Scielo RSS <![CDATA[Southern African Journal of HIV Medicine]]> vol. 20 num. 1 lang. <![CDATA[SciELO Logo]]> <![CDATA[<b>Sexually transmitted infections, the silent partner in HIV-infected women in Zimbabwe</b>]]> BACKGROUND: Coinfection rates of HIV and sexually transmitted infections (STIs) are not widely reported in Zimbabwe and no local guidelines regarding the screening of STIs in people living with HIV exist OBJECTIVES: This cross-sectional study was conducted to determine the prevalence and associated risk factors for STI coinfection in a cohort of HIV-infected women. METHODS: Between January and June 2016, 385 HIV-infected women presenting for routine cervical cancer screening were tested for five STIs: Neisseria gonorrhoeae (NG), Chlamydia trachomatis (CT), Trichomonas vaginalis (TV), Herpes Simplex Virus (HSV) type 2 and Treponema pallidum (TP). Socio-demographic characteristics and sexual history were recorded. Multiple logistic regression was used to identify factors associated with the diagnosis of non-viral STIs. RESULTS: Two hundred and thirty-three participants (60.5%) had a confirmed positive result for at least one STI: HSV 2 prevalence 52.5%, TV 8.1%, CT 2.1%, NG 1.8% and TP 11.4%. Eighty-seven per cent of the women were asymptomatic for any STI; 62.3% of women with a non-viral STI were asymptomatic. Women who had attended tertiary education were 90% less likely to have a non-viral STI (adjusted odds ratio [aOR]: 0.10, 95% confidence interval [CI]: 0.03-0.39, p < 0.01). Having more than three lifetime sexual partners was a significant predictor for a non-viral STI diagnosis (aOR: 3.3, 95% CI: 1.5-7.2, p < 0.01. CONCLUSION: A high prevalence of predominantly asymptomatic STIs is reported in a cohort of HIV-infected women. Syndromic management results in underdiagnosis of asymptomatic patients. More than three lifetime sexual partners and less formal education are risk factors for coinfection with non-viral STI. High-risk women should be screened using aetiological methods. <![CDATA[<b>HIV status and mortality of surgical inpatients in rural Zimbabwe: A retrospective chart review</b>]]> BACKGROUND: People living with HIV treated with antiretroviral therapy (ART) are now living longer and thus many are requiring surgical procedures. For healthcare resource planning, it would be helpful to better understand the prevalence of HIV in surgical patients, the types of surgery HIV-positive patients are undergoing and whether HIV status impacts mortality. OBJECTIVE: The goal of this study was to determine the prevalence of HIV in surgical inpatients and the extent of ART coverage, as well as to assess any differences between HIV-positive and HIV-negative patients in type of surgery undergone and in-hospital mortality at Karanda Mission Hospital, Mount Darwin, Zimbabwe. METHOD: A 1-year retrospective chart review was undertaken to collect clinical and demographic data for adult (excluding maternity cases) and paediatric surgical inpatients including age, sex, type of surgery, HIV status, CD4+ counts and, if patient was HIV-positive, whether he or she was taking ART. RESULTS AND CONCLUSION: Charts for 1510 surgical inpatient stays were reviewed. HIV prevalence among the adults was higher than that in the general population in Zimbabwe in 2016 (23.2% vs. 14.7%). There was no significant difference in inpatient mortality between the HIV-negative group and the HIV-positive group. Within the group of patients with malignancies, people living with HIV were significantly younger than uninfected patients (mean age 50.5 vs. 64.4 years; p < 0.01). There were correlations between HIV and certain malignancies. Thus, in addition to AIDS-defining illnesses, clinicians must be alert to squamous cell carcinoma and oesophageal, anal and penile cancers in HIV-positive patients. <![CDATA[<b>Targeted mentoring for human immunodeficiency virus programme support in South Africa</b>]]> BACKGROUND: Mentoring is a required component of health systems strengthening technical assistance interventions in low- and middle-income countries (LMICs). Mentoring is useful because it does not necessarily compromise service delivery and promotes the sharing of newly acquired knowledge and skills. However, there is a lack of research on the implementation of mentoring in the context of the HIV epidemic in southern Africa. OBJECTIVES: This qualitative evaluation focussed on understanding the implementation process of targeted mentoring for clinical practice, data management and pharmacy management, at public health care facilities in South Africa; and on identifying critical factors influencing the effectiveness of mentoring as a technical assistance intervention in this context. METHODS: Purposive sampling was used to select participants from public health facilities in three South African Provinces. Participants were invited to take part in structured interviews. Datawere analysed using thematic analysis, and two core themes were identified: mentoring as knowledge and skills transfer; and mentoring as psychosocial support. RESULTS: In terms of knowledge and skills transfer, the sequential implementation of proactive and reactive mentoring was critical. Initial proactive mentoring involved mentors initiating training and developing professional relationships with mentees. Thereafter, a reactive mentoring phase allowed mentees to request support when required. This enabled mentors to leverage real-world problems faced by health workers to support their implementation of new knowledge and skills. The availability and accessibility of mentors alongside the relationships between mentors and mentees provided psychosocial support for health care workers which facilitated their self-efficacy in implementing new knowledge and skills. CONCLUSION: These findings suggest that the success of mentoring programmes in LMICs may require specific attention to both knowledge transfer and the management of interpersonal relationships <![CDATA[<b>HIV-associated cavernous sinus disease</b>]]> INTRODUCTION: The underlying diagnosis of cavernous sinus disease is difficult to confirm in HIV-coinfected patients owing to the lack of histological confirmation. In this retrospective case series, we highlight the challenges in confirming the diagnosis and managing these patients. RESULTS: The clinical, laboratory and radiological data of 23 HIV-infected patients with cavernous sinus disease were analysed. The mean age of patients was 38 years. The mean CD4+ count was 390 cells/μL. Clinically, patients presented with unilateral disease (65%), headache (48%), diplopia (30%) and blurred vision (30%). Third (65%) and sixth (57%) nerve palsies in isolation and combination (39%) were most common. Isolated fourth nerve palsy did not occur. Tuberculosis (17%) was the most commonly identified disorder followed by high-grade B-cell lymphoma (13%), meningioma (13%), metastatic carcinoma (13%) and neurosyphilis (7%). In 22% of the patients, there was no confirmatory evidence for a diagnosis. The patients were either treated empirically for tuberculosis or improved spontaneously when antiretroviral therapy was started. Cerebrospinal fluid was helpful in 4/13 (31%) of patients where it was not contraindicated. Only 3/23 (13%) of the patients had a biopsy of the cavernous sinus mass. The outcomes varied, and follow-up was lacking in the majority of patients. CONCLUSION: In HIV-infected patients, histological confirmation of cavernous sinus pathology is not readily available for various reasons. In resource-limited settings, one should first actively search for extracranial evidence of tuberculosis, lymphoma, syphilis and primary malignancy and manage appropriately. Only if such evidence is lacking should a referral for biopsy be considered. <![CDATA[<b>HIV viraemia during pregnancy in women receiving preconception antiretroviral therapy in KwaDukuza, KwaZulu-Natal</b>]]> BACKGROUND: Preconception antiretroviral therapy (PCART) followed by sustained viral suppression is effective in preventing mother-to-child transmission of HIV. The rates of persistent and transient viraemia in such patients have not been prospectively assessed in South Africa OBJECTIVES: We determined the prevalence of transient and persistent viraemia in HIV-positive women entering antenatal care on PCART and studied variables associated with viraemia METHODS: We performed a prospective cross-sectional observational study of HIV-positive pregnant women presenting to a primary healthcare facility in KwaZulu-Natal. All had received at least 6 months of first-line PCART. Viral load (VL) was measured, patients were interviewed, adherence estimated using a visual analogue scale and adherence counselling provided. Viral load was repeated after 4 weeks where baseline VL exceeded 50 copies/mL RESULTS: We enrolled 82 participants. Of them, 59 (72%) pregnancies were unplanned. Fifteen participants (18.3%) were viraemic at presentation with VL &gt; 50 copies/mL. Of these, seven (8.5%) had viral suppression (VL < 50 copies/mL), and eight remained viraemic at the second visit. Adherence correlated significantly with viraemia at baseline. Level of knowledge correlated with adherence but not with lack of viral suppression at baseline. Socio-economic indicators did not correlate with viraemia. No instances of vertical transmission were observed at birth CONCLUSIONS: Approximately 20% of women receiving PCART may demonstrate viraemia. Half of these may be transient. Poor adherence is associated with viraemia, and efforts to encourage and monitor adherence are essential. The rate of unplanned pregnancies is high, and antiretroviral therapy programmes should focus on family planning needs of women in the reproductive age group to prevent viral non-suppression prior to pregnancy <![CDATA[<b>Comparison of non-invasive methods of assessing liver fibrosis in combination ART-experienced Zimbabweans</b>]]> BACKGROUND: The prevalence of morbidity and mortality associated with liver disease among HIV-infected individuals on combination antiretroviral therapy (ART) is high. Early screening of liver disease is essential, as it provides an opportunity for successful treatment. Hence, there is a need for reliable, inexpensive and non-invasive early markers of hepatic damage OBJECTIVES: Non-invasive algorithms are available for assessing the extent of liver fibrosis as markers of ongoing inflammatory damage. This study compared the use of the FibroTest, Fibrosis-4 (FIB-4) index, APRI test and AST:ALT ratio in assessing liver fibrosis in combination ART-experienced individuals METHODS: In a comparative cross-sectional study, 79 participants between the ages of 8 and 62 years were recruited. The performance of each fibrosis algorithm was determined using established cut-off scores for clinically significant liver fibrosis RESULTS: The prevalence of liver fibrosis as determined by the FibroTest, FIB-4 index, APRI test and AST: ALT ratio were 19.0%, 21.5%, 12.7% and 79.7%, respectively. For individual biomarkers, A-2M concentration (p < 0.001) and AST activity (p = 0.003) remained significantly elevated in participants with fibrosis than those without as defined by FibroTest and APRI test, respectively, after adjustments for multiple comparisons CONCLUSION: Our data demonstrate a high prevalence of asymptomatic liver fibrosis among combination ART-experienced individuals in Zimbabwe, and this warrants adequate monitoring of liver fibrosis in individuals on ART. Discordance of fibrosis results among the algorithms and individual biomarkers and calls for further work in identifying optimal biomarkers for detection of asymptomatic fibrosis <![CDATA[<b>Correlation of hair and plasma efavirenz concentrations in HIV-positive South Africans</b>]]> BACKGROUND: Antiretroviral concentrations in hair provide a longer window of drug detection and are useful for measuring longer-term drug exposure. Efavirenz is an important component of first-line treatment in resource-limited settings, but its concentrations in hair have not been well studied. METHODS: This study is a supplementary to a randomised controlled trial of an adherence intervention using an electronic adherence measuring device. Hair and plasma samples were collected from human immunodeficiency virus-positive patients in Cape Town, South Africa. Previously validated liquid chromatography tandem mass spectrometry methods were used to measure efavirenz concentrations in the collected hair and plasma samples. CYP2B6 genotyping of participants was also performed. Data analysis was performed using descriptive and comparative statistics as well as regression modelling. RESULTS: Hair samples were collected from 59% of patients enrolled in the parent study. Results indicated that hair efavirenz concentrations were significantly influenced by participants' CYP2B6 metaboliser status. Median efavirenz concentrations for extensive, intermediate and slow metaboliser genotypes were 3.54 ng/mg, 5.11 ng/mg and 10.66 ng/mg, respectively. A strong correlation was observed between the efavirenz concentrations measured in hair and plasma samples (Spearman's correlation coefficients, 0.672-0.741, p < 0.0001). No relationship between hair efavirenz concentrations and virological failure or adherence measured using an electronic adherence was shown. CONCLUSION: The results from this study provide further insight into the potential of using hair as a matrix for measuring antiretroviral concentrations. However, challenges experienced in collecting hair samples suggest that this adherence measure may have limited utility in an African population. <![CDATA[<b>Knowledge about male circumcision and perception of risk for HIV among youth in Harare, Zimbabwe</b>]]> BACKGROUND: Male circumcision will require high uptake among previously non-circumcising countries to realise the impact of circumcising in preventing HIV. Little is known about whether youths are knowledgeable about male circumcision and its relationship with HIV prevention and their perception of risk of HIV infection. OBJECTIVE: This article aimed to ascertain youth's knowledge about male circumcision and perception of risk of HIV infection. METHODS: A quantitative study on 784 youth (men aged 15-35 years) was conducted in Harare, Zimbabwe, after obtaining their consent. Multivariate analysis examined the associations between background characteristics and knowledge about male circumcision and the perception of risk of HIV infection. RESULTS: The results revealed that age was a significant predictor of knowledge about male circumcision among youth in Harare, as was educational attainment and ever having tested for HIV. In addition, youth who had heard of voluntary medical male circumcision were more likely to have high knowledge of male circumcision compared to those who had never heard of it. The results also showed that male circumcision status was associated with higher knowledge about male circumcision compared to those who were not circumcised. The study also found that educational attainment, belonging to the Shona ethnic group, never having tested for HIV and disapproval of voluntary counselling and testing prior to male circumcision were associated with the perception of risk of HIV infection. CONCLUSION: The study provides two recommendations: the need to strengthen perceived susceptibility to HIV among the youth and the need for advocacy on the health benefits of male circumcision <![CDATA[<b>'We must treat them like all the other people': Evaluating the Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa</b>]]> BACKGROUND: Sensitisation training can reduce judgemental and discriminatory attitudes amongst healthcare workers. The 'Integrated Key Populations Sensitivity Training Programme for Healthcare Workers in South Africa' aimed to improve access to appropriate and non-judgemental health services for 'key populations', specifically men who have sex with men, sex workers and people who use drugs, through the sensitisation of healthcare workers OBJECTIVES: The aim of this study was to evaluate the effects of the integrated key population sensitisation training intervention for healthcare workers, conducted between 2013 and 2014 in South Africa METHODS: This study used a combination of qualitative and quantitative methods. Qualitative methods compared attitudes between healthcare workers who received the training intervention and those who did not. Quantitative methods were used to compare similar changes in awareness amongst healthcare workers before and after receiving the training. We explored shifts in attitudes towards key populations, changes in awareness of health issues related to stigma, discrimination, and changes in capacity to manage sexual health and HIV risk behaviours, including substance use and anal sex RESULTS: The findings indicate that the training intervention resulted in a shift in attitudes, increased empathy for key populations, a reduction in negative and discriminatory moral-based judgements towards key populations and their behaviours, and increased self-perceived capacity to provide appropriate health services to key populations. Over 70% of healthcare workers trained in this programme strongly agreed that this intervention helped to increase awareness of psychosocial vulnerabilities of key populations, and address stigmatising attitudes CONCLUSION: The findings suggest that sensitisation training increases healthcare workers' knowledge and awareness about specific HIV-related health needs and psychosocial vulnerabilities of key populations, reduces moralising and judgemental attitudes, and results in healthcare workers feeling more skilled to provide appropriate and sensitive services <![CDATA[<b>Cutaneous tuberculosis in HIV-infected individuals: Lessons learnt from a case series</b>]]> INTRODUCTION: Extrapulmonary tuberculosis (TB) causes a significant burden of disease worldwide, especially among HIV-infected individuals and those with other immunosuppressive conditions. Cutaneous TB is an important manifestation of extrapulmonary TB but is uncommonly reported in South Africa despite the high burden of HIV and TB co-infection. There is a paucity of published data on clinical presentation and outcome of cutaneous TB in this context. Raising awareness of this condition among clinicians is imperative to improve early diagnosis and optimise treatment outcomes PATIENT PRESENTATION: In this series, we present three cases of cutaneous TB, two adults and one child, referred to a tertiary hospital from two primary healthcare centres and from a general practitioner. We demonstrate that the clinical presentation is diverse, ranging from papular lesions to abscesses, and that concordant pulmonary TB may be present MANAGEMENT: In particular, we show the importance of performing diagnostic procedures (e.g. aspiration) in individuals presenting with an abscess that does not respond to broad spectrum antimicrobial treatment, particularly in those with advanced immunosuppression OUTCOME AND CONCLUSION: The outcome of our three patients was poor, highlighting the need for earlier diagnosis in this WHO Stage 4 condition and intensive management of clinical cases.