Southern African Journal of HIV Medicine - Volume 2, Issue 1, January 2001

Zidovudine was approved for use as an antiretroviral agent in 1987. It was used, at that time, as a single agent to treat patients with HIV infection. The therapeutic effect of this monotherapy was, however, of short duration due to the rapid development of viral resistance to the drug. Subsequently the use of two drugs (dual therapies) became the standard of care. Their antiretroviral effect was more pronounced and of a longer duration, but regrettably viral resistance once again limited the therapeutic effects. Following the International AIDS Conference in Vancouver in 1996 triple combination therapies (HAART) were endorsed and proved to be effective in the majority of patients treated, as evidenced by profound and durable suppression of viral loads and an impressive rise in CD4 counts.

World AIDS Day (December 1st) at the end of last year saw the signing of a groundbreaking public-private partnership agreement between Pfizer Pharmaceuticals and the South African Ministry of Health. The Memorandum of Understanding that defines the conditions of Pfizer's 2-year donation of free Diflucan to South Africa (estimated at a market value of R375 million) was the culmination of months of negotiations to ensure that South Africa benefits appropriately from the offer.

Despite an abundance of data in recent months, a case definition for lipodystrophy has not yet been determined, nor have the pathogenesis and aetiology been elucidated. Complicating this is the wide array of clinical observations and cause-related hypotheses - often in conflict with each other - that have been made by many researchers the world over. Two important recurring themes suggest that the problem needs a multifactorial approach and that it might indeed involve multiple syndromes, both directly and indirectly related to antiretroviral therapy (ARD. These two caveats are that there appear to be gender differences, and that metabolic differences and body habitus changes do not uniformly coexist in all patients classified as having lipodystrophy.

Influenza vaccines are widely used throughout the world. Some 80 - 85 million doses are produced annually for distribution in the USA alone where coverage for the major risk group, persons over 65 years of age, was 63% in 1997 (surpassing the 6O% vaccine coverage goal for the country's Healthy People 2000 Project). The clinical effectiveness as well as the cost effectiveness of influenza vaccines have been clearly established in a number of studies in many parts of the world. Influenza vaccination has also been demonstrated to reduce hospitalisation significantly in elderly high-risk persons. In South Africa, influenza immunisation has similarly been demonstrated to be cost effective and utilisation of vaccine in this country has increased markedly over the past few years, reaching over 2 million doses administered in 2000. Annual influenza immunisation is sound preventive medicine generally, and in particular is mandated for persons at risk for complications of influenza.

In South Africa all urologists are at some stage likely to be faced with management of an AIDS patient because of the high incidence of the disease in this country. Despite thorough research, there still exists a paucity of data worldwide concerning the urological manifestations. Our experience in the Durban academic hospitals reveals that AIDS is associated with multiple opportunistic infections, unusual malignancies, voiding dysfunction as well as metabolic disturbances. The natural history of the disease process is frequently influenced by the patient's underlying immune status. Therefore, management of these conditions must take into consideration the patient's underlying HIV and immune status.

HIV infection causes progressive deterioration of cell-mediated immunity that results in an inability to contain pre-existing dormant infection with and new exposure to Mycobacterium tuberculosis. The risk of tuberculosis (TB) in HIV-infected individuals who have been exposed to M. tuberculosis, as assessed by a positive tuberculin skin test, is approximately 10% per annum. TB is the commonest cause of morbidity and mortality in HIV-infected patients in South Africa, as is the case elsewhere in sub-Saharan Africa. In areas of high HIV prevalence TB incidence has increased alarmingly. It is estimated that approximately 50% of new adult cases of TB in South Africa are attributable to HIV.

Developing health care professionals' knowledge and skills in HIV and AIDS care will bring about positive changes in their attitude towards caring for HIV-infected patients.

Early this year (2001) the US Centers for Disease Control (CDC) will release revised guidelines and a more comprehensive protocol for antiretrovirals (ARVs) after rape to prevent HIV.

As general medical practitioners, few of us have seen and managed rape victims on a regular basis. A major reason for this is that until recently only district surgeons saw and treated rape victims. However, if one takes the time to read the various provincial Health Departments' medical-legal services guidelines, all experienced registered health care workers may see and manage these 'types of patients'.

Progress in the field of HIV treatment and the prevention of AIDS-related complications has led to a significant decline in mortality and morbidity in developed countries. Limitations of the currently available antiviral therapies include the cost of treatment, metabolic complications of treatment, and the development of viral resistance. The development of resistant viral strains is related to difficulties with compliance, recognition of ongoing viral replication despite undetectable serum viral loads, poor drug penetration into sanctuary sites, and the discovery that resting CD4 cells can provide a reservoir for HIV-1 with a predicted decay rate of approximately 60 years. The chance of achieving viral eradication with currently available treatment options appears to be very small. Therefore strategies involving sustained treatment with enhancement of HIV-specific immune control mechanisms need to be investigated.

There is increasing evidence to suggest that one or more of the currently used antituberculosis (TB) drugs have direct effects on various neutrophil functions in patients diagnosed with pulmonary TB. These findings have prompted us to question how the use of various antibacterial agents may in fact impact on natural immune functions that are essential to the clearance of invading micro-organisms, particularly in those patients known to be at higher risk of acquiring secondary infections.