This issue features a diverse sampling of HIV medicine from across South Africa (SA). Several contributions provide a glimpse into the future of the HIV epidemic in the country, and in turn, our responses.
In the area of the prevention of mother-to-child transmission (PMTCT) of HIV, the use of triple-drug antiretroviral therapy (ART) regimens in HIV-infected pregnant women is becoming standard of care – whether as short-term prophylaxis against mother-to-child transmission or as lifelong treatment. In Europe and North America, the use of ART in pregnancy has raised concerns around potential toxicities in HIV-exposed pregnancies and infants. It is important to remember that almost any such toxicity is likely to be uncommon in comparison to the risk of vertical HIV transmission. Still, with more than 200 000 pregnant women exposed to ART each year across SA, the possibility that in utero ART exposure may contribute to adverse pregnancy or child health outcomes requires consideration. Aniji et al.1 report the outcomes of a small cohort of HIV-exposed pregnancies from Limpopo Province. While the sample is small and there are limitations to the design, the findings for no association between early in utero ART exposure and either prematurity or low birthweight appear somewhat reassuring. There are a number of major, ongoing studies across the country investigating these issues, and with the 2013 revisions to the PMTCT guidelines in full implementation, additional evidence is eagerly anticipated.
In thinking about health systems, we know that nurse-driven services form the basis of primary healthcare across SA, and most HIV-positive individuals are managed through nurse-initiated management of antiretroviral therapy (NIMART) services. One of the core challenges to NIMART services is providing appropriate clinical support to nurse practitioners. In this regard, the National HIV & TB Health Care Worker Hotline serves as a valuable resource. Swart et al.2 present a descriptive analysis of the queries that the hotline has received recently from nurses. Their report provides readers with valuable insight into the types of questions that arise in primary care, and with this, a valuable basis for future training interventions.
There is considerable excitement in public health circles about human papillomavirus (HPV) vaccination across SA and its eventual impact on cervical cancer epidemiology, particularly in HIV-positive women. However, the manifestations of HPV in men have been largely neglected. Delany-Moretlwe et al.3 review the epidemiology and natural history of HPV in men, emphasising the role of circumcision and vaccination in future prevention efforts. In addition, self-testing for HIV infection has been controversial, both locally and internationally, as a strategy to increase awareness of individual HIV status. Strode et al.4 comment on the ethico-legal aspects of HIV self-testing in adolescents, and raise important questions about the risks v. benefits of allowing self-testing in young people – clearly a double-edged sword.
Inevitably, the number of patients initiating second-line ART regimens is growing in most parts of the region, and following from this, a small but increasing number of patients are found to be failing second-line regimens. Failure of a second-line regimen is considered grounds for specialist referral in many settings, but this is certainly not always possible. This issue features two contributions regarding the management of patients on second-line regimens in primary care settings in Cape Town. First, in a group of 69 patients with sustained viraemia on a second-line regimen, Garone and colleagues5 report that a substantial proportion appeared to re-suppress with targeted adherence support. In parallel with this, Barnett et al.6 present a qualitative study using a unique photo-based methodology to suggest that the barriers to adherence in this group of patients vary notably between patients and providers, underscoring the complexity of supporting patient adherence. This research is from small, local studies, but is surely a harbinger of the kinds of issues that the national ART rollout will face in the years to come.
Finally, few among us would question the role of mental
health as part of long-term health outcomes in HIV-positive
patients, including the interplay of mental disorders and
treatment adherence, as well as the neurocognitive effects of
HIV disease. However, many providers struggle with practical
steps to support the mental health of their patients. To help
fill this gap, the Southern African HIV Clinicians Society
has
produced a valuable guideline7 on the management of
different types of mental health disorders in HIV-positive
patients. The guideline is at once comprehensive but
accessible – an impressive feat given the breadth and
complexity of mental disorders – and hopefully readers will be
able to put it to good use in practice.
Happy reading.
Landon Myer
School of Public Health & Family Medicine, University of Cape Town
1. Anjii CD, Towobola OA, Hoque ME, et al. Impact of antiretroviral therapy on pregnancy outcomes. Southern African Journal of HIV Medicine 2013;14(4):176-178. [http://dx.doi.org/10.7196/SAJHIVMED.834]
2. Swart AM, Chisholm BS, Cohen K, et al. Analysis of queries from nurses to the South African National HIV & TB Health Care Worker Hotline. Southern African Journal of HIV Medicine 2013;14(4):179-182. [http://dx.doi.org/10.7196/SAJHIVMED.948]
3. Delany-Moretlwe S, Chikandiwa A, Gibbs J. Human papillomavirus infection and disease in men: Impact of HIV. Southern African Journal of HIV Medicine 2013;14(4):183-188. [http://dx.doi.org/10.7196/SAJHIVMED.1002]
4. Strode AE, van Rooyen H, Makusha T. Is it lawful to offer HIV self-testing to children in South Africa? Southern African Journal of HIV Medicine 2013;14(4):151-154. [http://dx.doi.org/10.7196/SAJHIVMED.987]
5. Garone DB, Conradie K, Patten G, et al. High rate of virological re-suppression among patients failing second-line antiretroviral therapy following enhanced adherence support: A model of care in Khayelitsha, South Africa. Southern African Journal of HIV Medicine 2013;14(4):166-169. [http://dx.doi.org/10.7196/SAJHIVMED.980]
6. Barnett W, Patten G, Kerschberger B, et al. Perceived adherence barriers among patients failing second-line antiretroviral therapy in Khayelitsha, South Africa Southern African Journal of HIV Medicine 2013;14(4):170-176. [http://dx.doi.org/10.7196/SAJHIVMED.981]
7. Jonsson G, Davies N, Freeman C, et al. Management of mental health disorders in HIV-positive patients. Southern African Journal of HIV Medicine 2013;14(4):155-165. [http://dx.doi.org/10.7196/SAJHIVMED.995]