Sexual risk behaviour among HIV-positive individuals in clinical care in urban KwaZulu-Natal, South Africa

We assessed the incidence and predictors of unprotected sex among 152 HIV-positive patients in clinical care in KwaZulu-Natal, South Africa. Nearly 50% were sexually active; 30% of those reported unprotected sex. Alcohol use during sex, reporting forced sex, sex with a perceived HIV-positive partner, and sex with a casual partner predicted more unprotected sex, whereas HIV status disclosure was related to less unprotected sex. These findings highlight the need for linking HIV prevention and care in Africa.     

Thrombectomy in HIV related peripheral arterial thrombosis: a preliminary report.

OBJECTIVES: To evaluate the limb salvage rate in patients undergoing thrombectomy for HIV related peripheral arterial thrombosis. METHODS: A prospective review of patients with HIV related peripheral arterial thrombosis managed at the Durban Metropolitan Vascular Service in Kwazulu-Natal South Africa over a 5-year (1998-2003) period. All patients underwent thrombectomy. RESULTS: Twenty-two patients (20 males) with HIV related peripheral arterial thrombosis (two upper limbs, 20 lower limbs) were included in the study. The median age was 36 years (24-46 years). All patients had rest pain and seven patients had gangrene (digital five, forefoot two). Seven patients had a short history of claudication before development of rest pain. Mean duration of symptoms was 30 days (1-120 days) with 10 patients presenting within 24 h. Most patients had a good general state of health and only three had clinical evidence of HIV infection. Ten patients who presented with threatened limbs from acute arterial occlusion were subjected to thrombectomy without any diagnostic investigations. Twelve patients who did not present with critical limb ischaemia had duplex ultrasonography, which showed arterial occlusion by a thrombus with normal proximal arteries. The striking features were the normal proximal vessels and absence of distal run-off. The search for an underlying cause, echocardiography in seven patients and coagulation screening in 10 patients, was always negative. All patients were subjected to thrombectomy with an on-table angiogram and received systemic heparin intra-operatively and deltaparin post-operatively. In 20 patients, duplex ultrasonography confirmed re-thrombosis within 48 h. Two patients remained with patent arteries. Most (16/20) patients who re-thrombosed required a major amputation and thrombectomy did not alter the level of amputation. The other four patients with re-thrombosis had symptomatic relief. Three patients died within 30 days of thrombectomy, all of HIV related complications. Overall the limb salvage rate was 6/22 (27%). CONCLUSION: Limb salvage rate following thrombectomy in HIV related peripheral arterial thrombosis is very low. Duplex ultrasonography appears to be an adequate radiological diagnostic investigation for these patients.     

Nutrition and Immunity in Perinatal Hypoxic-Ischemic Injury

Perinatal hypoxia ischaemia (PHI), acute and chronic, may be associated with considerable adverse outcomes in the foetus and neonate. The molecular and cellular mechanisms of injury and repair associated with PHI in the perinate are not completely understood. Increasing evidence is mounting for the role of nutrients and bioactive food components in immune development, function and repair in PHI. In this review, we explore current concepts around the neonatal immune response to PHI with a specific emphasis on the impact of nutrition in the mother, foetus and neonate.     

The value of multi-modality imaging in establishing the diagnosis of Adolescent SAPHO

SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) is a rare chronic autoinflammatory disorder of unknown etiology. Radiological investigation, including the use of magnetic resonance imaging and nuclear medicine is pivotal to the diagnosis of SAPHO syndrome. We present a case of a 15-year-old male diagnosed with SAPHO syndrome displaying the classic diagnostic findings of this condition on bone scan and magnetic resonance imaging.     

A case of anti-neutrophil cytoplasmic antibody-associated vasculitis masquerading as Sjögren syndrome

Anti-neutrophil cytoplasmic antibody (ANCA) -positive vasculitis is a small-vessel vasculitis that affects multiple body systems. Salivary gland involvement in ANCA-associated vasculitis is rare. When present, it mimics infection or malignancy, which might lead to misdiagnosis. In this report, we describe a 72-year-old man who presented with parotid and submandibular gland pain and swelling in addition to dry mouth and eyes. He had bilateral non-tender parotid gland lumps and no lymphadenopathies. Laboratory tests were positive for ANCA, hematuria, and proteinuria but negative for Anti-Ro and -La. He was treated with corticosteroids and cyclophosphamide for acute kidney injury. Unfortunately, the patient died a few months later. This case report sheds light on a rare manifestation of salivary gland involvement in ANCA-associated vasculitis that mimics Sjögren syndrome and the challenges associated with its diagnosis and treatment.     

Informational Masking in Aging and Brain-lesioned Individuals

Auditory stream segregation and informational masking were investigated in brain-lesioned individuals, age-matched controls with no neurological disease, and young college-age students. A psychophysical paradigm known as rhythmic masking release (RMR) was used to examine the ability of participants to identify a change in the rhythmic sequence of 20-ms Gaussian noise bursts presented through headphones and filtered through generalized head-related transfer functions to produce the percept of an externalized auditory image (i.e., a 3D virtual reality sound). The target rhythm was temporally interleaved with a masker sequence comprising similar noise bursts in a manner that resulted in a uniform sequence with no information remaining about the target rhythm when the target and masker were presented from the same location (an impossible task). Spatially separating the target and masker sequences allowed participants to determine if there was a change in the target rhythm midway during its presentation. RMR thresholds were defined as the minimum spatial separation between target and masker sequences that resulted in 70.7% correct-performance level in a single-interval 2-alternative forced-choice adaptive tracking procedure. The main findings were (1) significantly higher RMR thresholds for individuals with brain lesions (especially those with damage to parietal areas) and (2) a left–right spatial asymmetry in performance for lesion (but not control) participants. These findings contribute to a better understanding of spatiotemporal relations in informational masking and the neural bases of auditory scene analysis.

     

Open axillary approach alternative access for stenting of external iliac total occlusion

A primary endovascular approach is the mainstay of intervention for type C aortoiliac disease. When the femoral artery is unsuitable, upper extremity access can be critical in the setting of severe tortuosity or occlusive disease. The axillary artery represents alternative upper extremity access that may accommodate larger sheath sizes for therapeutic interventions. A 44-year-old gentleman with a history of right below-knee amputation was referred to the vascular unit with a left foot non-healing wound post wound debridement for diabetic foot ulcer. On examination, the left foot was non-salvageable with pitting oedema extended until knee level. Left lower limb pulses were non-palpable from femoral downwards. A biphasic signal was audible at the left femoral and monophasic at the popliteal. Photoplethysmography showed poor flow distally. Computed tomography angiogram revealed a 12 cm long segment total occlusion of the left external iliac artery just below the bifurcation of iliac vessel. On the right side, there was a long segment occlusion of the superficial femoral artery and calcified common femoral artery. The left axillary artery was used as an access and angioplasty was performed successfully. The advantages of upper extremity access in the axillary artery include the relatively large size and lower atherosclerotic burden. Larger profile stents for aortoiliac occlusion can easily be handled with a good strength through an axillary approach which is antegrade compared to a retrograde femoral approach. With the advancement of safety features of endovascular devices complications with an axillary approach have become less in the recent era.Keyword: Axillary artery approach, Aortoiliac occlusion, External iliac stenting     

What will it take for an injectable ARV to change the face of the HIV epidemic in high-prevalence countries? Considerations regarding drug costs and operations

Introduction

The proven effectiveness of injectable cabotegravir (CAB-LA) is higher than that of any other HIV prevention intervention ever trialled or implemented, surpassing medical male circumcision, condoms and combination antiretroviral treatment. Based on our own analyses and experience with the South African oral pre-exposure prophylaxis (PrEP) programme, we review the supply and demand side factors that would need to be in place for a successful rollout of CAB-LA, and delineate lessons for the launch of other long-acting and extended delivery (LAED) antiretroviral drugs.

Discussion

On the supply side, CAB-LA will have to be offered at a price that makes the drug affordable and cost-effective to low- and middle-income countries, especially those with high HIV prevalence. An important factor in lowering prices is a guaranteed market volume, which in turn necessitates the involvement of large funders, such as PEPFAR and the Global Fund, and a fairly rapid scale-up of the drug. Such a scale-up would have to involve speedy regulatory approval and WHO pre-qualification, swift integration of CAB-LA into national guidelines and planning for large enough manufacturing capacity, including the enabling of local manufacture. On the demand side, existing demand for HIV prevention products has to be harnessed and additional demand created, which will be aided by designing CAB-LA programmes at the primary healthcare or community level, and involving non-traditional outlets, such as private pharmacies and doctors’ practices.

Conclusions

CAB-LA could be the game changer for HIV prevention that we have been hoping for, and serve as a useful pilot for other LAEDs. A successful rollout would involve building markets of a guaranteed size; lowering the drug's price to a level possibly below the cost of production, while also lowering the cost of production altogether; harnessing, creating and sustaining demand for the product over the long term, wherever possible, in national programmes rather than single demonstration sites; and establishing and maintaining manufacturing capacity and supply chains. For this, all parties have to work together—including originator and generic manufacturers, donor organizations and other large funders, and the governments of low- and middle-income countries, in particular those with high HIV prevalence.