1 patients may be associated with increased risk of HIV-1 progression. Further research is required to investigate the nature of this association.
Levels of procalcitonin, C-reactive protein and neopterin in patients with advanced HIV-1 infection : original articleSource: Southern African Journal of HIV Medicine 13, pp 78 –82 (2012)More Less
Objectives. To compare the value of procalcitonin, C-reactive protein (CRP) and neopterin as indicators of immune deficiency, co-infection, efficacy of treatment, and disease progression, in patients with advanced HIV-1 infection.
Design. Cross-sectional, investigating baseline blood measurements and clinical observations in 82 HIV-positive patients divided into an antiretroviral treatment (ART) group and an ART-naïve group.
Setting. Secondary general hospital in Pretoria.
Results. Procalcitonin and CRP levels showed no significant differences between the ART and ART-naïve groups, and no correlations with CD4 counts or viral loads. CRP levels were significantly higher with TB co-infection (p<0.05). Neopterin levels were raised above normal in 92% of the ART-naïve group and in 75% of the ART group. The levels were significantly higher (p<0.05) in the ART-naïve group. Negative correlations were found between neopterin and CD4 counts for the total patient group (r=-0.482; p<0.001). Neopterin was significantly (p<0.05) higher in the HIV/TB co-infection group than in those without TB. Higher neopterin levels at baseline were associated with a decline in CD4 counts over the ensuing 6-month period, and patients with higher baseline neopterin levels developed more complications over the 6-month period.
Conclusions. Compared with procalcitonin and CRP, neopterin appears to be associated with the degree of immunodeficiency and of co-infection with TB. Neopterin levels may be investigated further as a measure of disease progression or treatment response.
Source: Southern African Journal of HIV Medicine 13 (2012)More Less
The ultimate goal of HIV therapy in resource-constrained settings must be to keep as many people alive with the best possible quality of life using the resources available. The question debated between Andrieux-Meyer et al. and Venter et al. might therefore be: 'With the resources available, can we keep more people alive with the best possible quality of life using stavudine 20 mg bd or tenofovir 300 mg od as standard first line therapy?' Quality of life is extremely important but unlikely to be the overriding factor if budgetary constraints restrict access to ART and therefore increase mortality. Both groups seem to agree that tenofovir is superior to stavudine for most patients and that the crux of the argument is about cost. Venter et al. describe tenofovir as 'the gold standard' and state that 'these arguments [about the benefits of tenofovir] are likely to be irrelevant when the cost of medication is considered'. Andrieux-Meyer et al. acknowledge that 'the rationale for this [proposed] trial is to lower treatment costs'.
Authors: Karin Van den Berg, James Van Hasselt, Evan Bloch, Robert Crookes, James Kelley, Jonathan Berger, Charlotte Ingram, Anel Dippenaar, Rajendra Thejpal, Neil Littleton, Tersia Elliz, Gary Reubenson, Mark Cotton, Jennifer C. Hull, Pamela Moodley, Yasmin Goga, William Eldridge, Moosa Patel, Eric Hefer and Arthur BirdSource: Southern African Journal of HIV Medicine 13, pp 87 –104 (2012)More Less
Despite numerous publications on the appropriate use of blood and blood products, few specifically consider the role of transfusion in the management of HIV. This review is a synthesis of conditions encountered in the management of HIV-infected patients where the transfusion of blood or blood products may be indicated. A consistent message emerging from the review is that the principles of transfusion medicine do not differ between HIV-negative and -positive patients. The aim of the review is to provide clinicians with a practical and succinct overview of the haematological abnormalities and clinical circumstances most commonly encountered in the HIV setting, while focusing on the rational and appropriate use of blood and blood products for HIV patients. Important ethical considerations in dealing with both the collection and transfusion blood and blood products in the HIV era have also been addressed.