Southern African journal of HIV medicine最新文献

Background: Meeting the Joint United Nations Programme on HIV/AIDS targets and ending AIDS by 2030 requires global efforts, with a particular focus on older adolescents living with HIV (OALHIV) and younger adults living with HIV (YALHIV). These population groups are often associated with unsuppressed viral load compared to adults.

Objectives: This article assessed the extent of viral load suppression (VLS) and associated factors among this group in seven high-burden districts of Namibia.

Method: A cross-sectional survey was conducted to analyse data for 600 OALHIV and YALHIV, aged 15-24 years, who were already on antiretroviral treatment prior to 2020. The study employed a stratified cluster sampling across seven districts. Data were extracted from an electronic database and analysed using Statistical Package for Social Sciences (SPSS) software. However, limitations within the database restricted the availability of certain variables.

Results: Overall, the VLS (< 1000 copies/mL) was 84.8%, with female patients showing a significantly higher VLS 88.3% compared to male patients, with 78.5% (P < 0.01; odds ratio [OR] = 2.08). Although OALHIV had higher suppression (84.9%) than YALHIV (74.6%), age was not significantly associated with VLS (P = 0.9). Dolutegravir-based regimens had a suppression of 93.3% (P < 0.01; OR = 9.1), and those with a fixed home address had an 88.2% suppression (P = 0.014; OR = 1.76).

Conclusion: The VLS of 84.8% remains below the Joint United Nations Programme on HIV/AIDS target of 95%. There is a need for improvements in antiretroviral treatment programmes, particularly in scaling up dolutegravir-based regimens, enhancing adherence and peer support to end AIDS by 2030.

Background: The WHO emphasises contact investigation of people with HIV for case finding. However, satisfactory implementation of index contact testing remains challenging in Johannesburg.

Objectives: This study draws from the Consolidated Framework for Implementation Research to explore healthcare workers' (HCWs) insights on barriers and enablers of index contact testing implementation.

Method: Data were collected through semi-structured interviews, at four healthcare facilities and four non-profit organisations (NPOs) in Johannesburg, from October 2023 to November 2023, and analysed thematically, guided by the Consolidated Framework for Implementation Research framework.

Results: Twenty-three HCWs participated: 18 counsellors (78.3%) and 5 nurses (21.7%). Most participants were aged 20-40 years (56.5%). Participants were drawn from facilities (65.0%) and NPOs (35.0%). Counsellors demonstrated a more nuanced understanding of index contact testing. Major barriers were identified in the innovation, outer setting, and inner setting domains, and key enablers in the innovation and process domains. Innovation domain barriers included perceived complexity of guidelines and their time-consuming nature. Key enablers were adaptations to educate clients about pre-exposure prophylaxis (PrEP), incorporating index contact testing into pre-test counselling, and offering home-based testing for contacts. Outer setting barriers included fears of intimate partner violence (IPV), stigma, and geographic dispersion of contacts. Inner setting barriers were limited training, insufficient knowledge, and inadequate HCW skills, compounded by a lack of resources.

Conclusion: This study highlights critical barriers that need to be addressed, through simplified guidelines, targeted training, resource allocation, stigma reduction, and IPV-reduction strategies. Leveraging enablers like PrEP education and home-based testing can enhance implementation and engagement.

Background: In the HIV/tuberculosis endemic Western Cape public care setting, diagnostic consideration of patients with persistent lymphadenopathy focuses on extra-pulmonary tuberculosis (EPTB), delaying diagnosis of other infectious or malignant causes of lymphadenopathy.

Objectives: To evaluate the diagnostic pathways of patients investigated for lymphadenopathy at Groote Schuur Hospital.

Method: A retrospective review of patients undergoing lymph node excision biopsy was conducted to correlate test selection and results prior to biopsy with final patient diagnosis and assess the impact of pre-biopsy pathways on diagnostic delay.

Results: Of 86 patients undergoing excision biopsy, 61 (71%) had no previous diagnosis to explain the lymphadenopathy. Extra-pulmonary tuberculosis was the commonest diagnosis (24.6%, 15/61), followed by lymphoma (21.3%, 13/61), and metastatic cancer (14.8%, 9/61). Median time from presentation with lymphadenopathy to first excision biopsy was 55 days (interquartile range [IQR] 22-106). Fine needle aspiration (FNA) cytology of lymphadenopathy was performed in 30 out of 61 (49%) of the patients and repeated in a third of these, while smear for acid-fast bacilli and culture for Mycobacterium tuberculosis were infrequently performed, and the GeneXpert MTB/RIF assay on FNA was never performed. FNA cytology was non-diagnostic in all seven patients with lymphoma in whom it was performed.

Conclusion: In patients with lymphadenopathy, we demonstrate how poorly structured diagnostic pathways contribute to unnecessary healthcare utilisation and diagnostic delay in treatable conditions. Providing early access to biopsy after appropriate workup ensures accurate diagnosis of unexplained lymphadenopathy.

Background: Retention of people who inject drugs (PWID) on antiretroviral therapy (ART) is critical for viral suppression. However, PWID, a key population, traditionally have poor retention in care (RiC).

Objectives: To determine the prevalence of and factors associated with RiC at 6 months, following ART initiation in three South African districts.

Method: Data of 333 PWID (adults 18+ years), who commenced ART between July 2022 and March 2023, were retrieved from TIER.Net electronic database.

Results: RiC after 6 months on ART was 40% (n = 132). Bivariate analysis showed higher retention among those on Opioid Substitution Therapy (OST) with treatment support compared to those without support (95% vs 39%; P < 0.001); and lower RiC among those with unstable housing compared to those with stable housing (12% vs 75%; P < 0.001). In the survival analysis, PWID with unstable housing had a 5-fold increased risk of poor RiC (adjusted hazard ratio [AHR] = 4.94; 95% confidence interval [95% CI]: 2.35-10.35), while those in OST had a 75% decreased risk of poor RiC (AHR = 0.25; 95% CI: 0.10-0.60).

Conclusion: PWID face significant challenges in remaining engaged in ART care, particularly those experiencing unstable housing. OST uptake can facilitate improved RiC and health outcomes, highlighting the need for expanded harm reduction strategies. Addressing unstable housing remains urgent to strengthen HIV treatment outcomes for PWID in South Africa.

Access to HIV services in South Africa remains challenging, despite their availability in the public healthcare sector. While the legislative framework allows for the provision of these services in community pharmacies, the process is often complex. This article describes various models for the provision of HIV services in community pharmacies in South Africa through a review of existing policies and legislation. It further discusses barriers and opportunities for the expansion of services. The existing legal framework enables prescribing by healthcare professionals other than medical practitioners through authorisations issued under either the Medicines and Related Substances Act of 1965 or the Nursing Act of 2005. Community pharmacies have extended their role beyond dispensing medication, with the emergence of telehealth and potential initiatives such as Pharmacist-Initiated Management of Antiretroviral Therapy (PIMART). Telehealth, accelerated by the COVID-19 pandemic, provides remote consultations and electronic prescriptions. PIMART, on the other hand, can empower pharmacists to initiate and manage antiretroviral therapy (ART) for HIV patients, a role traditionally reserved for clinicians. Extending Nurse-Initiated Management of Antiretroviral Therapy (NIMART) into the private sector could further increase ART rollout. Despite these advancements made in the last two decades, legislative reforms are necessary to fully realise the potential of community pharmacies for providing HIV services.

Background: Mixed feeding (MF) among HIV-exposed infants is a common practice in sub-Saharan Africa. Evidence suggests that MF is an additional risk for postnatal HIV transmission, even with antiretroviral therapy (ART).

Objectives: To determine the risk of HIV transmission by infant feeding modality.

Method: We searched for studies focusing on mothers living with HIV and their infants, and their feeding modality. The primary outcome was postnatal HIV transmission.

Results: Nine studies were identified from 570 reports. Overall, postnatal HIV transmission was measured at varying time points across the studies. Five studies reported transmission rates at 12 months, estimates ranged from 0% to 7%. Higher transmission rates were reported at 18-24 months, peaking at 11.6%, compared to a peak of 5% at 6 months. Adherence to maternal ART was reported in three studies ranging from 84% to 98%. Exclusive breastfeeding (EBF) duration was established in seven studies ranging from 51% to 97% at 6 months, with early complementary feeding introduced as early as 2 weeks. Two studies reported increased risk in HIV transmission associated with MF: 4-6-fold higher risk of transmission in MF compared to EBF infants.

Conclusion: Reduced risk of postnatal HIV transmission was revealed in mothers on ART, and EBF, supporting WHO recommendations, two studies showed the presence of MF increased the risk of postnatal transmission. There is limited information on the actual risk of postnatal transmission associated with MF in mothers adhering to ART with suppressed viral loads.

Background: HIV-positive women with breast cancer do not exhibit significant differences in tumour characteristics when compared to their HIV-negative counterparts. Stromal tumour-infiltrating lymphocytes (TILs) serve as an important indicator of the host's capacity to combat malignancy, particularly during the early stages of tumour progression.

Objectives: The objective of this study was to assess and compare the pathological characteristics of breast carcinomas, specifically focusing on TILs in histological specimens obtained before and after systemic therapy, between HIV-positive and HIV-negative patient groups at a public hospital in the Western Cape province. Additionally, the study aimed to determine whether a higher percentage of TILs was associated with a favourable treatment response.

Method: A retrospective cohort study was conducted, incorporating a negative control group matched for histological subtype, and intrinsic subtypes among patients diagnosed between January 2017 and December 2018.

Results: There was no significant difference in TILs before and after treatment, nor was there a difference between patients treated with neoadjuvant chemotherapy (NACT) compared to those receiving endocrine therapy (ET) within both groups. A complete pathological response was achieved in four HIV-positive patients (14%) and one HIV-negative patient (2%). An inversely proportional relationship was noted between TILs and CD4 counts prior to treatment.

Conclusion: This study found no significant differences in TILs between HIV-positive and HIV-negative women with breast cancer. There is a need for further research on the prognostic value of TILs, especially for guiding additional treatment options including the use of immune checkpoint inhibitors.

Dolutegravir resistance is predominantly reported in antiretroviral therapy-experienced individuals. We describe an infant who developed high-level resistance to abacavir, lamivudine, and dolutegravir within 97 days of initiation, despite initial wild-type infection. Causative factors likely include probable sub-therapeutic antiretroviral drug levels, poor tolerance, severe immunocompromise, and a high pre-treatment viral load.

Background: The global community has set an ambitious goal of ending HIV as a public health risk by 2030. To achieve this, South Africa must have a robust routine health information management information system (RHIMS) that provides programmatic data disaggregated by key populations (KPs) to enable effective HIV response.

Objectives: To explore key stakeholders' perspectives regarding the incorporation of KPs unique identifier codes (UICs) in the RHIMS in terms of opportunities, procedures, vulnerabilities, challenges, and considerations for enhancement in tracking the HIV care cascade in South Africa.

Method: We conducted an exploratory, descriptive study that had three phases. First, we conducted stakeholder analysis and mapping using the power-interest matrix (Phase one). Second, we performed a qualitative document analysis (Phase two). Third, we conducted in-depth interviews with 20 stakeholders (Phase three).

Results: We mapped 100 stakeholders according to their power and interest regarding the KPs UICs inclusion in RHIMS, with the South African National AIDS Council and the National Department of Health being the primary stakeholders. Stakeholders highlighted the KPs UIC facilitators as District Health Information System (DHIS) policy support, integration with TIER.Net and DHIS, data security, improved monitoring and evaluation, and KP-targeted programming. Stakeholders also cited resistance to change, stigma and discrimination, data privacy, and security as key concerns for the inclusion of KPs UICs in the RHIMS.

Conclusion: Stakeholders support the inclusion of KPs UICs in public health data collection tools, emphasising its role in improving monitoring and evaluation, resource allocation, and KP-specific programming.