HIV medicine is a rapidly evolving field, perhaps more so than many other areas of clinical practice. The optimal choice of medicines changes regularly, but more profound changes in strategies to manage (and prevent) HIV infection also emerge at frequent intervals. To keep pace with these changes, guidelines to support different aspects of HIV medicine are updated regularly, and indeed we are in the midsts of another season of international guideline revisions; most notably, at the World Health Organization (WHO).
Given the heavy burden of HIV in South Africa, and the major international contributions of South African research to the global evidence base, it is unsurprising that this edition of the Journal contains a number of pieces of commentary on key issues facing the WHO guidelines group. One of the key issues in adult HIV medicine is the ‘best’ CD4 threshold for ART initiation – recognising that the ‘best’ can be defined in terms of individual patient management, cost-effectiveness for public health services, and even in terms of impact on HIV prevention efforts. In his commentary, Geffen1 touches on each of these concerns and arrives at a sensible position to maintain current CD4 starting points (i.e. with ART initiation below 350 cells/µl) until further evidence emerges. Meanwhile, the question of the most appropriate prevention of mother-to-child transmission (PMTCT) policy for South Africa was discussed in the previous issue2 – focusing on the question of 'Option B+'. An editorial written in response by Coutsoudis and colleagues3 is published here – and the question of whether South Africa should shift policy to universal initiation of lifelong ART for all HIV-infected women remains open. Finally, an issue that is not squarely in the sights of the WHO guidelines group – but perhaps should be – is the pervasive gender inequities in access to and outcomes of ART. As Cornell4 notes in her commentary, this inequality favours female patients, in contrast to many of the commonly held assumptions about gender and HIV, raising concerns about men’s health that many health services and policies are ill-equipped to address.
There are a number of other exciting contributions in these pages. Katusiime and colleagues5 describe the evaluation of a novel Ugandan programme to transition HIV-infected adolescents to routine adult care services – one of the first of its kind in Africa. Given the growing number of adolescents in our care and treatment programmes, examples of South African services that meet this need are urgently required. Meanwhile, Kenyon6 provides a creative analysis of HIV risk factors across language groups in South Africa, providing further indirect evidence for the role of sexual partner concurrency in the spread of the epidemic. Furthermore, Roussouw and colleagues7 provide a useful overview of HIV-associated liopdystrophy. Finally, this issue of the Journal is the first since the very successful SA HIV Clinicians Society Conference, held in November 2012 in Cape Town. We have published several of the best abstracts8 that were presented at the meeting, and look forward to seeing others published in SAJHIVMED soon.
Happy reading.
Associate Professor, School of Public Health & Family Medicine
University of Cape Town
landon.myer@uct.ac.za
1. Geffen N. World Health Organization guidelines should not change the CD4 threshold for antiretroviral therapy initiation. Southern African Journal of HIV Medicine 2013;14(1):6-7. [http://dx.doi.org/10.7196/SAJHIVMED.906]
2. Besada D, Van Cutsem G, Goemaere E, Ford N, Bygrave H, Lynch S. 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. Southern African Journal of HIV Medicine 2012;13(4):178-181. [http://dx.doi.org/10.7196/SAJHIVMED.864]
3. Coutsoudis A, Goga A, Desmond C, Barron P, Black V, Coovadia H. Is Option B+ the best choice? Southern African Journal of HIV Medicine 2013;14(1):8-10. [http://dx.doi.org/10.7106/SAJHIVMED.898]
4. Cornell M. Gender inequality: Bad for men's health. Southern African Journal of HIV Medicine 2013;14(1):12-14. [http://dx.doi.org/10.7196/SAJHIVMED.894]
5. Katusiime C, Parkes-Ratanshi R, Kambugu A. Transitioning behaviourally infected HIV-positive young people into adult care: Experiences from the young person's point of view. Southern African Journal of HIV Medicine 2012;14(1):20-23. [http://dx.doi.org/10.7196/SAJHIVMED.885]
6. Kenyon C. Association of HIV prevalence and concurrency of sexual partnerships in South Africa's language groups: An ecological analysis. Southern African Journal of HIV Medicine 2013;14(1):25-28. [http://dx.doi.org/10.7196/SAJHIVMED.884]
7. Roussow TM, Botes ME, Conradie F. Overview of HIV-related lipodystrophy. Southern African Journal of HIV Medicine 2013;14(1):29-33. [http://dx.doi.org/10.7196/SAJHIVMED.871]
8. Southern African HIV Clinicians Society. 'Striving for Clinical Excellence': Southern African HIV Clinicians Society Conference, Cape Town, 25 - 28 November 2012 (best astracts). Southern African Journal of HIV Medicine 2013;14(1):36-39. [http://dx.doi.org/10.7196/SAJHIVMED.893]