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- Volume 16, Issue 1, 2015
Southern African Journal of HIV Medicine - Volume 16, Issue 1, 2015
Volumes & issues
Volume 16, Issue 1, 2015
Reasons for failure of prevention of mother-to-child HIV transmission in a rural South African district hospital : scientific letterSource: Southern African Journal of HIV Medicine 16, pp 1 –3 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.365More Less
Further reduction of mother-to-child transmission (MTCT) of HIV requires improvedunderstanding of the reasons for MTCT. We reviewed maternal and infant case notes for HIVpositive infants diagnosed by polymerase chain reaction at Bethesda Hospital. Nineteen cases were analysed. Median gestation at first antenatal consultation (ANC) was 22.5 (interquartile range [IQR] 19.25-24). Eleven (57.9%) mothers were HIV positive at first ANC, whilst eight tested negative and later positive (2 antepartum, 6 postpartum). Median maternal CD4 was 408 cells/µL (IQR 318-531). Six (31.6%) received no antenatal antiretroviral therapy (ART) because they were diagnosed as HIV positive postpartum; 9 (47.3%) received antenatal ART and 3 (15.8%) were never initiated on ART. At 6 weeks postpartum, 5 infants (26.3%) were not on prophylactic nevirapine (NVP) because their mothers had not yet been diagnosed. Maternal seroconversion in pregnancy and breastfeeding, and possibly false-negative HIV tests, were important reasons for prevention of mother-to-child transmission (PMTCT) failure.
Source: Southern African Journal of HIV Medicine 16, pp 1 –8 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.361More Less
Rationale for initiating combination antiretroviral therapy during the neonatal period
Initiation of combination antiretroviral therapy (cART) at 6-9 weeks of age has been shown to reduce early infant mortality by 76% and HIV progression by 75% compared with cART deferred until clinical or CD4 criteria were met. In the landmark Children with HIV Early Antiretroviral Therapy (CHER) trial, although the median age of starting cART in the early treatment arm was 7.4 weeks, one-third (10/30) of the overall mortality in the trial occurred in the early treatment arm. In another study, 62% of 403 infants who initiated cART at median 8.4 weeks of age already had advanced HIV disease (CD4 < 25% or < 1500 cells/mm3 or World Health Organization [WHO] Stage 3 or 4) at initiation.
HIV testing and antiretroviral therapy initiation at birth : views from a primary care setting in Khayelitsha : forumSource: Southern African Journal of HIV Medicine 16, pp 1 –4 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.376More Less
Despite 95% coverage via the prevention-of-mother-to-child-transmission (PMTCT) programme, 14 000 children in South Africa became HIV-infected in 2012. There are many reasons for this gap in PMTCT efforts. Late maternal diagnosis of HIV, late antenatal antiretroviral therapy (ART) initiation, seroconversion in pregnancy, and inadequate adherence to ART during gestation singly and collectively increase the risk of transmission. Early initiation of ART in the first few weeks of life significantly reduces the HIV-associated morbidity and mortality in HIV-infected infants, compared with deferred initiation and may reduce the latent HIV-1 reservoir in children. Furthermore, a recent South African study documents that 76% of babies who would have tested HIV positive via polymerase chain reaction (PCR) by 6 weeks could have been diagnosed at birth. Therefore, the Western Cape Province (WCP) Department of Health adopted new guidelines in June 2014 (and the South African Department of Health in December 2014) to test 'high-risk' infants at birth. Infants testing PCR-positive are started on ART as soon as possible.
Source: Southern African Journal of HIV Medicine 16, pp 1 –3 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.362More Less
Testing for HIV in the neonatal period has been routinely recommended for all HIV-exposed infants in the developed world for over two decades. In 2015, birth testing for certain asymptomatic HIV-exposed infants was included in the South African National Consolidated Guidelines for the first time. Questions remain concerning the optimal recommendations for and implementation of HIV testing in neonates to achieve improved outcomes for HIV-infected infants in South African and other low-resource settings.
Evaluation of selected aspects of the Nutrition Therapeutic Programme offered to HIV-positive women of child-bearing age in Western Cape Province, South Africa : original researchSource: Southern African Journal of HIV Medicine 16, pp 1 –5 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.338More Less
Background: The Nutrition Therapeutic Programme (NTP) involves the provision of food supplements at primary health clinics (PHCs) to correct nutritional deficiencies in vulnerable groups. Although previous studies have identified problems with implementing the programme at PHCs, assessments of its efficiency have been scarce.
Objective: To evaluate implementation of the NTP at PHCs that provide antiretroviral therapy.
Methods: A cross-sectional, descriptive study was conducted at 17 PHCs located within 3 districts of Western Cape Province. Two target groups were chosen: 32 staff members working at the sites and 21 women of child-bearing age enrolled in the NTP. Questionnaires were used to obtain data.
Results: Only 2 women (10%) lived in food-secure households; the rest were either at risk of hunger (29%) or classified as hungry (61%). Most of the women knew they had to take the supplements to improve their nutritional status, but the majority only recalled receiving basic nutritional advice, and the information was mainly given verbally. Ten of the women had shared their supplements with others, mostly with their children. The study identified lack of clearly defined NTP responsibilities at the PHCs, causing confusion amongst the staff. Although many staff members expressed problems with the NTP, only 38% of them reported having routine evaluations regarding the programme.
Conclusion: Several aspects compromised the effectiveness of the NTP, including socio-economic factors leading to clients' non-compliance. The strategic organisation and implementation of the NTP varied between different PHCs offering antiretroviral therapy, and staff experienced difficulties with the logistics of the programme.
Breastfeeding and the 2015 South African guidelines for prevention of mother-to-child transmission of HIV : forumSource: Southern African Journal of HIV Medicine 16, pp 1 –5 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.377More Less
Breastfeeding, especially exclusive breastfeeding in the first months of life, is the cornerstone of good infant nutrition, health and survival. The various health benefits include the mother and also extend beyond infancy to protection against common noncommunicable diseases in adult life. These benefits take on even greater salience in low-resource settings.
Author Mary-Ann DaviesSource: Southern African Journal of HIV Medicine 16, pp 1 –6 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.375More Less
The South African prevention of mother to child transmission programme has made excellent progress in reducing vertical HIV transmission, and paediatric antiretroviral therapy programmes have demonstrated good outcomes with increasing treatment initiation in younger children and infants. However, both in South Africa and across sub-Saharan African, lack of boosted peri-partum prophylaxis for high-risk vertical transmission, loss to followup, and failure to initiate HIV-infected infants on antiretroviral therapy (ART) before disease progression are key remaining gaps in neonatal HIV-related care. In this issue of the Southern African Journal of HIV Medicine, experts provide valuable recommendations for addressing these gaps. The present article highlights a number of areas where evidence is lacking to inform guidelines and programme development for optimal neonatal HIV-related care.
Author Max KroonSource: Southern African Journal of HIV Medicine 16, pp 1 –7 (2015) 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 Brian EleySource: Southern African Journal of HIV Medicine 16, pp 1 –3 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.360More Less
South Africa has implemented a successful prevention-of-mother-to-child-transmission (PMTCT) intervention programme. Important milestones achieved in 2012 include: (1) an estimated 83% of all pregnant women living with HIV in South Africa received antiretrovirals (ARVs) for PMTCT, (2) early vertical transmission of HIV in infants ≤ 2 months of age declined to 2.4% and (3) early infant HIV diagnosis coverage (i.e. coverage in infants < 2 months of age) reached 72.6%.
Source: Southern African Journal of HIV Medicine 16, pp 1 –4 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.344More Less
The 2011 World Health Organization global report on HIV and/or AIDS estimated that sub-Saharan Africa comprised 67% of the global HIV burden, with a current estimate of 5.9 million cases in South Africa. Since the introduction of antiretroviral therapy, there has been an increase in the incidence of non-AIDS-defining cancers. Gestational trophoblastic neoplasm (GTN) is a rare pregnancy-related disorder with an incidence ranging from 0.12-0.7/1000 pregnancies in Western nations. The overall cure rate is about 90%. Response to treatment for GTN is generally favourable; but the sequelae of HIV and/or AIDS, the resultant low CD4 counts, comorbidities, poor performance status and the extent of metastatic disease in patients receiving chemotherapy, compromise the prognosis and survival.
Source: Southern African Journal of HIV Medicine 16, pp 1 –3 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.353More Less
Condoms are one of the cornerstones to any response to the HIV epidemic. However, targeted marketing strategies that make condoms more attractive to people at high risk of infection are often overlooked. The South African National Department of Health has recently purchased more attractive condoms to distribute in higher-education settings free of charge, targeting at-risk youth including young women. The authors applaud this move but note the importance of expanding better branded condoms to young people elsewhere - for example, via youth clinics and in high schools. Exploratory, routine data from Médecins Sans Frontières in Khayelitsha are presented, showing the popularity of alternatives to the government's 'Choice' brand.
Reconciling the science and policy divide : the reality of scaling up antiretroviral therapy in South Africa : forumSource: Southern African Journal of HIV Medicine 16, pp 1 –5 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.355More Less
With the world's largest national treatment programme and over 340 000 incident cases annually, the response to HIV in South Africa is hotly contested and there is sometimes a dissonance between activism, science and policy. Too often, policy, whilst well intentioned, is informed only by epidemiological data. The state of the healthcare system and sociocultural factors drive and shape the epidemic and its response. By analysis of the financial, infrastructural, human resources for health, and governance landscape in South Africa, we assess the feasibility and associated costs of implementing a universal test and treat programme. We situate a universal test and treat strategy within the governance, fiscal, human resources for health, and infrastructural landscape in South Africa. We argue that the response to the epidemic must be forward thinking, progressive and make the most of the benefits from treatment as prevention. However, the logistics of implementing a universal test and treat strategy mean that this option is problematic in the short term. We recommend a health systems strengthening HIV treatment and prevention approach that includes scaling up treatment (for treatment and prevention) along with a range of other prevention strategies.
Routine cranial computed tomography before lumbar puncture in HIV-positive adults presenting with seizures at Mitchells Plain Hospital, Cape Town : original researchAuthor Salma MoollaSource: Southern African Journal of HIV Medicine 16, pp 1 –7 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.354More Less
Background: Current international guidelines recommend that a cranial computed tomography (CT) be performed on all HIV-positive patients presenting with new onset seizures, before a lumbar puncture (LP) is performed. In the South African setting, however, this delay could be life threatening. The present study sought to measure the number of cranial CTs that contraindicate an LP and to predict which clinical signs and symptoms are likely to pose an increased risk from LP.
Methods: The study was performed at a district level hospital in Western Cape Province. Data were collected retrospectively from October 2013 to October 2014. Associations between categorical variables were analysed using Pearson's chi-squared test. Generalised linear regression was used to estimate prevalence ratios.
Results: One hundred out of 132 patients were studied. Brain shift contraindicated an LP in 5% of patients. Patients with brain shift presented with decreased level of consciousness, focal signs, headache and neck stiffness. Twenty-five per cent of patients had a space-occupying lesion (SOL) (defined as a discrete lesion that has a measurable volume) or cerebral oedema. Multivariate analysis showed a CD4 count <50 (p = 0.033) to be a statistically significant predictor of patients with SOL and cerebral oedema. Univariate analysis showed focal signs (p = 0.0001), neck stiffness (p = 0.05), vomiting (p = 0.018) and a Glascow Coma Scale (GCS) < 15 (p = 0.002) to be predictors of SOL and cerebral oedema.
Conclusion: HIV-positive patients with seizures have a high prevalence of SOL and cerebral oedema but the majority of them are safe for LP. Doctors can use clinical parameters to determine which patients can undergo immediate LP.
Outcomes from the implementation of a counselling model supporting rapid antiretroviral treatment initiation in a primary healthcare clinic in Khayelitsha, South Africa : original researchSource: Southern African Journal of HIV Medicine 16, pp 1 –7 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.367More Less
Background: Lengthy antiretroviral treatment (ART) preparation contributes to high losses to care between communicating ART eligibility and initiating ART. To address this shortfall, Médecins Sans Frontières implemented a revised approach to ART initiation counselling preparation (integrated for TB co-infected patients), shifting the emphasis from pre-initiation sessions to addressing common barriers to adherence and strengthening post-initiation support in a primary healthcare facility in Khayelitsha, South Africa.
Methods: An observational cohort study was conducted using routinely collected data for all ART-eligible patients attending their first counselling session between 23 July 2012 and 30 April 2013 to assess losses to care prior to and post ART initiation. Viral load completion and suppression rates of those retained on ART were also calculated.
Results: Overall, 449 patients enrolled in the study, of whom 3.6% did not return to the facility to initiate ART. Of those who were initiated, 96.7% were retained at their first ART refill visit and 85.9% were retained 6 months post ART initiation. Of those retained, 80.2% had a viral load taken within 6 months of initiating ART, with 95.4% achieving viral load suppression.
Conclusions: Adapting counselling to enable rapid ART initiation is feasible and has the potential to reduce losses to care prior to ART initiation without increasing short-term losses thereafter or compromising patient adherence.
Source: Southern African Journal of HIV Medicine 16, pp 1 –6 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.347More Less
Background: Lost to follow-up (LTFU) is a major challenge that hinders the success of antiretroviral treatment (ART).
Objective: To identify factors conducted to a low LTFU rate.
Methods: We conducted a two-part descriptive and quantitative study. Part 1 comprised interviews with clinic staff to determine their perspectives on LTFU and to establish the clinic's follow-up procedures for patients on ART. Part 2 of the study was a retrospective review of clinic and patient records. LTFU patients were identified and those with contact details were contacted for telephonic interview to determine if they were still on ART and/or their reasons for becoming LTFU.
Results: A low LTFU rate (7.9%; N = 683) was identified. Work-related stress, and lack of transport and funds were reported reasons for LTFU. Monthly visits, non-adherent defaulters and LTFU patients were tracked by an electronic system (SOZO). Factors contributing to high rates of retention in care were: location of the clinic in the inner city, thus in close proximity to patients' homes or work; clinic operating on Saturdays, which was convenient for patients who could not attend during the week; an appointment/booking system that was in place and strictly adhered to; a reminder SMS being sent out the day before an appointment; individual counselling sessions at each visit and referrals where necessary; and a stable staff complement and support group at the clinic.
Conclusion: Achieving a low LTFU rate is possible by having a patient-centred approach and monitoring systems in place.
Source: Southern African Journal of HIV Medicine 16, pp 1 –4 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.323More Less
We report the case of an HIV-positive female patient with neurofibromatosis type 1 who was treated for recurrent peptic ulcer disease and later developed diabetes mellitus and chronic diarrhoea. A metastasising somatostatinoma was histologically proven and evidence of a concomitant gastrin-producing neuroendocrine tumour was found. Neuroendocrine tumours (NETs) are very rare neoplasms originating from a wide variety of endocrine and nervous system tissue with the ability to produce different hormones. A somatostatin- and gastrinsecreting NET in a patient with HIV has not been reported in the literature, to the best of our knowledge. We discuss oncogenic pathomechanisms related to the underlying conditions and propose stringent monitoring for tumours in HIV-positive patients with phakomatoses as well as initiation of antiretroviral therapy.
Source: Southern African Journal of HIV Medicine 16, pp 1 –4 (2015) http://dx.doi.org/doi:10.4102/sajhivmed.v16i1.352More Less
Opportunistic fungal infections can cause significant morbidity and mortality in immunocompromised patients. We describe a paediatric case of an unusual disseminated fungal infection. A three-year-old HIV-infected child with severe immunosuppression (CD4+ T-cell count 12 x 106/L) was admitted to hospital with pneumonia, gastroenteritis and herpes gingivostomatitis. Despite antibacterial and antiviral therapy, he experienced high fevers and developed an erythematous maculopapular rash and abdominal tenderness. The child's condition progressively worsened during the admission. A thermally dimorphic fungus was cultured from bone marrow and identified as an Emmonsia species on DNA sequencing. The patient made a good recovery on amphotericin B deoxycholate and antiretroviral therapy. Itraconazole was continued for a minimum of 12 months, allowing for immune reconstitution to occur. This case is the first documented description of disseminated disease caused by a novel Emmonsia species in an HIV-infected child in South Africa.
Source: Southern African Journal of HIV Medicine 16, pp 1 –4 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.337More Less
Background: Botswana is one of the countries with the highest HIV prevalence rates in the world. Innovative HIV testing strategies are required to ensure that those infected or at risk of infection become aware of their HIV status and are able to access treatment, care and support. Despite this public health imperative, HIV testing strategies in Botswana will in future be based around the principles in the new Public Health Act (2013). The present article describes the HIV testing norms in the Act, and sets out the strengths and weaknesses of this approach and its implications for healthcare professionals in Botswana.
Objectives: To compare international norms on HIV testing with the provisions governing such testing in the new Botswana Public Health Act and to assess the extent to which the new Act meets international human rights norms on HIV testing.
Method: A 'desktop' review of international human rights norms and those in the Botswana Public Health Act.
Conclusion: HIV testing norms in the new Public Health Act in Botswana violate individual rights and will place healthcare workers in a position where they will have to elect between acting lawfully or ethically. Law reform is required in order to ensure that HIV testing achieves the joint goals of public health and human rights.
A prospective study of demographic features and quality of life in HIV-positive women with cervical cancer treated at Tygerberg Hospital : original researchSource: Southern African Journal of HIV Medicine 16, pp 1 –5 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.368More Less
Background: Cervical cancer and human immunodeficiency virus (HIV) infection/acquired immune deficiency syndrome (AIDS) both have a high incidence in South Africa. Cervical cancer treatment of HIV-positive women poses challenges. Treatment-related changes in quality of life (QOL) of such women are important to future treatment protocols.
Aim: To examine demographic data of HIV-negative and HIV-positive women at diagnosis of cervical cancer and describe their changes in QOL as a result of treatment.
Methods and materials: All newly diagnosed patients with cervical cancer at Tygerberg Hospital were approached to participate in the study. The European Organisation for Research and Treatment of Cancer Quality of Life Core Questionnaire (EORTC QLQ-C30) and the Cervix Cancer Module (QLQ-CX24) were used. General QOL was measured with the EORTC QLQ-C30 and cervical-specific QOL with the QLQ-CX24 questionnaire. The patients completed the questionnaire at diagnosis, on completion of treatment and at 3 months' follow-up.
Results: The study included a total of 221 women of whom 22% were HIV-positive; the latter were younger and of higher educational level than the rest. Mean monthly income and stage distribution was similar between the two groups. HIV-positive patients underwent radiation therapy more commonly than chemo-radiation. HIV-positive women showed statistically significantly higher loss to follow-up during the study. HIV-positive women experienced no improvement in insomnia, appetite loss, nausea, vomiting, diarrhoea, social role or any of the sexual domains. In contrast, HIV-negative women experienced statisticallysignificant improvement in all sexual domains other than sexual/vaginal functioning. The QOL improvement of HIV-negative women was statistically significantly greater than their HIV-positive counterparts in the majority of QOL domains. Global health improved in both groups, with HIV-negative women experiencing greater improvement. HIV-positive women experienced an initial decline of peripheral neuropathy (PN) symptoms post treatment with a return to pretreatment values at 3 months' follow-up. The change in PN was statistically significant between the HIV-negative and HIV-positive women.
Conclusion: Demographic differences exist between the HIV-negative and HIV-positive groups. The differential outcome in the QOL of HIV-positive and HIV-negative women treated for cervical cancer might be related to persistence of AIDS-related symptoms on completion of cervical cancer treatment.
Guideline on the management of occupational and non-occupational exposure to the human immunodeficiency virus and recommendations for post-exposure prophylaxis : 2015 Update : guidelinesSource: Southern African Journal of HIV Medicine 16, pp 1 –14 (2015) http://dx.doi.org/10.4102/sajhivmed.v16i1.399More Less
This guideline is an update of the post-exposure prophylaxis (PEP) guideline published by the Southern African HIV Clinicians Society in 2008. It updates the recommendations on the use of antiretroviral medications to prevent individuals who have been exposed to a potential HIV source, via either occupational or non-occupational exposure, from becoming infected with HIV. No distinction is made between occupational or non-occupational exposure, and the guideline promotes the provision of PEP with three antiretroviral drugs if the exposure confers a significant transmission risk. The present guideline aligns with the principles of the World Health Organization PEP guidelines (2014), promoting simplification and adherence support to individuals receiving PEP.