Southern African Journal of HIV Medicine - Volume 2, Issue 4, January 2001

In the minds of many clinicians the management of patients infected with HIV has a narrow focus involving antiretroviral therapies, high-tech laboratory monitoring, and so on. In the field of medicine generally, and in the field of HIV medicine in particular, this approach falls short of the mark. The broader issues of a more holistic approach to the comprehensive management of the patient are highlighted in this issue of the Journal.

'From bushveld through deserts and forests, up winter snow clad peaks down to wide, unspoiled beaches and coastal wetlands, lies the sprawling land called South Africa. This land of unequalled splendour and diversity beckons you...' These words, from the SATOUR website description of South Africa, entice multitudes of tourists to our exquisite beaches and sites all year round. There is no doubt that with so much exceptional natural beauty South Africa is a popular tourist destination. On just one such perfect day recently, under cornflower blue Cape Town skies, with the soothing sound of rolling waves in the background and the fragrant smell of fresh spring flowers, I dreamed of a perfect South Africa.

Aim. To maximise access of hospitalised AIDS patients to an integrated community-based home care (lCHC) programme.

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Objectives. To determine optimal standards for referral, to review current practice in relation to standards, to implement changes necessary to meet standards, and to reassess the functioning of the referral system after intervention.

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Design. Prospective collaborative audit using review of referral forms, interviews and focus group discussions.

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Setting. Port Shepstone health district, KwaZulu-Natal, South Africa.

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Subjects. Staff ICHC team, South Coast Hospice, and staff at Port Shepstone Hospital.

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Results. The referral system was suboptimal in terms of process, structure and awareness of function. Problems were reliance on a single co-ordinator, inappropriate referrals, and nonspecific documentation. There was also a cumbersome process of communication between the hospital and the ICHC team. Hospital and patients were unclear of the role of the ICHe. Changes included training nurses to increase the number of co-ordinators, production of written referral criteria, a patient information pamphlet and specific documentation. Communication channels were streamlined. Reassessment indicated that referral standards were being met.

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Conclusions. The referral system was initially suboptimal but was improved to meet standards. We recommend ongoing data collection and peer audit.

Medical practitioners can be either employers (when for example in private practice) or employees (when working for the state or another employer). They are also expected to deal with employers requesting HIV tests for prospective or existing employees. For these reasons they have to be familiar with the relevant provisions of labour law in this regard. The much-publicised cases of testing of domestic workers have emphasised instances where employers place doctors in difficult ethical and legal situations.

This guideline will address the principles of the palliative care approach, emphasising patients with HIV/AIDS, and the management of pain and some selected symptoms.

In immunocompromised patients a wide range of bacteria may be found colonising the oral cavity. Opportunistic bacterial infections occur in all three groups of lesions associated with HIV infection according to the European Commission-World Health Organisation (EC-WHO) classification.

Health care professionals have recognised the interaction between malnutrition, immune dysfunction and poor prognostic outcome for a number of years. Guidelines for medical nutritional therapy as part of the health care of HIV-infected people have been available in developed countries for some time. However, there is uncertainty among health professionals as to the most appropriate approach towards nutritional management of the HIV-positive patient in southern Africa. Although a high prevalence of malnutrition has been documented among HIV/AIDS patients in Africa, only a limited number of prospective trials are available to show the efficacy of nutritional intervention in HIV-infected adults in the African context.

Alternative specimens to blood, such as saliva and urine, have been considered for HIV antibody (anti-HIV) testing. However, concerns regarding anti-HIV salivary testing have been raised, including the fact that few such evaluations have been done in the local situation. Although a sample of saliva cannot meet the specific requirements for techniques detecting anti-HIV, oral mucosal transudate (OMT) appears to fulfil the criteria. The OMT sampling and collection is not a saliva-based system and has been shown to be a highly accurate alternative to blood testing for anti-HIV. To overcome the problems with sampling, the OMT collection pad has been devised and together with an anti-HIV-1 oral fluid assay, has been approved by the United States Food and Drug Administration (FOA) for individual patient HIV diagnosis. The University of Pretoria is currently evaluating the role of oral fluid anti-HIV testing in local high- and low-risk populations, and preliminary data comparing blood and oral fluid specimens are encouraging.

The past two decades have seen the emergence of two apparently unrelated pandemics - HIV/AIDS and allergic disorders. The relatively rapid rise in allergic disorders points to important environmental determinants associated with socio-economic development, which may interact with an underlying genetic predisposition to atopy. The rapid spread of the HIV/AIDS pandemic can be attributed to various viral and socio-economic factors.

HIV is a neutrophic virus. It is therefore not surprising that neurological symptoms are widely prevalent following infection, Peripheral and central nervous system (CNS) symptoms are common, frequently debilitating, and often life-threatening. These occur throughout the natural history of HIV-related illness, from seroconversion through to full-blown immunodeficiency disease. It is estimated that between 40% and 70% of persons infected with the HIV virus develop symptomatic neurological disturbances. In autopsy neuropathological studies. CNS abnormalities are found to occur in up to 90% of patients with advanced AIDS. Most of the information available to clinicians in South Africa comes from literature from the USA or Europe, despite the fact that we see a vast amount of HIV-related neurology. The aim of this article is to give an overview of the clinical neurological manifestations of HIV, to provide more detail on a few conditions that we see commonly, and to highlight South African neuro-HIV research.