HIV Focus - Vol 1 no 2, Edition 2 - September 2023

Introduction

HIV Focus: The African perspective

This issue of HIV Focus tackles four important areas of HIV management and research in our South African/ African setting; viz the 2023 treatment guidelines, whether drug regimen can be simplified in the presence of resistance, research challenges towards a functional cure of HIV in an African setting and diagnostic dilemmas in the interpretation of laboratory PCR tests in the presence of successful prevention of mother-to-child-transmission (PMTCT) programmes.

SA HIV Clinicians’ Society 2023 Adult Antiretroviral Therapy Guidelines: Comparison to SA Department of Health Antiretroviral Therapy Guidelines

The latest iteration of the SAHCS ART guidelines followed the principles that have animated previous versions. While they speak to the Southern African private sector principally, they are also used extensively by doctors in the region’s public sector, owing to their greater explanatory depth and strong focus on providing direction for common clinical questions that arise in the management of people living with HIV (PLWH). Providing a consistent message across the two sectors is therefore advantageous. Furthermore, patients often move between the private and public sectors as funds permit, necessitating harmonisation between the programmes where possible. Thus, although the SAHCS adult ART guidelines do differ from the SA Department of Health (DoH) ART guidelines in places where the greater available resources in the private sector can be harnessed to improve patient care, a conscious decision was made to align the two sets of guidelines as far as was feasible. To this end, several members of each guidelines committee were part of the processes for both sets of guidelines. 

Utilising ongoing activity of “nukes” (NRTIs [nucleoside reverse transcriptase inhibitors]) despite extensive resistance on HIV-DRT (genotyping).

South Africa has one of the highest number of people living with HIV (PLWH) in the world. Combination antiretroviral therapy (CART) has become the mainstay for the treatment of the human-immunodeficiency virus (HIV) since the early 90’s. Many drugs, over the years, have fallen out of favour, either due to unacceptable side-effects or due to the development of resistance.

Functional Cure of HIV: Some Research Challenges

Combination antiretroviral therapy (ART) to treat human immunodeficiency virus (HIV) infection has been highly successful in reducing transmission as well as morbidity and mortality, but is not curative. This is because HIV integrates into host DNA and persists in a latent form in reservoirs of cells, mainly resting CD4 memory T cells and other long-lived cells. Neither ART nor the host immune response can effectively eliminate these latent reservoirs – posing a major barrier to cure HIV infection. The global burden of 38 million people living with HIV (PLWH), together with the need for lifelong ART, the availability and cost of drugs, the challenges of adherence, the development of drug resistance, the risks of long-term drug toxicities, and social stigma and discrimination – all underscore the pressing need for the development of curative interventions.

The paediatric HIV diagnostic challenge

South Africa has the largest HIV treatment programme in the world, with 69% of the 8.2 million People Living with HIV (PLHIV) on antiretroviral therapy (ART).

The South African prevention of mother-to-child transmission (PMTCT) programme began in 2002 with the introduction of a single intrapartum dose of nevirapine (sdNVP) and to infants within 72 hours of birth. The PMTCT programme has come a long way in the two decades since. Currently all pregnant women are screened for HIV at every basic antenatal care visit, at delivery and 3 monthly for the duration of breastfeeding. At these multiple opportunities for detection of HIV seroconversion, women are initiated on highly efficacious ART of a fixed drug combination of tenofovir/lamivudine/ dolutegravir (TLD). Furthermore, infants are protected with single or dual prophylaxis for low risk and high risk exposure, respectively.