Scielo RSS <![CDATA[Southern African Journal of HIV Medicine]]> vol. 17 num. 1 lang. es <![CDATA[SciELO Logo]]> <![CDATA[<b>Feeding practices and nutritional status of HIV-exposed and HIV-unexposed infants in the Western Cape</b>]]> BACKGROUND: Optimal infant- and young child-feeding practices are crucial for nutritional status, growth, development, health and, ultimately, survival. Human breast milk is optimal nutrition for all infants. Complementary food introduced at the correct age is part of optimal feeding practices. In South Africa, widespread access to antiretrovirals and a programme to prevent mother-to-child transmission of HIV have reduced HIV infection in infants and increased the number of HIV-exposed uninfected (HEU) infants. However, little is known about the feeding practices and nutritional status of HEU and HIV-unexposed (HU) infants. OBJECTIVE: To assess the feeding practices and nutritional status of HIV-exposed and HIV-unexposed (HU) infants in the Western Cape DESIGN: Prospective substudy on feeding practices nested in a pilot study investigating the innate immune abnormalities in HEU infants compared to HU infants. The main study commenced at week 2 of life with the nutrition component added from 6 months. Information on children's dietary intake was obtained at each visit from the caregiver, mainly the mother. Head circumference, weight and length were recorded at each visit. Data were obtained from 6-, 12- and 18-month visits. World Health Organization feeding practice indicators and nutrition indicators were utilised. SETTING: Tygerberg Academic Hospital, Western Cape. Mothers were recruited from the postnatal wards. SUBJECTS: Forty-seven mother-infant pairs, 25 HEU and 22 HU infants, participated in this nutritional substudy. Eight (17%) infants, one HU and seven HEU, were lost to follow-up over the next 12 months. The HEU children were mainly Xhosa (76%) and HU were mainly mixedrace (77%). RESULTS: The participants were from poor socio-economic backgrounds. In both groups, adherence to breastfeeding recommendations was low with suboptimal dietary diversity. We noted a high rate of sugar- and salt-containing snacks given from a young age. The HU group had poorer anthropometric and nutritional indicators not explained by nutritional factors alone. However, alcohol and tobacco use was much higher amongst the HU mothers. CONCLUSION: Adherence to breastfeeding recommendations was low. Ethnicity and cultural milieu may have influenced feeding choices and growth. Further research is needed to understand possible reasons for the poorer nutritional and anthropometric indicators in the HU group. <![CDATA[<b>The profile and frequency of known risk factors or comorbidities for deep vein thrombosis in an urban district hospital in KwaZulu-Natal</b>]]> BACKGROUND: Although deep vein thrombosis (DVT) is a preventable disease, it increases the morbidity and mortality in hospitalised, patients, resulting in considerable economic health impact. The identification and primary prevention of risk factors using risk assessment and stratification with subsequent anti-thrombotic prophylaxis in moderate- to severe-risk categories is the most rational means of reducing morbidity and mortality. AIM AND SETTING: The aim of the study was to describe the profile and frequency of known risk factors or comorbidities of hospitalised medical patients with ultrasound-diagnosed DVT in an urban district hospital in KwaZulu-Natal. METHODS: A retrospective review of clinical notes of all medical patients (age > 13 years) admitted to the hospital with ultrasound-diagnosed DVT between July and December 2013. RESULTS: The median age was 40 years (interquartile range 32-60 years) and female preponderance was 72.84%. HIV and tuberculosis emerged as the prevalent risk factors, accounting for 51.85% and 35.80%, respectively. Other risk factors observed were recent hospitalisation (34.57%), smoking (25.93%), previous DVT (19.75%) and congestive cardiac failure (18.52%). CONCLUSION: DVT in our study occurred predominantly in young female patients unlike previous studies where patients were generally older. Furthermore, HIV and tuberculosis were the two most common known risk factors or comorbidities observed. Clinicians should have a heightened awareness of venous thromboembolism in patients with either condition or where both conditions occur together and appropriate thromboprophylaxis should be administered. <![CDATA[<b>Treatment outcomes in a rural HIV clinic in South Africa: Implications for health care</b>]]> OBJECTIVE: To assess the treatment outcomes of an HIV clinic in rural Limpopo province, South Africa. METHODS: A retrospective cohort study involving medical records review of HIV-positive patients initiated on antiretroviral treatment (ART) was conducted from December 2007 to November 2008 at Letaba Hospital. Data on socio-demographic characteristics, CD4 counts, viral loads (VLs), opportunistic infections, adverse effects of treatment, hospital admissions, and patient retention at 6, 12, 24, and 36 months on ART were collected. Analysis included descriptive statistics, chi-square and t-tests. RESULTS: Of 124 patient records sampled, the majority of patients were female (69%), single (49%), unemployed (56%), living at least 10 km from the hospital (52.4%), and were on treatment at 36 months (69%). Approximately 84% of patients achieved viral suppression (VLs < 400 copies/mL) by 6 months of ART and the mean CD4 count increased from 128 at baseline to 470 cells/mm³ at 24 months. There was a mean weight gain of 5.9 kg over the 36 months and the proportion of patients with opportunistic infections decreased from 54.8% (n = 68) at baseline to 15.3% (n = 19) at 36 months. Although the largest improvements in CD4, VLs, and weights were recorded in the first 6 months of ART, viral rebound became evident thereafter. Of all variables, only age < 50 years and being pregnant were significantly associated with higher VLs (p= 0.03). CONCLUSION: Good treatment outcomes are achievable in a rural South African ART clinic. However, early viral rebound and higher VLs in pregnancy highlight the need for enhanced treatment adherence support, especially for pregnant women to reduce the risk of mother to child transmission. <![CDATA[<b>The prevalence of HIV in the sudden, unexplained and unexpected death population at the Pretoria Medico-Legal Laboratory</b>]]> PURPOSE: To determine the prevalence of HIV in the sudden, unexplained and unexpected (SUU) death population admitted to the Pretoria Medico-Legal Laboratory. METHODS: This study was conducted at the Pretoria Medico-Legal Laboratory. Blood samples were obtained from decedents who died suddenly and/or unexpectedly, during autopsy, by a forensic pathologist. Sample collection continued until 100 valid samples were analysed for HIV antibodies. The data collected included demographic details and case-related information. RESULTS AND CONCLUSION: SUU deaths accounted for 14% of all cases admitted to the Pretoria Medico-Legal Laboratory. The HIV prevalence in the SUU deaths was 43%, which is 17% higher than the general mortuary population in Pretoria (p = 0.0045). The majority of these deaths were due to respiratory disease processes, with 12 cases having HIV/TB co-infection. <![CDATA[<b>Compliance to HIV treatment monitoring guidelines can reduce laboratory costs</b>]]> BACKGROUND: Panel tests are a predetermined group of tests commonly requested together to provide a comprehensive and conclusive diagnosis, for example, liver function test (LFT). South African HIV antiretroviral treatment (ART) guidelines recommend individual tests for toxicity monitoring over panel tests. In 2008, the National Health Laboratory Services (NHLS) request form was redesigned to list individual tests instead of panel tests and removed the 'other tests' box option to facilitate efficient ART laboratory monitoring. OBJECTIVES: This study aimed to demonstrate changes in laboratory expenditure, for individual and panel tests, for ART toxicity monitoring. METHOD: NHLS Corporate Data Warehouse (CDW) data were extracted for HIV conditional grant accounts to assess ART toxicity monitoring laboratory expenditure between 2010/2011 and 2014/2015. Data were classified based on the tests requested, as either panel (LFT or urea and electrolytes) or individual (alanine transaminase or creatinine) tests. RESULTS: Expenditure on panel tests reduced from R340 million in 2010/2011 to R140m by 2014/2015 (reduction of R204m) and individual test expenditure increased from R34m to R76m (twofold increase). A significant reduction in LFT panel expenditure was noted, reducing from R322m in 2010/2011 to R130m in 2014/2015 (60% reduction). CONCLUSION: Changes in toxicity monitoring guidelines and the re-engineering of the NHLS request form successfully reduced expenditure on panel tests relative to individual tests. The introduction of order entry systems could further reduce unnecessary laboratory expenditure. <![CDATA[<b>HIV and/or AIDS awareness among adolescents in a South African at-risk rural community</b>]]> BACKGROUND: The devastating effects of HIV and/or AIDS are widely documented. Despite ongoing efforts to address the challenges associated with the pandemic, the impact on children orphaned because of the disease, as well as on adolescents, remains problematic. More specifically, orphaned adolescents living in poverty are particularly vulnerable and are often exposed to, for example, emotional and physical abuse and transactional sexual exploitation. Against this background, the importance of informed awareness among adolescents is continually emphasised, yet the outcomes of awareness campaigns require ongoing research. OBJECTIVES: The main objective of this study was to explore HIV and/or AIDS awareness among adolescents living in a rural community in South Africa, in the Chris Hani District of the Eastern Cape Province. Sixteen adolescents (aged 12-24) who had lost one or both of their parents because of HIV and/or AIDS-related reasons were purposefully selected to participate in the study. METHOD: For this qualitative investigation, we implemented a descriptive case study design. Semi-structured individual interviews, observation and field notes were used to collect and document data, and inductive thematic analysis was completed using the software programme Atlas.ti 7. RESULTS: The three themes that were identified relate to HIV and/or AIDS awareness, disclosure of parents' HIV and/or AIDS status and experiences of adolescents surrounding the death of their parents. Adolescents of the community viewed HIV and/or AIDS as an infectious disease that can lead to death; however, this can be prevented by avoiding at-risk sexual behaviour. Schools and family members were the main sources of information regarding HIV and/or AIDS to the participants. Even though parents tended not to disclose their HIV and/or AIDS status, adolescents became aware of their parents' status when reading about this on their parents' medical report cards or when being told about the status by others following the death of their parents. For adolescents, their parents' deaths were associated with the parents being chronically ill or showing visible signs of deterioration such as weight loss. CONCLUSION: The study concludes that even though current campaigns and informative interventions have seemingly succeeded in ensuring HIV and/or AIDS awareness among adolescents - also those in remote areas - continued educational campaigns are important. Such initiatives may prove to be beneficial by focusing on ways that parents can discuss HIV and/or AIDS-related issues with their children and disclose an HIV-positive status. <![CDATA[<b>PIMA</b><b>™</b><b> point-of-care testing for CD4 counts in predicting antiretroviral initiation in HIV-infected individuals in KwaZulu-Natal, Durban, South Africa</b>]]> <![CDATA[<b>Computational models as predictors of HIV treatment outcomes for the Phidisa cohort in South Africa</b>]]> BACKGROUND: Selecting the optimal combination of HIV drugs for an individual in resource-limited settings is challenging because of the limited availability of drugs and genotyping. OBJECTIVE: The evaluation as a potential treatment support tool of computational models that predict response to therapy without a genotype, using cases from the Phidisa cohort in South Africa. METHODS: Cases from Phidisa of treatment change following failure were identified that had the following data available: baseline CD4 count and viral load, details of failing and previous antiretroviral drugs, drugs in new regimen and time to follow-up. The HIV Resistance Response Database Initiative's (RDI's) models used these data to predict the probability of a viral load < 50 copies/mL at follow-up. The models were also used to identify effective alternative combinations of three locally available drugs. RESULTS: The models achieved accuracy (area under the receiver-operator characteristic curve) of 0.72 when predicting response to therapy, which is less accurate than for an independent global test set (0.80) but at least comparable to that of genotyping with rules-based interpretation. The models were able to identify alternative locally available three-drug regimens that were predicted to be effective in 69% of all cases and 62% of those whose new treatment failed in the clinic. CONCLUSION: The predictive accuracy of the models for these South African patients together with the results of previous studies suggest that the RDI's models have the potential to optimise treatment selection and reduce virological failure in different patient populations, without the use of a genotype. <![CDATA[<b>Incidence of neuropsychiatric side effects of efavirenz in HIV-positive treatment-naïve patients in public-sector clinics in the Eastern Cape</b>]]> BACKGROUND: It is acknowledged that almost half of patients initiated on efavirenz will experience at least one neuropsychiatric side effect. OBJECTIVES: The aim was to determine the incidence and severity of neuropsychiatric side effects associated with efavirenz use in five public-sector primary healthcare clinics in the Eastern Cape. METHOD: The study was a prospective drug utilisation study. A total of 126 medical records were reviewed to obtain the required information. After baseline assessment, follow-up reviews were conducted at 4 weeks, 12 weeks and 24 weeks from 2014 to 2015. RESULTS: The participant group was 74.60% female (n = 94), and the average age was 37.57±10.60 years. There were no neuropsychiatric side effects recorded for any patient. After the full follow-up period, there were a total of 49 non-adherent patients and one patient had demised. A non-adherent patient was defined as a patient who did not return to the clinic for follow-up assessment and medication refills 30 days or more after the appointed date. Some patients (n = 11) had sent a third party to the clinic to collect their antiretroviral therapy (ART). The clinic pharmacy would at times dispense a two-month supply of medication resulting in the patient presenting only every two months. CONCLUSION: Further pharmacovigilance studies need to be conducted to determine the true incidence of these side effects. Healthcare staff must be encouraged to keep complete records to ensure meaningful patient assessments. Patients being initiated on ART need to personally attend the clinic monthly for at least the first 6 months of treatment. Clinic staff should receive regular training concerning ART, including changes made to guidelines as well as reminders of side effects experienced. <![CDATA[<b>Immune activation is associated with decreased thymic function in asymptomatic, untreated HIV-infected individuals</b>]]> BACKGROUND: Reduced thymic function causes poor immunological reconstitution in human immunodeficiency virus (HIV)-positive patients on combined antiretroviral therapy (cART). The association between immune activation and thymic function in asymptomatic HIV-positive treatment-naive individuals has thus far not been investigated. Aims and objectives: To optimise a five-colour flow cytometric assay for measurement of thymic function by measuring recent thymic emigrants (RTEs) in treatment-naive HIV-infected patients and healthy controls and correlate results with levels of immune activation, CD4 counts and viral load. METHODS: Blood obtained from 53 consenting HIV-positive individuals and 32 controls recruited from HIV prevention and testing clinic in Cape Town, South Africa. RTEs were measured (CD3+/CD4+/CD45RA+/CD31+/CD62L+) and levels were correlated with CD4 counts of HIV-infected individuals, log viral load and levels of immune activation (CD8+/CD38+ T-cells). RESULTS: HIV-infected individuals had reduced frequencies of RTEs when compared to controls (p = 0.0035). Levels of immune activation were inversely correlated with thymic function (p = 0.0403), and the thymic function in HIV-infected individuals showed no significant correlation with CD4 counts (p = 0.31559) and viral load (p = 0.20628). CONCLUSIONS: There was impaired thymic function in HIV-infected individuals, which was associated with increased levels of immune activation. The thymic dysfunction was not associated with CD4 counts and viral load. Immune activation may result in inflammatory damage to the thymus and subsequent thymic dysfunction, and CD4 counts and viral load may not necessarily reflect thymic dysfunction in HIV. <![CDATA[<b>Associations between plasma tenofovir concentration and renal function markers in HIV-infected women</b>]]> BACKGROUND: Tenofovir disoproxil fumarate (TDF) has been associated with kidney tubular dysfunction and reduced renal function. Limited studies were performed in Europe and Asia that related plasma tenofovir (TFV) concentration with renal function; no such studies to date have been performed on Africans. OBJECTIVE: To investigate the correlation between plasma tenofovir (TFV) concentration and certain renal function markers in HIV-infected women on TDF antiretroviral therapy (ART). These markers were also compared to a HIV-uninfected control group. METHODS: HIV-infected women (n = 30) on TDF-based ART were matched with 30 controls for age and body mass index. Renal markers analysed were estimated glomerular filtration rate (eGFR), creatinine clearance (CrCl), serum creatinine, albuminuria, glucosuria, serum urea, serum uric acid, urine sodium and maximum tubular reabsorption of phosphate. Baseline eGFR and CrCl data were obtained retrospectively for the HIV-infected women. Plasma TFV was assayed using a validated HPLC-MS/MS method. Stepwise regression, Mann-Whitney test, unpaired and paired t-tests were applied in the statistical analyses. RESULTS: TFV concentration was independently associated with albuminuria (adjusted r² = 0.339; p = 0.001) in HIV-infected women. In the adjusted (weight) analysis, eGFR (p = 0.038), CrCl (p = 0.032) and albuminuria (p = 0.048) were significantly higher in HIV-infected compared to the uninfected women, but eGFR was abnormally high in HIV-infected women. Both eGFR (p < 0.001) and CrCl (p = 0.008) increased from baseline to follow-up in HIV-infected women. CONCLUSION: Plasma TFV concentration was associated with increased albuminuria in HIV-infected women in this sub-study. Both eGFR and CrCl were increased in HIV-infected women from baseline. These findings should be confirmed in larger studies, and hyperfiltration in HIV-infected women warrants further investigation. <![CDATA[<b>The end of the line? A case of drug resistance to third-line antiretroviral therapy</b>]]> HIV drug resistance has been described in all antiretroviral drug classes and threatens the long-term success of HIV treatment. Here, we describe the first reported case of acquired resistance to the integrase strand transfer inhibitors in South Africa. This case illustrates the dilemma of treatment in the context of inadequate adherence and poor psychosocial support and highlights the potential risk of transmission of multidrug-resistant virus. <![CDATA[<b>Hepatitis B co-infection in HIV-infected patients receiving antiretroviral therapy at the TC Newman Anti Retroviral Treatment Clinic in Paarl, Western Cape</b>]]> BACKGROUND: Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) co-infection in South Africa is estimated to be between 5% and 23%; however, only limited evidence is available. Co-infection increases the risk of chronification of HBV, liver cirrhosis and death. OBJECTIVE: To assess the HBV and/or HIV co-infection rate amongst the adult antiretroviral treatment cohort at the TC Newman ART Clinic in Paarl, Western Cape. METHODS: In a retrospective, cross-sectional study, the routine hepatitis B surface antigen screening results for all adult HIV patients who were started on antiretroviral treatment over a period of 19 months were collected and analysed for gender, CD4 count and age. RESULTS: Amongst the 498 participants (60% female participants), the Hepatitis B surface Antigen positivity rate was 7.6%. Male gender, age between 50 and 59 years and a low CD4 count were correlated with higher rates. CONCLUSION: Useful insight could be obtained by analysing routine data. The prevalence of almost 8% confirms the need for testing of HIV-positive patients for hepatitis B. <![CDATA[<b>Recommendations for the management of indeterminate HIV PCR results within South Africa's early infant diagnosis programme</b>]]> Indeterminate HIV PCR results represent missed diagnostic opportunities within South Africa's early infant diagnosis programme. These results not only delay diagnosis and appropriate management but are also a source of confusion and apprehension amongst clinicians and caregivers. We describe the extent of indeterminate HIV PCR results within South Africa's early infant diagnosis programme and provide recommendations for the management of these cases, both in terms of laboratory practice and the clinical care of the infants. <![CDATA[<b>What is the role of CD4 count in a large public health antiretroviral programme?</b>]]> Indeterminate HIV PCR results represent missed diagnostic opportunities within South Africa's early infant diagnosis programme. These results not only delay diagnosis and appropriate management but are also a source of confusion and apprehension amongst clinicians and caregivers. We describe the extent of indeterminate HIV PCR results within South Africa's early infant diagnosis programme and provide recommendations for the management of these cases, both in terms of laboratory practice and the clinical care of the infants. <![CDATA[<b>Southern African guidelines on the safe use of pre-exposure prophylaxis in persons at risk of acquiring HIV-1 infection</b>]]> The Southern African HIV Clinicians Society published its first set of oral pre-exposure prophylaxis (PrEP) guidelines in June 2012 for men who have sex with men (MSM) who are at risk of HIV infection. With the flurry of data that has been generated in PrEP clinical research since the first guideline, it became evident that there was a need to revise and expand the PrEP guidelines with new evidence of safety and efficacy of PrEP in several populations, including MSM, transgender persons, heterosexual men and women, HIV-serodiscordant couples and people who inject drugs. This need is particularly relevant following the World Health Organization (WHO) Consolidated Treatment Guidelines released in September 2015. These guidelines advise that PrEP is a highly effective, safe, biomedical option for HIV prevention that can be incorporated with other combination prevention strategies in Southern Africa, given the high prevalence of HIV in the region. PrEP should be tailored to populations at highest risk of HIV acquisition, whilst further data from studies in the region accrue to guide optimal deployment to realise the greatest impact regionally. PrEP may be used intermittently during periods of perceived HIV acquisition risk, rather than continually and lifelong, as is the case with antiretroviral treatment. Recognition and accurate measurement of potential risk in individuals and populations also warrants discussion, but are not extensively covered in these guidelines.