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- Volume 15, Issue 2, 2014
Southern African Journal of HIV Medicine - Volume 15, Issue 2, 2014
Volumes & issues
Volume 15, Issue 2, 2014
Author Max KroonSource: Southern African Journal of HIV Medicine 15, pp 1 –7 (2014) http://dx.doi.org/http://dx.doi.org/10.4102/sajhivmed.v16i1.371More Less
Prevention of mother-to-child transmission (PMTCT) programmes have improved maternal health outcomes and reduced the incidence of paediatric HIV, resulting in improved child health and survival. Nevertheless, high-risk vertical exposures remain common and are responsible for a high proportion of transmissions. In the absence of antiretrovirals (ARVs), an 8- to 12-hour labour has approximately the same 15% risk of transmission as 18 months of mixed feeding. The intensity of transmission risk is highest during labour and delivery; however, the brevity of this intra-partum period lends itself to post-exposure interventions to reduce such risk. There is good evidence that infant post-exposure prophylaxis (PEP) reduces intra-partum transmission even in the absence of maternal prophylaxis. Recent reports suggest that infant combination ARV prophylaxis (cARP) is more efficient at reducing intra-partum transmission than a single agent in situations of minimal pre-labour prophylaxis. Guidelines from the developed world have incorporated infant cARP for increased-risk scenarios. In contrast, recent guidelines for low-resource settings have rightfully focused on reducing postnatal transmission to preserve the benefits of breastfeeding, but have largely ignored the potential of augmented infant PEP for reducing intra-partum transmissions. Minimal prelabour prophylaxis, poor adherence in the month prior to delivery, elevated maternal viral load at delivery, spontaneous preterm labour with prolonged rupture of membranes and chorioamnionitis are simple clinical criteria that identify increased intra-partum transmission risk. In these increased-risk scenarios, transmission frequency may be halved by combining nevirapine and zidovudine as a form of boosted infant PEP. This strategy may be important to reduce intra-partum transmissions when PMTCT is suboptimal.
Author Landon MyerSource: Southern African Journal of HIV Medicine 15 (2014)More Less
Most editions of SAJHIVMED are posted to you with a range of different inserts - materials sent in hard copy in addition to the Journal itself - related to different aspects of HIV prevention and treatment. Several times a year, this includes HIV Treatment Bulletin (HTB) South, an invaluable guide to recent developments in HIV medicine and antiretroviral therapy (ART). Other materials have included guides on specific aspects of HIV medicine, such as those assisting in the management of HIV-TB co-infection. With this edition of the Journal, we are sending a particularly important insert: the National Department of Health's new Contraception & Fertility Planning Guidelines. Experience over the last decade has demonstrated that unintended pregnancies are commonplace in HIV-infected women, and that preventing such pregnancies is a critical but neglected 'upstream' intervention to promote the health of HIV-infected women. In turn, these new guidelines place special emphasis on appropriate contraceptive choices for HIV-infected women, and feature integration of family planning services as a key intervention within HIV care and treatment programmes. Delivering appropriate counselling and contraception (when indicated) is a basic responsibility of every healthcare provider working in adult HIV services, and we hope that this month's insert will contribute towards this end.
Author Francesca ConradieSource: Southern African Journal of HIV Medicine 15 (2014)More Less
When the Minister of Health announced that the National Department of Health was introducing fixed-dose combinations (FDCs) into the antiretroviral programme in December 2012, as HIV clinicians we welcomed the decision. The FDC simplified prescription, dispensing and adherence messages.
Failing the vulnerable : three new consent norms that will undermine health research with children : forumSource: Southern African Journal of HIV Medicine 15, pp 46 –49 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAJHIVMED.1014More Less
The South African National Health Act (No. 61 of 2003) provides a legal framework for the regulation of the health system across the country. Within the Act, section 71 introduces a number of legal norms relating to research or experimentation with human subjects, including research on HIV prevention and treatment. These norms have been criticised for the negative impact they will have on research involving children. This article describes three of the new consent requirements in section 71 of the Act. It shows, using a range of case studies, how important HIV-related research will be halted or undermined if the current provisions are implemented. The article argues that the new consent requirements are out of step with other statutory provisions and ethical guidelines, and as a result they will exclude a large population group - children in diverse settings - from much-needed evidence-based healthcare interventions. The article concludes with a clarion call for support of advocacy on this issue with the Minister of Health and the Health Portfolio Committee.
Which clinical parameters predict a CSF diagnosis of meningitis in a population with high HIV prevalence? : original articleSource: Southern African Journal of HIV Medicine 15, pp 50 –54 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAJHIVMED.1004More Less
Background. The HIV epidemic has changed the aetiology of meningitis in sub-Saharan Africa, and frontline clinicians are faced with a variety of meningitic presentations. Doctors working in resource-limited settings have the challenge of appropriately selecting patients for lumbar puncture (LP), a potentially risky procedure that requires laboratory analysis.
Methods. In a rural South African hospital, the practice of performing LPs was audited against local guidelines. Data were collected retrospectively between February and June 2013. Symptoms and signs of meningitis, HIV status, investigations performed prior to LP and cerebrospinal fluid (CSF) results were recorded. With the aim of determining statistically significant clinical predictors of meningitis, parameters were explored using univariate and multivariate logistic regression analyses.
Results. A total of 107 patients were included, of whom 43% had an abnormal CSF result. The majority (76%) of patients were HIV-positive (CD4+ cell count <200 cells/µl in 46%). Cryptococcal meningitis (CCM) was the most prevalent microbiological diagnosis, confirmed in 10 out of 12 patients. Of the non-microbiological diagnoses, lymphocytic predominance was the most common abnormality, present in 17 out of 33 patients. Confusion (p=0.011) was the most statistically significant predictor of an abnormal CSF result. Headache (p=0.355), fever (p=0.660) and photophobia (p=0.634) were not statistically predictive.
Conclusion. The high incidence of CCM correlates with previous data from sub-Saharan Africa. In populations with high HIV prevalence, the classic meningitic symptoms of headache, fever and photophobia, while common presenting symptoms, are significantly less predictive of a meningitis diagnosis than confusion.
Timing of antenatal care and ART initiation in HIV-infected pregnant women before and after introduction of NIMART : original articleSource: Southern African Journal of HIV Medicine 15, pp 55 –56 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAJHIVMED.1009More Less
In this review of routinely collected data from five community health centres in the Johannesburg Health District, we assess timing of antenatal care and antiretroviral therapy (ART) initiation in HIV-infected pregnant women before and after the introduction of nurse-initiated management of ART in antenatal clinics. There are important lessons to be learnt as we reflect on the South African prevention of mother-to-child transmission of HIV programme.
Association between symptomatic vulvovaginal candidiasis and HIV RNA levels in plasma and genital secretions among women on HAART : original articleSource: Southern African Journal of HIV Medicine 15, pp 57 –64 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAJHIVMED.975More Less
Background. Genital tract (GT) inflammation plays a major role in HIV transmission. We aimed to determine the association between symptomatic vulvovaginal candidiasis (VVC) and HIV RNA levels in plasma and GTs of HIV-infected women on highly active antiretroviral therapy (HAART).
Method. Women with VVC on HAART were recruited from a primary healthcare clinic in KwaZulu-Natal Province, South Africa, between June 2011 and December 2011. VVC was diagnosed clinically, supported by Gram staining and culture of genital secretions. HIV RNA load was determined by reverse transcription polymerase chain reaction. CD4+ counts were obtained from patients' medical records.
Results. Plasma HIV RNA was detected in 42 of 60 (70%) patients on HAART. The mean duration (± standard deviation) on HAART for these patients was 4.2 (±1.6) months v. 10.7 (±1.4) months for the remaining 18 patients (p<0.0001). Of the 42 women with detectable plasma HIV RNA, 12 (28.6%) had detectable genital HIV RNA. Plasma HIV RNA levels ranged from 2.5 (±0.8) to 4.1 (±0.8) log10 copies/ml. Genital HIV RNA levels ranged from 1.4 to 2.5 (±1.1) log10 copies/ml. The adjusted odds ratios of plasma HIV RNA levels increased for patients <35 years (p=0.039) and in those with VVC (p=0.008). Detectability of HIV in genital secretions was significantly increased in patients with a plasma HIV load ≥10 000 copies/ml (p=0.032) and genital absolute counts of neutrophils >10 cells/5 high microscopic fields (p=0.007).
Conclusion. Given that the majority of women had recently initiated HAART (allowing a high rate of detectable plasma HIV RNA), there was insufficient evidence to conclude that VVC was predictive of high plasma HIV RNA levels. It is more likely that this cohort of immunosuppressed women were prone to develop VVC. Plasma HIV loads and local genital inflammation were predictors of genital HIV detectability.
Source: Southern African Journal of HIV Medicine 15, pp 66 –68 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAJHIVMED.1048More Less
Needlestick injury (NSI) is commonly reported among healthcare workers, but is not well documented in patients. We report a case of an NSI in an HIV-negative, gestational hypertensive patient admitted to a hospital for induction of labour at term. Owing to an insufficient number of hospital beds, patients were seated in an overcrowded corridor of the antenatal ward where a patient stepped on the needle of an inadvertently disconnected intravenous infusion set of another pregnant patient, who was HIV-infected. The injury occurred prior to labour induction. Antiretroviral post-exposure prophylaxis to prevent HIV infection was administered to the injured patient and her newborn. This report illustrates how hospital bed shortage may compromise patient safety and discusses measures to prevent NSI among patients and hospital overcrowding.
Source: Southern African Journal of HIV Medicine 15, pp 69 –71 (2014) http://dx.doi.org/http://dx.doi.org/10.7196/SAJHIVMED.1056More Less
Optic neuropathy in HIV-infected patients results from the HIV infection itself, post-infectious auto-immune disease, opportunistic infections and drugs. Nucleoside reverse transcriptase inhibitors (NRTIs) such as zidovudine and stavudine have known mitochondrial toxicity and can cause mitochondrial myopathies, neuropathies, hyperlactataemia, and can induce mitochondrial genetic disorders. Individuals with the mutation for Leber's hereditary optic neuropathy (LHON), a mitochondrial disorder, are usually asymptomatic but develop visual loss when exposed to external triggers such as smoking. We report on two HIV-infected patients with LHON mutations (m.14484T>C and m.11778G>A) who developed profound visual loss with antiretroviral therapy. We postulate that the phenotypic expression of LHON in these genetically predisposed individuals was triggered by NRTI drugs lamivudine and tenofovir when used in combination, despite their relatively weak mitochondrial toxic effects.