A brief history of South Africa's response to Aids

PKThe story of the AIDS response in South Africa over the past 4 years is one of great progress after almost a decade of complex and tragic denialism that united the world and civil society in a way not seen since the opposition to apartheid. Today the country can boast >2 million people on antiretroviral therapy, far and away the largest number in the world. Prevention efforts appear to be yielding results. The estimated number of annual new HIV infections declined by 79 000 between 2011 and 2012. New HIV infections among adults aged 15 - 49 years are projected to decline by 48% by 2016, from 414 000 (2010) to ~215 000 (2016). The national incidence rate has reached its lowest level since the disease was first declared an epidemic in 1992, translating into reductions in both infant and under-5 mortality and an increase in life expectancy from 56 to 60 years over the period 2009 - 2011 alone. This is largely thanks to a civil society movement that was prepared to pose a rights-based challenge to a governing party in denial, and to brave health officials, politicians and clinicians working in a hostile system to bring about change

Antiretroviral therapy non-adherence among HIV- positive patients presenting to an emergency department in Johannesburg, South Africa: associations and reasons

BACKGROUND. Suboptimal antiretroviral therapy (ART) adherence is associated with viral resistance, opportunistic infections and increased mortality. OBJECTIVES. To determine the rates of ART non-adherence and its associations, and also the reasons for ART non-adherence, among HIV-positive patients presenting to a major central hospital emergency department (ED). METHODS. Consecutive HIV-positive patients presenting to the Charlotte Maxeke Johannesburg Academic Hospital adult ED between 7 July 2017 and 18 October 2018 were prospectively enrolled. Self-reported adherence was assessed using the AIDS Clinical Trials Group Adherence Questionnaire (ACTG-AQ). RESULTS. Of the 1 224 consecutive HIV-positive participants enrolled, 761 (75.2%) were on ART at the time of ED presentation. Of these, 245 (32.2%) were non-adherent as per the ACTG-AQ. Participants not yet on ART prior to ED presentation had significantly higher in-hospital mortality than participants on ART (odds ratio 1.69; 95% confidence interval 1.21 - 2.34; p=0.002). Younger age, male sex, CD4 count <100 cells/µL, lack of viral suppression, a high National Early Warning Score 2 (≥7 points) and length of hospital stay ≥7 days were significantly associated with ART non-adherence (p<0.05). Forgetfulness (13.9%) and lack of social support, depression/stress/mental illness, and lack of money for transport to collect medications (9.9% each) were the most common reasons given for ART non-adherence. CONCLUSIONS. Of HIV-positive patients presenting to the ED, a high proportion were either not yet initiated on ART or ART non-adherent. HIV programmes should focus on HIV-positive ED attendees with the aim of identifying high-risk patients and providing adequate ART adherence supporthttp://www.samj.org.zadm2022Critical Car

The prevalence of smoking and the knowledge of smoking hazards and smoking cessation strategies among HIV-positive patients in Johannesburg, South Africa

BACKGROUND. While the detrimental effects of smoking among HIV-positive patients have been well documented, there is a paucity of data regarding cigarette smoking prevalence among these patients in South Africa (SA). OBJECTIVES. To establish the frequency, demographics, knowledge of harmful effects, and knowledge of smoking cessation strategies among HIV-positive patients in Johannesburg, SA. METHODS. We conducted a prospective cross-sectional survey using a structured questionnaire to interview HIV-positive patients attending the HIV Clinic at the Charlotte Maxeke Johannesburg Academic Hospital between 1 July and 31 October 2011. RESULTS. Of 207 HIV-positive patients attending an antiretroviral therapy (ART) roll-out clinic, 31 (15%) were current smokers (23.2% of males and 7.4% of females) and a further 45 (21.7%) were ex-smokers. Most of the current smokers (30/31 patients) indicated their wish to quit smoking, and among the group as a whole, most patients were aware of the general (82.1%) and HIV-related (77.8%) risks of smoking and of methods for quitting smoking. Despite this, however, most (62.3%) were not aware of who they could approach for assistance and advice. CONCLUSIONS. Given the relatively high prevalence of current and ex-smokers among HIV-positive patients, there is a need for the introduction of smoking-cessation strategies and assistance at ART roll-out clinics in SA.W D F Venter is supported by the US President’s Emergency Plan for AIDS Relief (PEPFAR). D Murdoch is part of the Fogarty International Center (grant no. K01TW008005). C Feldman is supported by the National Research Foundation (SA).http://www.samj.org.zaam2013ay201

Ideal Cardiovascular Health Index and Its Determinants in a Rural South African Population

Background: The ideal cardiovascular health index (CVHI) is a measure to summarize cardiovascular (CV) health, and includes smoking, body-mass index, physical activity, blood pressure, glucose, total cholesterol, and diet. Objective: This study aimed to assess CV health using the CVHI and determinants on CV health in a rural African population, and correlate carotid intima-media thickness (CIMT), a surrogate marker for atherosclerosis, with CVHI. Methods: A cross-sectional analysis was performed on baseline data of the Ndlovu Cohort Study, located in rural South Africa. CVHI score (CVHIs) was calculated by the sum of favourable CVHI factors (range 0 to 7). Logistic regression was performed to examine the association of age, sex, HIV-status, education level, employment status, and income with good CV health (5-7 favourable health factors). Mean CIMT was displayed by poor, intermediate and good CV health. Results: The study included 1927 participants with a mean age of 38.7 years (SD ± 12.8). Of the factors contributing to the CVHI, glucose and total cholesterol scored best; diet least good. Average CVHIs for the population was 4.4 (SD ± 1.2) and 53% of the population had a good CV health. Determinants associated with good CV health were younger age, higher educational attainment, and HIV positivity. CVHIs showed good agreement with CIMT. Conclusion: CVHIs showed that more than half of the participants had a good CV health. Agreement between CVHIs and CIMT indicates potential use of CVHIs as a surrogate marker for CV risk. The study highlights the importance of education for health promotion; good CV health in HIV-positive participants may in part be attributed to more frequent health care contact and provision of chronic disease care. Highlights: Good cardiovascular health (CVH) was observed in 53% of the study population.In global comparison, rural African study participants showed a good CVH score.HIV positivity was associated with a good CVH score.CVH score showed good agreement with carotid intima-media thickness

Comparative performance of cardiovascular risk prediction models in people living with HIV

Background: Current cardiovascular risk assessment in people living with HIV is based on general risk assessment tools; however, whether these tools can be applied in sub-Saharan African populations has been questioned.Objectives: The study aimed to assess cardiovascular risk classification of common cardiovascular disease (CVD) risk prediction models compared to the Data Collection on Adverse Events of Anti-HIV Drugs (D:A:D) 2010 and 2016 models in people living with HIV.Method: Cardiovascular disease risk was estimated by Framingham Cardiovascular and Heart Disease (FHS-CVD, FHS-CHD), Atherosclerotic Cardiovascular Disease (ASCVD) and D:A:D 2010 and 2016 risk prediction models for HIV-infected participants of the Ndlovu Cohort Study, Limpopo, rural South Africa. Participants were classified to be at low ( 20%) of CVD within 10 years for general CVD and five years for D:A:D models. Kappa statistics were used to determine agreement between CVD risk prediction models. Subgroup analysis was performed according to age.Results: The analysis comprised 735 HIV-infected individuals, predominantly women (56.7%), average age 43.9 (8.8) years. The median predicted CVD risk for D:A:D 2010 and FHS-CVD was 4% and for ASCVD and FHS-CHD models, 3%. For the D:A:D 2016 risk prediction model, the figure was 5%. High 10-year CVD risk was predicted for 2.9%, 0.5%, 0.7%, 3.1% and 6.6% of the study participants by FHS-CVD, FHS-CHD, ASCVD, and D:A:D 2010 and 2016. Kappa statistics ranged from 0.34 for ASCVD to 0.60 for FHS-CVD as compared to the D:A:D 2010 risk prediction model.Conclusion: Overall, predicted CVD risk is low in this population. Compared to D:A:D 2010, CVD risk estimated by the FHS-CVD model showed similar overall results for risk classification. With the exception of the D:A:D model, all other risk prediction models classified fewer people to be at high estimated CVD risk. Prospective studies are needed to develop and validate CVD risk algorithms in people living with HIV in sub-Saharan Africa.</div

A randomized study of intensified antiretroviral treatment monitoring versus standard-of-care for prevention of drug resistance and antiretroviral treatment switch

Introduction: Standard-of-care antiretroviral treatment (ART) monitoring in low and middle-income countries consists of annual determination of HIV-RNA viral load with confirmatory viral load testing in case of viral rebound. We evaluated an intensified monitoring strategy of three-monthly viral load testing with additional drug exposure and drug resistance testing in case of viral rebound. Methods: We performed an open-label randomized controlled trial (RCT) at a rural South African healthcare clinic, enrolling adults already receiving or newly initiating first-line ART. During 96 weeks follow-up, intervention participants received three-monthly viral load testing and sequential point-of-care drug exposure testing and DBS-based drug resistance testing in case of rebound above 1000 copies/ml. Control participants received standard-of-care monitoring according to the WHO guidelines. Results: Five hundred one participants were included, of whom 416 (83.0%) were randomized at 24 weeks. Four hundred one participants were available for intention-to-treat analysis. Viral rebound occurred in 9.0% (18/199) of intervention participants and in 11.9% (24/202) of controls (P = 0.445). Time to detection of rebound was 375 days [interquartile range (IQR): 348-515] in intervention participants and 360 days [IQR: 338-464] in controls [hazard ratio: 0.88 (95% confidence interval (95% CI): 0.46-1.66]; P = 0.683]. Duration of viral rebound was 87 days [IQR: 70-110] in intervention participants and 101 days [IQR: 78-213] in controls (P = 0.423). In the control arm, three patients with confirmed failure were switched to second-line ART. In the intervention arm, of three patients with confirmed failure, switch could initially be avoided in two cases. Conclusion: Three-monthly viral load testing did not significantly reduce the duration of viraemia when compared with standard-of-care annual viral load testing, providing randomized trial evidence in support of annual viral load monitoring

A randomized study of intensified antiretroviral treatment monitoring versus standard-of-care for prevention of drug resistance and antiretroviral treatment switch

Introduction: Standard-of-care antiretroviral treatment (ART) monitoring in low and middle-income countries consists of annual determination of HIV-RNA viral load with confirmatory viral load testing in case of viral rebound. We evaluated an intensified monitoring strategy of three-monthly viral load testing with additional drug exposure and drug resistance testing in case of viral rebound. Methods: We performed an open-label randomized controlled trial (RCT) at a rural South African healthcare clinic, enrolling adults already receiving or newly initiating first-line ART. During 96 weeks follow-up, intervention participants received three-monthly viral load testing and sequential point-of-care drug exposure testing and DBS-based drug resistance testing in case of rebound above 1000 copies/ml. Control participants received standard-of-care monitoring according to the WHO guidelines. Results: Five hundred one participants were included, of whom 416 (83.0%) were randomized at 24 weeks. Four hundred one participants were available for intention-to-treat analysis. Viral rebound occurred in 9.0% (18/199) of intervention participants and in 11.9% (24/202) of controls (P = 0.445). Time to detection of rebound was 375 days [interquartile range (IQR): 348-515] in intervention participants and 360 days [IQR: 338-464] in controls [hazard ratio: 0.88 (95% confidence interval (95% CI): 0.46-1.66]; P = 0.683]. Duration of viral rebound was 87 days [IQR: 70-110] in intervention participants and 101 days [IQR: 78-213] in controls (P = 0.423). In the control arm, three patients with confirmed failure were switched to second-line ART. In the intervention arm, of three patients with confirmed failure, switch could initially be avoided in two cases. Conclusion: Three-monthly viral load testing did not significantly reduce the duration of viraemia when compared with standard-of-care annual viral load testing, providing randomized trial evidence in support of annual viral load monitoring

Enhanced and Timely Investigation of ARVs for Use in Pregnant Women

Item does not contain fulltextBACKGROUND: Concerns have been voiced that the exclusion of pregnant women from clinical trials results in a lack of safety and pharmacokinetic data for antiretroviral drugs (ARVs) in pregnancy, creating clear risks to pregnant women living with HIV (PWLHIV), and their infants. SETTING: The World Health Organization convened a Paediatric Antiretroviral Drug Optimization group meeting, December 10-12, 2018, in Geneva, Switzerland. METHODS: The group, comprised of clinicians, scientists, HIV program managers, regulators, and community representatives, were tasked to consider how ARVs are studied in PWLHIV, define alternative approaches to studying ARVs in PWLHIV, identify ways to shorten the timeline to determine safe use of new agents during pregnancy, and define strategies to collaborate with regulators and industry to change longstanding practices. RESULTS: Most new ARVs are not studied in pregnant populations until after drug licensure, primarily opportunistically among women who become pregnant while taking the ARV of interest. Acceleration of the timeline will require earlier completion of preclinical studies and a new paradigm, namely-under certain conditions-allow women who become pregnant while participating in phase III ARV studies the option of remaining on study and enroll pregnant women into phase III trials of new agents to obtain preliminary safety and dosing and efficacy data. CONCLUSION: A revision of the current approach to the study of antiretrovirals in pregnant women is urgently needed to improve timely access and safe use of new agents during pregnancy

Phased implementation of screening for cryptococcal disease in South Africa

Cryptococcus neoformans is the most common cause of laboratoryconfirmed meningitis in South Africa.1 Despite the increased coverage of antiretroviral treatment (ART), the country’s incidence of cryptococcal meningitis remains high, and in routine care settings, the disease has a case-fatality ratio of >50% at 12 weeks post-diagnosis.2-4 Screening and pre-emptive antifungal treatment is desirable to prevent the development of cryptococcal meningitis and associated deaths.www.samj.org.zaam201