HIV This Week

Undiagnosed HIV Infection among Adolescents Seeking Primary Health Care in Zimbabwe.

Ferrand RA, Munaiwa L, Matsekete J, Bandason T, Nathoo K, Ndhlovu CE, Munyati S, Cowan FM, Gibb DM, Corbett EL. Clin Infect Dis. 2010; 51:844-51

Mother-to-child transmission of human immunodeficiency virus (HIV) infection was extremely common in southern Africa during the 1990s, and a substantial minority of infected infants have survived to reach adolescence undiagnosed. Studies have shown a high prevalence of HIV infection in hospitalized adolescents who have features associated with long-standing HIV infection, including stunting and frequent minor illnesses. The authors therefore investigated the epidemiology of HIV infection at the primary care level. Adolescents (aged 10-18 years) attending two primary care clinics underwent HIV and Herpes simplex virus-2 (HSV-2) serological testing, clinical examination, and anthropometry. All were offered routine HIV counselling and testing. Patients attending for acute primary care who were HIV infected were asked about their risk factors. Five hundred ninety-four participants were systematically recruited (97% participation), of whom 88 (15%) were attending for antenatal care. HIV infection prevalence was higher among acute primary care attendees than among antenatal care attendees (17% vs 6%), but for the prevalence of HSV-2 infection, a marker of sexually acquired HIV, the converse was true (4% vs 14%). Seventy (81%) of 86 HIV-positive acute primary care attendees were previously undiagnosed. They had a broad range of presenting complaints, with a median CD4 cell count of 329 cells/muL(interquartile range, 176-485 cells/muL) and a high prevalence of stunting, compared with the corresponding prevalence among HIV-negative attendees (40% vs12%). Maternal transmission was considered to be likely by 69 (80%) of the 86 HIV-positive acute primary care attendees, only one of whom was HSV-2positive. Unrecognized HIV infection was a common cause of primary care attendance. Routine HIV counselling and testing implemented at the primary care level may provide a simple and effective way of identifying older long-term survivors of mother-to-child transmission before the onset of severe immunosuppression and irreversible complications.

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Editors’ note: Adolescents living in countries with longstanding generalised HIV epidemics should be offered HIV testing and counselling by health care providers, regardless of their presenting complaint. Given the high number of infants infected in the 1990s before the introduction of programmes to prevent mother-to-child transmission and evidence that up to a third may be slower progressors, it is estimated that as much as 1 to 2% of all children aged 10 to 15 years in such settings may have HIV infection. That the vast majority of these children will have been infected through vertical transmission is not in doubt. In this study, there was an equal sex distribution, a strong association with maternal but not paternal orphanhood, and a low prevalence of herpes simplex 2 infection. The latter is an independent marker of sexually acquired HIV because it is a highly prevalent sexually transmitted infection among southern Africans. Finally, Zimbabwe instituted effective polices to stop transmission through contaminated blood and blood products early on in its epidemic. The point is that there are thousands and thousands of undiagnosed young adolescents in southern Africa that could benefit from clinical assessment, prophylaxis for opportunistic illness, and antiretroviral therapy initiation before life-threatening illness and chronic complications announce the possibility of HIV infection, if only they had the chance to learn their serostatus.

Economic outcomes of patients receiving antiretroviral therapy for HIV/AIDS in South Africa are sustained through three years on treatment.

Rosen S, Larson B, Brennan A, Long L, Fox M, Mongwenyana C, Ketlhapile M, Sanne I. PLoS One. 2010;5(9):e12731.

Although the medical outcomes of antiretroviral therapy for HIV are well described, less is known about how antiretroviral therapy affects patients' economic activities and quality of life, especially after the first year on antiretroviral therapy. The authors assessed symptom prevalence, general health, ability to perform normal activities, and employment status among adult antiretroviral therapy patients in South Africa over three full years following antiretroviral therapy initiation. A cohort of 855 adult pre- antiretroviral therapy patients and  patients on antiretroviral therapy for <6 months was enrolled and interviewed an average of 4.4  times each during routine clinic visits for up to three years after treatment initiation using an instrument designed for the study. The probability of pain in the previous week fell from 74% before antiretroviral therapy initiation to 32% after three years on antiretroviral therapy, fatigue from 66% to 12%, nausea from 28% to 4%, and skin problems from 55% to 10%. The probability of not feeling well physically yesterday fell from 46% to 23%. Before starting antiretroviral therapy, 39% of subjects reported not being able to perform their normal activities sometime during the previous week; after three years, this proportion fell to 10%. Employment rose from 27% to 42% of the cohort. Improvement in all outcomes was sustained over 3 years and for some outcomes increased in the second and third year. Improvements in adult antiretroviral therapy patients' symptom prevalence, general health, ability to perform normal activities, and employment status were large and were sustained through the first three years on treatment. These results suggest that some of the positive economic and social externalities anticipated as a result of large-scale  treatment provision, such as increases in workforce participation and  productivity and the ability of patients to carry on normal lives, may indeed be accruing.

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Editors’ note: These are encouraging findings – this is the first report to indicate that the benefits of antiretroviral treatment in sub-Saharan Africa, in terms of ability to participate in normal activities, fewer symptoms, and increased employment potential, are sustained to 3 years, well beyond the 12 months documented in the existing small body of literature on antiretroviral treatment and quality of life. The proviso is that these patients were those who continued on antiretroviral treatment in these clinical settings – post-enrolment loss to follow-up was high. Some indicators were slow to increase, for example, the probability of having a job did not increase until about 18 months after starting treatment. But the median CD4 count at treatment initiation was low at 105 cells/mm³, unemployment was high in South Africa at a sustained 24% through the study period, and it takes time to find employment after one becomes capable of working. Further studies will help populate the cost-benefit models that inform our thinking about the positive ‘externalities’ of antiretroviral treatment.

Aerobic exercise interventions for adults living with HIV/AIDS.

O'Brien K, Nixon S, Tynan AM, Glazier R. Cochrane Database Syst Rev. 2010 Aug 4;8:CD001796.

Access to combination antiretroviral therapy has turned HIV into a chronic and manageable disease for many. This increased chronicity has been mirrored by increased prevalence of health-related challenges experienced by people living with HIV. Exercise is a key strategy for people living with HIV and recommended by rehabilitation professionals to address these disablements; however, knowledge about the effects of exercise among adults living with HIV still is emerging. The objective of the study was to examine the safety and effectiveness of aerobic exercise interventions on immunologic and virologic, cardiopulmonary, psychological outcomes and strength, weight, and body composition in adults living with HIV. Searches of MEDLINE, EMBASE, SCIENCE CITATION INDEX, CINAHL, HEALTHSTAR, PsycINFO, SPORTDISCUS and Cochrane Review Group Databases were conducted between 1980 and June 2009. Searches of published and unpublished abstracts and proceedings from major international and national HIV conferences were conducted, as well as a hand search of reference lists and tables of contents of relevant journals and books. The authors included studies of randomised controlled trials comparing aerobic exercise interventions with no aerobic exercise interventions or another exercise or treatment modality, performed at least three times per week for at least four weeks among adults (18 years of age or older) living with HIV. Data on study design, participants, interventions, outcomes, and methodological quality were abstracted from included studies by two reviewers. Meta-analyses, using RevMan 5 computer software, were performed on outcomes when possible. A total of 14 studies met inclusion criteria for this review and 30 meta-analyses over several updates were performed. Main results indicated that performing constant or interval aerobic exercise, or a combination of constant aerobic exercise and progressive resistive exercise for at least 20 minutes at least three times per week for at least five weeks appears to be safe and may lead to significant improvements in selected outcomes of cardiopulmonary fitness (maximum oxygen consumption), body composition (leg muscle area, percent body fat), and psychological status (depression-dejection symptoms). These findings are limited to participants who continued to exercise and for whom there were adequate follow-up data. Aerobic exercise appears to be safe and may be beneficial for adults living with HIV. These findings are limited by the small sample sizes and large withdrawal rates described in the studies. Future research would benefit from participant follow-up and intention-to-treat analysis. Further research is required to determine the optimal parameters in which aerobic exercise may be most beneficial for adults living with HIV.

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Editors’ note: In the general population, exercise improves strength, cardiovascular function, and psychological status. Many people, living with HIV and not, seek improved fitness, well-being, and body image through exercise. This systematic review of the available information on the risks and benefits of exercise for people living with HIV examined trials of aerobic exercise at least 3 times per week. Not only was such exercise safe for five weeks or more, it led to improvements in cardiopulmonary fitness, body composition, and psychological status. There is insufficient information about the effects on women and older people but this does not provide an excuse for sitting around waiting for more data. When considering an unaccustomed exercise programme, it is best to consult one’s health care provider before starting but, after that, people living with HIV can enjoy the benefits of physical fitness and psychological improvements in depression symptoms just as others do. There is no time like the present to get active.

Reproductive choices for women with HIV

Wilcher R, Cates W. Bull World Health Organ. 2009 87:833-9.

Access to reproductive health services for women with HIV is critical to ensuring their reproductive needs are addressed and their reproductive rights are protected. In addition, preventing unintended pregnancies in women with HIV is an essential component of a comprehensive prevention of mother-to-child transmission (PMTCT) programme. As a result, a call for stronger linkages between sexual and reproductive health and HIV policies, programmes and services has been issued by several international organizations. However, implementers of PMTCT and other HIV programmes have been constrained in translating these goals into practice. The obstacles include: (i) the narrow focus of current PMTCT programmes on treating HIV-positive women who are already pregnant; (ii) separate, parallel funding mechanisms for sexual and reproductive health and HIV programmes; (iii) political resistance from major HIV funders and policy-makers to include sexual and reproductive health as an important HIV programme component; and (iv) gaps in the evidence base regarding effective approaches for integrating sexual and reproductive health and HIV services. However, we now have a new opportunity to address these essential linkages. More supportive political views in the United States of America and the emergence of health systems strengthening as a priority global health initiative provide important springboards for advancing the agenda on linkages between sexual and reproductive health and HIV. By tapping into these platforms for advocating and by continuing to invest in research to identify integrated service delivery best practices, we have an opportunity to strengthen ties between the two synergistic fields.

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Editors’ note:  This ‘must read’ article cogently lays out the human rights and public health arguments for effective linkages and integration of HIV services with sexual and reproductive services. If you have not been convinced that contraceptive use should be an indicator of programmatic success for vertical transmission prevention programmes, you may think twice after reading this article about measuring only the ‘cascade’ which starts with the proportion of women accessing antenatal care services. Women living with HIV need sexual and reproductive health services when they do not wish to become pregnant, when they wish to become pregnant, when they are pregnant and wish to continue their pregnancy, and when they are pregnant and do not wish to continue their pregnancy. As the Convention on the Elimination of all Forms of Discrimination Against Women states: all women have the right ‘to decide freely and responsibly on the number and spacing of their children and to have access to the information, education, and means to enable them to exercise these rights’. A new wind is blowing and it is high time to make both vertical and integrated sexual and reproductive health services priority strategies as we aim to eliminate mother-to-child HIV transmission.