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SA Orthopaedic Journal

On-line version ISSN 2309-8309
Print version ISSN 1681-150X

SA orthop. j. vol.11 n.2 Centurion Apr. 2012


• Don't want to know

• Too painful to consider

• Of the 246 patients who agreed to be tested, 71 (27%) said they did not want to know the results. Fifty-seven (23%) of the patients who were tested were found to be HIV seropositive.



HIV seroprevalence in South Africa is high.1-5 Many studies of prevalence are hampered by the low recruitment rate (Table I). This can have a bearing on the interpretation of results obtained. The prevalence will be different in different population groups (Table II). High risk groups have been reported as young women and men between the ages of 20 and 49 years with a mean age of 34. This is the population group that normally would present to a casualty after an acute traumatic event. This study and the reports from Martison4 and Bowley5 show a high seroprevalence in a trauma setting. From this evidence one would extrapolate that almost a quarter of all patients that present to casualties after a traumatic episode are likely be HIV positive.

Since 1986 when Aids was first identified, and the isolation of the virus thereafter, every medical discipline has been faced with challenges in managing HIV/Aids patients. HIV/Aids presents specific challenges in the discipline of orthopaedics.7,8 Patients who are HIV positive have been shown to develop aggressive malignant tumours affecting bones.9 The prevalence of TB in HIV-positive patients has been reported to be 500 times greater than in HIV-negative individuals.10

The incidence of osteonecrosis or avascular necrosis (AVN) of the hip in HIV-positive patients is reported to be 45 times greater than in the normal population.11 HIV-positive patients have also been reported to be at higher risk of developing deep vein thrombosis. The risk of viral transmission can be expected to be higher in orthopaedic procedures due to the bony spikes and sometimes prolonged surgery.

In orthopaedic trauma the biggest concern is postoperative infection. The infection rate of open fractures in HIV-positive patients has been reported to be as high as 42%.12 Late infections around implants following trauma surgery have also been reported in HIV-positive patients.13 Early outcomes of providing antiretroviral medications in HIV-positive patients with a low CD4 count have been shown to be effective in decreasing the risks to the same level as HIV-negative patients.14 To improve treatment outcomes it would therefore be important to know the HIV status of patients managed for orthopaedic injuries in order to be able to add antiretroviral and prolonged prophylactic antibiotic treatment in those who are HIV-positive and have a low CD4 count.

In this study 62% of eligible patients did not consent to be tested. This low recruitment rate was experienced in a number of other studies (Table I). Several factors have been postulated and they range from indifference, the stigma attached to seropositivity, inadequate counselling and apathy. The national drive to know your HIV status and the utilisation of trained counsellors may improve the acceptance rate for testing. There have been several studies that have reported on the efficacy of voluntary counselling and testing (VCT) but the main problem has always been the low rate of recruitment of eligible candidates who are prepared to offer informed consent. Hutchinson and Mahlalela 2006,15 in a population-based survey and a government clinic in the Eastern Cape Province, found that utilisation of VCT services was positively associated with age, education, socio-economic status, proximity to clinics, availability of rapid testing and lower levels of HIV/AIDS stigma. Bassett et al 200716 in an outpatient-based study in kwaZulu-Natal reported a response rate of 48.6% (n=1414). Kalichman et al 200317 recorded a response rate of 47% in a study on HIV-testing attitudes in Cape Town, South Africa. Karl Peltzer et al reported a 73% capture.18 Table I clearly shows the huge discrepancies in the response rate between studies that were VCT aligned and those in which the researcher also doubled as the counsellor. Rate (of non-response) from this study is a case in point: a 38% recruitment rate compared to 73% in the Karl Peltzer study.



There was a high HIV seroprevalence (23%) in our academic hospital's Orthopaedic Trauma Unit. The low recruitment rate decreased the power of this study.

VCT is a gateway to both prevention and treatment of HIV. VCT interactions can also serve as important conduits of health information and promotion, encouraging changes in risky behaviours for those not infected and modifications in behaviour for discordant couples and those already infected.



1. UNAIDS/WHO AIDS epidemic update available at:         [ Links ]

2. South Africa HID and AIDS Statistics from:         [ Links ]

3. Connolly C, Colvin M, Shisana O, Stoker D. Epidemiology of HIV in South Africa: a result of a national, community-based survey. South African Medical Journal. 94(9):776-81.         [ Links ]

4. Martison N, Omar J, Gray G, Vermaak J. High rates of HIV in surgical patients in Soweto, South Africa: Impact on resource utilization and recommendations for HIV testing. Transactions of the Royal Society of Tropical Medicine and Hygiene. Feb 2007;101(2):176-82.         [ Links ]

5. Bowley DM, Cherry R, Synman T et al. Seroprevalence of human immunodeficiency virus in major trauma patient in Johannesburg. South African Medical Journal 2002 Oct;92(10):792-93.         [ Links ]

6. Yeung S et al. Paediatric HIV infection in a rural South African district hospital. Journal of Tropical Pediatrics 2000 46(2):107-10.         [ Links ]

7. Govender S, Harrison WJ, Lukhele M. Impact of HIV on bone and joint surgery. Best Practice & Research Clinical Rheumatology. 2008;22(4):605-19.         [ Links ]

8. Biviji AA, Paiement GD, Steinbach LS. musculoskeletal manifestations of human immunodeficiency virus infection. J Am Acad Orthop Surg 2002;10:312-20         [ Links ]

9. Bayley AC. Surgical pathology of HIV infection: lessons from Africa. British Journal of Surgery 1990;76(8):863-68.         [ Links ]

10. Barnes PF, Bloch AB, Davidson PT et al. Tuberculosis in patients with human immunodeficiency virus infection. New England Journal of Medicine. 1991;324(23):1644-50.         [ Links ]

11. Brown P, Crane L. Avascular necrosis of bone in patients with human immunodeficiency virus infection: report of 6 cases and review of the literature. Clinical Infectious Disease. 2001;32(8):1221-26.         [ Links ]

12. Harrison WJ, Lewis CP, Lavy CB. Wound healing after implant surgery in HIV-positive patients. Journal of Bone and Joint. British 2002;84(6):802-806.         [ Links ]

13. Brijlall S, Lioma ID and Govender S. Implants sepsis in the HIV-infected patients. South African Orthopaedic Journal 2003;2(3):26-30.         [ Links ]

14. Bahenbeck J, Handy Eone D, Ngo Nonga B et al. Implant orthopaedic surgery in HIV asymptomatic carriers: management and early outcome. Injury, Int J Care Injured 2009;40:1147-50.         [ Links ]

15. Hutchinson PL, Mahlalela X. Utilization of voluntary counseling and testing services in the Eastern Cape, South Africa. AIDS Care 2006;18:446-55.         [ Links ]

16. Bassett IV, Giddy J, Nkera J et al. Routine voluntary HIV testing in Durban, South Africa: The experience from an outpatient department. J Acquir Immune Defic Syndr 2007;46(2):181-86.         [ Links ]

17. Kalichman SC, Simbayi LC. HIV testing attitudes, AIDS stigma, and voluntary HIV counseling and testing in a black township in Cape Town, South Africa. Sex Transm Infect 2003;79:442-47.         [ Links ]

18. Peltzer K, Matseke G, Mzolo T, Majaja M. Determinants of knowledge of HIV status in South Africa: results from a population-based HIV survey. BMC Public Health 2009, 9:174. Availble at:         [ Links ]



Reprint requests:
Dr TI Sefeane
Division of Orthopaedics Room 4M12 Wits Medical School



Approval for the study was obtained from the Human Research Ethics Committee. The content and preparation of this paper is the sole work of the authors. The study is part of the MMed dissertation submitted to the University of Witwatersrand by the first author.
No benefit of any form was or will be received from a commercial party related directly or indirectly to the subject of this article.


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