Editors's Choice

The age of HIV exceptionalism has passed

JP de V van Niekerk

Shame, because of the largely sexual transmission of the disease, stigma, denial and inevitable death due to lack of adequate treatment made medicine and society treat HIV/ AIDS quite differently to other diseases. The view is gaining ground that the age of 'exceptionalism' in HIV has passed. Two papers in this journal address different aspects of clinical practice and recommend a rethink of current HIV policies.

Cogent reasons for offering HIV-positive donor kidneys to HIV-infected renal failure patients are provided by Venter and colleagues.¹ Kidney transplantation has been established as the most effective form of renal replacement therapy from a cost and quality of life perspective. The number of donated organs is the primary limiting factor in meeting transplantation needs. In South Africa this is compounded by the fact that the cadaver donor pool has a very high HIV infection rate. South Africa is therefore unique - it provides transplant services, including to HIV-positive people, yet loses a large proportion of the donor pool. Since antiretroviral treatment (ART) is onerous, HIV patients on successful ART, a precondition for transplant, are theoretically ideal transplant patients, with objectively demonstrated medication adherence pre-transplant. A good starting point for research would be to ask HIV-positive transplant recipients whether they would accept an HIV-infected kidney.

A new approach to testing for HIV in patients with severe mental illness is proposed by Joska, Kaliski and Benatar.² They argue that the HIV/AIDS context has changed dramatically. The prevalence of HIV infection is likely to be higher in psychiatric populations than in the general population. People with mental illness are at greater risk of becoming infected with HIV. The number of individuals with mental illness complicated by HIV infection is rising. Access to ART continues to improve. They provide a proposed new HIV testing protocol in individuals with severe mental illness who are admitted to hospitals in South Africa.

Maggot debridement therapy

The use of maggots to clean necrotic wounds, known as maggot debridement therapy (MDT), has been recorded since the 1500s. Williams and colleagues stress the importance of identifying the correct species for this purpose.³

William Baer is considered to be the founder of modern MDT. While treating soldiers in World War I he noted the good condition of wounds that had been infested with maggots and was the first doctor on record to experiment with the use of maggots in treating infections.

Various species of fly have been used for MDT. The most commonly used is Lucilla sericata, a greenbottle blowfly. A closely related greenbottle, L. cuprina, feeds on live as well as necrotic tissue, which is undesirable in MDT. It is extremely difficult to correctly identify them except by genetic testing.

Huntington's disease and look-alike

Three contributions in this journal throw further light on Huntington's disease (HD) and a clinically and pathologically virtually indistinguishable disorder, Huntington's disease-like 2 (HDL2) in South Africa.^4-6

HD is a late-onset, autosomal dominant neurodegenerative disorder characterised by progressive movement impairment, affective disturbance and cognitive dysfunction. In 2001, HDL2 was identified. A molecular diagnostic test for HD and HDL2 is now available to test simultaneously for both conditions.⁴

Elsewhere in the world HD is a homogeneous disease, whereas in South Africa it is heterogeneous.⁵ HD has been reported to occur rarely in black patients. Magazi et al. report on the clinical and genetic features in 11 black African families and review the literature.⁶

Influenza guideline update

This revision of the 1999 influenza guideline indicates the viral stains that are incorporated into the vaccine for the 2008 season, adds new data regarding treatment of influenza, adds a section on influenza in children and clarifies issues in managing and preventing influenza in HIV-infected individuals.⁷

Influenza vaccine is the mainstay of influenza prevention strategies. All persons who are at high risk of influenza and its complications should be vaccinated. Neuraminidase inhibitors are an important adjunct to influenza vaccination. Because of concerns about the possibility of the development of viral resistance with overuse of these agents, they should be reserved for high-risk or sicker influenza patients.

1. Venter WDF, Naicker S, Dhai A, et al. Uniquely South African: Time to consider offering HIV-positive donor kidneys to HIV-infected renal failure patients. S Afr Med J 2008; 98: 182-183.         [ Links ]

2. Joska JA, Kaliski SZ, Benatar SR. Patients with severe mental illness: A new approach to testing for HIV. S Afr Med J 2008; 98: 213-217.         [ Links ]

3. Williams KA, Cronje FJ, Avenant L, Villet MH. Identifying flies used for maggot debridement therapy. S Afr Med J 2008; 98: 196-197.         [ Links ]

4. Greenberg J, Bardien S, Carr J. Huntington's disease-like 2 in South Africa. S Afr Med J 2008; 98: 166.         [ Links ]

5. Krause A, Greenberg J. Genetic testing for Huntington's disease in South Africa. S Afr Med J 2008; 98: 193-194.         [ Links ]

6. Magazi DS, Krause A, Bonev V, Iqbal Z, Dludla M, Van der Meyden CH. Huntington's disease: Genetic heterogeneity in black African patients. S Afr Med J 2008; 95: 200-203.         [ Links ]

7. Green RJ, Feldman C, Schoub B, et al. Influenza Guideline for South Africa - Update 2008. S Afr Med J 2008; 98: 223-230.         [ Links ]