Guideline for the prevention, diagnosis and management of cryptococcal meningitis among HIV-infected persons: 2013 update

Six years after the first Society guidelines were published, cryptococcal meningitis (CM) remains an important cause of morbidity and mortality among HIV-infected adults in South Africa. Several important developments have spurred the  publication of updated guidelines to manage this common fungal opportunistic infection. Recommendations described here include: (1) screening and pre-emptive treatment; (2) laboratory diagnosis and monitoring; (3) management of a first episode of CM; (4) amphotericin B deoxycholate toxicity prevention, monitoring and management; (5) timing of antiretroviral therapy among patients with CM; (6) management of raised intracranial pressure; (7) management of relapse episodes of CM

Management of mental health disorders in HIV-positive patients

These guidelines are intended as a reference document to assist HIV nurse and doctor clinicians in managing mental health disorders. It is intended to improve awareness, knowledge and capacity to support patients living with HIV and mental health disorders

Guidance for antiretroviral therapy in HIV-infected infants less than 1 year of age

Forty per cent of HIV-infected children die before they reach their first year of life, mainly in the first 6 months. Data from the Children with HIV Early Antiretroviral Therapy (CHER) study indicate that even when infants appear well and their CD4 counts are >25% there is a 75% increased risk of mortality when antiretroviral therapy (ART) is deferred until threshold CD4 depletion occurs or clinical criteria are met.1 Even after starting ART, young infants have excess mortality within the first year of life. Every effort should therefore be made to identify HIV-infected infants as early as possible so that ART can be initiated without delay. Southern African Journal of HIV Medicine Vol. 9 (4) 2008: pp. 34-3

Addressing social issues in a universal HIV test and treat intervention trial (ANRS 12249 TasP) in South Africa: methods for appraisal

Background: The Universal HIV Test and Treat (UTT) strategy represents a challenge for science, but is also a challenge for individuals and societies. Are repeated offers of provider-initiated HIV testing and immediate antiretroviral therapy (ART) socially-acceptable and can these become normalized over time? Can UTT be implemented without potentially adding to individual and community stigma, or threatening individual rights? What are the social, cultural and economic implications of UTT for households and communities? And can UTT be implemented within capacity constraints and other threats to the overall provision of HIV services? The answers to these research questions will be critical for routine implementation of UTT strategies. Methods/design: A social science research programme is nested within the ANRS 12249 Treatment-as-Prevention (TasP) cluster-randomised trial in rural South Africa. The programme aims to inform understanding of the (i) social, economic and environmental factors affecting uptake of services at each step of the continuum of HIV prevention, treatment and care and (ii) the causal impacts of the TasP intervention package on social and economic factors at the individual, household, community and health system level. We describe a multidisciplinary, multi-level, mixed-method research protocol that includes individual, household, community and clinic surveys, and combines quantitative and qualitative methods. Discussion: The UTT strategy is changing the overall approach to HIV prevention, treatment and care, and substantial social consequences may be anticipated, such as changes in social representations of HIV transmission, prevention, HIV testing and ART use, as well as changes in individual perceptions and behaviours in terms of uptake and frequency of HIV testing and ART initiation at high CD4. Triangulation of social science studies within the ANRS 12249 TasP trial will provide comprehensive insights into the acceptability and feasibility of the TasP intervention package at individual, community, patient and health system level, to complement the trial's clinical and epidemiological outcomes. It will also increase understanding of the causal impacts of UTT on social and economic outcomes, which will be critical for the long-term sustainability and routine UTT implementation. Trial registration: Clinicaltrials.gov: NCT01509508; South African Trial Register: DOH-27-0512-3974

Southern African HIV Clinicians Society Conference – Striving for Clinical Excellence, 2012 – Best Abstracts

Over 100 scientific abstracts were submitted for consideration by the scientific programme committee of the Society's conference, Striving for Clinical Excellence. The top nine papers were chosen and the authors were invited to present during the conference in Cape Town in November 2012. A panel comprised of Profs Linda-Gail Bekker, Brian Eley, Koleka Mlisana and Ian Sanne judged the papers and presentations and selected the best abstract and a runner-up. The first and second place winners were awarded a cash prize of R10 000 and R5 000, respectively, sponsored by Discovery Health

Southern African guidelines for the safe use of pre-exposure prophylaxis in men who have sex with men who are at risk for HIV infection

Background. The use of oral antiretrovirals to prevent HIV infection among HIV-negative men who have sex with men (MSM) has been shown to be safe and efficacious. A large, randomised, placebo-controlled trial showed a 44% reduction in the incidence of HIV infection among MSM receiving a daily oral fixed-dose combination of tenofovir disoproxil fumarate and emtricitabine (Truvada) in combination with an HIV prevention package. Improved protection was seen with higher levels of adherence. Aim. The purpose of this guideline is to: (i) explain what pre-exposure prophylaxis (PrEP) is; (ii) outline current indications for its use; (iii) outline steps for appropriate client selection; and (iv) provide guidance for monitoring and maintaining clients on PrEP. Method. PrEP is indicated for HIV-negative MSM who are assessed to be at high risk for HIV acquisition and who are willing and motivated to use PrEP as part of a package of HIV prevention services (including condoms, lubrication, sexually transmitted infection (STI) management and risk reduction counselling). Recommendations. HIV testing, estimation of creatinine clearance and STI and hepatitis B screening are recommended as baseline investigations. Daily oral Truvada, along with adherence support, can then be prescribed for eligible MSM. PrEP should not be given to MSM with abnormal renal function, nor to clients who are unmotivated to use PrEP as part of an HIV prevention package; nor should it be commenced during an acute viral illness. Three-monthly follow-up visits to assess tolerance, renal function, adherence and ongoing eligibility is recommended. Six-monthly STI screens and annual creatinine levels to estimate creatinine clearance are recommended. Hepatitis B vaccination should be provided to susceptible clients. Gastro-intestinal symptoms and weight loss are common side-effects, mostly experienced for the first 4 - 8 weeks after initiating PrEP. There is a risk of the development of antiretroviral resistance among those with undiagnosed acute HIV infection during PrEP initiation and among those with sub-optimal adherence who become HIV infected while on PrEP. Risk compensation (increasing sexual behaviours that can result in exposure to HIV) while on PrEP may become a concern, and clinicians should continue to support MSM clients to continue to use condoms, condom-compatible lubrication and practice safer sex. Research is ongoing to assess optimum dosing regimens, potential long-term effects and alternative PrEP medications. Recommendations for the use of PrEP among other at-risk individuals, and the components of these recommendations, will be informed by future evidence. S Afr J HIV Med 2012;13(2):40-55

A 13-year-old HIV-infected girl with thrombocytompenia: Paeditric case discussion, July 2006

The Paediatric Internet-based Discussion Group (PDG) assists health care professionals to resolve HIV-related clinical problems through the use of case studies. Difficult and interesting cases are e-mailed to group members, who e-mail their responses to all participants. This forum allows users to consult with one another, share their experiences, and utilise one another's expertise of treatment of HIV and HIV-related illnesses in an online discussion. The following case was presented to a group of South African paediatricians. The opinions of the participants are outlined below, followed by recommendations from experts in the field. Readers should be aware that opinions vary and may depend on resources available and regional differences in standard of care. Clinical judgement, reinforced by data, is of paramount importance. Southern African Journal of HIV Medicine Vol. 7 (4) 2006: pp. 45-4

Guidelines for antiretroviral therapy in adults

These guidelines are intended as an update to those published in the Southern African Journal of HIV Medicine in January 2008. Since the release of the previous guidelines, the scale-up of antiretroviral therapy (ART) in Southern Africa has continued to grow. Cohort studies from the region show excellent clinical outcomes; however, ART is still being started late (in advanced disease), resulting in relatively high early mortality rates. New data on antiretroviral (ARV) tolerability in the region and several new ARV drugs have become available. Although currently few in number, some patients in the region are failing protease inhibitor (PI)-based second-line regimens. To address this, guidelines on third-line (or ‘salvage’) therapy have been expanded