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- Volume 14, Issue 1, 2013
Southern African Journal of HIV Medicine - Volume 14, Issue 1, 2013
Volumes & issues
Volume 14, Issue 1, 2013
Author Landon MyerSource: Southern African Journal of HIV Medicine 14 (2013)More Less
HIV medicine is a rapidly evolving field, perhaps more so than many other areas of clinical practice. The optimal choice of medicines changes regularly, but more profound changes in strategies to manage (and prevent) HIV infection also emerge at frequent intervals. To keep pace with these changes, guidelines to support different aspects of HIV medicine are updated regularly, and indeed we are in the midsts of another season of international guideline revisions; most notably, at the World Health Organization (WHO).
Author F. ConradieSource: Southern African Journal of HIV Medicine 14 (2013)More Less
There is little doubt that 2012 ended on a high note. The inaugural conference of the Southern African HIV Clinicians Society was a resounding success; with over 950 attendees and excellent speakers (both local and international), I believe that we achieved our aim of 'Striving for Clinical Evidence.'
World Health Organization guidelines should not change the CD4 count threshold for antiretroviral therapy initiation : forumAuthor N. GeffenSource: Southern African Journal of HIV Medicine 14, pp 6 –7 (2013)More Less
The World Health Organization (WHO) currently recommends that HIV-positive adults start antiretroviral therapy (ART) at CD4 counts <350 cells/µl. Several countries have changed their guidelines to recommend ART irrespective of CD4 count or at a threshold of 500 CD4 cells/µl. Consequently, WHO is currently revising its treatment guidelines and considering recommending ART initiation at CD4 counts <500 cells/µl. Such decisions are critically important, as WHO guidelines inform healthcare policies in developing countries and are used by activists in their advocacy work. Changing the CD4 initiation point from 350 to 500 cells/µl would, however, be premature and have profound cost implications on Global Fund, President's Emergency Plan for AIDS Relief (PEPFAR) and developing country health budgets. We should be willing to campaign for such a change in guidelines despite cost implications, if supported by evidence. However, the evidence remains outstanding.
Source: Southern African Journal of HIV Medicine 14, pp 8 –10 (2013)More Less
The success of prevention of mother-to-child transmission (PMTCT) programmes (Options A and B) in middle-income countries, together with clinical trial data on antiretroviral (ARV) treatment as prophylaxis, has emboldened UN agencies to aggressively promote lifelong ARVs for PMTCT (Option B+). Unsubstantiated claims submit that Option B+ is cost-effective at population-level, will protect HIV-negative male partners, improve maternal and infant health, and increase ARV coverage. We provide counterfactual arguments about the ethics, medical safety, programme feasibility and economic benefits of Option B+.
Option B+ offers no advantage to PMTCT and there are social hazards associated with privileging pregnant woman for treatment over men and non-pregnant women, especially with the absence of data to suggest that discordant relationships are more frequent among pregnant women or that they contribute disproportionately to the horizontal HIV transmission. The benefits and safety of long-term ARVs - including adherence and resistance - in mothers who do not need treatment for their own health, need to be considered, as well as, crucially, health service costs. The assumption that a decrease in efficiency caused by inappropriate targeting is compensated for by lower recruitment costs, is untested. Lives could be saved instead with appropriately targeted interventions. Countries should make individual decisions based on their HIV epidemiology, resources, priorities and local evidence.
Author M. CornellSource: Southern African Journal of HIV Medicine 14, pp 12 –14 (2013)More Less
Men's increased risk of death in ART programmes in sub-Saharan Africa is widely reported but poorly understood. Some studies have attributed this risk to men's poorer health-seeking behaviour, which may prevent them from accessing ART, being adherent to treatment, or remaining in care. In a multicentre analysis of 46 201 adults starting ART in urban and rural settings in South Africa, these factors only partly explained men's increased mortality while receiving ART. Importantly, the gender difference in mortality among patients receiving ART (31% higher for men than women) was substantially smaller than that among HIV-negative South Africans, where men had twice the risk of death compared with women. Yet, this extreme gender inequality in mortality, both within and outside of ART programmes, has not given rise to widespread action. Here it is argued that, despite their dominance in society, men may be subject to a wide range of unfair discriminatory practices, which negatively affect their health outcomes. The health needs of men and boys require urgent attention.
HIV/AIDS and admission to intensive care units : a comparison of India, Brazil and South Africa : forumSource: Southern African Journal of HIV Medicine 14, pp 15 –16 (2013)More Less
In resource-constrained settings and in the context of HIV-infected patients requiring intensive care, value-laden decisions by critical care specialists are often made in the absence of explicit policies and guidelines. These are often based on individual practitioners' knowledge and experience, which may be subject to bias. We reviewed published information on legislation and practices related to intensive care unit (ICU) admission in India, Brazil and South Africa, to assess access to critical care services in the context of HIV. Each of these countries has legal instruments in place to provide their citizens with health services, but they differ in their provision of ICU care for HIV-infected persons. In Brazil, some ICUs have no admission criteria, and this decision vests solely on the 'availability, and the knowledge and the experience' of the most experienced ICU specialist at the institution. India has few regulatory mechanisms to ensure ICU care for critically ill patients including HIV-infected persons. SA has made concerted efforts towards non-discriminatory criteria for ICU admissions and, despite the shortage of ICU beds, HIV-infected patients have relatively greater access to this level of care than in other developing countries in Africa, such as Botswana. Policymakers and clinicians should devise explicit policy frameworks to govern ICU admissions in the context of HIV status.
Screening for HIV-associated neurocognitive disorders (HANDs) in South Africa : a caution against uncritical use of comparative data from other developing countries : forumAuthor C. Van WijkSource: Southern African Journal of HIV Medicine 14, pp 17 –19 (2013)More Less
The prevalence of HIV-associated neurocognitive disorders necessitates community-based screening. In recent years, progress has been made in developing more localised comparative data for use in such screening on the African continent. These studies used measurements that are considered fair, easily accessible, and quick to administer. However, the variance in available international data limits their usefulness and poses a risk to the appropriate streaming of individuals. Here, examples are presented of variance in both cross-national and local demographic screening and neuropsychological test scores, with the aim of cautioning practitioners against undue reliance on general African data for classification of individuals. Recommendations are provided for the development of appropriate norms, specific to local communities.
Transitioning behaviourally infected HIV-positive young people into adult care : experiences from the young person's point of view : original articleSource: Southern African Journal of HIV Medicine 14, pp 20 –24 (2013)More Less
Background. There is limited literature on the transition of young people living with HIV/AIDS (YPLHIV) from adolescent/young adult HIV care to adult HIV care in sub-Saharan Africa.
Objective. We aimed to share the experiences of HIV-seropositive young adults transitioning into adult care, to inform best practice for such transitioning.
Methods. We conducted a retrospective evaluation of the transition of 30 young adults aged ≥25 years from our adolescent/young adult HIV clinic at the Infectious Diseases Institute, Makerere University, Kampala, Uganda, to adult HIV healthcare services between January 2010 and January 2012.
Results. Six major themes emerged from the evaluation: (i) adjustment to adult healthcare providers, (ii) the adult clinic logistics, (iii) positive attributes of the adult clinic, (iv) transfer to other health centres, (v) perceived sense of stigma, and (vi) patient-proposed recommendations. A model for transitioning YPLHIV to adult care was proposed.
Conclusion. There is a paucity of evidence to inform best practice for transitioning YPLHIV to adult care in resource-limited settings. Ensuring continuity in HIV care and treatment beyond young adult HIV programmes is essential, with provision of enhanced support beyond the transition clinic and youth-friendly approaches by adult-oriented care providers.
Association of HIV prevalence and concurrency of sexual partnerships in South Africa's language groups : an ecological analysis : original articleSource: Southern African Journal of HIV Medicine 14, pp 25 –28 (2013)More Less
Background. There is considerable variation in HIV prevalence between different language groups in South Africa (SA). Sexual partner concurrency has been linked to the spread of HIV, but its effect on differential HIV transmission within SA's language groups has not been investigated quantitatively.
Objective. This ecological analysis was intended to explore the degree to which the variation in HIV prevalence according to language group can be explained by differential concurrency rates.
Method. Linear regression was used to assess the association between each language group's HIV prevalence and four risk factors: the prevalence of concurrency, multiple sexual partners in the preceding year, circumcision, and condom utilisation.
Results. In multivariate analysis, only the point prevalence of concurrency remained associated with HIV prevalence.
Conclusion. There is evidence of a high prevalence of point concurrency in sexual partnerships in SA's most HIV-affected language groups. Together with evidence that relatively small decreases in concurrency can lead to large declines in HIV incidence, this provides impetus for interventions to promote having only one sexual partner at a time.
Source: Southern African Journal of HIV Medicine 14, pp 29 –33 (2013)More Less
Lipodystrophy is a well-recognised adverse effect of HIV and antiretroviral therapy, with certain antiretrovirals, specifically thymidine analogues, implicated in the aetiology and pathogenesis. Lipodystrophy is often accompanied by metabolic complications, such as hyperlipidaemia and insulin resistance, which increase risk for cardiovascular disease. There are limited data on the effect of treatment modification, pharmacological interventions and surgical management on this condition.
Here we summarise the latest data on lipodystrophy, with the aim of facilitating informed decision-making in managing this condition. In light of the absence of cost-effective measures to treat lipoatrophy and lipohypertrophy, prevention remains the best option; we recommend targeted annual screening. Healthcare workers should be sensitised to early detection in patients on thymidine-based regimens, and affected patients should be switched to an appropriate regimen as soon as feasible. There is no evidence to support the use of new-generation ARVs, except in patients with significant hypercholesterolaemia, where atazanavir and raltegravir may present better options.
Stavudine dosage reduction : effect on symptomatic hyperlactataemia and lactic acidosis in patients at Dr George Mukhari Hospital, Pretoria : scientific letterSource: Southern African Journal of HIV Medicine 14, pp 34 –35 (2013)More Less
A range of studies have demonstrated that symptomatic hyperlactataemia and lactic acidosis are associated with antiretroviral combinations containing stavudine. The HIV treatment programme in Khayelitsha, Cape Town, which began using stavudine as a first-line therapy in 2003, reported approximately 10% of patients switching from stavudine to the alternative drug after 12 months due to hyperlactataemia. Following a meta-analysis showing that lower doses of stavudine are safer and as effective, the World Health Organization (WHO) issued a statement that only a low dose of stavudine (30 mg) should be used.
'Striving for Clinical Excellence' : Southern African HIV Clinicians Society Conference, Cape Town, 25 - 28 November 2012 : abstractsSource: Southern African Journal of HIV Medicine 14, pp 36 –39 (2013)More Less
Author N.E.C.G. DaviesSource: Southern African Journal of HIV Medicine 14, pp 41 –43 (2013)More Less