Scielo RSS <![CDATA[SAMJ: South African Medical Journal]]> http://www.scielo.org.za/rss.php?pid=0256-957420140012&lang=en vol. 104 num. 12 lang. en <![CDATA[SciELO Logo]]> http://www.scielo.org.za/img/en/fbpelogp.gif http://www.scielo.org.za <![CDATA[<b>Making us fat (and sick)</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200001&lng=en&nrm=iso&tlng=en <![CDATA[<b>Editor's Choice</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200002&lng=en&nrm=iso&tlng=en <![CDATA[<b>Insulin receptor substrate-1 Gly972Arg variant and type 2 diabetes mellitus</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200003&lng=en&nrm=iso&tlng=en <![CDATA[<b>HIV research for prevention - huge potential but no 'magic bullet'</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200004&lng=en&nrm=iso&tlng=en <![CDATA[<b>Using basic technology - and corporate social responsibility - to save lives</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200005&lng=en&nrm=iso&tlng=en <![CDATA[<b>Health minister's ex-legal advisor slams Certificate of Need law</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200006&lng=en&nrm=iso&tlng=en <![CDATA[<b>New HASA board: The right mix at the right time</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200007&lng=en&nrm=iso&tlng=en <![CDATA[<b>Lorna Macdougall, 1924 - 2014</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200008&lng=en&nrm=iso&tlng=en <![CDATA[<b>Recommendations for amniocentesis in HIV-positive women</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200009&lng=en&nrm=iso&tlng=en There is limited literature on the known risk of HIV transmission during amniocentesis. Before the introduction of highly active antiretroviral therapy (HAART), amniocentesis was avoided owing to the increased risk of HIV transmission. Recent literature suggests that it is safe to perform amniocentesis in women on HAART with undetectable viral loads. In South Africa (SA), many women access antenatal care late in pregnancy and there is often insufficient time to attain undetectable viral loads within a pre-viability period. Guidelines and recommendations for invasive testing in HIV-positive women in the SA setting are lacking. This article provides recommendations to healthcare practitioners who are faced with an HIV-positive patient requiring amniocentesis. <![CDATA[<b>Newborns should be receiving premedication before elective intubation</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200010&lng=en&nrm=iso&tlng=en BACKGROUND: Intubation is a common neonatal procedure. Premedication is accepted as a standard of care, but its use is not universal and wide variations exist in practice. OBJECTIVE: To evaluate current practices for premedication use prior to elective neonatal intubation in South Africa (SA). METHOD: We invited 481 clinicians to participate in a cross-sectional web-based survey. RESULTS: We received responses from 28.3% of the clinicians surveyed; 54.1% were from the private sector and 45.9% from the state sector. Most respondents worked in medium-sized neonatal units with six to ten beds. Most paediatricians (76.0%) worked in the private sector, and 78.6% of neonatologists in the state sector. Premedication was practised by 71.9% of the respondents, but only 38.5% of neonatal units had a written policy. Sedatives were used for premedication by 63.2% of the respondents. Midazolam (41.5%), morphine (34.0%) and ketamine (20.8%) were most commonly used. Muscle relaxants and atropine were not routinely administered. Suxamethonium was the muscle relaxant of choice. Varied combinations of agents or single agents were used. Midazolam used alone was the preferred option. CONCLUSION: This first survey of premedication for neonatal intubation in SA revealed variations in practice, with a minority of clinicians following a written policy. The findings can be used to benchmark practice and inform the design of local collaborative trials aimed at determining optimal premedication prior to neonatal intubation. The survey demonstrates clinicians' reluctance to participate in surveys, suggesting a need for a national collaborative network to obtain representative data. <![CDATA[<b>The structured communication tool SBAR (Situation, Background, Assessment and Recommendation) improves communication in neonatology</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200011&lng=en&nrm=iso&tlng=en BACKGROUND: Effective communication, co-operation and teamwork have been identified as key determinants of patient safety. SBAR (Situation, Background, Assessment and Recommendation) is a communication tool recommended by the World Health Organization and the UK National Health Service. SBAR is a structured method for communicating critical information that requires immediate attention and action, contributing to effective escalation of management and increased patient safety. To our knowledge, this is the first study showing use of SBAR in South Africa (SA). OBJECTIVE: To determine the effectiveness of adopting the SBAR communication tool in an acute clinical setting in SA. METHODS: In the first phase of this study, neonatal nurses and doctors at Groote Schuur Hospital, Cape Town, were gathered in a focus group and given a questionnaire asking about communication in the neonatal department. Neonatal nurses and doctors were then trained to use SBAR. RESULTS: A telephone audit demonstrated an increase in SBAR use by registrars from 29% to 70% when calling consultants for help. After training, the majority of staff agreed that SBAR had helped with communication, confidence, and quality of patient care. There was qualitative evidence that SBAR led to greater promptness in care of acutely ill patients. CONCLUSIONS: Adopting SBAR was associated with perceived improvement in communication between professionals and in the quality and safety of patient care. It is suggested that this simple tool be introduced to many other hospitals in SA. <![CDATA[<b>Tricuspid valve endocarditis associated with intravenous nyoape use: A report of 3 cases</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200012&lng=en&nrm=iso&tlng=en We report three cases of tricuspid valve infective endocarditis associated with intravenous nyoape use. Nyoape is a variable drug combination of an antiretroviral (efavirenz or ritonavir), heroin, metamphetamines and cannabis. Its use is becoming increasingly common among poor communities in South Africa. All our patients were young HIV-positive men from disadvantaged backgrounds. They all presented with tricuspid regurgitation and septic pulmonary emboli. They were treated with prolonged intravenous antibiotic courses, and one required referral for surgery. <![CDATA[<b>Towards early detection of retinoblastoma</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200013&lng=en&nrm=iso&tlng=en We report three cases of tricuspid valve infective endocarditis associated with intravenous nyoape use. Nyoape is a variable drug combination of an antiretroviral (efavirenz or ritonavir), heroin, metamphetamines and cannabis. Its use is becoming increasingly common among poor communities in South Africa. All our patients were young HIV-positive men from disadvantaged backgrounds. They all presented with tricuspid regurgitation and septic pulmonary emboli. They were treated with prolonged intravenous antibiotic courses, and one required referral for surgery. <![CDATA[<b>Why aren't women getting safe abortions?</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200014&lng=en&nrm=iso&tlng=en We report three cases of tricuspid valve infective endocarditis associated with intravenous nyoape use. Nyoape is a variable drug combination of an antiretroviral (efavirenz or ritonavir), heroin, metamphetamines and cannabis. Its use is becoming increasingly common among poor communities in South Africa. All our patients were young HIV-positive men from disadvantaged backgrounds. They all presented with tricuspid regurgitation and septic pulmonary emboli. They were treated with prolonged intravenous antibiotic courses, and one required referral for surgery. <![CDATA[<b>Retinoblastoma outcome at a single institution in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200015&lng=en&nrm=iso&tlng=en INTRODUCTION: Retinoblastoma (RB) is the most common eye cancer in children. Early detection is necessary for cure OBJECTIVE: To compare stage and outcome of children with RB treated at Kalafong Hospital, Pretoria, South Africa (SA), during two time periods (1993 - 2000 and 2001 - 2008, after outreach interventions in 2000 and introduction of compulsory community service for doctors in 1998 METHODS: Data collected included demography (age, gender, date of birth), stage and treatment received. The main outcome measure was disease-free survival and the study end-point was 60 months after diagnosis RESULTS: There were 51 patients during the time period 1993 - 2000 (group 1) and 73 during 2001 - 2008 (group 2), with median ages of 32 and 26 months, respectively (marginally significantly younger in group 2; p=0.046). In group 1, the majority (57%) presented with advanced disease (stages III and IV), with a decline in this proportion in group 2 (40%) indicating a downward but not significant trend (p=0.075). Bilateral disease was diagnosed in 22% of patients in group 1 and 33% in group 2. Overall survival was 33% and 43% for groups 1 and 2, respectively. Excluding absconding patients, event-free survival was 50% in group 1, improving to 68% in group 2 (not statistically significant; p=0.18). Fewer patients needed radiotherapy during the second period (statistically significant; p=0.04), probably because of less advanced disease CONCLUSION: Poor outcome is probably a result of late diagnosis. It is important to implement a strategy that will ensure early diagnosis and optimal management of RB in SA <![CDATA[<b>Unwanted pregnancies in Gauteng and Mpumalanga provinces, South Africa: Examining mortality data on dumped aborted fetuses and babies</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200016&lng=en&nrm=iso&tlng=en BACKGROUND: Across the world, millions of women unintentionally become pregnant and decide to terminate the pregnancy. Despite progressive abortion laws in South Africa (SA), evidence suggests that many women of all ages still resort to unsafe terminations outside legal, designated facilities. Media reports alert the public to an increase in the illegal dumping of fetuses and abandoned babies, suggesting an increase in unsafe termination practices as well as concealed births OBJECTIVE: To examine mortality data to identify trends in the dumping of aborted fetuses and abandoned babies in SA METHOD: This study utilised data from the National Injury Mortality Surveillance System in two provinces, namely Gauteng and Mpumalanga. A total sample of mortality data was used to analyse trends associated with this phenomenon from 2009 to 2011. Descriptive, exploratory statistics were used and included the calculation of crude population incidence rates for abortions and abandoned babies as well as figures (n) and percentages (%) for each category under investigation RESULTS: An increase in the rate of discovery of non-viable fetuses was noted for both provinces over the 3-year period, while there was a significant decrease in the discovery of deceased abandoned babies in Gauteng only CONCLUSION: The illegal dumping of fetuses and babies is a very real public health concern in both Gauteng and Mpumalanga. Information is insufficient for adequate surveillance, and improved data collection systems should be prioritised <![CDATA[<b>Blood pressure measurements in the ankle are not equivalent to blood pressure measurements in the arm</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200017&lng=en&nrm=iso&tlng=en BACKGROUND: Blood pressure (BP) is often measured on the ankle in the emergency department (ED), but this has never been shown to be an acceptable alternative to measurements performed on the arm OBJECTIVE: To establish whether the differences between arm and ankle non-invasive BP measurements were clinically relevant (i.e. a difference of >10 mmHg METHODS: This was a prospective cross-sectional study in an urban ED making use of a convenience sample of 201 patients (18 - 50 years of age) who were not in need of emergency medical treatment. BP was measured in the supine position on both arms and ankles with the correct size cuff according to the manufacturer's guidelines. The arm and ankle BP measurements were compared RESULTS: There was a clinically and statistically significant difference between arm and ankle systolic BP (SBP) and mean arterial pressure (MAP) (-13 mmHg, 95% confidence interval (CI) -28 - 1 mmHg and -5 mmHg, 95% CI -13 - 4 mmHg, respectively), with less difference in diastolic BP (DBP) (2 mmHg, 95% CI -7 - 10 mmHg). Only 37% of SBP measurements and 83% of MAP measurements were within an error range of 10 mmHg, while 95% of DBP measurements agreed within 10 mmHg. While the average differences (or the bias) were generally not large, large variations in individual patients (indicating poor precision) made the prediction of arm BP from ankle measurements unreliable CONCLUSION: Ankle BP cannot be used as a substitute for arm BP in the ED <![CDATA[<b>Adolescent and young pregnant women at increased risk of mother-to-child transmission of HIV and poorer maternal and infant health outcomes: A cohort study at public facilities in the Nelson Mandela Bay Metropolitan district, Eastern Cape, South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200018&lng=en&nrm=iso&tlng=en BACKGROUND: South Africa (SA) has the highest burden of childhood HIV infection globally, and has high rates of adolescent and youth pregnancy OBJECTIVE: To explore risks associated with pregnancy in young HIV-infected women, we compared mother-to-child transmission (MTCT) of HIV and maternal and infant health outcomes according to maternal age categories METHODS: A cohort of HIV-positive pregnant women and their infants were followed up at three sentinel surveillance facilities in the Nelson Mandela Bay Metropolitan (NMBM) district, Eastern Cape Province, SA. Young women were defined as <24 years old and adolescents as <19 years. The effect of younger maternal age categories on MTCT and maternal and child health outcomes was assessed using log-binomial and Cox regression controlling for confounding, using women aged &gt;24 years as the comparison group RESULTS: Of 956 mothers, 312 (32.6%) were young women; of these, 65 (20.8%) were adolescents. The proportion of young pregnant women increased by 24% between 2009/10 and 2011/12 (from 28.3% to 35.1%). Young women had an increased risk of being unaware of their HIV status when booking (adjusted risk ratio (aRR) 1.37; 95% confidence interval (CI) 1.21 - 1.54), a reduced rate of antenatal antiretroviral therapy (ART) uptake (adjusted hazard ratio 0.46; 95% CI 0.31 - 0.67), reduced early infant HIV diagnosis (aRR 0.94; 95% CI 0.94 - 0.94), and increased MTCT (aRR 3.07; 95% CI 1.18 - 7.96; adjusted for ART use). Of all vertical transmissions, 56% occurred among young women. Additionally, adolescents had increased risks of first presentation during labour (aRR 3.78; 95% CI 1.06 - 13.4); maternal mortality (aRR 35.1; 95% CI 2.89 - 426) and stillbirth (aRR 3.33; 95% CI 1.53 - 7.25 CONCLUSION: An increasing proportion of pregnant HIV-positive women in NMBM were young, and they had increased MTCT and poorer maternal and infant outcomes than older women. Interventions targeting young women are increasingly needed to reduce pregnancy, HIV infection and MTCT and improve maternal and infant outcomes if SA is to attain its Millennium Development Goals <![CDATA[<b>The use of VTE prophylaxis in relatioN to patiEnt risk profiling (TUNE-IN) Wave 2 study</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200019&lng=en&nrm=iso&tlng=en BACKGROUND: The TUNE-IN (The Use of VTE prophylaxis in relatioN to patiEnt risk profiling) study evaluated venous thromboembolism (VTE) risk assessment and prophylaxis in private medical and surgical inpatients in Gauteng Province, South Africa. The study concluded that of the 608 patients enrolled, 54.1% were clinically evaluated to be at risk for VTE. A VTE risk assessment model (RAM), the Caprini score, increased the rate to 74.6% OBJECTIVES: TUNE-IN Wave 2, an extension of TUNE-IN, was conducted on a national level including the public sector, focusing on surgical inpatients METHODS: The study was a national, prospective, non-interventional, multisite, epidemiological disease registry enrolling 453 surgical inpatients. The perceived clinical VTE risk, VTE risk score on Caprini RAM, VTE prophylaxis and clinical details were documented during a baseline visit. A bleeding risk score was provided RESULTS: Of the cohort, 269 patients (59.4%) were assessed to be at risk for VTE before applying the RAM. All patients (100%), however, were at risk on the RAM score. Early mobilisation and assessment of the VTE risk as low were the most frequent reasons for non-prescription of prophylaxis. Only 15 patients in the private and 2 in the public sector were assessed as having a bleeding risk. Chemoprophylaxis differed between the healthcare sectors, with low-molecular-weight heparin predominating in the private sector and unfractionated heparin being prescribed only in the public sector CONCLUSION: VTE risk assessment and prophylaxis need to improve in both the public and the private sectors. A formal RAM will improve identification of patients at risk of VTE <![CDATA[<b>Management challenges in tuberculosis and HIV</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200020&lng=en&nrm=iso&tlng=en BACKGROUND: The TUNE-IN (The Use of VTE prophylaxis in relatioN to patiEnt risk profiling) study evaluated venous thromboembolism (VTE) risk assessment and prophylaxis in private medical and surgical inpatients in Gauteng Province, South Africa. The study concluded that of the 608 patients enrolled, 54.1% were clinically evaluated to be at risk for VTE. A VTE risk assessment model (RAM), the Caprini score, increased the rate to 74.6% OBJECTIVES: TUNE-IN Wave 2, an extension of TUNE-IN, was conducted on a national level including the public sector, focusing on surgical inpatients METHODS: The study was a national, prospective, non-interventional, multisite, epidemiological disease registry enrolling 453 surgical inpatients. The perceived clinical VTE risk, VTE risk score on Caprini RAM, VTE prophylaxis and clinical details were documented during a baseline visit. A bleeding risk score was provided RESULTS: Of the cohort, 269 patients (59.4%) were assessed to be at risk for VTE before applying the RAM. All patients (100%), however, were at risk on the RAM score. Early mobilisation and assessment of the VTE risk as low were the most frequent reasons for non-prescription of prophylaxis. Only 15 patients in the private and 2 in the public sector were assessed as having a bleeding risk. Chemoprophylaxis differed between the healthcare sectors, with low-molecular-weight heparin predominating in the private sector and unfractionated heparin being prescribed only in the public sector CONCLUSION: VTE risk assessment and prophylaxis need to improve in both the public and the private sectors. A formal RAM will improve identification of patients at risk of VTE <![CDATA[<b>The diagnosis, management and prevention of HIV-associated tuberculosis</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200021&lng=en&nrm=iso&tlng=en BACKGROUND: The TUNE-IN (The Use of VTE prophylaxis in relatioN to patiEnt risk profiling) study evaluated venous thromboembolism (VTE) risk assessment and prophylaxis in private medical and surgical inpatients in Gauteng Province, South Africa. The study concluded that of the 608 patients enrolled, 54.1% were clinically evaluated to be at risk for VTE. A VTE risk assessment model (RAM), the Caprini score, increased the rate to 74.6% OBJECTIVES: TUNE-IN Wave 2, an extension of TUNE-IN, was conducted on a national level including the public sector, focusing on surgical inpatients METHODS: The study was a national, prospective, non-interventional, multisite, epidemiological disease registry enrolling 453 surgical inpatients. The perceived clinical VTE risk, VTE risk score on Caprini RAM, VTE prophylaxis and clinical details were documented during a baseline visit. A bleeding risk score was provided RESULTS: Of the cohort, 269 patients (59.4%) were assessed to be at risk for VTE before applying the RAM. All patients (100%), however, were at risk on the RAM score. Early mobilisation and assessment of the VTE risk as low were the most frequent reasons for non-prescription of prophylaxis. Only 15 patients in the private and 2 in the public sector were assessed as having a bleeding risk. Chemoprophylaxis differed between the healthcare sectors, with low-molecular-weight heparin predominating in the private sector and unfractionated heparin being prescribed only in the public sector CONCLUSION: VTE risk assessment and prophylaxis need to improve in both the public and the private sectors. A formal RAM will improve identification of patients at risk of VTE <![CDATA[<b>Diagnosis and management of drug-resistant tuberculosis in South African adults</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200022&lng=en&nrm=iso&tlng=en Detection of drug-resistant tuberculosis (DR-TB) increases each year in South Africa (SA). Most cases result from airborne transmission of already resistant TB strains. Epidemic control relies on rapid diagnosis and initiation of effective treatment to reduce the period of infectiousness and ongoing transmission. The rapid diagnostic test, Xpert MTB/RIF, has replaced smear microscopy for routine screening of all cases of presumptive TB in SA. Xpert also detects rifampicin (RIF) resistance, an indicator of more extensive drug resistance, allowing rapid initiation of effective second-line treatment. Definitive diagnosis of DR-TB relies on laboratory confirmation of MTB, along with drug-susceptibility testing (DST) using culture-based (phenotypic) and/or molecular (genotypic) techniques. A standardised treatment regimen, consisting of five (or six) drugs (pyrazinamide, (ethambutol), kanamycin, moxifloxacin, ethionamide, terizidone), is offered to individuals following initial diagnosis of RIF resistance. Treatment regimens are individualised if and when molecular mutation details and second-line DST results indicate more extensive second-line drug resistance. DR-TB treatment outcomes are poor owing to death, and interruption and failure of current treatment. Reliable access to newer, more effective drugs within shorter, more tolerable regimens is desperately needed to improve the chance of a cure for DR-TB patients. <![CDATA[<b>The diagnosis and medical management of tuberculous meningitis in adults</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200023&lng=en&nrm=iso&tlng=en Tuberculous meningitis (TBM) is a medical emergency for which tuberculosis (TB) treatment should be initiated as soon as possible after diagnosis. Owing to the low diagnostic yields of confirmatory tests, TBM is often diagnosed based on suggestive clinical and cerebrospinal fluid findings, evidence for TB outside the central nervous system (CNS), typical brain imaging features and exclusion of other causes of meningitis. TB drug regimens used in TBM may be suboptimal as they are informed by studies of TB outside the CNS, rather than being based on randomised controlled trials in TBM. TBM has a high mortality and the management of HIV-co-infected patients is further complicated by neurological TB-immune reconstitution inflammatory syndrome (IRIS), which frequently occurs after starting antiretroviral therapy (ART) during TBM treatment and contributes to the poor outcome in HIV-associated TBM. HIV-infected TBM patients due to start ART should be counselled about the risk of developing neurological TB-IRIS, typical symptoms that could be expected and need to return to hospital should any of these develop. Currently, the only evidence-based treatment for TB-IRIS is with corticosteroids, which should be considered in all cases of neurological TB-IRIS. <![CDATA[<b>Management of HIV-associated cryptococcal disease in South Africa</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200024&lng=en&nrm=iso&tlng=en In routine-care settings, the 10-week mortality associated with cryptococcal meningitis (CM) is high, even with prompt, appropriate antifungal treatment and correctly timed initiation of antiretroviral therapy (ART). While early diagnosis of HIV infection and initiation of ART prior to the development of AIDS is the most important way to reduce the incidence of CM, a cryptococcal antigenaemia screen-and-treat intervention has the potential to reduce mortality by identifying patients prior to onset of CM. Antifungal treatment for HIV-associated CM is divided into three phases over a minimum period of 1 year: (i) a 2-week induction phase, including intravenous amphotericin B deoxycholate as a backbone; (ii) an 8-week consolidation phase with fluconazole 400 mg daily; and (iii) a maintenance phase with fluconazole 200 mg daily. Amphotericin B should be paired with another antifungal agent to maximise cerebrospinal fluid fungal clearance. World Health Organization guidelines emphasise that patients receiving amphotericin B-containing regimens should have access to a 'minimum package of toxicity prevention, monitoring and management to minimise the serious amphotericin B-related toxicities particularly hypokalaemia and nephrotoxicity'. Raised intracranial pressure is a serious and often fatal complication of CM, which requires good pressure management with repeat lumbar punctures. ART should be initiated 4 - 6 weeks after starting antifungal therapy. In many cases, relapse CM among South African patients occurs because of suboptimal adherence to secondary prophylaxis with fluconazole and/or the antifungal not being prescribed. <![CDATA[<b>Focus on adolescents with HIV and AIDS</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200025&lng=en&nrm=iso&tlng=en Adolescents living with HIV, including those infected perinatally and non-perinatally, bear a disproportionate burden of the HIV epidemic in South Africa. This article discusses HIV management in adolescents including the following aspects: (i) burden of HIV disease, modes of HIV acquisition and implications for management; (ii) initiation of combination antiretroviral therapy (ART), outcomes and complications of ART in adolescents, including virological failure and switching regimens; (iii) adherence in adolescence, including factors that may contribute to poor adherence and advice to improve adherence; (iv) issues particular to adolescents, including sexual and reproductive health needs, disclosure to adolescents and by adolescents, and transition to adult care. This article aims to provide insights based on the literature and experience to assist the clinician to navigate the difficulties of managing HIV in adolescence and achieving successful transition to adult care. <![CDATA[<b>Antiretroviral therapy for the management of HIV in children</b>]]> http://www.scielo.org.za/scielo.php?script=sci_arttext&pid=S0256-95742014001200026&lng=en&nrm=iso&tlng=en Since 2004, when antiretroviral therapy (ART) was first available to children through the National Department of Health, there has been significant progress in preventing and treating paediatric HIV. Large cohort studies and prospective trials confirmed that young children require early diagnosis with rapid access to ART regardless of CD4+ lymphocyte count. Studies also confirmed the importance of ritonavir-boosted protease inhibitors during therapy, regardless of prior nevirapine exposure. As prevention strengthens and the paediatric population ages, the goal posts are shifting towards even earlier diagnosis, targeting newborn infants on the first day of life and also the perinatally infected adolescent.