Building on the first decade of ART

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Promoting adherence to antiretroviral therapy: the experience from a primary care setting in Khayelitsha, South Africa.

OBJECTIVE: To describe the approach used to promote adherence to antiretroviral therapy (ART) and to present the outcomes in the first primary care public sector ART project in South Africa. DESIGN: The study is a prospective open cohort, including all adult patients naive to previous ART who received antiretroviral treatment in Khayelitsha, from May 2001 to the end of 2002. Patients were followed until their most recent visit before 31 July 2003. METHODS: Plasma viral load was determined at 3, 6, 12, 18 and 24 months after ART was initiated, and CD4 cell counts 6-monthly. Kaplan-Meier estimates were determined for the cumulative proportions of patients surviving, and patients with viral load suppression and viral rebound. RESULTS: A total of 287 patients were initiated on triple therapy. The probability of survival was 86.3% at 24 months. The median CD4 cell count gain was 288 cells/microliters at 24 months. Viral load was less than 400 copies/ml in 89.2, 84.2 and 69.7% of patients at 6, 12 and 24 months, respectively. The cumulative probability of viral rebound (two consecutive HIV-RNA measurements above 400 copies/ml) after achieving an HIV-RNA measurement below 400 copies/ml was 13.2% at 18 months. CONCLUSION: The study shows that, with a standard approach to patient preparation and strategies to enhance adherence, a cohort of patients on ART can be retained in a resource-limited setting in a developing country. A high proportion of patients achieved suppression of viral replication. The subsequent probability of viral rebound was low

Nevirapine-Induced Heratotoxicity: Incidence, Risk Factors and Associated Mortality in a Primary Care ART Programme in South Africa

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The prevention of mother-to-child HIV transmission programme and infant feeding practices

Since the first cases of HIV transmission through breastfeeding were documented, a fierce debate has raged on appropriate guidelines for infant feeding in resource-poor settings. A major problem is determining when it is safe and feasible to formula-feed, as breast-milk protects against other diseases. A cross-sectional survey of 113 women attending the programme for the prevention of mother-to-child transmission in Khayelitsha, Cape Town, was conducted. Over 95% of women on the programme formula-fed their infants and did not breast- feed at all. Seventy per cent of women said that their infant had never had diarrhoea, and only 3% of children had had two episodes of diarrhoea. Focus groups identified the main reasons for not breast-feeding given by women to their families and those around them. Formula feeding is safe and feasible in an urban environment where sufficient potable water is available

The case for Option B and Optional B+: Ensuring that South Africa’s commitment to eliminating mother-to-child transmission of HIV becomes a reality

In a previous issue of the Southern African Journal of HIV Medicine, Pillay and Black summarised the trade-offs of the safety of efavirenz use in pregnancy (Pillay P, Black V. Safety, strength and simplicity of efavirenz in pregnancy. Southern African Journal of HIV Medicine 2012;13(1):28-33.). Highlighting the benefits of the World Health Organization’s proposed options for the prevention of mother-to-child transmission (PMTCT) of HIV, the authors argued that the South African government should adopt Option B as national PMTCT policy and pilot projects implementing Option B+ as a means of assessing the individual- and population-level effect of the intervention. We echo this call and further propose that the option to remain on lifelong antiretroviral therapy, effectively adopting PMTCT Option B+, be offered to pregnant women following the cessation of breastfeeding, for their own health, following the provision of counselling on associated benefits and risks. Here we highlight the benefits of Options B and B+

Review: Khayelitsha 2001 - 2011: 10 years of primary care HIV and TB programmes

Tuberculosis (TB) and HIV care in Khayelitsha, and in South Africa as a whole, has overcome numerous obstacles in the past three decades. This article highlights what has been achieved in Khayelitsha, describes the key clinical programme and policy changes that have supported universal coverage for HIV and TB care over the last 10 years, and outlines the challenges for the next decade

Extraskeletal benefits and risks of calcium, vitamin D and anti-osteoporosis medications

Drugs used for the prevention and the treatment of osteoporosis exert various favourable and unfavourable extra-skeletal effects whose importance is increasingly recognized notably for treatment selection. INTRODUCTION: The therapeutic armamentarium for the prevention and the treatment of osteoporosis is increasingly large, and possible extra-skeletal effects of available drugs could influence the choice of a particular compound. METHODS: The present document is the result of a national consensus, based on a systematic and critical review of the literature. RESULTS: Observational research has suggested an inverse relationship between calcium intake and cardiovascular diseases, notably through an effect on blood pressure, but recent data suggest a possible deleterious effect of calcium supplements on cardiovascular risk. Many diverse studies have implicated vitamin D in the pathogenesis of clinically important non-skeletal functions or diseases, especially muscle function, cardiovascular disease, autoimmune diseases and common cancers. The possible effects of oral or intravenous bisphosphonates are well-known. They have been associated with an increased risk of oesophageal cancer or atrial fibrillation, but large-scale studies have not found any association with bisphosphonate use. Selective oestrogen receptor modulators have demonstrated favourable or unfavourable extra-skeletal effects that vary between compounds. Strontium ranelate has a limited number of non-skeletal effects. A reported increase in the risk of venous thromboembolism is not found in observational studies, and very rare cases of cutaneous hypersensitivity reactions have been reported. Denosumab has been introduced recently, and its extra-skeletal effects still have to be assessed. CONCLUSION: Several non-skeletal effects of bone drugs are well demonstrated and influence treatment choices

Intraoperative assessment and reporting of radical prostatectomy specimens to guide nerve-sparing surgery in prostate cancer patients (NeuroSAFE)

AIMS: Radical prostatectomy for prostate cancer is frequently complicated by urinary incontinence and erectile dysfunction. Nerve-sparing surgery reduces the risk of post-operative complications and can be optimized using intraoperative frozen sections of the adjacent neurovascular structure (NeuroSAFE). The aim of t